Electronic Medical Record–Based Electronic Messaging Among Patients with Breast Cancer: A Systematic Review

Abstract

Background Electronic medical record (EMR) systems and electronic messages are an increasingly common conduit between physicians and patients. Clear benefits of this type of communication have been established, especially among cancer patients. Studies suggest that patient portals and electronic messaging platforms can help with care coordination between oncology providers and facilitate asynchronous patient-provider communication. Despite the many benefits, there is little research regarding EMR and secure messaging use, particularly among patients with breast cancer.

Objectives The objective of this systematic review was to examine the evidence supporting the use of EMR-based messaging systems in patients with breast cancer.

Methods A systematic literature search of Ovid MEDLINE, PubMed, Scopus, Web of Science CINAHL, and Cochrane Library was conducted. Studies were required to be published between 2005 and 2022 and report data on demographic information and electronic messaging between patients and providers. Studies were excluded if they reported insufficient data, did not include breast cancer patients, or were not published in English.

Results This study identified 10 articles that met inclusion criteria. The resulting studies investigated topics such as: patterns of messaging and medication adherence, cancer screening, messaging as a predictor of behavior or outcomes, and symptom management. The literature indicates that electronic messaging with providers was associated with clinical benefits for breast cancer patients and improved screening behaviors.

Conclusion This review uncovered multiple areas to focus future research on, including ideal volume of electronic messages sent and their relation to prescription adherence, studies focusing solely on the breast cancer population, racial disparities in electronic messaging, and provider perceptions of electronic messaging. It is vital that more work be done to understand barriers and gaps in EMR usage to ensure that all individuals can access this increasingly essential medical service while minimizing physician workload and burnout.

Keywords

breast cancer - electronic health records and systems - patient-provider communications - patient-reported outcomes - health care disparities

Background and Significance

The electronic medical record (EMR) is a digital medical chart that makes health information instantly available to patients, allows for care coordination, and facilitates physician-patient communication. EMR systems have been implemented by many health care systems throughout the United States over the past decade.[1] The widespread use of Web-based patient portals is partially due to the requirements of the 2009 Health Information Technology for Economic and Clinical Health Act, which created incentive programs and required meaningful use of patient portals by health care systems.[2] The most well-known and widespread electronic patient portal is Epic's MyChart (Verona, Wisconsin, United States).

Benefit of Patient Portals and Electronic Messaging

Patient portals are beneficial in a variety of ways; practically, they allow patients to view their health information, schedule appointments, refill medications, look up test results, and engage in secure communication with their providers.[3] Portals can also be used by physicians to improve patient understanding of diseases and treatment plans and increase sharing and confirmation of medical information.[4] [5] [6] [7] Portals engage individuals with chronic conditions by allowing them to track health information over time and access details about diseases and management techniques.[8] [9]

One of the most popular features of patient portals is secure electronic messaging between patients and providers.[10] There are many benefits to electronic messaging. Access to messaging via patient portal provides patients opportunities for communication outside of the exam room. It encourages better self-symptom management, as patients inquire about their own health management including questions regarding medication regimens and side effects.[11] This ability to have their voices heard, at any time, enables them to participate as an active member of their care[12] and increases patient autonomy and empowerment which can be ultimately beneficial to the patient's health.[13]

Electronic Messaging Among Cancer Patients

In 2022, a total of 1.9 million new cancer cases will be diagnosed in the United States.[14] Cancer treatment requires chemotherapy regimens, radiation, and surgeries, often demanding frequent visits to manage medications and their toxicities.[15] Studies suggest that patient portals and electronic messaging platforms can help with care coordination between oncology providers and facilitate asynchronous patient-provider communication.[5] [16] Electronic messaging has been associated with improved patient outcomes and quality of life, particularly in patients with cancer.[17]

