Digital health technologies have the potential to help transform patient care, but there are barriers that need to be overcome, said Deb Schrag, MD, MPH, George J. Bosl Chair, Department of Medicine, Memorial Sloan Kettering Cancer Center (MSKCC), and Professor, Medicine, Weill Cornell Medical College, New York City, during a keynote lecture at the European Society for Medical Oncology Congress 2022.
“Digital technologies have an overarching definition. This is an umbrella term that covers electronic health records, patient portals, various health apps, wearables and trackers, and telehealth,” she explained.
The pandemic led to an increased use of telehealth, and it became clear that this was not only feasible, but preferable and more efficient in some scenarios. Today, many clinical visits can be done remotely.
“We built these systems quickly in response to the pandemic. We don’t want to go back to the way we used to do things, and we need to define the appropriate uses of telehealth for cancer patients,” Dr Schrag said.
“The pandemic catalyzed the industry to develop digital diagnostics and predictive artificial intelligence, ranging from devices such as smart toilets that can detect a change in the microbiome signaling colorectal cancer to machines that can detect a mole that will become cancerous,” she continued.
“We now have a proliferation of digital health apps and wearables. It is open to question whether they will be really useful. For the most part, these devices are not approved and not covered by insurers,” she added.
Only 6% of all health apps focus on cancer, but it is only a matter of time before there is a greater incursion of digital technology in the field of oncology. Currently, most of these health apps and devices monitor mental health and diabetes.
Although patient monitoring using glucose monitors is reimbursable, to date, no monitoring devices for patients with cancer have been approved. One category of devices that may be useful is digital pill dispensers.
“These are likely to be approved and they will be helpful when integrated into smart phone apps,” Dr Schrag predicted.
Dr Schrag and her colleagues at MSKCC worked to develop patient-reported outcome (PRO) measurement systems, which have been utilized in clinical trials.
“We wanted to symptom monitor patients, instead of monitoring symptoms in a reactive manner,” she explained. “We don’t get information on all the symptoms, and it leads to missed opportunities.”
They envisioned a system that would allow patients with cancer to report their own symptoms during treatment. The idea was that when patients rated a symptom as severe, this would generate a prompt to call the healthcare team. This led to the launch of a clinical trial that included 300 patients with cancer who agreed to monitor their symptoms during treatment. Results showed that patients randomized to the PRO system had improved quality of life (QOL) and even a small improvement in survival.
The PRO-Common Terminology Criteria for Adverse Events (CTCAE) was developed as a standardized method of reporting symptoms, and it is now used globally to report adverse events in the context of clinical trials. This was customized for patients in 3 domains—severity, frequency, and interference with daily activities.
The next step was to integrate the PRO-CTCAE into clinical trials. The PROSPECT study revealed that clinicians and patients reported similar symptoms, but severity was much greater according to patients versus clinicians. The PRO-TECT trial was conducted in a large group of patients with cancer in Texas. Patients were able to choose which type of device they wanted to use to track their symptoms. More than 20,000 surveys were completed, with results indicating a high level of adherence.
“Symptom control and QOL were significantly improved when patients were randomized to system tracking, but unfortunately nurses found this burdensome,” Dr Schrag explained.
Currently, PRO systems are not integrated into electronic health records, which remains a major barrier. At MSKCC, Dr Schrag and colleagues collaborated with EPIC to build an electronic PRO platform that can be integrated into electronic health records in large and small oncology practices. The product, known as eSyM (electronic symptom management), includes features that make it easy to use, such as asking patients basic questions about their symptoms during chemotherapy or postoperatively using emojis.
“eSyM is now an integrated component of the secure patient portal. The patient answers questionnaires several times per week and it takes less than 2 minutes each time. If there is a patient report of a severe symptom, the system prompts the patient to call their healthcare team for help,” she explained.
“There is a path forward to digital health technology and how it can transform clinical trials. The current ecosystem is too burdensome, too expensive, and too cumbersome,” Dr Schrag asserted.
In the short-term, digital tools should be used to provide better access to prognostic information for patients. Telehealth will enable more centers to participate in clinical trials and will make these trials more efficient, more equitable, and less expensive.
“Better digital capture of salient study end points will result in fewer patients lost to follow-up and will be less expensive. We need to make sure that everyone benefits, not just the advantaged and prevent digital redlining. If we don’t address these barriers, we will widen disparities,” Dr Schrag concluded.
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