At 8 a.m., the inbox may look manageable. By noon, lab questions, refill requests, scheduling issues, symptom updates and “quick” clinical questions have piled up for every clinician on the schedule. Practice leaders must decide who handles them and whether staffing, schedules and pay reflect the time involved.

An Oct. 27, 2026, MGMA Stat poll asked medical group leaders: “Is anyone designated to handle portal/inbox messages for other providers?” Seven in 10 (71%) said yes, 24% said no, 1% were unsure and 4% reported no portal. The poll had 238 applicable responses. Those answering yes were asked to identify the role and whether time was reflected in schedules or pay. Those answering no or unsure were asked who handles the messages; the "no" group also said whether they considered assigning someone.

Follow-up comments showed how broadly practice leaders interpreted "designated."

• Nearly two-thirds of "yes" respondents who named a role cited medical assistants (MAs), nurses or both. Some practices pair an MA with each physician; others have triage nurses screen messages before they reach the provider, or split administrative messages among front-desk staff and clinical messages among nurses and MAs.
• About one in 10 named advanced practice providers (APPs), and roughly one in eight described physicians and APPs covering each other's inboxes during vacations and other absences.
• Only a few described creating a position for the work: one practice hired clinical staff specifically for inbox management; another gives APPs dedicated time and salary to review messages needing a licensed provider review. A third is piloting an "inboxologist" clinician whose main job is the inbox.

Most comments on time or pay described inbox work added to an existing job: About 71% of "yes" respondents who addressed either reported no separate schedule time or added pay. "No protected time provided, simply a new expectation," one wrote about nurses answering messages for physicians and APPs. One practice allots 30 minutes daily during work hours for inbox tasks.

Among those with no designated person, about six in 10 said the treating provider handles their own messages. Almost as many had considered or were pursuing a role, including an inboxologist, outsourcing or protocols that let MAs and other clinical staff respond. Those who had not considered it cited costs, messages needing provider input or an existing team approach. "At this point," one respondent wrote, "it's just faster to have the provider handle it."

Other research points to growing message volume:

• A January 2025 MGMA Stat poll found 70% of groups reported increased portal messages during 2024.¹
• Epic Cosmos EHR data published in JAMA showed patient-authored portal messages per active patient rose 153% from 2020 to 2025.²
• A 2026 Health Affairs study found uneven burden: The top 5% of patients at UCSF Health, an academic health system, generated more than half of patient-initiated medical advice messages. Nationally, the highest-volume quartile of primary care physicians received 53.3 messages weekly compared with a median of 9.6.³

Answering these messages between visits is increasingly difficult to sustain.

Sorting messages before assigning a role

For midsize groups, an inbox manager or shared inbox pool can give every message an owner. An MA, licensed practical nurse (LPN), registered nurse (RN), APP, pharmacist or other team member can screen messages, resolve those within their scope and escalate the rest.

A first-pass model can reduce clinic interruptions, make response times more predictable, cover messages during absences and show how much work the inbox creates. American Medical Association (AMA) guidance recommends sorting administrative, refill, clinical and other messages into team pools best equipped to handle them.⁴

Before assigning staff, leaders need to know what types of messages arrive. APPs can handle medication questions, lab follow-up or clinical triage, while records requests, appointment changes and paperwork are a costly use of their time. Sending all clinical messages to MAs raises scope-of-practice and escalation concerns, particularly when a question needs licensed clinical judgment.

The AMA also recommends using EHR audit logs to understand inbox work before redesigning it.⁴ Leaders can review several weeks of messages by type, sender, handling time and how each was resolved. The findings can show whether the group needs an inbox APP, RN-led triage, MA or front-desk screening, separate pools by specialty or a combination of approaches.

Making room in schedules and pay

Compensation complicates the picture for clinicians paid mainly for visits or work relative value units (wRVUs).

When clinicians absorb another provider’s inbox on top of a full schedule, the work has no dedicated time. Leaders using production-heavy pay models may need fewer scheduled visits, protected administrative time, a salary component or a stipend to recognize non-visit work.

A 2025 JAMA Network Open study followed internal medicine physicians in a large ambulatory network that reserved one 20- to 30-minute appointment slot per half-day for messages, refills, prior authorizations and other EHR work. Their after-hours and non-workday EHR use fell, with only a small decrease in wRVU productivity.⁵ The amount of protected time will vary by specialty and message load, but it allows more work to be finished during clinic hours.

Deciding when a message becomes a visit

Inbox teams also need rules for when a message requires an appointment. Some are simple requests; others warrant a telehealth or in-person visit.

Our 2025 guidance remains current: Patient-initiated portal messages from established patients may qualify as e-visits (CPT 99421–99423) when they involve clinical evaluation and at least five minutes of cumulative physician or other qualified health professional time over seven days. MA and nursing staff time does not count. Consent, documentation and payer rules also apply.¹ Inbox teams need practical rules for what staff can resolve, what needs physician or APP review, what becomes an appointment and what requires urgent attention.

Technology may help sort messages. A 2026 JAMA Network Open study of a tool at Southern California Permanente Medical Group, serving 4.9 million Kaiser Permanente patients, found it classified more than 3 million portal messages by topic and urgency more accurately than its predecessor. Median time until a clinician first read a high-acuity message fell from about 22 hours to five.⁶ The practice still needs a person or team responsible for acting on the results.

Groups should check for unintended effects. Is the designated person becoming a bottleneck? Are physicians re-reviewing delegated messages? Is inbox coverage pulling an APP out of clinic when patients are waiting?

In this poll, most designated inbox workers were MAs or nurses handling other providers’ messages within existing jobs, often without added time or pay. Where no one was assigned, messages generally stayed with the treating provider. Leaders weighing a new role should decide which messages to delegate, who can handle them and how the work fits into schedules and compensation.

Notes

1. Bradley V, Good C. “Ensuring accurate coding and billing for patient portal messages as e-visits.” MGMA. Jan. 29, 2025. Available from: https://www.mgma.com/mgma-stat/ensuring-accurate-coding-and-billing-for-patient-portal-messages-as-e-visits
2. Long JJ, McAdams-DeMarco MA, Schwartz MD, et al. “Trends in Patient Portal Messages, Office Visits, and Telephone Encounters.” JAMA. 2026;336(3):252–254. doi:10.1001/jama.2026.8690
3. Holmgren AJ, Apathy NC, Mehrotra A, Chernew ME. “The Uneven Distribution of Patient Portal Messages Across Patients and Physicians.” Health Affairs. Aug. 3, 2026. Available from: https://www.healthaffairs.org/doi/10.1377/hlthaff.2025.01416
4. American Medical Association, “A Systematic Approach to Reducing EHR Inbox Burden.” AMA STEPS Forward. Available from: https://edhub.ama-assn.org/steps-forward/module/2821565
5. Kanaparthy NS, Holmgren AJ, Sun Y, et al. “Protected Time for Electronic Health Record Work and Physician Productivity.” JAMA Netw Open. 2025;8(12):e2546550. doi:10.1001/jamanetworkopen.2025.46550
6. Nguyen D, Lee S, La K, et al. “Performance of an Intelligent Messaging Tool for Clinical Communications.” JAMA Netw Open. 2026;9(1):e2553174. doi:10.1001/jamanetworkopen.2025.53174