Jonathan Staloff, MD, Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
SEATTLE — As a resident during the COVID-19 pandemic, Jonathan Staloff, MD, quickly noticed that secure messaging through the patient portal had become a major part of primary care. “So much of what I perceive my job to be as a primary care doctor is rooted in the patient portal,” he said. “I noticed that certain patients were in my inbox all the time, while many others rarely reached out this way.”
This observation led to a national study to understand who the heaviest users of secure messaging are, how much of the total messaging they represent, and how this communication fits into overall healthcare use.
The study, published in The Annals of Family Medicine, analyzed more than 1.6 million veterans who exchanged at least one secure message with their primary-care team between October 2022 and September 2023. Researchers found that a small minority of patients accounted for a disproportionate share of messages: The top 5% of users were responsible for 30.5% of all secure messages exchanged.
“The top 10% of veterans exchanged 43.3% of all messages, and the top 20% exchanged essentially 60%,” explained Staloff of the Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System. “That communicated that a small sub cohort of veterans are exchanging a disproportionately large share of secure messages in the patient portal. … There’s a select few that seem to have an outside presence in my inbox.”
High users are more likely to be older, frail and managing multiple chronic conditions, the study found. Veterans with mental health diagnoses such as PTSD, anxiety or depression were also more likely to fall into this category.
Conversely, disparities emerged across race and ethnicity. Veterans who identified as Black, Hispanic, or Asian/Pacific Islander/Native Hawaiian were less likely to be high users.
To Staloff, these findings were striking. “Secure messaging is an important access point to primary care for patients with significant medical conditions and mental health conditions,” he told U.S. Medicine. “But it also communicated to me that disparities that exist in all forms of healthcare utilization also exist when it comes to using secure messaging, where white patients tend to use care and have higher accessibility than other historically minoritized racial groups.”
Although the study did not address reasons for the disparities, Staloff suggested a few possible explanations. “Historically minoritized racial groups have an earned mistrust of the healthcare system; using secure messaging also requires digital literacy and digital access. Perhaps white individuals living in high socio-economic neighborhoods may have a historic facility of using things like patient portals … whereas digital literacy might be less socialized in groups who have had less access to these types of technologies in general.”
One surprising finding was that high users of secure messaging were not also high users of other healthcare services. Only 14% of the top secure messaging users were in the top tier of in-person visits, 11.3% in video visits, 11.8% in telephone visits and 8% in emergency department visits.
“The overwhelming majority of secure messaging high utilizers were not also high utilizers across the board,” Staloff said. “That communicated to me that secure messaging is an important access point to primary care.”
This distinction suggests secure messaging can serve as a primary means of access for certain veterans, particularly those with complex medical and mental health needs.
For clinicians, the workload implications are significant. “I was struck by just how many messages are exchanged in this group,” Staloff admitted. “That validated my own personal experience as a clinician of ‘Gosh, I’m spending a lot of time in this portal’ … either before you’re in clinic, in between patients trying to sneak in responses … or when you’re at home and trying to relax and spend time with your family.”
Staloff said he hopes this work will spark deeper exploration into secure messaging’s role in primary care. “What I think is important to understand is a little bit more of the texture of how people are using secure messaging. And also why patients aren’t using secure messaging,” he said. He pointed to the need for qualitative research with both high utilizers and patients who rarely use messaging to better understand benefits, barriers and potential improvements.
Clinician experiences also warrant further study. “How is this intruding into the other kinds of primary-care services they’re trying to deliver? How much is it intruding to their home life? How sustainable do they feel it is? Or do they feel that secure messaging is a wonderful tool that’s complementing the care they provide in person?”
For now, his study highlights that secure messaging is no longer peripheral. It is a major channel of care delivery, especially for patients with significant needs. As Staloff summed up: “This is a body of work … becoming a huge portion of what a primary care doctor does that it just simply wasn’t even a decade ago.”
- Staloff J, Gunnink E, Rojas J Jr, Wong ES, Hagan S, Nelson K, Reddy A. High Users of Primary Care Secure Messaging in the Veterans Health Administration. Ann Fam Med. 2025 Jul 28;23(4):285-293. doi: 10.1370/afm.240360. PMID: 40721336; PMCID: PMC12306986.
