Patients who opened a portal message with their clinician’s last name heard back from that clinician 38.7% of the time. Patients who opened with no greeting at all heard back 25.7% of the time, according to a cross-sectional study of 3.6 million patient message threads published yesterdat in JAMA Network Open.
The study covered messages sent by 511,020 adults to primary care physicians, nurse practitioners and physician assistants across Mass General Brigham between Jan. 1, 2021, and Dec. 31, 2023. Researchers used natural language processing to code what each message asked for and how it was written, then measured which factor explained gaps in response rates.
In most practices studied, portal messages do not land in a clinician’s inbox. They go to a shared pool, where a triaging nurse or medical assistant decides whether to answer or forward them. Across the full sample, 77.5% of threads drew a response from someone on the care team and 32.0% drew a response from the clinician the patient originally wrote to.
After adjusting for clinical characteristics, practice, clinician and send time, Black patients were 1.1 percentage points less likely than White patients to receive any care team response, and 3.7 percentage points less likely to hear from the intended clinician, an 11.6% relative decrease. Similar patterns appeared for patients with a preferred language other than English, patients whose highest education level was high school, and patients on Medicaid or Medicare-Medicaid dual coverage.
Message content explained little of those differences, accounting for 5.7% of the intended-clinician gap for Black patients and 12.7% for patients with only a high school education. Writing style accounted for 48.0% of the gap for Black patients, 34.9% for Hispanic patients, 60.5% for patients with a high school education and 42.8% for Medicaid patients.
Length tracked closely with replies. Threads of 200 or more words reached the intended clinician 49.7% of the time, against 21.0% for messages of 25 words or fewer. Question marks, exclamation points and positive sentiment all corresponded with higher response rates. Response peaked among messages written at a sixth to ninth grade reading level. Messages containing the word “please” reached the intended clinician less often, 26.8% versus 33.8%.
By topic, refill requests drew the lowest clinician response at 19.6%. Nutrition, diet or weight questions drew the highest at 51.6%.
The authors noted the study draws on one academic health system, excludes the 1% of messages written in other languages, and cannot capture replies delivered by phone or in person.
