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Dear Editor
We read with great interest the article by Lee et al. on “Utilizing Medical Assistants to Manage Patient Portal Messages” (1) and commend the authors for addressing an increasingly pressing issue in primary care. As a family medicine researchers in Spain, we wish to offer a perspective on how the innovations described by Lee and colleagues could be adapted to the Spanish National Health System’s primary care setting. Lee et al. demonstrated that routing patient portal messages to trained certified medical assistants (CMAs) led to a 40% reduction in messages reaching physicians and improved efficiency in their U.S. academic practice (1). Adopting a similar team-based approach in Spain is compelling, yet it requires careful consideration of contextual differences. In Spain’s public primary care system, there is no direct equivalent to the U.S. CMA role. Therefore, we explore alternative personnel (such as nurses, administrative staff, or even emerging artificial intelligence tools under supervision) to assume responsibility for managing patient digital messages. In this series of 8 letter contributions, we examine several key themes related to this adaptation: how the U.S. model might translate to Spain’s health system without CMAs (2); the growing burden of digital patient messages in primary care and the value of task-shifting (3); the potential role of supervised AI in triaging and responding to messages (4); barriers to implementing asynchronous communication in Spain’s predominantly real-time communication culture (5); the importance of protocols and standardized workflows to enable safe delegation (6); patient acceptance of team-based care in Spain and how to facilitate a positive experience (7); resource limitations and ethical issues surrounding automation or delegation of these tasks (8); and some lessons from other health systems that have implemented comparable models (9). Our aim is to provide a thoughtful and evidence-informed perspective of how Lee et al.’s innovation could be adapted to support primary care in Spain, acknowledging both the opportunities and the challenges involved.
Lee et al. describe an intervention in which certified medical assistants were trained to triage and manage patient portal messages, drawing on existing telephone triage guidelines. This approach take advantage of the availability of CMAs in U.S. primary care clinics, a role that does not exist in the Spanish primary care system. In Spain, primary care is delivered in community-based health centers by multidisciplinary teams composed mainly of family physicians (general practitioners), nurses specialized in family and community health, and support staff (such as clerical or administrative personnel) (10). Notably, Spain has no tradition of physician extenders equivalent to U.S. CMAs or physician assistants. Instead, nurses play a central role alongside physicians, and “nurse aides” or auxiliary nurses provide support in some centers, but their scope is more limited and generally does not include direct clinical communication with patients. Therefore, implementing a similar message-management innovation in Spain would mean reallocating tasks to existing professionals (most likely nurses for clinical questions and administrative staff for non-clinical inquiries) rather than to a distinct CMA role.
Adapting the U.S. model begins with recognizing the structural and training differences. Spanish primary care nurses are highly trained professionals, many with university degrees and specialization in community care (11). They routinely carry out chronic disease management (12), preventative activities (13), and even acute care triage within their clinics. In fact, multiprofile primary care teams in Spain rely heavily on nurses who often serve as first contact for same-day acute demands, resolving up to 70% of acute cases independently without direct physician intervention (11). This indicates that Spanish nurses possess the clinical expertise to handle a significant portion of patient requests. It would be a natural extension of their role to have nurses manage many patient portal messages, particularly those related to chronic condition follow-up, medication renewals, test results, or common minor complaints. Lee et al. themselves acknowledge that most published models for portal message management involve registered nurses, but that nursing shortages in the U.S. prompted their team to train CMAs as an alternate solution. In Spain, while we also face nursing workforce limitations, the absence of a mid-level provider like the CMA means our first option would likely be to enhance the role of existing nurses in handling portal communications.
For non-clinical messages (for example, appointment requests, administrative questions, or follow-ups on referrals) Spanish practices could lean on administrative staff (recepcionistas or administrativos) who already handle patient scheduling and coordination. These staff members might not give medical advice, but with proper training they could sort incoming messages, respond to simple logistical queries, and forward messages to the appropriate health professional. In the Penn Medicine innovation, patients were informed that a “team supporting the PCP” would review their message (1), emphasizing the team-based nature of care. Spanish primary care has long promoted a team ethos, officially since the primary care reforms of 1985 that established multi-professional health center teams (14). Thus, framing a portal message delegation system as a team-based care enhancement would be culturally consistent with our model of care.