The complex nature of cancer and cancer treatment can leave patients overwhelmed and confused[15]; patients often have many questions that cannot all be discussed in the time frame of a clinic visit.[18] If patients are given an outlet to express their feelings, function, symptoms, and quality of life, clinicians can capitalize on that data to better their care.[19] For example, one study among lung cancer patients demonstrated that electronic monitoring of patient-reported symptoms helped with detection of concerning symptoms and adverse effects.[20]

Additional advantages of electronic messaging among cancer patients include increased screening rates and even survival benefits in patients receiving chemotherapy.[21] [22]

Despite the many benefits, there continues to be a dearth of research regarding EMR and secure messaging usage, particularly in patients with breast cancer.[17] Breast cancer diagnoses continue to rise, and the disease is now the leading cause of cancer malignancy and cancer-related death in women worldwide.[23] Because of the large burden of breast cancer among women, it is especially important to understand the use of electronic messaging in this population. Breast cancer treatment is multifaceted and can include chemotherapy, hormonal therapy, radiation, and surgical procedures. Although EMR-based systems have been shown to enhance patient-provider communication, there is little known about patterns of electronic messaging among breast cancer patients, specifically. The objective of this systematic review was to examine the evidence supporting the use of EMR-based messaging systems in patients with breast cancer.

Methods

This systematic review was constructed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.[24] A systematic literature search of Ovid MEDLINE, PubMed, Scopus, Web of Science CINAHL, and Cochrane Library was conducted in conjunction with an institutional research librarian. The searches were performed on February 7, 2022, and the following search terms were used: Electronic Health Records; Health Records, Personal; Electronic Medical Record; Electronic Health Record; Computerized Medical Record; Access to information; Communication; Messaging; Health Services Accessibility; Patient Participation; Information Seeking Behavior; Neoplasms; Cancer; Malignancy; Tumor. The complete search strategies are available in [Supplementary Appendix 1] (available in the online version). A total of 612 articles were returned after removing duplicates. The titles and abstracts were then assessed based on inclusion and exclusion criteria.

We included original, peer-reviewed, randomized controlled, and observational (retrospective or prospective) studies. We reviewed studies that were published in English between 2005 and 2022. Articles from 2005 onwards were included as EMRs became much more widely utilized at that time and thereafter.[25] Studies were required to have reported data on demographic information and electronic messaging between patients and providers. Studies were excluded if they reported insufficient data, did not include breast cancer patients, or were not published in English. Abstracts were excluded as reported data may be preliminary and such studies may not contain adequate information. Review articles were also excluded as the focus was empiric, original studies.

Two blinded authors reviewed titles and abstracts of the 612 identified articles. After excluding 591 papers that did not fit the criteria, 21 were read in full and discussed by the authors. It was determined that a total of 10 studies met inclusion criteria for this systematic review ([Fig. 1]). If the two authors disagreed, a third author was available to make the final decision. From each article, the authors collected data on study design, sample size, and key findings. Articles were analyzed and their respected findings were separated into broad categories based on how they pertained to EMR electronic messaging. The included studies and their key findings can be seen in [Table 1].

Fig. 1 Literature search and selection process. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram detailing the systematic literature search of Ovid MEDLINE, PubMed, Scopus, Web of Science CINAHL, and Cochrane Library. The following search terms were used: Electronic Health Records; Health Records, Personal; Electronic Medical Record; Electronic Health Record; Computerized Medical Record; Access to information; Communication; Messaging; Health Services Accessibility; Patient Participation; Information Seeking Behavior; Neoplasms; Cancer; Malignancy; Tumor. A total of 612 articles were returned after removing duplicates. The titles and abstracts were then assessed based on inclusion and exclusion criteria by two blinded authors. Twenty-one full-text articles were assessed for eligibility. Ten studies were included in the final review.

