Portal message utilization in orthopedic spine surgery: patterns, predictors, and financial implications

Electronic patient portals (EPPs) facilitate communication between patients and providers, but their utilization and impact in orthopedic spine surgery are poorly defined. This study aims to quantify portal message volume and content, identified demographic predictors of high utilization, and estimated the associated administrative and financial burden.

A retrospective review was conducted of 833 new patients presenting to a single tertiary-care orthopedic spine practice over 6 months (April 2-October 31, 2024). Portal messages were categorized by timeframe and subject matter. Patients were classified as low- or high-volume (HV) users, with HV defined as ≥4 messages. Demographic predictors were assessed using independent t-tests and chi-square analyses. Messages meeting Centers for Medicare and Medicaid Services (CMS) criteria for billable Evaluation and Management (E/M) services were identified and assigned reimbursement values. A Monte Carlo simulation (100,000 iterations; R v4.5.1) estimated lost revenue from unbilled encounters.

A total of 548 portal messages were sent (median 0 messages per patient; IQR 0-1). Common message topics included appointment scheduling (n=97), imaging-related concerns (n=94), postoperative issues (n=79), pain management (n=70), and third-party requests (n=59). High-volume utilization occurred in 43 patients (5.2%), with a mean of 5.19 messages per patient (range 3-18). Age was not associated with portal use (p=.276). Race was the only significant predictor of HV utilization (χ²=6.172, p=.046), with White/Caucasian patients overrepresented and Black/African American patients underrepresented. Only 25 messages (4.6%) met CMS billing criteria, primarily Level III E/M encounters (72%). Estimated median lost billable revenue was $7,501 (95% CI $3,845-$12,539).

Electronic patient portal (EPP) use in orthopedic spine surgery is highly skewed, with a small subset of patients generating disproportionate message volume. Despite limited billable encounters, portal messaging represents a growing administrative burden. Observed racial disparities highlight the need to further evaluate equity in digital patient engagement.