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Using Digital Patient Engagement to Support the Management of Oral Anticancer Therapy

Melika Fini, PharmD
PGY-2 Hematology/Oncology Pharmacy Resident
Froedtert and the Medical College of Wisconsin
Milwaukee, WI

Erin McGurty, PharmD
Hematology/Oncology Clinical Pharmacist
Froedtert and the Medical College of Wisconsin
Milwaukee, WI

The Evolution of Patient Engagement
In the United States, approximately 40 million people suffer from one or more chronic health conditions. Chronic diseases play a major role in healthcare utilization in the United States and are responsible for 75% of total healthcare costs.1,2 The most common chronic conditions in the United States are heart disease, mental disorders, pulmonary conditions, and cancer.3 Prevalence of these diseases is projected to increase by an additional 16 million by 2020, accounting for 48% of the population.4 In oncology, significant advances in cancer treatment have led to prolonged treatment of certain types of cancer, with therapy length comparable to that in the management of patients with hypertension or diabetes. Current care delivery models are not optimized to manage major chronic diseases, primarily because of (1) demands on physicians’ time, (2) rapidly expanding medical databases, (3) a large and continuously increasing number of treatment options, and (4) lack of supporting infrastructure.

The Institute of Medicine (IOM) issued a statement in 2013 addressing ways to improve the quality of cancer care. One of the initiatives set forth was to make patients the center of their own care, which reinforces communication and shared decision making. The IOM expressed the need for a system that supports patients in making informed medical decisions according to their needs, values, and preferences in consultation with experts in the field.6 Several terms assist in defining this concept. Patient activation encompasses the knowledge, skills, ability, and willingness to manage one’s own health care.7 However, this definition does not address the effect of external influences on an individual’s behavior and decision making. Patient engagement is a broader notion that entangles patient activation with modalities aimed at enhancing activation and positive patient behavior. Patient- and family-centered care is an even broader term that conveys a vision for what health care should be: “a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care.”9 Patients engaging in their own care have a better understanding of their own health, which leads to fewer complications from treatment, better triaging of complications, and the potential for fewer hospital admissions.10

Financial motivation to enhance the current care model has been stimulated by ongoing changes in reimbursement models. As health care transitions from a fee-for-service to a pay-for-performance model, healthcare providers are recognizing that patient engagement is a crucial piece of delivering high-quality health care at a low cost.11 Additionally, the Centers for Medicare and Medicaid Services (CMS) has proposed the addition of new payment codes for patient engagement and remote patient monitoring (RPM). Some of the projected payment codes include virtual check-in appointments, asynchronous video and image review, and clinical staff allocation for providing virtual patient care.12

The evolution of patient engagement is not free of challenges. In 2017, the New England Journal of Medicine (NEJM) Catalyst Insights Council survey regarding patient engagement found that 63% of respondents reported that the time investment required by health teams is the biggest challenge in designing patient engagement into care delivery. Fifty-four percent of providers perceived adoption by patients as another big barrier, and 52% indicate adoption by providers as an obstacle in designing patient engagement into care delivery.13

Defining Digital Patient Engagement Platforms
Patient engagement is multifaceted; optimal results cannot be achieved with a single strategy. Incorporating digital technology into the patient-engagement process is an opportunity that is often underutilized. According to a recent patient-engagement survey published by the NEJM Catalyst Insights Council, 63% of responders used team members for patient engagement, 44% of responders used technology (e.g., remote devices), and 24% used patients’ social networks. The relatively low use of technology in this setting illustrates a remarkable opportunity for improvement, which can lead to enhancements in patient engagement and make patients the center of their own care.13,14

Automated digital patient engagement (DPE) platforms combine remote guidance and telemonitoring to notify the healthcare team about potential clinical concerns and may assist in bridging the postdischarge or postclinic visit gap. These include mobile applications (e.g., SONIFI Health, HealthLoop) as well as wearable devices (e.g., Proteus Digital Health, Fitbit, Garmin, Apple Watch) that are designed to increase opportunities for education and counseling.15-17 By detecting developing problems or complications through interaction with the patient, DPE has the potential to increase satisfaction with the healthcare process and avoid hospital admissions and other costly interventions.10 Employment of such technologies has been shown to improve patients’ engagement with their own care as well as improve patients’ satisfaction with the healthcare system.18

