Portal Message Style Linked to Clinician Response Gaps

A cross-sectional study published in JAMA Network Open found that patient portal message writing style accounted for a substantial share of observed demographic disparities in target-clinician response, whereas message content explained little of the differences.

Investigators evaluated 3,619,390 patient-initiated medical advice message threads from 511,020 adults. Messages were sent from 2021 through 2023 to nontrainee physicians, nurse practitioners, or physician assistants in primary care practices at one academic health system. Outcomes included any care-team response and a response from the originally intended clinician.

After adjustment for clinical characteristics, message timing, recipient practice, and intended clinician, Black patients had a 3.7-percentage-point lower target-clinician response rate than White patients (P < .001), an 11.6% relative reduction. Lower response rates were also observed among Hispanic patients, patients with lower educational attainment, and Medicaid beneficiaries.

Natural language processing characterized message topics and writing features in a random sample of 1 million threads; after exclusion of non-English messages, 989,602 were analyzed. Writing style accounted for 48.0% of the target-clinician response gap for Black patients, 34.9% for Hispanic patients, 60.5% for patients with a high school education rather than a college degree, and 42.8% for Medicaid beneficiaries compared with commercially insured patients. Message length, use of the clinician's name, positive sentiment, and expressive punctuation were associated with higher response rates. Message content accounted for comparatively small portions of the gaps.

The investigators characterized writing style as a potential source of bias in message triage, while cautioning that the observational design does not establish causality. Other limitations included use of data from a single health system, exclusion of non-English messages, incomplete capture of responses outside the electronic health record, and text features that could not represent every aspect of message content or style.

Source: Tang M, Rotenstein LS, Stern AD, Mishuris RG, Barnett ML. Care team response to patient portal message content and writing style. JAMA Netw Open. 2026;9(8):e2630379. doi:10.1001/jamanetworkopen.2026.30379