This project team was part of our COVID-19 pop-up theme, which tackled research related to the COVID-19 pandemic.

Symptom monitoring is integral to quality oncology care. The majority of cancer patients experience symptoms related to the disease itself or to the treatment toxins. Symptoms can worsen and lead to unnecessary complications and suffering, even death, if not detected early enough. Several previous studies have shown that up to 50% of cancer patient ‘symptoms go undetected by their care team.

Research shows that the collection and monitoring of patients’ symptoms using electronic Patient Reported Outcomes (ePROs) assessments can enhance care and lead to improved quality of life, prolonged survival and reduced resource utilization . The Duke Cancer Institute has successfully implemented ePRO assessments into routine in-person cancer care visits; however, given the rapid increase in telehealth visits due to COVID-19, it has resulted in new unmet patient needs. There is currently no method for collecting and utilizing ePRO symptom screening data in the context of telehealth visit workflows. Given that use of ePRO tools is now more important than ever, as clinicians aim to reduce the number of high-risk visits for cancer patients during the pandemic and beyond, it was our goal to develop a system that implements ePROs for telehealth visits. 

This Bass Connections team is led by Dr. Kris Herring of the Duke Cancer Institute and Dr. Thomas Leblanc of the Duke School of Medicine - Division of Hematology. The team consists of graduate members Dr. Timothy Tsai, seeking a Master of Management in Clinical Informatics, and Michael Tang, seeking a Masters in Interdisciplinary Data Science. In addition, the team includes undergraduate members Laura Benzing, Augusto (Trey) de Leon, Reanna Shah, Alexandra Lawrence, Joshua Nidus, and Alexander Hong.

Throughout this past year, we have made a great deal of progress towards our end goal. We first designed a flowchart outlining the steps that needed to be taken to implement the Edmonton Symptom Assessment Survey-Revised (ESASr) ,  into telehealth visits. We made sure to minimize the survey fatigue patients experience and optimize the platform for physicians by incorporating it into the existing workflow framework. After identifying the physicians who will participate in the test run, we submitted a ticket to the Duke Health IT department to refit the ESASr survey used in a previous project and implement it into the e-check in process. The trial-run workflow recently became active, and, during the summer, the participating physicians will start being interviewed to determine the success of this initiative and changes that need to be made.

While great progress has been made, the path has not always been easy. In the beginning stages of developing the workflow, survey fatigue proved to be the biggest obstacle. In addition to the proposed ESASr, patients were already required to complete the NCCN Distress Thermometer. The electronic check-in process had to be designed in a way that would not overburden the patient with forms, while still providing up to date information for the physician and following the general timeline of the process. Additionally, our team had to ensure that any electronic implementation continued to comply with HIPAA guidelines. As we worked through these challenges, our team was able to gain a better understanding of the current workflow within the Duke Cancer Institute (DCI). Our team incorporated the ESASr into the pre-existing e-check in process, required for telehealth visits to increase the completion rate and decrease patient burden. We also hope that by addressing these concerns early on, our workflow may be easily implemented in other clinics at the DCI and elsewhere in the future. 

Our team will continue this pilot into the summer and conduct qualitative interviews with physicians. We plan to interview physicians involved with the pilot program, analyze the results, and translate our findings into a manuscript. The current pilot of 5 physicians (soon to include a total of 7 physicians) from across Duke Cancer Institute may be expanded to include more departments and more physicians. We hope to apply the lessons we learn here to expand the use of ESASr in telehealth and in-person visits.

Implementing Electronic Symptom Screening for Telehealth Visits

Poster by Kris Herring, Thomas Leblanc, Timothy Tsai, Michael Tang, Laura Benzing, Augusto de Leon, Alexander Hong, Alexandra Lawrence, Joshua Nidus and Reanna Shah