As patient-initiated messaging rises, identifying variation in message volume and its relationship to clinician workload is essential.


To describe the association between variation in message volume over time and time spent on the electronic health record (EHR) outside of scheduled hours.


Retrospective cohort study.


Primary care clinicians at Cleveland Clinic Health System.

Main Measures

We categorized clinicians according to their number of quarterly incoming medical advice messages (i.e., message volume) between January 2019 and December 2021 using group-based trajectory modeling. We assessed change in quarterly messages and outpatient visits between October–December 2019 (Q4) and October–December 2021 (Q12). The primary outcome was time outside of scheduled hours spent on the EHR. We used mixed effects logistic regression to describe the association between incoming portal messages and time spent on the EHR by clinician messaging group and at the clinician level.

Key Results

Among the 150 clinicians, 31% were in the low-volume group (206 messages per quarter per clinician), 47% were in the moderate-volume group (505 messages), and 22% were in the high-volume group (840 messages). Mean quarterly messages increased from 340 to 695 (p < 0.001) between Q4 and Q12; mean quarterly outpatient visits fell from 711 to 575 (p = 0.005). While time spent on the EHR outside of scheduled hours increased modestly for all clinicians, this did not significantly differ by message group. Across all clinicians, each additional 10 messages was associated with an average of 12 min per quarter of additional time spent on the EHR (p < 0.001).


Message volume increased substantially over the study period and varied by group. While messages were associated with additional time spent on the EHR outside of scheduled hours, there was no significant difference in time spent on the EHR between the high and low message volume groups.


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Author Descriptions

Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA

Kathryn A. Martinez PhD, MPH, Michael B. Rothberg MD, MPH & Elizabeth R. Pfoh PhD, MPH

Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA

Rebecca Schulte MPH

Department of Pediatrics, Cleveland Clinic, Cleveland, OH, USA

Maria Charmaine Tang MD, FAAP