Adaptation of DPE platforms has increasingly been seen in community and academic medical centers over the past 5 years.19

DPE platforms can be used simply to provide educational materials, but they can also be used for patient-reported outcomes (PROs) for monitoring adverse events related to medications or procedures. The benefits of using DPE platforms with the sole intent of providing educational materials are demonstrated in a study by Steele and colleagues at MD Anderson Cancer Center, in which patient comprehension of diagnostic imaging information was assessed in 2,226 patients with cancer. Patients were randomized to receive information about diagnostic imaging via a Web-based interactive education platform (HealthLoop, Inc., Mountain View, CA), the same information in document format, or no specialized education (control group). The study concluded that patients using the DPE application had a significantly better understanding of diagnostic imaging information than those who were provided the same information in paper form.20 DPE platforms deliver information to patients in a sequential manner and in small increments, which reinforces the learning of information.

DPE platforms can further be used with the collection of PROs or adverse event monitoring with medications or procedures. In a study by Basch and colleagues, patients receiving outpatient chemotherapy for advanced solid tumors at Memorial Sloan Kettering Cancer Center were assigned to a PROs group or received usual care consisting of symptom monitoring at the discretion of clinicians. Self-reporting in this study was conducted via Web-based Symptom Tracking and Reporting (STAR). Patients who participated in PROs had better health-related quality of life (HRQoL), fewer emergency room admissions (34% vs. 41%; p = .02), and a trend toward fewer hospitalizations (45% vs. 49%; p = .08).21 Post-hoc analysis of overall survival in this study reported significantly improved median overall survival in patients who participated in PRO (31.2 vs. 26 months; p = .03).22 DPE platforms have also been used in pre- and postsurgical patients and have demonstrated that implementation of such tools leads to a significant reduction in avoidable, postsurgery complications (29.6% vs. 7%; p = .002) and a trend toward reduction in hospital admissions (7.4% vs. 1.6%; p = .12).10

Implementing a Digital Patient Engagement Platform
The first and most important step in the implementation of DPE is choosing an appropriate platform. Various DPE platforms offer diverse technologies for follow-up, including automated phone calls, texts, or application alerts. Some applications are automatic in nature; others are not. Some use the voice of the physician and generate check-in notifications over prespecified intervals, and others focus on PROs or HRQoL surveys. DPE platforms can perform a mix of these features, and finding a suitable platform depends on the patient population, physician preference, and current workflows within a practice setting.

A second fundamental step in implementing a DPE platform is to adequately pilot the platform prior to expanding it sitewide. Selecting a patient population to pilot a DPE platform allows for testing the platform and advancing the platform as needed prior to sitewide enrollment. An example patient population is chronic myeloid leukemia (CML). Development of tyrosine kinase inhibitors for treatment of CML has substantially improved the 5-year overall survival rate for this patient population and made it a chronic disease.23 Additionally, assessing HRQoL and side effects plays a considerable role in managing these patients. At our institution, clinical pharmacists play an integral role in the management of these anticancer agents and perform follow-up via telephone. With a growing number of patients, providing this service is becoming increasingly difficult because of time constraints and limited available resources. It is hypothesized that piloting a DPE platform for use with the CML population may lead to optimal patient care outcomes, cost avoidance as a result of preventing complications, and a decrease in phone call follow-ups made by clinical pharmacists and nursing staff.

On the basis of our institution’s experience, other vital steps that can potentially lead to a successful implementation would include (1) creation of a supportive multidisciplinary team of physicians, nurses, and pharmacists, (2) comprehensive education of the staff regarding every step of a DPE platform implementation, (3) use of a specialized DPE team to provide comprehensive education for staff members, and (4) creation of an achievable timeline.

Conclusion and Future Directions
The evolution of patient engagement is inevitable, and its integration into the current health system will be necessary in order to provide optimal patient care and receive payment in future reimbursement models. Nevertheless, the incorporation of patient engagement into care delivery faces several challenges. Consistently, the time investment required by health teams is the biggest challenge. Implementing DPE is one potential way to overcome this challenge. Choosing a DPE platform that best fits current workflows is important, and piloting the platform in certain chronic oncologic disease states may facilitate implementation in a large oncology facility. In the future, as pilot projects with DPE platforms are completed, comparisons between platforms may help to define the role of DPE platforms in current care models and assist in the evolution of patient engagement.


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