Table 1 Studies of electronic messaging among patients with breast cancer and their key findings

Study (year)	Study design	Sample size	Key findings
Coquet et al[22] (2020)	Retrospective cohort study of patients with cancer designated as e-mail users or e-mail nonusers	n = 5,395 e-mail users n = 4,505 non-e-mail users	● Prior to propensity score matching, e-mail users were significantly more likely to be white, non-Hispanic, privately insured, and have a higher median household income ● The median 2-year survival was 78.29% (95% CI, 79.85–76.63%) for e-mail users and 75.22% (95% CI, 76.79–73.55%) for non-e-mail users (difference, 5 months; p < 0.01) ● E-mail users were significantly more likely to have more face-to-face visits, drug prescriptions and phone calls, and were less likely to miss appointments compared with nonusers (p < 0.01 for all of these) ● E-mail users had significantly fewer chemotherapy-related inpatient admissions for e-mail users (10.7% of e-mail users vs. 12.7% of nonusers, p = 0.015)
Crafoord et al[33] (2020)	Qualitative semistructured interviews + prospective cohort study of app-based intervention for symptom management	n = 74 (BC) n = 75 (PC)	● Median adherence to daily reporting in breast cancer group was 83% ● 93% (69/74) of patients in the breast cancer group used the free text function at least once ● The free text messages were about symptoms, requesting or declining contact, care-related information, and issues linked to the app or to reporting ● Higher age predicts lower total number of free text messages sent in breast cancer group
Dorfman et al[34] (2022)	Qualitative semistructured interviews + survey of patient and provider communication preferences	n = 21 cancer patients n = 11 oncology providers	● Majority of patients (61.9%) ranked MyChart as their preferred means for communicating with providers about symptoms ● Oncology providers unanimously ranked communication during a scheduled clinic visit (100%) as their preferred method of communication ● Patients ranked lack of time during clinic visits as the primary barrier to symptoms communication ● Patients and providers described MyChart as convenient and effective means of communication; however, physicians noted that the ease of use often lead to high message volumes
Gerber et al[26] (2014)	Retrospective cohort study of enrollment in and use of MyChart among patients seen at a National Cancer Institute designated cancer center	n = 6,495 (n = 1,310 BC)	● Most common portal actions were viewing test results (37%), viewing and responding to clinic messages (29%), and sending medical advice requests (6.5%) ● Increased portal use was significantly associated with younger age and white race
Kindratt et al[27] (2021)	Cross-sectional analysis of e-mail patient-provider communication and likelihood of cancer screening	n = 35,912 BC screening n = 48,512 CC screening n = 5,884 CRC screening	Women who used e-mail to communicate with their health care providers had greater odds (32%) of receiving breast and cervical cancer screenings than women who did not use e-mail
Totzkay et al[28] (2017)	Cross-sectional analysis of effects of patient-centered communication and the use of EHR on likelihood of patients receiving recommended screening	n = 700 BC risk n = 261 PC risk	● Patient-centered communication and EHR use predicted screening among patients eligible for breast cancer screening (mediated through patient activation)
Wolff et al[31] (2019)	Single-blind randomized control trial of a behavioral intervention consisting of a 3-step patient-family agenda setting checklist	n = 138 dyads (n = 69 intervention dyads; n = 69 control dyads)	● Patient-family agenda setting (intervention) was found to be easy, useful, and helpful to patient and care partner ● Intervention patients were more likely to have viewed clinical notes in MyChart at six weeks (50.7% vs. 9.5%) ● Intervention care partners were more likely to be registered for MyChart (75.4% vs. 1.6%; p < 0.001), have accessed the patient's information at 6 weeks (43.5% vs. 0%; p < 0.001), and to view clinical notes in the patient portal (30.4% vs. 0%; p < 0.001) ● No difference was detected in exchange of direct message in patient portal in intervention patients or care partners
Wolff et al[32] (2021)	Single-blind randomized control trial of a behavioral intervention consisting of a 3-step patient-family agenda setting checklist	n = 138 dyads (n = 69 intervention dyads; n = 69 control dyads)	● At 9 months, intervention care partners were more likely to be registered for the patient's MyChart account (77.8% vs. 1.8%; p < 0.001) ● Intervention care partners who were registered for the patient's MyChart account viewed patient messages (44.9%), test results (42.9%), and clinical visit notes (38.8%), but few (6.1%) engaged in messaging with clinicians using their own identity credentials ● Intervention patients and control patients had no significant differences in use of patient portal at 9 months ● Intervention patients whose care partners logged into MyChart were more likely to have complete illness understanding at 9 months (changed 70.0 to 80.0% vs. 69.7 to 54.5%; p = 0.03)
Yin et al[29] (2018)	Retrospective cohort study of the association between EMR messaging patterns and discontinuation of hormone therapy in breast cancer patients	n = 1,106	● Messaging rate over time (hazard ratio [HR] = 1.373, p = 0.002), mentions of side effects (HR = 1.214, p = 0.006), and surgery-related topics (HR = 1.170, p = 0.034) were associated with increased risk of early medication discontinuation ● Seeking professional suggestions (HR = 0.766, p = 0.002), expressing gratitude to health care providers (HR =0.872, p = 0.044), and mentions of drugs used to treat side effects (HR = 0.807, p = 0.013) were associated with decreased risk of medication discontinuation
Yin et al[30] (2020)	Retrospective cohort study of the association between EMR messaging patterns and initiation of hormone therapy in breast cancer patients	n = 336	● Most patients sent only a limited number of messages (71.7% of patients sent less than 10 messages) ● Patients primarily communicated about their symptoms, chemotherapy, surgery, laboratory tests, and prescriptions ● Patients who mentioned consulting-related words and chemotherapy were more likely to initiate hormonal therapy ● 90.1% of the cohort (those who used messaging) were Caucasian

