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Not that many years ago, when Philadelphia internist Michael Stillman’s patients wanted to discuss some concern or renew a prescription, they would call and his staff would handle most of the requests.

Today, those calls have morphed into a relentless 24/7 torrent of emails that he finds almost impossible to keep up with.

“I spend over two hours/day (in addition to patient care) responding to computer messages,” Stillman recently wrote in an email to his patients after one particularly demanding night responding to dozens of patient missives. “Some are simple, but some are hugely complex.” If he doesn’t clear out his inbox each night by the next day, he’ll have so many more that “I’ll drown.”

<a href="https://academic.oup.com/jamia/article/29/3/453/6458072" target=_blank>A 2021 study </a>in the Journal of the American Medical Informatics Association found that messages to doctors in patient portals increased by 157 percent between early 2020 and late 2021. And national data through mid-2022 show that the rates have stayed that high or even slightly increased, the study authors say.

“Blame the pandemic,” says <a href="https://cliir.ucsf.edu/people/jay-holmgren" target=_blank>A. Jay Holmgren,</a> one of those authors and an assistant professor in medicine at the University of California at San Francisco and the Center for Clinical Informatics and Improvement Research. While messaging capability between patients and medical practices has been around for more than a decade, Holmgren says, most people learned about that option only when the pandemic began and they needed to use in-portal email to set up a telehealth or other virtual visit.

But even as the pandemic has receded, “there’s a lot more awareness of … how great it is to be able to just message your physician or clinical team at any time and say, ‘Hey, I got this question,’ and then get a response for free,” Holmgren says.

The interest in an email interaction isn’t surprising, Stillman, Holmgren and others say. Contacting physicians can be challenging for patients — from getting a phone call back from a doctor or assistant to losing work time for an appointment since most practices stick to standard workday hours.

Many physicians — <a href="https://www.reddit.com/r/medicine/comments/u16sh5/how_many_patient_messages_do_you_get_a_day/" target=_blank>including dozens on Reddit</a> — say they want to connect with patients — they just don’t want to do it every night in their pajamas. Physician <a href="https://profiles.ucsf.edu/jack.resneckjr" target=_blank>Jack Resneck, </a>chairman of dermatology at UCSF and the immediate past president of the American Medical Association, says “sometimes in health-care things get turned on without a plan for how we are going to build this into our workday and how are we going to compensate for the time and … how will physicians … have protected time.” Resneck says he often answers patient emails after putting his children to bed.

Some of the portal messages deal with issues that are best discussed in person since they are complex and may need a back and forth. “A portal used to ask for an appointment or ask for a refill is very different than the use of a portal to ask questions that require evaluation and management by the physician in the same way that we do for an office visit,” Resneck says.

Holmgren says universal guidelines about email communication between patients and their providers won’t necessarily work because doctors and doctor practices have different cultures. Kelly Cassano, chief executive of the Mount Sinai Doctors Faculty Practice in New York, agrees. “I like getting emails from patients who have been ill, letting me know when they’re feeling better, while other doctors may not need that follow up,” Cassano says.

Some doctors have begun dealing with overflowing patient emails and the time they spent on them by charging patients or their insurers for some of them (which can generate a patient co-pay), adding staff members to help with patient queries and setting rules of email etiquette for that medical practice.

Some larger health-care institutions have begun to charge for email time, including physician offices at the Cleveland Clinic, Ohio State University Wexner Medical Center, Northwestern Medicine and Lurie Children’s Hospital in Chicago, UCSF Health, Oregon Health &amp; Science University, and the University of Washington.

The University of Washington explained in a June <a href="https://rightasrain.uwmedicine.org/well/health/messaging-your-doctor" target="_blank">blog post</a> for patients that billing had been initiated because the 500,000 emails their doctors received in 2019 had skyrocketed to 1.4 million in 2022. “Adding a charge to receive messages on complex health topics, and using these messages in place of some appointments, means your doctors can devote more concentrated time to these messages,” according to the blog post, which added that it “takes a lot of medical expertise to answer a question comprehensively.”

In the post, Adam Jayne-Jensen, internal medicine physician and associate medical director of the UW Medicine Primary Care Central Region, wrote, “The big thing I want people to know is that the vast majority of messages will not be billed. It’s only a small subset of complex messages that take a lot of time and personalized medical advice to address.”

At UW, the emails patients may be charged for include: requests for new prescriptions, questions about new symptoms or conditions, questions about changes to long-term conditions, requests to complete medical forms, such as life insurance or medical clearance forms, and requests for new referrals.

Email billing <a href="https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet" target=_blank>rules </a>established by the federal Centers for Medicare and Medicaid Services allow doctors who care for Medicare patients to charge for email if it takes more than five minutes to write the message, and some insurers are doing the same.

But <a href="https://washpost.arcpublishing.com/ellipsis/:%20https:/jamanetwork.com/journals/jama/fullarticle/2800370" target=_blank>a study</a> Holmgren published this year found that, in most cases, email messages were not being billed for anyway — only about 3 percent had elicited charges — and those charges have only led to a 2 percent decline in the number of messages patients sent to their doctors.

Billing generates its own paperwork — and huge time demands — for doctors, Holmgren says.

One Medical, a national primary care practice, charges members a $199 annual fee that in part helps cover the cost of time spent on responding to patient messages. “Answering patient email is part of the doctors’ salaried workweek,” says Breanna Shirk, a One Medical spokesperson. Providers have time outside of patient appointments to address administrative work, like responding to patient messages.”

That membership fee also covers digital tools that can cut down on patient emails. “Urgent Video Chat” connects members to a health-care provider 24/7 who can make treatment decisions on the spot, such as prescribing an antibiotic for a lingering illness. “Treat Me Now” is a messaging tool in the One Medical app that links patients with providers who offer treatment suggestions for nonurgent issues, such as skin rashes and headaches. (One Medical is owned by Amazon, whose founder Jeff Bezos owns The Washington Post.)

In part to manage patient email and patient requests for immediate care, the Mount Sinai Health System in New York launched a similar set of tools in June. “We’re still working on a patient brochure for the system, though,” Cassano says.

Cassano says that’s because different doctors have different ideas about what sorts of issues merit an email. Cassano says “some doctors complain that it can be hard to focus on patient care when you’re getting multiple emails all day asking what floor the office is on, though I’m mindful, of course, that that’s an important question for patients.”

Holmgren says he thinks that ultimately more practices will give paid time to physicians to answer patient emails, “though that is likely to raise health insurance premiums.”

One project he’s working on may help to keep those costs down. Several University of California medical centers, as well as several large academic medical centers, including Stanford, Vanderbilt and UNC, are working on a ChatGPT pilot project that could help quickly generate replies to patients that are then reviewed and edited by the doctor before heading to a patient’s inbox.

Meanwhile, Stillman came up with a plan for his own patients that he says seems to be working.

The patient portal he uses automatically includes a pop-up reminder that lets patients know it may be several days before they get a response to their email — and that he generally doesn’t check email on nights and weekends. His email also advised patients to call the office and leave a message during the day for emergencies that aren’t life-threatening, and to leave a message on nights and weekends for an on-call doctor.

“If you have a more complex question or need, please call the office and get an appointment with me,” Stillman writes in his email to his patients.

Patient feedback to Stillman’s email was wildly supportive.

“I received more than 50 responses from patients … assuring me that my requests were reasonable and that they would help take care of me as I had of them,” he says.

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