Abstract
BackgroundPatient 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.MethodsWe 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.ResultsOf 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.ConclusionsWeb-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.
Highlights
Prior studies of advanced cancer patients suggest that patient-reported symptom monitoring is associated with prolonged survival [1], improved communication with physicians, nurses [2, 3] and other members of the healthcare team [4], and decreased utilization of unplanned healthcare
We conducted a randomized clinical trial for the introduction of electronic Patient reported outcomes (PROs) (ePRO) at an academic medical center to: (1) identify key features that could be applied in general clinical practice, and (2) assess impact on healthcare utilization
This report describes a subset of the clinical trial outcomes, including ePRO implementation, feasibility, and acceptability, and its effect on health care utilization. We defined patient feasibility a priori as greater than 70% completion of questionnaires, and defined patient acceptability as a neutral or higher satisfaction
Summary
We designed a clinical trial with an accrual goal of 144 subjects from the thoracic, genitourinary, and gastrointestinal disease groups at Stanford Cancer Center. This report describes a subset of the clinical trial outcomes, including ePRO implementation, feasibility, and acceptability, and its effect on health care utilization. We measured symptom responses and ambulatory healthcare (HC) utilization The latter was assessed by retrospective chart review of numbers of phone messages, electronic portal messages, and referrals to supportive care services (including social work, psycho-oncology, psychiatry) during the six-month trial period. Clinical workflow development The clinical care teams of each oncology disease group included physicians, advanced practice providers (nurse practitioners and physician assistants), and registered nurses These teams performed initial testing at Stanford Cancer Center (October 2016). Ambulatory healthcare utilization Ninety patients from both arms of the trial completed a 24-week follow up questionnaire These patients generated a median of 1–2 phone encounters, 5–6 electronic portal messages, and 0–1 supportive care referrals. The interquartile ranges were narrow, ranging from 0–1 for all three outcomes
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