Abbreviations: BC, breast cancer; CC, cervical cancer; CI, confidence interval; CRC, colorectal cancer; EHR, electronic health record; EMR, electronic medical record; PC, prostate cancer.

Results

After careful review, articles and their respective findings were separated into broad categories based on how they pertained to EMR electronic messaging, such as patterns of messaging and MyChart use, cancer screening patterns among EMR users, messaging as a predictor of health outcomes, patterns of hormone therapy adherence among messaging users, EMR-based communication after a behavioral intervention, electronic messaging for symptoms management, and communication preferences for symptom management.

Patterns of Messaging and MyChart Use

Gerber et al[26] published the first study of the prevalence and patterns of electronic portal use in a large oncology-specific population. The authors' objective was to determine predictors and patterns of Web-based portal use for accessing personal health records and communicating with health providers among patients with cancer. Prior to this study, EMR use had not been studied in a specialty clinic setting. Of note, breast cancer patients made up the largest proportion of patients in this study. Messaging accounted for 29.1% of all patient-initiated MyChart actions. Black patients were less likely to make medical advice requests via electronic messaging than white counterparts. Additionally, the authors found that 30% of all medical advice requests via messaging were sent during non-clinic hours.[26]

Cancer Screening Patterns among EMR Users

Messaging was also used to predict breast cancer screening behaviors. Kindratt et al[27] conducted a cross-sectional analysis of individuals eligible for breast cancer screening. Survey data from the National Health Interview Study was used to determine whether patients who used computers and messaging systems to communicate with health care providers were more likely to receive appropriate breast cancer screenings. Individuals who used email to communicate with providers had 32% greater odds (95% confidence interval [CI] = 1.20, 1.44) of receiving breast cancer screenings than individuals who did not use messaging systems.[27]

Similarly, Totzkay et al[28] conducted a cross-sectional analysis of the effects of patient-centered communication and the use of electronic health records on the likelihood of patients receiving recommended cancer screening using data from the 2013 Health Information National Trends Survey. These researchers found that 21% (N = 668) of individuals used e-mail or the Internet to communicate with a doctor or doctor's office. Additionally, 18.5% of individuals used e-mail to exchange medical information with a health care professional. Electronic portal use indirectly predicted the likelihood of breast cancer screening recommendation adherence in women (point estimate = 0.045, 95% CI [0.02, 0.09]).[28]

