Using Technology to Improve Cancer Care, with Michael J. Fisch, MD, MPH, Melissa K. Accordino, MD, and Arlene E. Chung, MD, MHA, MMCi

November 28, 2016
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In this podcast, Dr. Michael Fisch, Dr. Melissa Accordino, and Dr. Arlene Chung discuss their article, “Using Technology to Improve Cancer Care: Social Media, Wearables, and Electronic Health Records,” and explain how doctors are using digital technology to communicate with their patients, and each other.

Transcript: 

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ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the world’s leading professional organization for doctors who care for people with cancer.

This podcast is part of a series featuring articles from the 2016 ASCO Educational Book. Published annually, the Educational Book is a collection of articles written by ASCO Annual Meeting speakers and oncology experts. Each volume highlights the most compelling research and developments across the multidisciplinary fields of oncology.

In this podcast, Dr. Michael Fisch, Dr. Melissa Accordino, and Dr. Arlene Chung discuss their article, “Using Technology to Improve Cancer Care: Social Media, Wearables, and Electronic Health Records,” and explain how doctors are using digital technology to communicate with their patients, and each other.

Dr. Fisch is the medical director of medical oncology for AIM Specialty Health. Dr. Accordino is an assistant professor of medicine in the Division of Hematology and Oncology at Columbia University Medical Center. Dr. Chung is an assistant professor of medicine and pediatrics at the Lineberger Comprehensive Cancer Center at the University of North Carolina at Chapel Hill. ASCO would like to thank Dr. Fisch, Dr. Accordino, and Dr. Chung for discussing this topic.

Dr. Fisch: Hello, my name is Dr. Michael Fisch from AIM Specialty Health in Chicago, Illinois. I'm joined today by Dr. Melissa Accordino from the Herbert Irving Comprehensive Cancer Center of Columbia University Medical Center, and Dr. Arlene Chung of the Lineberger Comprehensive Cancer Center from the University of North Carolina at Chapel Hill. We will be sharing some of the key points from our 2016 educational book article titled Using Technology to Improve Cancer Care: Social Media, Wearables, and Electronic Health Records. Doctors are using digital platforms more than ever to deliver cancer care. The web and smartphones allow large groups of people to engage with each other and share information. Health systems and individual health professionals are adapting to this revolution by developing ways to incorporate the benefits of technology with the ultimate goal of improving the quality of medical care. So Melissa, let me start with you. Can you tell us more about how doctors and specifically oncologists are using digital technology these days?

Dr. Accordino: Dr. Fisch, it's amazing how digital technology has allowed oncologists to communicate with patients in new and exciting ways. For one, we can use social media to talk to our patients and to other people who are interested in oncology, about science, about medicine, and about real life cancer care. Wearable activity trackers, like Fitbit or Apple Watch which you might have, have provided new and growing dimensions of health engagement and have added another layer of patient-generated health data to help foster better care in new and exciting areas of research. Lastly, electronic health records have become the new standard for oncology care delivery, and they bring new opportunities to measure quality in real time and to follow a practice pattern.

Dr. Fisch: Melissa, thank you. It's really encouraging how doctors and other healthcare providers are integrating this technology to produce more satisfaction and hopefully, measurably better outcomes for our patients. So Arlene, let's talk for a moment about the social media landscape in oncology. Can you tell us what kinds of health information doctors are sharing these days on social media?

Dr. Chung: There's multiple types of information that oncologists and doctors might share on social media. There's also a number of different ways we might use social media. For example, some may use it to crowd source for information that might be outside of their expertise or just to also search for the latest news and research. I'll admit that I think for many of us, we just don't have time to sift through all that information on our own. So using Twitter and other types of social media to really keep up-to-date and to follow the latest news within cancer care is a really nice way that social media sort of integrates within our professional lives. We're able to use that for interactions with our patients and also sort of spreading knowledge into the public arena as well. As we tweet these types of things out or as we use Facebook or other social media avenues, it's a really great opportunity for us to spread that information to others who may not be aware of that. And we'll start to see other platforms like Snapchat and potentially even being integrated into things like patient portals in the future.

