Implementation of Electronic Patient-Reported Outcomes for Symptom Monitoring in a Large Multisite Community Oncology Practice: Dancing the Texas Two-Step Through a Pandemic

Abstract

PURPOSE Among patients receiving chemotherapy, symptom monitoring with electronic patient-reported outcomes (ePROs) is associated with improved clinical outcomes, satisfaction, and compliance with therapy. Standard approaches for ePRO implementation are not established, warranting evaluation in community cancer practices. We present implementation findings of ePRO symptom monitoring across a large multisite community oncology practice network. METHODS Patients initiating a new systemic therapy at one of the 210 practice sites at Texas Oncology were invited to use the Navigating Cancer ePRO platform, with stepped-wedge implementation from July to December 2020. Participating patients received a weekly prompt by text message or e-mail to self-report common symptoms and well-being. Severe self-reported symptoms triggered a real-time notification to nursing triage to address the symptom. Enrollment and compliance were systematically tracked weekly with evaluation of barriers and facilitators to adoption and sustainability. RESULTS Four thousand three hundred seventy-five patients planning systemic treatment were enrolled and participated. Seventy-three percent (1,841 of 2,522) of enrolled patients completed at least one ePRO assessment. Among these individuals, 64% (16,299 of 25,061) of available weekly ePRO assessments were completed. Over a 10-week period, compliance declined from 72% to 52%. Barriers currently being addressed include lack of a second reminder text or e-mail prompt, inconsistent discussion of reported ePROs by clinicians at visits, and COVID-related changes in workflow. Facilitators included ease of use and patient and staff engagement on the importance of PROs for symptom management. CONCLUSION ePROs can be effectively implemented in community oncology practice. Utilization of ePROs is high but diminishes over time without attention to barriers. Ongoing work to address barriers and optimize compliance are underway.

Real-World Adherence to Patient-Reported Outcome Monitoring as a Cancer Care Quality Metric

“…16 To promote widespread practice-level uptake of PRO monitoring, payers and policymakers are considering measuring adherence to PRO monitoring as a cancer care quality metric, which could benchmark performance under an oncology payment model and incentivize innovative, comprehensive PRO monitoring programs. Although high levels of adherence to PRO monitoring have been reported in clinical trials, 2,7,8,[17][18][19] real-world adherence under conditions of actual use is unknown and cannot be gleaned from even pragmatic trials. Therefore, our objective was to evaluate adherence to PRO monitoring and its potential predictors across sites collecting PROs routinely for patients with cancer.…”

Analysis of a Remote Monitoring Program for Symptoms Among Adults With Cancer Receiving Antineoplastic Therapy

“…A weekly assessment with a 7-day recall period may not allow for this continuous, just-in-time management that could improve clinical outcomes. 11 …”

“…Selecting dose or ePRO cadence is crucial because ePRO assessments can be a burden for patients to complete and clinicians to interpret and can impact the workflow and workforce necessary for proper monitoring. 9 , 11 , 12 ePRO cadences have varied from daily, 6 to weekly, 4 , 5 , 13 to a prespecified period postantineoplastic treatment, 14 , 15 to coordinated with clinic visits, 16 with no consensus around optimal timing. Patients and clinical stakeholders are interested in determining the optimal ePRO cadence in cancer care.…”

“…Recent studies evaluating large-scale ePRO implementation in community oncology practices have deployed with weekly cadences based on the National Cancer Institute PRO version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE). 11 , 12 , 17 The PRO-CTCAE uses a recall period of the last 7 days (eg, “In the last 7 days, how OFTEN did you have PAIN?”) based on the practical considerations that daily assessments would not be feasible in most cancer clinical trials and a longer recall period would lead to memory degradation and loss of symptom information. 17 In contrast, we launched a clinical program, InSight Care, that provided daily ePROs to patients initiating antineoplastic therapy who were at a high risk for toxic effects to allow real-time symptom monitoring.…”

Digital disparities: lessons learned from a patient reported outcomes program during the COVID-19 pandemic

“… 12–14 The majority of current programs assign PROMs through the patient portal in the week prior to a clinic visit; on the day of the visit, tablets with PROMS are distributed to any patient who failed to complete them online. 1 , 15–19 It is important to note, however, that historically the majority of patients have not chosen to use the portal to complete PROMs. As an example, prior to the COVID-19 pandemic only 17% of Mass General Brigham’s 10 million PROs were collected using our online patient portal.…”