Integrating Remote Symptom Management With ePROs in Cancer Care

Both cancer and its treatments are highly symptomatic, making it difficult at times for clinicians to closely monitor every symptom a patient experiences outside the office walls. But advances in technology are making It easier to use patient-reported outcomes (PROs) as a tool for remote symptom management (RSM). A presentation at the Association of Community Cancer Centers 47th Annual Meeting & Cancer Center Business Summit titled, “The Role of Remote Cancer Symptom Management in an Evolving Reimbursement Landscape,” gave virtual attendees an overview of the latest research on PROs and how RSM can be incorporated into an oncology practice.

The discussion began with a presentation from Ethan Basch, MD, MSc, director of the Cancer Outcomes Research Program at University of North Carolina (UNC) Lineberger Comprehensive Cancer Center, chief of the Division of Oncology and physician in chief at NC Cancer Hospital, and professor of health policy and management at the UNC Gillings School of Global Public Health. The panel also included Nadia Still, DNP, RN, senior director of client services at Carevive Systems, Inc; Madelyn Trupkin Herzfeld, cofounder and vice chair of Carevive; and Bruno Lempernesse, chief executive officer of Carevive.

“A mainstay of quality cancer care is symptom management. It’s core to what we do because cancer is so symptomatic, and our treatments are highly symptomatic as well,” Basch said. “And early in my career, I began to observe that, unfortunately, we often miss symptoms that patients may be experiencing that emerge later on. We realized that really, they were presenting themselves much earlier—but they evaded our notice.”

This realization led him and his research group to conduct early studies on whether utilizing PROs and clinician reporting simultaneously would reveal gaps in reported symptoms. They found significant differences between the incidence of symptoms reported by patients vs clinicians, with symptoms underreported by clinicians compared with PROs. “This is a missed opportunity to catch symptoms early to intervene and to improve the patient experience and potentially avoid downstream complications,” Basch said.

Basch highlighted electronic PRO (ePRO) systems as one way to implement patient reporting and symptom management. Patients self-report symptoms with the system, whether through a web interface, smartphone, or an automated telephone questionnaire. He noted that a traditional telephone system is most accessible to patients, especially in community practices and rural areas. The system can automatically reply with information on how to self-manage the symptoms while conveying the information to providers and electronic health records.

Providing multiple interface options for patients and preset reminders for them to input their surveys are 2 key best practices to help ensure adherence on the patient’s end, Basch said.

One randomized controlled trial from Basch’s research group found that compared to standard care, patients utilizing ePRO were 7% less likely to visit the emergency department.1Median survival was also 5.2 months longer among patients in the self-reporting arm of the study. “In this study and in other studies, patients have been able to stay on chemotherapylonger when using this kind of ePRO intervention,” Basch added. Better quality of life and functionality were also seen in those patients.

Basch noted that patients have generally reported satisfaction with ePRO systems and so have nurses. He cautioned that these systems do increase up-front work for nurses but will save work down the line if fewer patients have hospital visits. Therefore, workflow accommodation should be planned, and clinics must be prepared before beginning to utilize ePRO systems.

Introducing patients to ePRO systems can be quick, Still explained during her presentation. In the case of Carevive PROmpt, for example, a physician could introduce the concept to patients before a patient navigator explains the system to the patient in more depth. By the next week, patients should be comfortable completing weekly surveys from home.

Based on survey answers, the system responds with a self-management plan that includes evidence-based methods to manage their symptoms. Regarding provider notifications, practitioners can set the threshold to avoid being bogged down with alerts.

Herzfeld discussed reimbursement, high-lighting reimbursement codes that were createdspecifically to address the boom in telehealth during the pandemic. Some examples she provided were codes for e-visits, which are set up by providers to address situations for which a clinic visit is not necessary; codes for virtual check-ins initiated by the patient; the Principal Care Management code, which is for compre-hensive care management for a single, high-risk disease lasting more than 3 months; and reimbursement for remote monitoring with an FDA-approved device such as a fitness tracker.

RSM may be included as a required enhanced patient service in the upcoming Oncology Care First Model, which is expected to begin in July 2022, Herzfeld pointed out. For physicians who plan on participating, it would be a good idea to become accustomed to utilizing ePROs beforehand, she said.

Finally, Lempernesse touched on the importance of patient experience data, which include disease symptoms, impact on quality of life, experience with treatments, input on the outcomes most important to patients, and the relative importance of any given issue to each patient. Use of ePROs provides a full picture of the patient experience, he said.

“So if we look at the implications for the future of cancer care with these data, what do we see? Well, today [there are] already several applications and benefits to using this kind of data in cancer care,” Lempernesse said. “These data empower patients as an active stakeholder, with more engagement in their treatment and disease. From the clinician standpoint, the use of data and patient-reported outcomes improves patient-provider communication, informs treatment and symptom pathways, increases vigilance and real-time actions with alerts, and finally, supports personalized care.”

_{1. Basch E, Deal AM, Dueck AC, at al. Overall survival results of a tri-al assessing patient-reported outcomes for symptom monitoring during routine cancer treatment. JAMA. 2017;318(2):197-198. doi:10.1001/jama.2017.7156}