However, successfully adapting the model requires structural adjustments. Spanish nurses already have high workloads managing in-person consultations, home visits, and telephonic queries. To avoid simply shifting burden from doctors to nurses, health centers might need to adjust schedules or staffing; for instance, allocating specific protected time for nurses to handle e-consultations, or hiring additional nursing staff if message volume grows. Another possibility is exploring new roles: Spain could consider creating a position akin to a “primary care assistant” or adding some temporal competences to empower residents (15) through additional training of either nursing aides or administrative workers in basic clinical triage. This would be analogous to the CMA concept, though no such role formally exists today. Any such change would demand policy support, including clarifying legal scopes of practice. Presently, the legal framework in Spain tightly regulates who can perform clinical tasks like advising patients or prescribing; nurses have some autonomy in chronic care protocols, but any expansion (for example, having nurses independently manage more clinical advice via portal) may require regulatory updates (11). Still, the strong foundation of multi-professional teamwork in Spain’s primary care provides a favorable environment to innovate. By clearly delineating which types of portal messages can be managed by nurses or administrative staff and which must be escalated to physicians, Spanish clinics could emulate the success of Lee et al.’s model. The key is careful adaptation: leveraging nurses’ clinical skills for appropriate messages, using administrative staff for workflow support, and maintaining physician oversight for complex or uncertain cases. In summary, while we lack “medical assistants”, Spain’s primary care could harness its existing human resources, with nurses at the forefront, to achieve a similar redistribution of digital workload, reinforcing a team-based approach to patient communication.
REFERENCES
1. Lee JN, Kurash L, Yang M, Teel J. Utilizing Medical Assistants to Manage Patient Portal Messages. Ann Fam Med. 2024 May 1;22(3):261–261.
2. Tenajas R, Miraut D. Sustainable Communication Workflows Through Smart Message Delegation in Public Healthcare. Ann Fam Med. 2025 May 23;22(3):eLetter.
3. Tenajas R, Miraut D. When the Screen Never Sleeps: Digital Fatigue in Primary Care. Ann Fam Med. 2025 May 24;22(3):eLetter.
4. Tenajas R, Miraut D. A New Kind of Assistant in our Inboxes: Can AI Join the Family Medicine Team? Ann Fam Med. 2025 May 25;22(3):eLetter.
5. Tenajas R, Miraut D. Fighting the Clock When Real-Time is the Norm: Asynchronous Care in a Synchronous System. Ann Fam Med. 2025 May 26;22(3):eLetter.
6. Tenajas R, Miraut D. Rules That Save Time and Lives: Building Safe Workflows for Shared Medical Messaging. Ann Fam Med. 2025 May 27;22(3):eLetter.
7. Tenajas R, Miraut D. From Individual Attention to Collective Care: Patient-Centered Messaging in Primary Care Settings. Ann Fam Med. 2025 May 28;22(3):eLetter.
8. Tenajas R, Miraut D. More Tasks and Fewer Hands While Preserving Trust: The Ethics of Digital Delegation in Primary Care. Ann Fam Med. 2025 May 29;22(3):eLetter.
9. Tenajas R, Miraut D. How Health Systems Around the World Show the Way for Smarter Team-Based Messaging. Ann Fam Med. 2025 May 30;22(3):eLetter.
10. World Health Organization. Multidisciplinary primary care teams in Spain provide person-centred care [Internet]. 2018 [cited 2025 May 23]. Available from: https://www.who.int/europe/news-room/photo-stories/item/multidisciplinar...
11. Hämel K, Toso BRG de O, Casanova A, Giovanella L. Advanced Practice Nursing in Primary Health Care in the Spanish National Health System. Ciênc Saúde Coletiva. 2019 Dec 20;25:303–14.
12. Tenajas R, Miraut D. Collaborative Practice Shapes Continuity in Chronic Disease Management. Ann Fam Med. 2025 Apr 13;23(2):eLetter.
13. Tenajas R, Miraut D. Obesity Control Through Household-Level Engagement in Primary Care. Ann Fam Med. 2025 Apr 12;23(2):eLetter.
14. Guillén AM, Cabiedes L. Towards a National Health Service in Spain: the Search for Equity and Efficiency. J Eur Soc Policy. 1997 Nov 1;7(4):319–36.
15. Tenajas R, Miraut D. Making Space for Residents to Lead and Learn in Family Medicine. Ann Fam Med. 2024 Apr 2;23(2):eLetter.