Benefits and Challenges of ePRO Implementation in Oncology

Patient-reported outcomes (PROs) have grown in importance in recent years, giving physicians insight into the symptoms and concerns patients have outside of their visits to the clinic. During a session at the National Comprehensive Cancer Network (NCCN) annual virtual conference, the payer perspective and physician experiences with PRO systems in both the community and academic settings took center stage.

Discussants were Emma Hoo, director of Value-Based Purchasing at the Purchaser Business Group on Health (PBGH); Debra A. Patt, MD, PhD, MBA, MPH, executive vice president of public policy and strategic initiatives at Texas Oncology; and Fernanda C. G. Polubriaginof, MD, PhD, director of Consumer Health Informatics and Consumer Digital Product Management at Memorial Sloan Kettering Cancer Center (MSKCC).

The Payer Perspective

Hoo took the reins to touch on PROs from the payer perspective. First, she highlighted the disparity that exists between traditional outcome metrics and new options that can help physicians and payers in their goal to deliver more patient-centered care.

“We have been trapped in a world of retrospective claims, denials, analysis for much of our quality measurement, relying on many of the same HEDIS [Healthcare Effectiveness Data and Information Set] measures for many years. In some cases, those results have topped off without really being able to advance toward more patient-centered types of measurement that look at how we coordinate care, what patient expectations are, and how they view their own outcomes.”

PBGH has been investing to work directly with providers and adopt initiatives to forward patient-centered care, and to address barriers to implementing it. One of those initiatives is to advance patient-centric measures.

“At the end of the day, our view is that patient-reported outcomes, when integrated into patient care, really engage patients more in how they care for themselves, how they express their goals for treatment, and ultimately improve their satisfaction with the care experience because the expectations and outcomes are more in alignment with their understanding of their treatment, or other innovative interventions that may be undertaken,” she said.

It is no small undertaking to integrate PRO systems into practice, but many practices were pushed by the pandemic in 2020. Filling out surveys digitally before visits, whether in person or virtual, has become the “new normal” in many cases. PBGH hopes for broader implementation of PRO systems both in routine care and contracting expectations over time, she said, and has convened a national steering committee to provide guidance. Priorities include both educating stakeholders and integrating PROs in contracts that some member employers have used with directly contracted accountable care organizations and their plans.

A grant from the Center for Medicare and Medicaid Services (CMS) has allowed PBGH to engage community and academic sites in validating measures and assessing potential barriers to PRO implementation. In the oncology patient population, some key design considerations are areas where there were current gaps in quality measurement:

• to identify ways in which we can create actionable information for providers to adapt treatment
• to help patients and understanding what the course of treatment would entail in terms of symptoms and actions that they could take to also better manage their daily activities
• to better anticipate when complications might surface, or symptoms might affect their ability to do their daily activities

Now in the third year since the grant from CMS, PBGH has learned that patients place high value on the patient-centered approach to measures and that repeat questions such as smoking status were not as burdensome as anticipated. Data are being captured with an independent digital application as well as REDCap, a secure web application.

Ultimately, the goal is to focus on collecting information more efficiently and working to provide feedback to member providers in real-time to allow them to optimize the integration of PROs in practice.

PROs in Community Oncology

Perspective from the community practice side came from Patt, who comes from a large private practice setting at Texas Oncology, which has about 220 sites across the state and treats roughly half of Texans with cancer. She also emphasized the difficulties with implementation that arise with new PRO tools.

Doing a better job of symptom management for patients outside the clinic has been a priority at Texas Oncology, because chronically controlling a patient’s cancer does not necessarily translate to helping them live quality lives. Reducing hospitalizations and emergency department visits is also a main goal in the push for more comprehensive patient monitoring outside of clinic visits.

“We want patients to sit at the dinner table with their spouses, we want them to pick up their kids from soccer. And in order to do that, we need to be better at improving symptom management,” Patt said. “We have many strategies that we've implemented over the last two years to try to decrease prolonged callback times during business hours, and initiate proactive symptom management to improve outcomes.”