Dr. Fisch: Arlene, great. It seems clear that social media is increasingly a way to interact and share information. And also from what you're telling us, it's pretty clear it's not something that's going to replace face-to-face visits between patients and their doctors, and certainly is not going to expose patients' private health information. It's good to know that the health professionals who are using social media have those professional reflexes intact.

Dr. Chung: I think as long as social media is used appropriately and professionally, none of our patients' information should ever be out there for anyone to see, and the health care system obviously has other ways to communicate privately and securely with our patients through patient portals and through secure text messaging. So we really would use those medium rather than using social media for those types of interactions.

Dr. Fisch: That makes sense. So that shifts us to the realm of electronic health records, or the so-called EHR. And that reflects, really, a new digital landscape that extends far beyond mere documentation as the EHR these days brings features that have been shown to improve quality and efficiency of care for patients. So Melissa, we're getting into a realm of great expertise for you. Can you talk to us a bit more about electronic health records and how oncology practices are using these systems to improve patient care?

Dr. Accordino: Of course, Mike. I think it's first important to define what an electronic health record or an EHR is capable of doing. It first and foremost has the ability to collect and to store patient data and can supply information on demand. It also permits providers to enter orders and can provide decisional support. Some EHRs also have the ability to provide secure electronic communication, sometimes called a patient portal, when it can be used to communicate with patients. It can provide administrative support and patient support, and also some have the capabilities for population health management reporting. EHRs have the potential to improve healthcare quality by improving adherence to evidence-based guidelines, the ability to reduce medical errors by improving data accuracy and data clarity, and also provide a potential for cost reduction. Some EHRs have the ability to share secured information with patients directly through the patient portal. And this might actually improve patient satisfaction through increased data-sharing with increased transparency with the providers.

Through the patient portal, we can help bridge the gap between patients and their doctors. And this allows improved communication between all members of the healthcare team, not just physicians. And this includes staff who can help answer questions, who can provide assistance and troubleshooting with symptom management. It can provide communication with social workers to help with prior authorization to help offset some of those high out-of-pocket costs that we discussed earlier. It's important to note that the EHR is not without limitation. They come with high operating costs, there's sometimes unreliability of the electronic healthcare system, they can disrupt the patient-physician encounter, and there's significant work flow limitations that we're starting to sort through.

Dr. Fisch: Thank you, Melissa. Another recent advancement in healthcare technology, above and beyond the EHR that you've been talking about, has to do with so-called wearables. Wearables are worn on or close to the body, and include a growing number of different types of items, such as wrist-worn sensors, that detect and measure physical activity and intensity. So Arlene, tell us more about wearables and how you see the use of these things evolving and how it might intersect in the world of cancer care.

Dr. Chung: Thanks, Mike. In addition to the wearables that you just described that can be worn on the body and other places throughout the skin, we're also starting to see some emerging sensors that can be ingested or swallowed and continuously monitor data as well. In terms of these wearables, they collect data such as biometric data, like heart rate and blood pressure, pulse oximetry, for example, and then also physical activity and intensity. I think what's on the market right now is pretty dominant in those specific areas. These are the types of data that were traditionally very difficult to capture continuously in the past because patients would have to have a huge device or a box, basically, delivered to their house. It wasn't very comfortable to use, and it was quite expensive to obtain that type of data. I think what's really promising now with these wearables is that we can actually get all this data for remote monitoring of our patients through these smaller wearable devices that are much more easy to use, as well as a lot cheaper to collect that data. We can imagine one of our cancer patients who's maybe going through treatment who might have this wearable device. We also have our patient reported outcome questionnaires pushed to them to the patient portal. The combination of these types of data are going to really help us paint a more holistic picture of how our patients are doing in real-time monitors longitudinally, and not just intermittently through our traditional office-based visits or hospital-based visits.

