Modest Decline in Patient Portal Messages After Billing Initiative Launched

Billing for certain patient portal messages was associated with a modest decrease in message volume in a large health system, researchers found.

In the 6 months after starting to bill for some messages as “e-visits,” the volume of patient-initiated medical advice message threads decreased 8.8% compared with the same dates in the previous year (P=0.002), reported Shannon Dunlay, MD, MS, of the Mayo Clinic in Rochester, Minnesota, and colleagues.

Between patients who sent a message after viewing a billing disclaimer on the patient portal versus those who did not, there was no difference in 7-day emergency department visits (1.6% in both groups) or hospitalizations (1.7% vs 1.6%), Dunlay and colleagues noted in the Annals of Internal Medicine.

Additionally, though providers did report overall acceptance of e-visit billing, they expressed concerns about increased workload with the process.

“As digital healthcare practices continue to evolve, opportunities exist to optimize interactions to maximize patient satisfaction and outcomes and minimize care team burden and burnout,” Dunlay and colleagues concluded.

Over the past several years, there has been a substantial increase in patient-initiated messages submitted to clinicians through the healthcare patient portal, the authors wrote. Due to its convenience for patients, it has increasingly been used as a way to get clinician feedback about medical issues instead of an office visit, but this has resulted in many providers spending several hours a day, often outside of regular clinical hours, responding to portal messages.

“Responding to patient portal messages has increased provider and care team burden,” they wrote. “This increase in patient-initiated messages has been seen by healthcare institutions nationwide, with a reported 157% increase in patient-initiated messages over prepandemic averages. Many healthcare facilities have implemented programs to enable providers to bill for responding to patient-initiated messages that require substantive medical decision making through an e-visit.”

Among providers who responded to a survey, 42.6% indicated that they had used e-visit billing codes, and about 80% of providers who did reported that it was acceptable or completely acceptable to them.

But 141 providers reported “mixed perceptions” about the process.

For example, one provider commented: “I think this is a good update, but it needs to also come with the plan for more dedicated non-visit care time. Our patients are using this technology more and more (and we want them to), but this is all being completed outside of patient-facing time so we need to track those metrics and allow time to provide this care for our patients. I know that patients appreciate timely and thorough patient portal responses, and we want to build on this as it is the way of the future.”

Among the providers who shared additional feedback, 29.8% said they approved of e-visit billing or appreciated having the option, but 44% reported challenges, particularly regarding burden.

In 40 out of 41 comments related to burden, it was reported that the process required more time to complete documentation with limited administrative time or incentives; 37 reported an onus placed on providers to determine when to initiate the billing process.

Researchers noted that in August of 2023, the Mayo Clinic, which has sites in four states, implemented e-visit billing at all sites for eligible patient-initiated portal messages.

“Healthcare is changing rapidly in the setting of technological advances,” Dunlay further told MedPage Today in an email. “As new innovations and care models are introduced, such as e-visit billing programs, it is important to critically evaluate their impact on patients and clinicians.”

For the study, researchers used electronic health records from all Mayo Clinic sites from August 2023 to February 2024 to identify patient-initiated medical advice threads. They compared these with messages received over the same time period in 2022 to 2023 to assess change in volume. Mayo Clinic emergency department visits, hospitalizations, and outpatient office visits in the 7 days after viewing the billing disclaimer were compared between those that sent a message and those that did not.

In addition, an online survey was developed to assess provider perceptions of e-visit billing. Of 1,146 healthcare providers who were sent the survey, 305 completed the survey — 215 physicians and 90 advanced practice providers.

Limitations of the study include that the research team was not able to “rigorously capture” alternative contact methods (i.e. telephone calls) that patients may have used instead of sending a portal message, and that the provider survey response rate was 26.6%.

Additionally, most patients in the analysis were white and English-speaking, meaning that findings may not apply to populations with varying racial and ethnic diversity, and that results may not apply to non-English speakers, they noted.