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Digital Solutions Connect Resources to Patients at the Right Time


September 15, 2022
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Cancer programs and practices can leverage technology to mitigate the impact of social determinants of health (SDOH) and advance equity in cancer care delivery. And the National Cancer Institute’s (NCI) Small Business Innovation Research Program (SBIRP) set that challenge through its 2021 contract topic: Software to Address Social Determinants of Health in Oncology Practices. Referencing the American Cancer Society’s blueprint to address SDOH in patients with cancer, the NCI SBIRP solicited proposals for the development of oncology-specific software that would support evidence-based clinical actions and include referrals to address identified patient needs. The solution would be developed in collaboration with oncology programs and practices, integrate with existing clinical workflows and electronic health records (EHRs)—as an overarching goal—and make the collection and synthesis of SDOH data collection less burdensome.

Sound like a tall order? Three companies have stepped up to the challenge and work is underway. 

This summer, a webinar series co-hosted by Janeth Sanchez, PhD, MPH, program director in the Health Systems and Interventions Branch of the Healthcare Delivery Research Program at NCI, offered a look at works in progress from three recipients of the NCI SBIRP’s topic 423 funding: Pistevo Decision, Pieces, and XanthosHealth. The multiple factors—societal, economic, and environmental—that comprise SDOH are intertwined, complex, and dynamic. Software in development at each of these companies demonstrates the potential to bridge communication gaps among stakeholders and streamline patient access to needed resources. 

A Decision Support Platform

In June, Cupid Chan, chief executive officer and co-founder of Pistevo Decision, shared steps on the company’s development of an integrated multi-level decision support platform to address SDOH impacts on patients with cancer. With utmost concern for patient privacy, convenience, and comfort, Pistevo Decision is developing a platform that would include a patient-facing application (app) to empower them to answer SDOH screening questions “whenever and wherever they are most comfortable,” Chan said. 

In developing the platform, the company is engaging with stakeholders from the oncology community, including Johns Hopkins Medicine oncologists, patient advocates, community-based social services, and Johns Hopkins Bloomberg School of Public Health. The latter is for its expertise in SDOH screening and implementation, as well as its health services and disparities research measurements and metrics.

A key goal is to increase patients’ opportunities to proactively address unmet needs, Chan said. The vision is that with one click a patient could state a need and the relevant community-based organization would be alerted and connected with the patient. Partnering with community organizations and local social care networks is an essential for the tool to be effective, Chan said. 

Data collected in the app will integrate with EHRs. Healthcare providers can then access and update the information through a provider portal, closing the care coordination loop. Pistevo Decision’s platform is currently being piloted in three oncology programs among patients with head and neck, breast, or prostate cancers, Chan said. The big picture goal: to harmonize SDOH data with medical oncology data to provide a full picture of patients’ cancer experience. 

A SDOH Screening Platform

In July, a team from Pieces—a healthcare-focused artificial intelligence and technology company—presented on the company’s cloud-based multi-tenant environment, Pieces Connect, including the platform’s potential to accelerate care coordination among patients, community-based organizations, and providers to address SDOH issues. The company has partnered with NCI Community Oncology Research Program members to develop a workflow and tools to identify patients with SDOH needs. On a single platform, Pieces Connect brings together patient assessment and integration of SDOH positive screening data, closed-loop referrals, and access to pertinent community-based organizations.

Presenters emphasized the need for an “organizational mindset change” to succeed in addressing SDOH through screening and navigation. This includes educating staff about the importance of assessing patients’ challenges, such as food and housing insecurity, household expenses, and transportation. Buy-in from cancer program leadership, staff, and community organizations is essential. 

Through the Pieces Connect platform, patients can complete SDOH screening before their clinic visit or on-site using a tablet. The platform supports a 10-step closed-loop process:

  1. The patient completes SDOH screening by text or email via a survey.
  2. If the patient has not completed the screening, it can be done during their check-in process on-site.
  3. Cancer care team members are alerted to positive survey screens.
  4. Cancer care team members make referrals to community-based organizations.
  5. An electronic referral is transmitted to community-based organizations through a database/directory that is integrated with the platform.
  6. The community organization receives the patient’s referral.
  7. The patient visits the community-based organization, and their social needs are addressed.
  8. The cancer care team is notified through EHR integration.
  9. The patient receives a follow-up survey 30 days after their referral to a community organization.
  10. Data and reports are available to the referring team.

A Referral Assist and Tracking Platform

In August, XanthosHealth described its ConnectedNest platform as an innovative EHR-enabled mobile health technology designed to identify patients’ SDOH needs and “integrate SDOH data with an intelligent community referral system to match patient needs and connect them to social support services and community-based organizations.” Developed in collaboration with researchers from the University of Minnesota, the platform aims to “support convenient, secure, and user-friendly data collection” of patients’ social risk (e.g., housing, transportation, financial, social support, etc.) from their use of mobile technology. Helen M. Parsons, PhD, MPH, associate professor at the University of Minnesota, explained the company’s comprehensive research approach and stakeholder-informed platform development process.

Dr. Parsons’ highlighted research findings on the financial toxicity patients with cancer and their families often endure and increasing hardships in terms of food insecurity, housing, and transportation. To better understand specific community needs, the research team engaged a community advisory group, conducted focus groups, and held one-on-one key-informant interviews with social workers, oncologists, and community-based organizations. This work revealed communication gaps among these stakeholders. Healthcare providers reported a lack of resources to help patients with their needs, and community-based organizations didn’t feel well connected with healthcare providers to help identify those they directly serve. Additionally, patients didn’t feel connected to community resources and services. As one participant said, “There needs to be a nimble way to help refer and connect to this wide network of resources.” 

ConnectedNest is designed to be a nimble solution. The platform has three interfaces: patient-, provider-, and community organization- and/or resource-facing. In this model, community-based organizations can register, create a profile, and monitor and update their information in real-time. For example, if funding closes or re-opens, an organization can easily update its profile. The app also interfaces with EHRs, so providers can refer patients to specific resources. Through the patient-facing app, patients can see when they’ve received a referral and initiate a request for a specific resource or service. An asynchronous chat feature is planned to be added to help speed up the process, Dr. Haynes said. Connected Nest aims to seamlessly connect individuals with the most relevant support from community-based organizations.  

While demonstrating the ConnectedNest patient-facing app prototype, Dr. Hayes stressed that the technology had to be responsive to patients’ cancer care trajectory—needs will change over time. Connected Nest is designed to be dynamic and responsive to patients’ real-time needs. XanthosHealth conducted a usability test of its Connected Nest prototype among different 30 stakeholders, including patients, community-based organizations, and oncology team members, from January 2022 through May 2022. 

Learn more about this NCI SBIR initiative and watch the archived webinar online.



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