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Doolin JW, Haakenstad EK, Neville BA, Lipsitz SR, Zhang S, Cleveland JLF, Hiruy S, Hassett MJ, Revette A, Schrag D, Basch E, McCleary NJ. Feasibility of Weekly Electronic Health Record-Embedded Patient-Reported Outcomes for Patients Starting Oral Cancer-Directed Therapy. JCO Clin Cancer Inform 2023; 7:e2300043. [PMID: 37788407 DOI: 10.1200/cci.23.00043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/30/2023] [Accepted: 06/21/2023] [Indexed: 10/05/2023] Open
Abstract
PURPOSE To examine the feasibility of integrating a symptom management platform into the electronic health record (EHR) using electronic patient-reported outcomes (ePROs) during oral cancer-directed therapy (OCDT) and explore the impact of prompting oncology nurse navigators (ONNs) to respond to severe symptomatic adverse events (SAEs). MATERIALS AND METHODS Adults prescribed OCDT at Dana-Farber Cancer Institute were consecutively invited to participate. Participants received weekly messages to complete ePROs. The first half enrolled in a passive (P) group where ePROs responses could be viewed anytime, but outreach was not expected. The second half enrolled in an active (A) group where severe SAEs prompted emails to ONNs for outreach within 1 business day. Feasibility was the proportion of participants completing ≥2 ePROs during the first 30 days. Participants were followed for up to 90 days. RESULTS From June 25, 2019, to August 18, 2021, 100 participants enrolled, and 96 remained enrolled for at least 30 days. Overall, average age was 59 years, 80% female, and 9% used the platform in Spanish. Twenty-two A (45%) and 27 P (57%) participants met the feasibility threshold (P = .26). ePROs returned at 30 days were similar (P = .50): 0 ePROs 17 A, 13 P; 1 ePRO 10 A, 7 P; 2 ePROs 3 A, 5 P; 3 ePROs 1 A, 4 P; 4 ePROs 7 A, 8 P; and 5 ePROs 11 A, 10 P. Documented telephone encounters at 30 days were similar (109 A, 101 P; P = .86). CONCLUSION EHR-embedded ePROs administered weekly for people on OCDT was feasible, although many went incomplete. ePRO completion was not clearly affected by nursing calls for severe SAEs. Future efforts will investigate improving engagement and addressing symptoms proactively.
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Affiliation(s)
- Jim W Doolin
- Department of Quality and Patient Safety, Dana-Farber Cancer Institute, Boston, MA
| | - Ellana K Haakenstad
- Department of Quality and Patient Safety, Dana-Farber Cancer Institute, Boston, MA
| | - Bridget A Neville
- Center for Surgery and Public Health, Brigham and Womens' Hospital, Boston, MA
| | - Stu R Lipsitz
- Center for Surgery and Public Health, Brigham and Womens' Hospital, Boston, MA
| | - Sunyi Zhang
- Department of Quality and Patient Safety, Dana-Farber Cancer Institute, Boston, MA
| | | | - Semegne Hiruy
- Department of Quality and Patient Safety, Dana-Farber Cancer Institute, Boston, MA
| | - Michael J Hassett
- Department of Quality and Patient Safety, Dana-Farber Cancer Institute, Boston, MA
| | - Anna Revette
- Department of Quality and Patient Safety, Dana-Farber Cancer Institute, Boston, MA
| | | | - Ethan Basch
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Nadine J McCleary
- Department of Medical Oncology, Gastrointestinal Oncology, Dana-Farber Cancer Institute, Boston, MA
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McCleary NJ, Haakenstad EK, Cleveland JLF, Manni M, Hassett MJ, Schrag D. Framework for integrating electronic patient-reported data in routine cancer care: an Oncology Intake Questionnaire. JAMIA Open 2022; 5:ooac064. [PMID: 35898610 PMCID: PMC9315161 DOI: 10.1093/jamiaopen/ooac064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/19/2022] [Accepted: 07/21/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objective
As part of ongoing implementation of electronic patient-reported outcome tools at the Dana-Farber Cancer Institute, here we describe the development of the electronic New Patient Intake Questionnaire.
Materials and Methods
The original New Patient Intake Questionnaire includes a review of symptoms, oncology history, family history, health behaviors, health and social status, health literacy and numeracy, which was modified for integration into the EHR using content determination, build and configuration, implementation, analytics, and interventions. The engagement of key stakeholders, including patients, clinical staff, and providers, throughout the development and deployment of the electronic Questionnaire was crucial to producing a successful tool. Continual modifications based on input of stakeholders (such as mode of tool deployment) were made to ensure the utility and usability of the tool for both patients and providers.
Results
Implementation of the EHR-integrated electronic New Patient Intake Questionnaire improved collection of the PRD by increasing questionnaire accessibility for patients, while also providing all available data to clinicians and researchers. Careful consideration of the content and configuration of the questionnaire allowed for a successful, institute-wide implementation of the tool.