Messaging as a Predictor of Health Outcomes

Coquet et al[22] conducted a retrospective cohort study of 9,900 patients undergoing chemotherapy who were either users or nonusers of secure messaging. The median 2-year survival was 78.29% (95% CI, 79.85–76.63%) for e-mail users and 75.22% (95% CI, 76.79–73.55%) for nonmessaging users (difference, 5 months; p < 0.01). Users had significantly more face-to-face visits, drug prescriptions, and phone calls and were less likely to miss appointments compared with nonusers (p < 0.01 for all). E-mail users had significantly fewer chemotherapy-related inpatient admissions (10.7% of e-mail users vs. 12.7% of nonusers, p = 0.015). Prior to propensity score matching, e-mail users were significantly more likely to be white, non-Hispanic, privately insured, and have a higher median household income.[22]

Patterns of Hormone Therapy Adherence among EMR Users

Two studies by Yin et al[29] [30] used messaging patterns to predict behaviors around cancer treatment among patients with breast cancer. In the first publication, Yin et al[29] conducted a retrospective cohort study of the association between EMR messaging patterns and discontinuation of hormone therapy in breast cancer patients. Increased messaging rate over time (hazard ratio [HR] = 1.373, p = 0.002), mentions of side effects (HR = 1.214, p = 0.006), and surgery-related topics (HR = 1.170, p = 0.034) were associated with increased risk of early medication discontinuation. However, sending greater than 20 messages was associated with a lower probability of medication discontinuation. Seeking professional suggestions (HR = 0.766, p = 0.002), expressing gratitude to health care providers (HR = 0.872, p = 0.044), and mentions of drugs used to treat side effects (HR = 0.807, p = 0.013) were associated with decreased risk of medication discontinuation.[29] [30]

The second study by Yin et al[30] was a retrospective cohort study in which the content of electronic messages was used to predict initiation of hormonal therapy among breast cancer patients. The authors hypothesized that online patient portal messages by breast cancer patients convey both clinical and personal factors that can be used to predict whether that patient will decide to initiative hormone therapy. Ultimately, they wanted to use electronic messages to understand why some patients choose to undergo hormone therapy while others do not. The authors applied word clustering techniques to generate groups of semantically similar words for analysis purpose. They found that patients whose messages contained communication-related words such as, “meet, speak, talk” (HR = 1.405 p = 0.001) and chemotherapy-related words such as, “Avastin, inhibitors, Cytoxan” (HR = 1.238, p = 0.026) were more likely to initiate hormonal therapy. Patients whose messages contained symptom-related words such as, “watery, sweating, feverish” (HR = 0.596, p < 0.001) and words conveying negative emotion such as, “depression, anxiety, mood” (HR = 0.811, p = 0.033) were less likely to start hormonal therapy. Of interest, a similar disparity was noted, as in prior outlined studies, in that 90.1% of the cohort of patients who sent messages were Caucasian.[30]

EMR-Based Communication after Behavioral Intervention

Two studies focused on changes in messaging patterns among breast cancer patients after a behavioral intervention. The first study by Wolff et al[31] was a single-blind randomized control trial of a behavioral intervention to improve both patient and caretaker engagement and utilization of EMR. The intervention was a self-administered, “agenda setting checklist”[31] that patients filled out with their care partner while in the waiting room prior to a visit with their medical oncologist. Patients and their caretakers responded to three questions: “How can your family member or friend be most helpful today?,” “What do you want to discuss with your doctor today?,” and “How do you want to manage the patient's health information after today's visit?.” The questionnaire was brought into the exam room and discussed by the patient, caretaker, and oncologist. The authors then compared MyChart registrations, log ins, and direct messages between those who received this intervention and those in the control group who did not receive the intervention.[31]

No difference was detected between the breast cancer patients in the intervention and control group in MyChart registration, log ins, or exchange of direct message. However, intervention patients were more likely to have viewed clinical notes in MyChart at 6 weeks (50.7 vs. 9.5%). Intervention care partners were more likely to be registered for MyChart (75.4 vs. 1.6%; p < 0.001), have accessed the patient's information at 6 weeks (43.5 vs. 0%; p < 0.001), and to view clinical notes in the patient portal (30.4 vs. 0%; p < 0.001). However, no difference was detected in exchange of direct messages by patients or caretakers in the control and intervention groups.[31]

