Article

Digital Health Is Enabling Better Patient Reported Outcomes and Reshaping Cancer Care Delivery

Collaborative medicine is taking on an entirely new meaning as digital health technology, Internet of Things (IoT), and mobile apps impact cancer care. Physicians, cancer centers, patients, and many other segments of oncology care delivery inside and outside the hospital or doctor’s office are finding it necessary to restructure everything from their thinking and workflows to data silos and communication pathways.

Data aggregation eliminates big data silos

Applying big data algorithms across electronic health records, clinical practice guidelines, and clinical trials have been deemed essential for dissembling data silos and developing high-quality cancer care delivery.1 As a result, collaborations among oncologists and industry leaders on a technology platform, known as CancerLinQ, that monitors, aggregates, and evaluates real-time large-scale data are removing walls between isolated data.1 What is emerging in their place is a learning system with a greater capacity to address issues unique to cancer treatment.1

Collaborative communication restructures boundaries, workflows

One cancer center successfully removed conventional boundaries and reinvented traditional workflows and communication pathways by implementing clinical collaboration technology (a desktop and mobile app).2 Upon diagnosis, the cancer care coordinator, whose role was designed from the ground up for this new workflow, is notified to start a dedicated patient channel to which all appropriate physicians, specialists, and healthcare staff are assigned as members.2 Coordination of testing and appointments, as well as assigning a navigator, can now often begin before the patient has been told of their diagnosis.2

One specific example of this new workflow occurred after a patient’s Friday bronchoscopy assessment confirmed the presence of non-small cell carcinoma but not what type.2 In order to assign the case a record in the EHR more stains were needed.2 To avoid delay in updating physicians, a dedicated patient care communication channel was initiated the following day on Saturday that immediately notified the coordinator, nurse navigator for lung cancer patients, and pulmonologist.2 The oncologist who was asked to see this patient by the pulmonologist sent a message through the app and was immediately added to ensure receipt of time-sensitive updates.2 As a result, the patient was receiving care and being scheduled for staging studies without delays due to official report timing.2

While it has always been important for healthcare staff to be aware of the right metrics in order to know which actions and methods produce improvements, it can be difficult to track the effectiveness of communication collaboration technology.2 This is because tracking how often the right decision was made because all the essential data was available can be challenging since mistakes are rarely attributed to a lack of communication, or access to the right information.2

Patient-reported outcomes, wearables improve symptom management, communication

Integrating patient-reported outcomes (PROs) to inform treatment decisions is becoming an accepted method for improving symptoms, communication, and treatment efficacy.3 One mobile health pilot study seeking to incorporate PROs and activity data as a measure of health status evaluated 10 patients diagnosed with gynecologic cancers receiving palliative chemotherapy.3

Physical activity was evaluated by providing patients with a wearable accelerometer and PROs were collected using a research platform that classified responses by risk, provided customized symptom management recommendations, and flagged high-risk symptoms to clinicians and patients.3

Feasibility and acceptability were evaluated through enrollment and adherence.3 All 10 patients approached for the study consented to participate.3 Nine out of 10 (90 percent) adhered to the wearable accelerometers and seven out of 10 (70 percent) participated in smartphone surveys.3 During the study period, the mean daily step count increased from 3,973 during the first week to 4,136 in week three.3 Behavior patterns suggesting poor health for two patients (20 percent) were identified from the active monitoring of heart rates, daily steps, and PROs.3

Both clinicians and patients reported the actions taken as part of the mobile health program improved communication, symptom management, and physical activity.3 Further research as part of a larger, multisite, randomized clinical trial was recommended by the patients' oncologists.3

External patient data will support decision-making

Another way data will soon be aggregated to support treatment decision-making focuses on combining data generated from outside the hospital, clinic, or doctor's office where patients spend most of their lives.1 This includes health and/or medical wearable devices, sensor-generated data from smart home environments, and patient-reported outcomes - three types of data not currently incorporated into electronic health records.1

Cancer patients often have comorbidities and monitoring their physical activity via IoT sensors on a range of devices and objects, such as pillboxes, beds, and floors could notify their oncologist in real-time if they have not left their bed or opened their pillbox.1 Combining this information with vital sign surveillance from mobile devices using advanced algorithms will increasingly produce recommendations that help patients and oncologists make individualized decisions for self-care and treatment.1

Oncologists will be able to check on patients directly or through a caregiver to determine if any interventions could prevent complications due to missed medication doses or symptom decline before a situation becomes critical.1 Recommendations and reminders could also be further tailored by pulling data from social media, consumer purchases, and GPS.1

Remote monitoring of a patient’s home environment can help prevent hospital admissions and manage side effects by incorporating PRO questionnaires that help patients remain in familiar environments.1 Or know when an emergency intervention is needed.1