Discussion
This effort demonstrates the feasibility of implementation of a system-wide electronic questionnaire, emphasizing the importance of iterative refinement to create a tool that is both patient-centric and usable for clinicians.
Conclusions
The electronic New Patient Intake Questionnaire allows for systematic collection of the PRD, which should benefit cancer care outcomes through innovative care delivery and healthcare interventions.
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Affiliation(s)
- Nadine J McCleary
- Medical Oncology, Dana-Farber Cancer Institute , Boston, Massachusetts, USA
| | | | | | - Michael Manni
- Information & Analytics, Dana-Farber Cancer Institute , Boston, Massachusetts, USA
| | - Michael J Hassett
- Medical Oncology, Dana-Farber Cancer Institute , Boston, Massachusetts, USA
| | - Deb Schrag
- Medical Oncology, Dana-Farber Cancer Institute , Boston, Massachusetts, USA
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Garcia Farina E, Rowell J, Revette A, Haakenstad EK, Cleveland JLF, Allende R, Hassett M, Schrag D, McCleary NJ. Barriers to Electronic Patient-Reported Outcome Measurement Among Patients with Cancer and Limited English Proficiency. JAMA Netw Open 2022; 5:e2223898. [PMID: 35867056 PMCID: PMC9308052 DOI: 10.1001/jamanetworkopen.2022.23898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Often electronic tools are built with English proficient (EP) patients in mind. Cancer patients with limited English proficiency (LEP) experience gaps in care and are at risk for excess toxic effects if they are unable to effectively communicate with their care team. OBJECTIVE To evaluate whether electronic patient-reported outcome tools (ePROs) built to improve health outcomes for EP patients might also be acceptable for LEP patients in the context of oral cancer-directed therapies (OCDT). DESIGN, SETTING, AND PARTICIPANTS This qualitative study was conducted at a single National Cancer Institute-designated comprehensive cancer center. In 2019, English-speaking and Spanish-speaking LEP patients with cancer receiving oral chemotherapies were recruited to participate in a qualitative focus group examining patient attitudes toward ePROs and electronic tools that are used to manage adherence and symptoms related to oral therapies. Six focus groups were held for EP patients and 1 for Spanish-speaking LEP patients. LEP was defined as patients who self-identified as needing an interpreter to navigate the health care system. Data analysis was performed April through June of 2019. EXPOSURES Enrolled patients participated in a focus group lasting approximately 90 minutes. MAIN OUTCOMES AND MEASURES The perspectives of patients with cancer treated with oral chemotherapies on integrating ePROs into their care management. RESULTS Among the 46 participants included in the study, 46 (100%) were White, 10 (22%) were Latinx Spanish-speaking, 43 (93%) were female, and 37 (80%) were aged at least 50 years or older. Among the 6 focus groups with 6 to 8 EP patients (ranging from 6 to 8 participants) and 1 focus group with 10 Spanish-speaking LEP patients, this qualitative study found that EP and LEP patients had different levels of acceptability of using technology and ePRO tools to manage their OCDT. EP patients felt generally positive toward OCDT and were not generally interested in using electronic tools to manage their care. LEP patients generally disliked OCDT and welcomed the use of technology for health management, particularly when addressing gaps in symptom management by their oncology clinicians. CONCLUSIONS AND RELEVANCE Although most electronic interventions target EP patients, these findings reveal the willingness of LEP patients to participate in technology-based interventions. Expanding ePROs to LEP patients may help to manage gaps in communication about treatment and potential adverse events because of the willingness of LEP patients to use ePRO tools to manage their health. This qualitative assessment is a strategic step in determining the resources needed to narrow the digital health gap and extend the value of PROs to the LEP oncology population.