The second study, also conducted by Wolff et al,[32] provided data on long-term follow-up of the same breast cancer patients and caretakers detailed above. At 9 months, intervention (vs. control) care partners were more likely to be registered for the patient's MyChart account (77.8 vs. 1.8%; p < 0.001). Intervention care partners who were registered for the patient's MyChart account viewed patient messages (44.9%), test results (42.9%), and clinical visit notes (38.8%), but few (6.1%) engaged in messaging with clinicians using their own identity credentials. Intervention patients and control patients had no significant differences in use of patient portal at 9 months.[32]

Electronic Messaging for Symptom Management

One study looked at the efficacy of using electronic messaging for symptom management. This was a mixed-methods study of engagement in an application for symptom self-management during treatment in patients with breast cancer by Crafoord et al.[33] This study was conducted in Sweden using an app-based intervention for symptom management. Utilizing the app, breast cancer patients were able to report symptoms, view self-care advice, and send free messages to members of their care team. Ninety-five percent of patients in the breast cancer group used the free text function of the app at least once. The free text messages were mainly about symptoms, requesting or declining contact, care-related information, and issues linked to the app or to reporting. There was variability in how the function was used; some patients wrote short, condensed messages, while some wrote longer, richer descriptions. The authors found that higher age predicted a lower total number of free text messages sent.[33]

Communication Preferences for Symptom Management

The last category of studies focused on communications preferences of individuals with cancer. Dorfman et al[34] used surveys and semistructured interviews to understand communication preferences of both young adults (age: 18–39 years) with cancer, including breast cancer, and oncologists. Most patients (61.9%) ranked MyChart as their preferred means for communicating with providers about symptoms. On the other hand, oncology providers unanimously ranked communication about symptoms during a scheduled clinic visit (100%) as their preferred method of communication. Both patients and providers described MyChart messaging as convenient and effective means of communication; however, physicians noted that the ease of use often lead to high message volumes. Additionally, patients reported lack of time during clinic visits as the primary barrier to symptom communication.[34]

Discussion

We conducted this review to systematically examine how EMR-based messaging use in patients with breast cancer has been reported in the literature. Our review illustrates that messaging with providers is associated with clinical benefits for breast cancer patients[22] such as improved screening behaviors,[27] [28] medication adherence,[29] [30] and even survival benefits.[22] Additionally, interventions like preclinic visit check lists or symptom management apps allow for patient-provider interactions and can be used to improve patient and caretaker engagement.[31] [32]

It is important to consider trends in messaging rates and volumes as they relate to clinical benefits and physician workloads. Yin et al[29] uncovered a nonlinear relationship between number of messages sent and probability of hormone therapy discontinuation. Patients sending more than 3 but less than 20 messages had a higher probability of discontinuation. Patients sending more than 20 messages were much less likely to discontinue medication. However, patients sending messages at a high rate, many messages in a short period of time, were significantly more likely to discontinue cancer medications. It is possible that messaging rates increase when patients experience drug toxicities, making them more likely to discontinue therapy. Providers can use this knowledge to anticipate when patients are struggling with medication regimens. These findings align with previous research showing that electronic or text messaging can be used to manage symptoms and improve treatment compliance in patients with breast cancer.[35] [36] Additionally, having a good relationship with a cancer provider can improve medication adherence.[37] More research is needed to fully understand treatment adherence patterns as it relates to messaging use.[29]

In addition to medication adherence, messaging was related to improved breast cancer screening behaviors.[27] [28] Reasons for this may be that asynchronous health maintenance reminders can be sent on electronic messaging platforms. Previous research has shown that electronic reminders on patient health portals can increase utilization of preventative health services.[38] [39] One limitation to this reasoning is that individuals who utilize electronic messaging may be more engaged in their health care than those who do not, making it difficult to determine the true clinical benefit of messaging.[27] [40] For example, Coquet et al found that individuals in the messaging group also made more telephone calls and attended more face-to-face visits.[22] However, providers could capitalize on this knowledge by encouraging messaging use to increase patient engagement as a whole.

