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Strategies for Implementing ePROs in Cancer Care

January 5, 2023
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Six has been a significant number in the professional life of Jeff Kendall, PsyD, LP—he has worked at six different cancer programs across six states, gaining a wealth of experience in cancer care delivery along the way. Now, Dr. Kendall calls Minnesota home. He has spent the last six years plying his trade at M Health Fairview—a partnership between the University of Minnesota, University of Minnesota Physicians, and Fairview Health Services. As the director of Oncology Supportive Services, Dr. Kendall has spearheaded the implementation of an electronic patient-reported outcomes (ePROs) program. Through a series of questions, M Health Fairview’s ePROs tool, scheduled to be launched in January 2023, will give healthcare providers an unprecedented insight on the symptoms patients may be experiencing, in addition to the efficacy of different anti-cancer treatment options.  

Developing Organizational Support for the Program  

Although Dr. Kendall was the strategic influence for implementing the program, the multifaceted nature of the endeavor required buy-in from various departments at M Health Fairview and acceptance from the highest levels of the organization’s leadership. “When you are getting all IT [information technology] people to build things for clinical people, they need to collaborate to discuss possibilities or limitations before they start building,” Dr. Kendall said. “Equally important was getting the president of the health system and vice presidents of digital experience on board because of the herculean nature of the project.” 

Buy-in from both the president and vice presidents was necessary for funding the development of the hardware and software needed to implement the program. Additionally, meetings were held to help clinical staff understand the program’s benefits. “These meetings helped the healthcare professionals understand that ePROs achieve simplicity for patients and simplicity and usability for staff,” Dr. Kendall said. “Those were the two primary goals of the build.”  

Technological Considerations and Design 

Once buy-in was established, Dr. Kendall and his team began developing the program by examining the infrastructure necessary to accomplish their goals. “PRO [patient-reported outcome] management has to be in your EHR [electronic health record]. For us, that’s Epic, as it is for 80 percent of the U.S. healthcare system,” Dr. Kendall said. “These [patient-reported data] must be in the EHR or it’s worthless. If it’s not in there and easy to access, it’s not going to succeed. For us, the PRO data that will come from patients is going to be held in the same area of Epic as their labs and distress screening results.”  

A decision was made to collect patient-reported data through the health system’s enterprise-wide app. At the launch of its ePROs program, patients with cancer enrolled in MyChart will be automatically registered. “Eighty percent of our oncology patients are enrolled in MyChart,” Dr. Kendall said. According to Dr. Kendall, the patient population at M Health Fairview has been polled, and the vast majority have a smartphone with reliable access to the internet. For the group of patients who have not yet accessed MyChart, they will still be treated with the same standard of care they are already receiving.  

M Health Fairview’s ePROs program will also use the Common Terminology Criteria for Adverse Events (CTCAE), published by the National Cancer Institute, as a basis for its questionnaire. “It is the gold standard in the U.S right now. We have a set of 84 questions, but we will never give patients all 84,” Dr. Kendall said. “We will only give patients the ones that are most relevant to their treatment.” When a patient reports their experience through the CTCAE questionnaire, their data is immediately sent to Epic. “This next piece, to me, is the cornerstone in what we’ve built here,” Dr. Kendall explained. “I have taken the 84 CTCAE questions and divided them into 3 groups.” These groups include: 

1. Symptoms for which there are generally no treatments (i.e., hair loss) and will be addressed in the clinical setting with an advanced practice provider (APP) or physician. This encompasses about 65 of the 84 questions.  

2.  Symptoms—there are seven of them—that if reported as mild or moderate are handled during a clinic appointment. But if a patient reports a symptom in this category as severe, a message is generated for the triage nurse reviewing the data. This nurse is charged with contacting the patient on the same day. Examples of these symptoms include vomiting, diarrhea, nausea, and constipation. 

3.  Binary symptoms like fever, difficulty breathing, and anaphylaxis/allergic reaction, where patients will answer yes or no. If yes, the app informs patients to contact M Health Fairview immediately.  

The decision was then made at M Health Fairview for triage nurses to handle any severe symptom-generated messages, rather than APPs or nurse care coordinators, due to scheduling challenges. “The benefit of these generated messages going to an APP is that they have more interventions available to them than triage nurses,” Dr. Kendall explained. “However, this would have required each APP to have 2 slots available per day to follow-up with these patients via same-day, virtual visits, which ended up not being feasible.” 

Implementation and Operationalization 

Patients, who receive surgery or chemotherapy, will be administered the program’s questionnaire seven days after their treatment or procedure. Patients receiving radiation treatment, on the other hand, will likely be given the questionnaire once every two weeks. In addition, patients will be sent the Functional Assessment of Cancer Therapy – General (FACT-G) questionnaire once a month because the CTCAE does not include quality-of-life-related questions.  

In Epic, patient responses to the CTCAE questions will be color coded, so the physician or APP going into the appointment with a patient need only quickly scan these data. “Green means everything is fine (e.g., ‘I labeled my nausea as zero’). Moderate symptoms are yellow, and severe symptoms are red,” Dr. Kendall explained. “Epic will show us the last three sets of the data, so we can see if a patient was nauseous after chemotherapy one, with yellow after chemotherapy two and green after chemotherapy three.” This will allow physicians and APPs to effectively track patient symptoms over time and will be a rich source of data to help identify commonalities among those receiving the same treatment to further aid in symptom management. 

In 2020, a successful pilot was launched to the delight of many patients. “The connections between our physicians and APPs improved dramatically with it,” Dr. Kendall said. “Patients loved it because they felt their needs were being closely monitored.” M Health Fairview plans to fully launch its ePROs program in January 2023, initially recording reports solely from patients with breast cancer. “We have the triage nurses on board, and three physicians who primarily see patients with breast cancer excited to do this,” Dr. Kendall said. “One good thing about Epic is that we can select only the patients who are seeing specific physicians for certain treatments to get these post-treatment questions and, thereby, roll this out incrementally to targeted patient groups over time.”  

Advice to Other Programs  

Dr. Kendall asserts that this ePROs program could be incredibly beneficial for cancer programs and practices around the country. “We are building it in a way that, potentially down the road, we can share it with other organizations,” he said.  “Cancer programs could benefit financially from doing the right thing clinically.” However, Dr. Kendall emphasizes the importance of buy-in from the entire organization prior to embarking on this journey.  

In addition, he recommends that cancer programs and practices follow change management guidelines prior to implementing an ePROs program. “You are changing multiple systems at the same time,” Dr. Kendall said. “The operationalization of this program was just as difficult, if not more difficult than building the software. So I recommend setting the expectation that the implementation may take just as long as the technological build.” 

ACCCBuzz will conduct a follow-up with Dr. Kendall once the program goes live later this month.  

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