IoT-enabled radiology improves safety, workflow

IoT is expected to impact radiology by improving safety and managing patient flow.4 For example, continuous monitoring of radiation levels in scanning rooms remains a priority.4 Even though scanning devices are evolving to allow for reduced radiation doses and dosimeters are worn by radiology specialists, real-time radiation exposure cannot be tracked for patients or radiology specialists.4 To address this, a new IoT-enabled dosimeter for each specialist to wear during a scan is expected to address this safety issue.4 Smart dosimeters will be able to transfer each reading directly to an EHR for patient safety monitoring and to a mobile app for real-time dose tracking of radiology specialists.4

Radiology workflows are designed around the availability and downtimes of scanning devices, which can present difficulties when trying to balance busy versus slow days.4 Combining the advantages of IoT sensors, machine learning, and cloud technology provides radiologists with a big picture real-time status of all devices for better planning of preventive quick checks and fixes during optimal time slots.4

Digital health challenges to reshaping oncology care delivery

There are several challenges to widespread integration of IoT devices for improving the quality of cancer care.1 Security and privacy are primary concerns in the context of increasing numbers of IoT devices because the number of opportunities for cyber attacks also increases.1 Streaming sensitive health information from a device creates an ideal target for hackers while a medical device attacked in real time could result in extreme consequences.1

Data standards and interoperability also present significant challenges because it is essential for the various IoT devices and sensors to share and evaluate data with each other as well as with EHRs.1 Yet data accuracy from consumer devices like accelerometers and heart rate monitors are highly variable and subject to analysis by proprietary algorithms that are different from one to another.1 Increasing the use of IoT data requires standardizing the output across devices and performing validation studies with various cancer patient populations.1

Policy makers, healthcare systems, physicians, and patients have all expressed significant concern about data provenance and ownership.1 For example, a great debate has ensued regarding who owns patient-generated health data if the information is synced to the EHR or patient portal.1

Patients who own their health data can contribute it for research purposes to bolster citizen science initiatives that are helping better understand patient experiences that are not captured in clinical trials.1 This kind of large-scale patient-generated health IoT data could provide insights on the influence of contextual factors on health status.1

Integrating digital health data, including IoT and patient-generated, into the workflows of clinical practice is another challenge for several reasons related to a still-evolving evidence base.1 For example, knowing which types of cancer patients would benefit most, which types of data will accurately illustrate the quality of care that improves outcomes, and whether to collect data continuously versus intermittently are still unknown.1

Additionally, it is one thing for patients to report their willingness to provide information about vital signs and symptoms through mobile phones and tablets but little evidence exists when it comes to those patients being continuously monitored by more intrusive wearables.1 Not to mention the sea of Big Data physicians are already dealing with, only to add smart device streams on top of that.1

Finally, adding streams of IoT patient data without knowing frequency much less how to alert and notify physicians about abnormalities in ways that support decision-making and facilitate treatment amount to safety issues.1 For example, if a breast cancer patient was receiving treatment with a cardiotoxic medication and developed an arrhythmia but her heart rate monitor was not being monitored in real time, her physician would not receive an alert and serious consequences could result.1

When it comes to connecting medical equipment like scanning devices to the internet, the primary challenge is absence of standardized APIs to manage the internet of medical things and ensure secure communication that prevents exploitation of the backdoor by hackers.1 Medical scanners and dosimeters compromised by unauthorized access or that have come under the control of outside data thieves could cause substantial damage.4

The IoT healthcare ecosystem will expand over the next several years offering increased opportunities for oncologists to gain insights that improve the ability to tailor treatment  and enhance their understanding of how a cancer patient's microenvironment contributes to long-term outcomes.1

REFERENCES:

  1. Leveraging Emerging Technologies and the “Internet of Things” to Improve the Quality of Cancer Care. Journal of Oncology Practice http://ascopubs.org/doi/10.1200/JOP.2016.015784 Accessed 3/14/201
  2. Cancer center taps clinical collaboration tech to connect caregivers including competitors. HealthcareIT News https://www.healthcareitnews.com/news/cancer-center-taps-clinical-collaboration-tech-connect-caregivers-including-competitors Accessed 3/14/2019
  3. The HOPE Pilot Study: Harnessing Patient-Reported Outcomes and Biometric Data to Enhance Cancer Care. Journal of Clinical Oncolgy http://ascopubs.org/doi/full/10.1200/CCI.17.00149 Accessed 3/14/2019
  4. The Takeoff of the IoT in Radiology. Imaging Technology News https://www.itnonline.com/article/takeoff-iot-radiology Accessed 3/14/2019