It is important to note that while higher messaging volumes may improve clinical measures like therapy adherence and cancer screening, providers often struggle to keep up with high inbox volumes in addition to providing clinical care.[41] Additionally, patients experience uncertainty regarding appropriate use of portal messaging systems.[42] We should seek to understand and inform patients of the best way to engage in care through electronic health messaging for maximum health benefit while minimizing physician workload and burnout.

As electronic messaging becomes a more established way to provide clinical care, it is important to explore the complexity of this topic from the perspective of the health care team. As Dorfman et al[34] uncovered, there is a disconnect between patient and provider communication preferences in some populations. Patients appreciate the ease of being able to send a message to their provider at any time.[34] [43] However, providers have been shown to have a more negative perception of current electronic communication platforms.[44] [45] The ease of accessibility creates issues with provider workload and time reimbursement as previous work has shown that 30% of messages from patients with cancer are sent outside of clinic hours.[26] Cancer providers have been shown to engage in electronic messaging even on days when they do not have clinical responsibilities.[41] Furthermore, providers have expressed concerns that frequent utilization of messaging services by patients leads to increased workloads.[46] [47] Specifically, there have been concerns regarding lack of reimbursement for time spent reading and responding to messages.[48] [49] Additional training for providers and patients may be required to address concerns of both parties.[43] Potential solutions for high inbox burden have been suggested including workflow redesign, team-based inbox management, and consideration of reimbursement for inbox-related work.[50]

Limitations exist in these studies. First, there may be some variation in what is considered patient-provider based messaging. Some studies looked directly at EMR messages[22] [29] [30] [31] [32] [33] while others used national surveys[27] [28] to assess patient use of electronic messages with care teams. The latter method introduces potential bias as patients may have different ideas on what is considered an electronic message. Additionally, this data may be confounded by recall bias. Other studies used apps developed in-house by the researchers themselves.[33] Because electronic messaging is not standard across the studies included in this analysis, comparison between studies may not be reliable.

Second, not all the studies focused on breast cancer patients alone. While breast cancer patients made a large proportion of people in the studies, only 4 of 10 studies included only breast cancer patients. It is important that future research focuses solely on individuals with breast cancer to better understand issues that face those patients specifically.

This review uncovered one substantial gap in the literature around electronic messaging by patients with breast cancer. None of the papers in this analysis focused on differences and potential disparities in electronic messaging among racial or ethnic groups despite clear evidence that differences exist. While 3 out of 10 papers discussed differences in patient use of messaging features, this was not the sole focus of their work. Gerber et al[26] found that black patients were less likely to send messages to their providers. Coquet et al[22] found that messaging users were significantly more likely to be white, non-Hispanic, privately insured, and have a higher median household income. However, these disparities disappeared with propensity score matching and were not discussed as a focus of the research. Finally, Yin et al[29] found that over 90% of individuals who sent messages were Caucasian. Again, no comment was made about the significance of this finding in the context of disparities.

Previous work has established that there are disparities in patient enrollment in electronic health portals. Men, members of racial and ethnic minority groups, individuals with lower education and household incomes, and those without Internet access were less likely to be offered access to online medical records.[51] Similar trends exist for EMR use as well.[52] Nonusers are significantly more likely to be male, black, have Hispanic ethnicity, have lower education attainment, and have lower income.[53] [54] [55] [56] However, our review of literature illustrates that reasons for these disparities have not been well-established in the setting of breast cancer.

Strategies have been proposed to enhance uptake and usage of electronic patient portals and messaging. Patient-focused strategies include in-office modules before or after appointments and multimodal training programs with information about MyChart messages including tips for proper message use.[57] Physician-focused strategies include exposing providers to patient-facing portals during training so that they can better guide patients to appropriate resources.[57] Additionally, institutions need to offer robust support to patients with lower computer and health literacy to complete enrollment and training to reduce health disparities.[55] Future work should focus on tailoring interventions to the breast cancer population.