Texas Oncology partnered with Navigating Cancer to implement interventions over the past 2 years. The goal is to make proactive care, not reactive care, the norm in cancer treatment. One way they work toward this goal is a centralized, standardized triage pathway that has patients report symptoms to an operator, who then manually adds the incident to Navigating Cancer’s triage work board. Then, a triage nurse provides symptom management to resolve the incident, and home care instructions are sent remotely.

With this system, incident resolution time has improved by 33%. More than 60% of incidents are resolved in less than an hour, and 8% of those interventions were associated with emergency department avoidance based on nurse assessment.

In the move from reactive to proactive care, electronic PROs (ePROs) have been key. Patients report ongoing symptoms and treatment adherence weekly, the care team proactively sends medication reminders and assessments digitally, and nurses intervene to resolve incidents. But the biggest undertaking is ensuring your practice is ready to fully implement the system, she said.

“In pre-implementation, you have to have a kickoff meeting, you have to educate people and communicate what your goals are, what your plan is, identify pilot sites,” Patt said. “If you can pilot it in a few sites, or 1 site first, you can learn what's working in terms of workflow, what's not working, what other information people need to be successful, and you need to have clinical champions, people that at the site will be able to answer questions and heighten awareness that this issue.”

Implementation and upkeep post implementation—including weekly calls with clinic staff and ongoing improvements.

In a study of real-world use, Texas Oncology targeted patients initiating systemic therapy. The process included patient screening, introduction to the Health Tracker ePRO, enrollment, initiation, observation, and intervention by the triage board workflow. There was a 65% ePRO compliance rate in the 4375 patients enrolled, and there was a reduction in emergency department visits, hospitalization, and improvement of time on therapy.

Overall, factors that can make or break ePRO implementation are clinician buy-in, a limited target population to start with, patient outreach and follow-ups, and ongoing feedback from patients. Surveys also found that patients valued the tools more than providers.

Incorporating PROs in the Institutional Setting

Polubriaginof shared the experience at MSKCC when a home-grown ePRO tool, MSK Engage, was implemented to collect patient-reported data for both research and clinical purposes.

With MSK Engage, clinicians can collect data from new and active patients either remotely or on-site, an electronic questionnaire assists in the collection of patient-generated health data (PGHD), and ePROs can be used for intake and quality of life monitoring, symptoms, patient satisfaction, and research.

One key aspect of the program is its ability to securely capture data from patients just once and make it available across multiple applications and care teams. With uniform question formats across tools, patients also avoid repeat questions that appear in multiple questionnaires. Instead, data can auto populate and needs only be reviewed as patients go through questions.

Making the technology available in multiple languages has been one way to make it more accessible to a wider population, she said.

“We've shown that overall, there is really a change in patient outcomes. In addition to that, we've been seeing that we can proactively monitor patients more and more. We're trying to reach our patients where they are, and we can, based on patient-reported outcome tools, provide guidance and early intervention and improve patient satisfaction and their engagement with their care,” Polubriaginof said.

Advanced reporting and analytics inform MSK staff of how the tools are utilized over time, and questionnaires are tweaked over time to avoid patient fatigue. With 98 instruments available in the program, patients can be targeted with questionnaires specific to their disease and receive timed notifications post treatment. Clinicians can also pull the data that was shared from patients through clinical documentation directly into their clinical notes.

With MSK Engage’s Recovery Tracker, she noted that urgent care visits have been reduced by 22% just through simple symptom monitoring. The tool has also facilitated remote clinical trials on the research front. There are 18 research questionnaires currently live, and 20 clinical trials have been supported by the program in the 5 years MSK Engage has been in use.

Overall, Polubriaginof said, “We have seen that if we establish a tool that is easy to use, and we will provide patients with the appropriate modifications, we can really engage them.”