Hospitalists who feel like they are drowning in the volume of messages sent and received over electronic secure messaging systems apparently are not exaggerating.

While the systems are viewed as a welcome communication advance, recent studies have found that the volume of messages sent back and forth during a single shift is much higher than previous studies have suggested — sometimes at a pace of 13 messages an hour. Managing that volume can result in excessive interruptions, a frustrating workday, and the potential for medical errors, researchers said.

However, researchers who have been looking more closely at messaging volume and patterns said there are ways to tame the beast while preserving the advantages.

How High Is a High Volume?

In one of the latest studies, researchers counted messages over 1 weekday and 1 weekend day at a single 721-bed Colorado hospital. The total? 2706, including 265 conversations.

That study didn’t calculate messages by hour, but a 2024 study by some of the same Colorado researchers did, finding an average of 130 messages over a typical shift, or about 13 per hour, sent or received by hospitalists.

In the 2025 study, while many of the messages were urgent, requiring immediate reaction or action by the hospitalists, a surprising percentage was not.

“One of the major takeaways was the number of ‘lower-acuity’ or not clinically relevant messages,” said Jessica Clawson, MD, a third-year internal medicine resident at the University of Colorado Anschutz School of Medicine, Aurora, Colorado, and a lead author of the 2025 study. These included the nearly one third classified as acknowledgement, gratitude, apology, or social interactions.

Researchers have also discovered that despite the built-in features that let senders flag a message as urgent or nonurgent, “people aren’t using these indicators correctly,” said Michelle Knees, DO, assistant professor and a hospitalist at the University of Colorado Anschutz School of Medicine and a researcher on both the 2025 and 2024 research.

Trend: From Texts and Phone Calls to Secure Messaging

For inpatient clinicians, 25% of the day is spent in communication with other healthcare members, Clawson and Knees reported, and that statistic is from a 2006 study. Gradually, the pagers, phone systems, and hands-free systems used by hospitals are being replaced by the asynchronous electronic secure messaging systems. The systems are meant to be compliant to the Health Insurance Portability and Accountability Act and aim to ease both emergency and routine communications among healthcare providers.

While some hospitals use the platform for all communication, others use it to supplement other communication forms such as pager and overhead announcements.

Knees said her Colorado hospital uses Epic Secure Chat, but other commonly used ones include Voalte, TigerText, CareConnect, and others.

While the Colorado research has found a much higher volume than some other studies, Knees and Clawson said that may be because some hospitals use secure messaging only to supplement text and phone communication. Other hospitals, including theirs, have transitioned to unified communication, using the system’s platform for all health communications. It can be accessed via a smartphone or computer.

Research Details: A Closer Look

In the 2025 study, Knees and Clawson found that of the 2706 messages coded, 38% were sent and received by physicians, 22% by advanced practice providers, 33% by nurses, and 8% by other healthcare team members.

While 99% were described as nonurgent, 64% were termed clinical and 66% as “nonactionable.”

About the so-called “lower-acuity” messages: 13% were for acknowledgement, 8% for gratitude, another 8% for both gratitude and acknowledgment, 2% for apologies, and 0.6% for social interaction. (Think “Thank you!” and “Of course!” for instance.)

In the 2024 study, researchers found that 39 seconds was the average time between receiving a message and reading that message — so that could mean many interruptions in the course of a day.

Pros and Cons

In a point-counterpoint, Knees and other hospitalists noted the advantages of secure messaging:

• Asynchronous two-way communication
• No need for pagers
• Interdisciplinary collaboration
• Fewer barriers to communication

But also the downsides:

• Increased volume of messages
• Workflow interruptions
• Misunderstandings
• Unclear about message urgency

Issues and Solutions

“Policies are really critical at a hospital level,” Clawson said, especially to minimize the lower-acuity messages. “And we already have these cultural tendencies that have bled over from texting,” she said. So users’ secure chat habits may be mimicking how they text in nonmedical conversations.

Maintaining the social interaction professionally is important, Clawson and Knees agreed, but so are finding ways to decrease those lower-acuity messages. Some platforms, including the one used at the Colorado medical center, now include emoticons embedded within the secure chat.

Users can send a smiley face, thumbs up, or a heart, Clawson said, “to maintain that social interaction we all crave.” People tell her they love them, she said, and want more.

Knees was hesitant to mention a specific emoji request but then did. “There’s been a specific request for the poop emoji,” she said. “Multiple times.” While Knees enjoys appropriate humor, the poop emoji starts to “verge into unprofessionalism.” But she said she definitely sees the value of other emojis.

The emojis seem to be reducing the lower-acuity messages, Clawson said, though they haven’t studied it formally. Other researchers have found that introducing emojis reduced push notifications — and thus interruptions — by nearly 5%.

Using the secure messaging features correctly also helps minimize interruptions, Knees and Clawson said. In short, if a message isn’t marked urgent, it doesn’t need to be read immediately.

The sender also needs to be clear about a message’s urgency if it is urgent, Knees said. Recently, she happened to read a message not marked urgent soon after it arrived, and it was actually urgent, telling her a patient’s blood pressure was extremely low and she was needed at the bedside.

Other Tips From the Trenches

Hospitalists accustomed to working with electronic secure messaging offered other management tips.

• “Batch communication to minimize interruptions for nonurgent messages,” said Esther Hsiang, MD, MBA, assistant professor of medicine and director of the night hospitalist service at the University of California San Francisco. Resist the urge to follow social texting conversation patterns, said Hsiang, who co-authored a point-counterpoint on secure messaging.
• “Our team put together a document outlining the hospitalist service’s day-to-day operations,” including communication and contact methods, said Nikhil Sood, MD, assistant professor and clinical scholar at the University of Arizona College of Medicine - Phoenix and a hospitalist at Banner Gateway Medical Center, Gilbert, Arizona. CareAware is for routine requests, and the answering service is for admissions and after-hours operations, he said. Acknowledgement texts such as “thank you” are discouraged.

• Hospital policies about managing secure chats are crucial, agreed Ethan Babcock, MD, executive medical director of hospital medicine for Providence Swedish in Seattle. “We consider all secure chats to be nonurgent with a definition of a 1-hour response time on average,” he said. “Most are responded to much faster than that, but that helps set expectations. For urgent messages, we still use pagers and overhead for rapid responses and codes.” One other policy: “It is the responsibility of the sender to ensure that their message was received.” And users are encouraged to use the thumbs-up emoji over “Thank you.”

• Know when to go “old-school.” “When a thread is becoming longer and longer, perhaps we should examine what underlies our reluctance to simply pick up the phone and talk to each other,” said Areeba Kara, MD, MS, associate professor of clinical medicine at Indiana University (IU) School of Medicine and a hospitalist at the IU Health Medical Group, Indianapolis, who has researched clinical text messages by hospitalists. “Perhaps patient care needs more authentic communication and connections between the teams — and secure messages may simply be adding quantity but eroding quality.”

Clawson, Knees, Hsiang, Sood, Babcock, and Kara had no relevant disclosures.