Implementation of a cloud-based electronic patient-reported outcome (ePRO) platform in patients with advanced cancer

Abstract

Background Patient reported outcomes (PROs) have been associated with improved symptom management and quality of life in patients with cancer. However, the implementation of PROs in an academic clinical practice has not been thoroughly described. Here we report on the execution, feasibility and healthcare utilization outcomes of an electronic PRO (ePRO) application for cancer patients at an academic medical center. Methods We conducted a randomized trial comparing an experimental ePRO arm to standard of care in patients with advanced cancer in the thoracic, gastrointestinal, and genitourinary oncology groups at Stanford Cancer Center from March 2018 to November 2019. We describe the pre-implementation, implementation, and post-implementation phases of the ePRO arm, technological barriers, electronic health record (EHR) integration, clinician burden, and patient data privacy and security. Feasibility was pre-specified to be at least 70% completion of all questionnaires. Acceptability was based on patient and clinician feedback. Ambulatory healthcare utilization was assessed by reviewing numbers of phone messages, electronic portal messages, and referrals for supportive care. Results Of 617 ePRO questionnaires sent to 72 patients, 445 (72%) were completed. Most clinicians (87.5%) and patients (93%) felt neutral or positive about the ePRO tool’s ease of use. Exposure to ePRO did not cause a measurable change in ambulatory healthcare utilization, with a median of less than two phone messages and supportive care referrals, and 5–6 portal messages. Conclusions Web-based ePRO tools for patients with advanced cancer are feasible and acceptable without increasing clinical burden. Key lessons include the importance of pilot testing, engagement of stakeholders at all levels, and the need for customization by disease group. Future directions for this work include completion of EHR integration, expansion to other centers, and development of integrated workflows for routine clinical practice.

Perceived Barriers and Facilitators in Using Patient-Reported Outcome Systems for Cancer Care: Systematic Mapping Study

“…Of the total 17 papers, 8 introduced a study in which study participants had used only ePROs [21][22][23][24][25][26][27][28]. In the other 9 papers [29][30][31][32][33][34][35][36][37], only some of the participants had used ePROs, while others had used nondigital PROMs.…”

“…In the other 9 papers [29][30][31][32][33][34][35][36][37], only some of the participants had used ePROs, while others had used nondigital PROMs. The ePRO systems used were AmbuFlex [21,26], OncoQuest [22], Noona [23], the KLIK method [25], and PatientViewpoint [28]. No type of cancer was particularly emphasized, but PROMs were used in different target populations, such as patients with breast, lung, head and neck, prostate, melanoma cancer, and pediatric patients with cancer.…”

“…The most frequently used PROM was the Edmonton Symptom Assessment Scale (ESAS) [32][33][34]. Studies were carried out in multiple countries: the Netherlands [22,25,31], Germany [27,29], the United Kingdom [24], the United States [23,28,35,37], Denmark [21,26], Canada [32,34], Australia [33] Laitio et al JMIR CANCER…”

“…The theme was associated with barriers by 8 comments in 13 papers [21][22][23][25][26][27][28][29][30][31]34,35,37]. The lack of integration into EHRs or other hospital systems is highlighted as a barrier in 7 papers [21][22][23]26,28,29,37].…”

Digitally supported shared decision-making and treat-to-target in rheumatology: a qualitative study embedded in a multicenter randomized controlled trial

“…A major challenge, not limited to RA and rheumatology is poor ePRO adherence [4,[6][7][8]. Poor adherence can stem from a multitude of factors, including but not limited to lack of perceived benefit [9], age and high disease activity among patients [10] or lack of integration into clinical workflows and electronic health records among professionals [11,12]. In a recent review, Wiegel et al concluded that to optimize adherence to tele-monitoring with ePRO, mixed-method studies are needed [7].…”