Integrating Patient-Reported Outcomes into Cancer Care

Charles Bankhead

November 2013, Vol 4, No 9 - ASCO Quality Care Symposium

San Diego, CA—The Patient-Reported Outcomes Measurement Information System (PROMIS) tool can inform clinical care delivery for patients with cancer, according to the initial results of a National Institutes of Health (NIH)-funded project.

The integration of the PROMIS tools into oncology clinical care has provided actionable information about cancer-related symptoms. The information is fed into patients’ electronic medical records (EMR) in real time to aid clinical care decision-making and delivery, reported Lynne I. Wagner, PhD, Associate Professor of Medical Social Sciences, Northwestern University, Chicago, IL, at the 2013 ASCO Quality Care Symposium.

“Clinical application of PROMIS computer adaptive tests has provided an assessment center platform for electronic patient-reported outcomes (ePRO) assessment,” said Dr Wagner.

“Integration with the patient’s electronic health record triggers ePRO assessment through a patient communication portal and populates the EMR with results of the assessment. When an assessment shows a patient has severe symptoms, clinicians receive notifications through their EMR in-basket. Integration also facilitates automatic triage for supportive oncology services,” she pointed out.

Patients with cancer often have a significant symptom burden that can interfere with treatment and adversely affect quality of life. However, clinical practices often face multiple barriers to obtaining meaningful symptom assessments, said Dr Wagner.

The NIH has supported the development of the PROMIS network to improve the assessment of patient-reported outcomes and their integration into clinical management. By means of an online communication portal, patients can report their symptom status, which is automatically captured by the EMR.
If a patient has a score in the “severe” range for fatigue, pain, or physical functioning, a message is generated automatically and sent to the patient’s oncologist and to the nursing messaging system. The portal can be accessed by a home computer or tablet computer.

Dr Wagner described the implementation of the PROMIS system in the gynecologic oncology outpatient clinic. Patients receive e-mail notices 72 hours before scheduled visits with their doctors, and are asked to complete the online symptom assessment. Patients provide information related to 5 domains—pain, fatigue, physical function, depression, and anxiety.

If scores for depression or anxiety are in the severe range, messages are sent to the oncologists, nursing pool, and psychosocial services. Social work needs, informational needs, and nutrition status are also assessed. If patients’ responses reflect potential problems in any of the areas, messages are sent to the appropriate services.

The system can also link patients to an online health resource library, which contains cancer-related information, symptom management, and psychosocial resources, among others. Moreover, members of specific services can respond to concerns or informational needs expressed by patients, using the interface between the EMR and the assessment center.

Dr Wagner presented findings for the first 558 patients who completed an initial assessment. Approximately 75% of the patients were white (mean age, 56 years). The majority of cancer types included ovarian (37.1%), uterine (28.7%), and cervical (6.9%) cancers.

The majority of the assessment (87%) was done from home, showing that:

  • 1 patient had severe anxiety
  • 1 had depression
  • 11 had severe fatigue
  • 11 had significant pain
  • 22 had significant problems related to physical functioning.

In addition, 43% of the initial assessments triggered social work triage, 23% health education center triage, 16% sought information about advance directives, and 9% requested information about financial resources.

Preliminary analysis of follow-up assessments showed that the proportion of patients with psychosocial concerns declined to 20.6% on the second assessment, 13% on the third, and 8.2% on the fourth.