Understanding Patient Distress via EHR in Community Oncology
Kat M. Aguilar, MPH, discussed the findings of the recent study evaluating the early adoption of the distress thermometer.
Kat M. Aguilar, MPH
The distress thermometer is a validated tool for identifying psychological distress and health-related social concerns in patients with cancer. Integrating the distress thermometer into electronic health records (EHRs) has shown the potential to enhance providers' ability to address determinants of health within routine care, ultimately aiming to improve patient outcomes.
A study presented at the 2025 International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Meeting retrospectively evaluated the initial patterns of distress thermometer utilization within a large network of US community oncology clinics following its integration into the iKnowMed EHR in 2023.
The study analyzed data from over 235,000 adult patients with cancer treated between July 2023 and November 2024, categorizing them based on whether they received distress thermometer screening in the EHR. The findings revealed that while only 12% of eligible patients had documented distress thermometer screening within the EHR during this early adoption phase, a significant proportion of those screened exhibited elevated distress.
Specifically, approximately 1 in 4 patients reported clinically elevated initial distress (a score of 4 or greater). Among those who underwent multiple screenings, a promising trend of improved distress at follow-up was observed, particularly in patients who initially reported higher levels of distress.
In an interview with Targeted OncologyTM, Kat M. Aguilar, MPH, director of real-world research at Ontada, discussed these findings of the recent study evaluating the early adoption of the distress thermometer.
Targeted OncologyTM: Can you discuss the study regarding distress thermometer screening in the US community oncology setting?
Aguilar: This is a very compelling study that my colleagues and I did to examine EHR-based distress screening in the community oncology setting. I want to start with the challenges.
This study examined early adoption of EHR-based screening. It took place in the context of the US Oncology Network, which is a large network of community oncology practices. They treat about 12% of all patients with cancer in the US annually, and they follow NCCN guidelines and have been using the distress thermometer for many years. However, this early adoption study considered the period after the integration of the distress thermometer into the iKnowMed EHR in July 2023.
One of the most striking findings that we found was that 12% of patients during this period received EHR-based distress screening. This does not mean only 12% of patients were screened. In discussions with our colleagues at the Transformation Quality Division, we learned that likely many clinics were still using paper and pencil to capture the distress screening. We did not necessarily capture the full range of distress screening that was occurring, just those that [were] entered into the EHR. When we think about one of the biggest challenges, it is actually having the clinics implement the distress screening in this context.
The next is we do anticipate that there was some response hesitancy, which caused us to underestimate distress levels in the oncology setting. In particular, patients may have been reluctant to divulge distress if they perceived there was a stigma about it, or they were unsure how the information would be used. We would like to monitor this over time. There are interventions that are a way to reduce that response hesitancy and increase EHR-based distress screening. But even so, you know, even though our estimates of distress may have been underrepresented in this population, we still found a relatively high proportion of patients who exhibited elevated levels of distress, which reinforces the benefit of screening for these patients, as this information can be used to guide targeted interventions that address distress, both physical and nonphysical, including health-related social needs.
What were the main findings?
I talked about the relatively low proportion of patients that had distress screening during this period. We found that during this period, 1 out of every 4 patients approximately reported elevated distress as being a score of 4 or greater on the distress thermometer. We also found that 1 out of every 20 patients reported significant distress in the elevated range based on a score of 8 or greater on the distress thermometer, which reinforces the findings that there is a need to address distress in the community oncology setting.
There was a subset of patients who received EHR-based screening not once, but multiple times during this period. When we considered the change from their initial score to follow-up, we observed that of those with elevated distress, approximately 70% of them improved, which is a really promising and compelling finding. This is something obviously we would like to consider further and supplement the descriptive analyses we performed with additional analysis to examine co-founders and then the associations with interventions that were ongoing.
The results indicate that a significant proportion of patients reported elevated distress. How can community oncology practices use this data to inform their supportive care services and allocate resources effectively?
The distress thermometer contains 2 portions. One is an overall rating of patients' distress from zero to ten. The second component, though, allows patients to indicate specific concerns that they have across 5 different domains. So, there's physical, such as pain or fatigue, but there are also 4 other domains that address health-related social needs, for example, social relationships with family, emotional (anxiety, depression), and, very importantly, practical, which contains things like income, housing, transportation, and childcare. And so, if we think about the targeted interventions that can address those social needs, health-related social needs, using this information from the distress thermometer can be a very powerful tool.
How can the integration of this into electronic health records impact long-term patient outcomes and quality of life, specifically in community oncology settings?
In this preliminary study, we found that EHR-based distress screening did seem to be impactful in terms of, we were able to monitor that there was improved distress from initial response to follow up. This suggests that there may be interventions taking place at the clinic. Of course, this is a finding that we need to confirm and evaluate more holistically to understand the true association, controlling for any confounders that may have happened. Though, this is evidence that there is a benefit of distress screening in the community, and so we have used this information to guide targeted interventions.
