Researchers analyzing Epic electronic health record data across 2,067 hospitals and 47,100 clinics tracked more than 8 billion patient-provider interactions between 2020 and 2025. Patient-authored portal messages rose 153% over the period, according to the study published in JAMA in June 2026, while office visits climbed 17% rather than falling, placing messaging on top of existing care rather than replacing it.

 

How large the shift is

Active patient records on Epic grew from roughly 94 million to 140 million across the study period, and total patient-authored messages reached 1.34 billion. Among patients who sent messages, the average rate rose from 2.2 per year in early 2020 to 5.4 per year by late 2025, and roughly 30% of active patients sent at least one portal message during the first quarter of 2025 alone.

Messages from clinicians and staff rose 24% to 5.70 per patient per year after peaking at 6.86 during the pandemic. Telephone encounters fell about 6%, nowhere near enough to offset the growth in written communication. The researchers described the trajectory as "indicating a structural shift in communication rather than a transient disruption."

 

Where the time comes from

A 2025 study in JAMA Internal Medicine drew on de-identified EHR data from more than 280,700 outpatient physicians between June 2019 and March 2022. Primary care physicians went from about 10 medical advice messages a week at the end of 2019 to 16 by March 2020, and their off-hours time in the EHR rose from 10.6 to 11.3 hours weekly. The authors described the growth as "a sustained, ongoing source of physician work."

Research in the Journal of the American Medical Informatics Association found clinicians in the highest quartile for message volume carried more than six times the odds of high exhaustion compared with those in the lowest quartile. Primary care physicians seeing more than 40 patients a week logged more than 15 hours of off-hours EHR work weekly.

More than 30% of patient-initiated EHR messages involve administrative rather than medical content, covering scheduling, billing questions, and form requests. Those messages land in the same inbox as clinical questions and compete for the same after-hours time.

 

What health systems have tried

Some organizations began billing for messages requiring substantive medical decision-making, using CPT codes 99421 through 99423 to treat them as e-visits. A study in Annals of Internal Medicine assessed a large integrated health system operating across four states after it implemented e-visit billing in August 2023, comparing message volume before and after alongside a provider survey.

An accompanying JAMA editorial by Melanie Molina of UCSF and Joseph Ross, JAMA's deputy editor, argued billing alone does not resolve a structural problem, writing that "health systems must account for message volume in staffing models."

Several health systems are piloting generative AI tools that draft replies for clinicians to review. Dorry Segev, vice chair of surgery at NYU Grossman School of Medicine and a co-investigator on the JAMA study, said clinicians will need to balance their digital workload on top of their traditional clinical workload, including through AI support tools.

 

Who is not in the numbers

The JAMA analysis found the highest message volumes among women aged 40 to 64 in lower-vulnerability neighborhoods. Messaging was markedly lower among patients in high social vulnerability areas, rural and micropolitan communities, men, and people at both ends of the age range.

Paubox research on portal use found that 65% of patients stop using a portal after the first day, and its research on rural providers found 85% of rural healthcare IT leaders reporting that portals cause delays and complaints. The 1.34 billion messages come from patients who cleared the login barrier, and a large population never did.

 

Two problems pulling in opposite directions

Patients who use the portal are sending more messages than clinicians can absorb without working overtime. Patients who abandon it fall back on phone calls, unprotected email, or no contact between visits, and those patients are concentrated in exactly the populations the JAMA data shows messaging least.

Paubox Email Suite encrypts every outbound message by default and delivers it to the patient's regular inbox with no account creation and no password, reaching the patients the portal lost. Routing administrative correspondence through encrypted email rather than the clinical inbox separates the non-clinical 30% from the queue physicians work through after hours, and Paubox Forms moves intake and paperwork out of that queue entirely.

Learn more: HIPAA Compliant Email: The Definitive Guide

 

Why charging for messages may widen the gap

Holmgren and colleagues examined the association between billing patient portal messages as e-visits and subsequent messaging volume in a 2023 JAMA research letter, assessing clinician adoption of e-visit billing after the sharp rise in message traffic. A follow-up study by the same lead author, National Trends in Billing Secure Messages as e-Visits, tracked the practice across the full Medicare fee-for-service population between January 2020 and December 2022.

Oncology has produced the clearest evidence on who absorbs the cost. Analysis published by Cancer Therapy Advisor found that billing for portal messages reduces clinician workload while raising financial toxicity for cancer patients, who use messaging heavily for symptom management between appointments.

Patients most likely to be deterred by a charge tend to have fewer resources, and those are the groups the 2026 JAMA analysis found already messaging least. High-volume users in lower-vulnerability neighborhoods are the least sensitive to cost, so a mechanism intended to reduce clinician burden lands hardest on patients who were already underusing the channel. The JAMA editorial pointed toward staffing and workflow redesign as the more durable answer.

 

FAQs

How much have patient portal messages increased?

Patient-authored messages rose 153% between 2020 and 2025 according to a JAMA study using Epic data from more than 2,000 hospitals, with the average rate among senders climbing from 2.2 to 5.4 per year.

 

Did messaging reduce the need for office visits?

No. Office visits rose 17% over the same period while telephone encounters fell about 6%, so messaging adds a layer of care rather than substituting for visits.

 

Is message volume linked to physician burnout?

Research in the Journal of the American Medical Informatics Association found clinicians in the top quartile for message volume had more than six times the odds of high exhaustion.

 

Why do some patients not use portals at all?

Paubox research found 65% of patients stop using a portal after the first day, and portal messaging runs markedly lower among rural patients, men, and people in high social vulnerability areas.

 

How can secure email help with portal overload?

Encrypted email delivered directly to a patient's inbox reaches people who abandoned the portal, and routing administrative correspondence outside the clinical inbox keeps non-clinical messages out of the queue physicians handle after hours.