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Affiliation(s)
| | | | - Anna Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | | | - Rachel Allende
- Social Work, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Michael Hassett
- Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Deborah Schrag
- Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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Keating NL, Cleveland JLF, Wright AA, Brooks GA, Meneades L, Riedel L, Zubizarreta JR, Landrum MB. Evaluation of Reliability and Correlations of Quality Measures in Cancer Care. JAMA Netw Open 2021; 4:e212474. [PMID: 33749769 PMCID: PMC7985722 DOI: 10.1001/jamanetworkopen.2021.2474] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Measurement of the quality of care is important for alternative payment models in oncology, yet the ability to distinguish high-quality from low-quality care across oncology practices remains uncertain. OBJECTIVE To assess the reliability of cancer care quality measures across oncology practices using registry and claims-based measures of process, utilization, end-of-life (EOL) care, and survival, and to assess the correlations of practice-level performance across measure and cancer types. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used the Surveillance, Epidemiology, and End Results (SEER) Program registry linked to Medicare administrative data to identify individuals with lung cancer, breast cancer, or colorectal cancer (CRC) that was newly diagnosed between January 1, 2011, and December 31, 2015, and who were treated in oncology practices with 20 or more patients. Data were analyzed from January 2018 to December 2020. MAIN OUTCOMES AND MEASURES Receipt of guideline-recommended treatment and surveillance, hospitalizations or emergency department visits during 6-month chemotherapy episodes, care intensity in the last month of life, and 12-month survival were measured. Summary measures for each domain in each cohort were calculated. Practice-level rates for each measure were estimated from hierarchical linear models with practice-level random effects; practice-level reliability (reproducibility) for each measure based on the between-measure variance, within-measure variance, and distribution of patients treated in each practice; and correlations of measures across measure and cancer types. RESULTS In this study of SEER registry data linked to Medicare administrative data from 49 715 patients with lung cancer treated in 502 oncology practices, 21 692 with CRC treated in 347 practices, and 52 901 with breast cancer treated in 492 practices, few practices had 20 or more patients who were eligible for most process measures during the 5-year study period. Patients were 65 years or older; approximately 50% of the patients with lung cancer and CRC and all of the patients with breast cancer were women. Most measures had limited variability across practices. Among process measures, 0 of 6 for lung cancer, 0 of 6 for CRC, and 3 of 11 for breast cancer had a practice-level reliability of 0.75 or higher for the median-sized practice. No utilization, EOL care, or survival measure had reliability across practices of 0.75 or higher. Correlations across measure types were low (r ≤ 0.20 for all) except for a correlation between the CRC process and 1-year survival summary measures (r = 0.35; P < .001). Summary process measures had limited or no correlation across lung cancer, breast cancer, and CRC (r ≤ 0.16 for all). CONCLUSIONS AND RELEVANCE This study found that quality measures were limited by the small numbers of Medicare patients with newly diagnosed cancer treated in oncology practices, even after pooling 5 years of data. Measures had low reliability and had limited to no correlation across measure and cancer types, suggesting the need for research to identify reliable quality measures for practice-level quality assessments.
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Affiliation(s)
- Nancy L. Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jessica L. F. Cleveland
- Department of Informatics and Analytics, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Alexi A. Wright
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gabriel A. Brooks
- Section of Medical Oncology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Laurie Meneades
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Lauren Riedel
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Jose R. Zubizarreta
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Statistics, Harvard Faculty of Arts and Sciences, Cambridge, Massachusetts
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Kadish SS, Mayer EL, Jackman DM, Pomerantz M, Brady L, Dimitriadis A, Cleveland JLF, Wagner AJ. Implementation to Optimization: A Tailored, Data-Driven Approach to Improve Provider Efficiency and Confidence in Use of the Electronic Medical Record. J Oncol Pract 2018; 14:e421-e428. [PMID: 29939808 DOI: 10.1200/jop.18.00093] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Nine months after the implementation of a new electronic medical record (EMR) system at a single institution, physicians (MDs), nurse practitioners (NPs), and physician assistants (PAs) expressed frustration with its use. We aimed to test if an individually tailored training approach reduced time spent with the EMR and increased confidence. MATERIALS AND METHODS Two hours of training were conducted in a one-on-one manner with a trainer. Content was individualized according to the following: provider survey, EMR utilization profile, and shadowing in clinic. Surveys assessed confidence before training and immediately after training. Changes in time spent in various EMR activities before training and after training were compared. RESULTS Three trainers delivered one-on-one training to 133 MDs, 42 NPs, and 10 PAs who specialized in medical oncology. Participants reported an increase in confidence across all activities, and almost all providers (98%) who responded to our survey agreed that the training enhanced their efficiency. A non-statistically significant trend toward reduction in the overall time in the system was observed. Time in system was reduced primarily in activities such as documentation and ordering of laboratory tests, imaging, medications, and chemotherapy. CONCLUSION A personalized and data-driven training approach was highly regarded by providers. EMR usage reports provided extensive data to identify and prioritize training content and were valuable to measure the impact of training on provider time in system. With the growth of EMR implementation and the reported relationship of EMR use to burnout, continuous and personalized training after EMR implementation is effective to reduce the time in system and increase confidence.
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Affiliation(s)
- Sarah S Kadish
- Dana-Farber Cancer Institute, and Partners Healthcare, Boston, MA
| | - Erica L Mayer
- Dana-Farber Cancer Institute, and Partners Healthcare, Boston, MA
| | - David M Jackman
- Dana-Farber Cancer Institute, and Partners Healthcare, Boston, MA
| | - Mark Pomerantz
- Dana-Farber Cancer Institute, and Partners Healthcare, Boston, MA
| | - Lauren Brady
- Dana-Farber Cancer Institute, and Partners Healthcare, Boston, MA
| | | | | | - Andrew J Wagner
- Dana-Farber Cancer Institute, and Partners Healthcare, Boston, MA
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