Although outside of the scope of this review, emerging concerns and future directions related to research in electronic messaging should explore the impact of the 21st Century Cures Act which allows for the immediate release of test results to patient portals on breast cancer patient anxiety, liability associated with emergencies communicated through electronic messaging, and the impact of electronic messaging on trust in patient-provider relationships. These topics will be very important to understand as electronic messaging becomes a standard method of providing clinical care.

Conclusion

It is vital that more work be done to understand barriers and gaps in EMR usage to ensure that all individuals can access this increasingly essential medical service that has been associated with clinical benefits. Once we fully understand characteristics of users and nonusers of electronic messaging, interventions like the agenda setting checklist studied by Wolff et al or other multimodal training programs may be implemented to address disparities in a meaningful way.[32] Along with expanding access to electronic messaging, it is important to consider the impact on providers as expanded use of patient portals can lead to increased workload and burn out. It is essential that researchers focus on this complex issue to promote equitable health care delivery going forward.

Clinical Relevance Statement

As the use of electronic medical record-based messaging systems (e.g., Epic's MyChart) increases across the country, it is imperative that providers understand how, when, and for what purposes these systems are being utilized. These questions are especially relevant for individuals with chronic illnesses requiring multidisciplinary care, like patients with breast cancer. Thus, the findings of this article are directly related to clinical practice and the care of breast cancer patients.

Multiple-Choice Questions

1. When considering the studies included in this systematic review, which of the following statements is true regarding their findings?

   • Yin et al (2018) found that patients sending fewer than 20 messages were more likely to discontinue hormone therapy.

   • Gerber et al found that 30% of all medical advice requests via messaging were sent during nonclinic hours.

   • Coquet et al found that e-mail users were significantly more likely to be black, Hispanic, and publicly insured.

   • Wolff et al (2021) found a significant difference in MyChart use among patients in the intervention and control group after 9 months.

   Correct Answer: The correct answer is option b. Gerber et al found that 30% of all medical advice requests via messaging were sent during nonclinic hours. This finding may warrant further investigation into provider workload and perceptions around electronic messaging systems. Option a is incorrect. Yin et al 2018 found that those sending greater, not fewer, than 20 messages were more likely to discontinue hormone therapy. Option c is incorrect. Coquet et al found that e-mail users were significantly more likely to be white, non-Hispanic, and privately insured. Finally, option d is also incorrect. Wolff et al (2021) did not find a significant difference in patient portal use after implementation of a behavioral intervention after 9 months.

2. Which of the following statements is true regarding a need for future research around breast cancer patients and their usage of electronic medical record-based messaging systems?

   • More research is needed to understand best practices regarding how breast cancer patients should use EMR-based messaging systems (i.e., quality and quantity of messages) to achieve the best clinical outcomes.

   • More research is needed to understand why there are differences in usage of EMR-based messaging systems among different racial/ethnic groups.

   • Multiple stakeholders (i.e., physicians, patients, administrators) should be consulted to develop future research initiatives around most effective and clinically useful ways of managing cancer-related problems with EMR-based messaging systems.

   • All of the above.

   Correct Answer: The correct answer is option d. All three statements in a to c are true and supported by the findings of this systematic review. More research into how breast cancer patients, providers, and administrators use and benefit from EMR-based messaging systems is desperately needed. There are very few studies that look directly at this patient population, leaving a host of questions unanswered. As EMR becomes even more widespread and electronic messaging between provider and patient becomes the norm, is important that researchers look to fill these gaps in the literature.

Conflict of Interest

None declared.

Protection of Human and Animal Subjects

No human subjects were involved in this research.

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Publication History

Received: 09 October 2022

Accepted: 27 December 2022

Accepted Manuscript online:
29 December 2022

Article published online:
15 February 2023