Many of our patients already have devices like Fitbits. One of the ways that we might use these in cancer care is specifically for tracking physical activity and intensity. We know that from research, physical activity is very important, both during treatment as well as in survivorship. That activity has been shown to not only improve a patient's ability to tolerate their cancer treatment, and therefore being able to complete the entire regimen, but also helps them improve their quality of life and symptoms so that they feel better throughout the cancer treatment process. I think we can also envision a future state where patient-generated health data from these devices and sensors worn on the body. And then also placed in the home environment - what we would sort of call a smart and connected home - could also provide a really rich picture of how the patient is doing and also the environment that the patient is in.

For example, a patient might have a sensor on a pill bottle that could detect that they've actually missed three days’ worth of their oral chemotherapeutic medication and that they have not been out of bed very much. Those are things that I would maybe never know as a clinician, but this could trigger then a cascade of a lot of different actions where the healthcare team could then call that patient, see what they're doing, what's happening at home. Are they having too much pain? Is that the reason they haven't been out of bed and couldn't actually get to the pill bottle? And there's a lot of different issues that could be discovered through that process. We can also start to see use cases where wearables could remotely monitor for cardiovascular complications, and our patients undergoing potentially cardiac toxic treatment regimens that include things like anthracycline, for example, and to be able to monitor those patients well into survivorship, which can be many, many years obviously. And we'd be able to detect those complications hopefully at an earlier time point before they have hospitalizations and hopefully improve outcomes.

 

Dr. Fisch: Thank you, Arlene. That's amazing stuff. As you were describing that, I couldn't help but recall the old commercial about the older patient who says, "I've fallen and I can't get up," and then there's a device being advertised. That's been around for awhile, but I was thinking that's sort of the original wearable for healthcare. But boy, it's come a long way with a lot of exciting possibilities. And as digital patient engagement advances and further matures, there's no doubt there will be more applications that will really help both providers and patients along the way. What do you see as some of the current challenges with wearables?

Dr. Accordino: I think it is important to note that this is still new technology and it's not entirely clear what types of data that are collected will be the most effective to improve symptoms, to improve the care experience, and short and long-term health outcomes. Current adoptions of wearables is low and is rarely sustained beyond several months. This is likely attributable to high cost, lack of integration with other devices, and the absence of integrative and dynamic feedback. There are also security and privacy concerns which could be a barrier to adoption. The overall tangible benefit is currently lagging behind the rapid growth of the device market. So it is expected that the adoption will ramp up as software platforms provide better personalization and insight, which can also better sustain patient engagement. There's currently a lack of accurate, validated, biometric data from the majority of wearables, which could also be a barrier to adoption within healthcare.

Dr. Fisch: Makes sense. So Arlene, back to you. Maybe you can play the role of futurist a little bit for us, and paint us a picture of how you think things might unfold in this wearables market as it matures and as technology continues to improve.

Dr. Chung: Sure, Mike. I think what is super exciting right now and over the past several years is that we've seen a lot of emerging devices, rapid growth in the adoption of at least in the fitness device market as well. And I think as the next few years progresses, we'll start to see a movement away from these traditional wrist-worn devices like the Fitbit and Apple Watch, and start to see a rise in smart garments, smart socks for example, smart shoes that have all the sensors embedded in them, so I don't have to have four or five different devices measuring different parameters. These sensors will be embedded into smaller and thinner, more flexible patches and stickers that I can just slap on underneath my clothes, for example, and no one would really know that I actually had one on. So we're starting to see that they'll be less and less intrusive, more and more like what we would normally see and wear. We're already starting to see a shift from these consumer devices, which in all honesty, they were not designed and developed to be specifically met for clinical care or to be used in the healthcare context. But we are starting to see them be used in more of these medical grade devices.

Melissa mentioned the question and concern about accurate and validated data. Particularly if we're going to use these for healthcare decisions, we will see more and more movement towards medical grade devices that have been tested and validated rigorously for accuracy and then also FDA-approved. We'll see more advances also in comfort, the size of these devices and sensors, better battery life. Potentially even self-charging devices where your own body heat or just moving around will charge it up and you don't have to actually plug it in to a charger. And we'll see better interoperability between devices and then also the movement of these data back and forth from of these devices to electronic health records and patient portals. As we start to see a more of an up-kick in the connected home arena and markets, we'll see more and more devices that you can place around the home environment, as well as smart appliances. You can start to picture how there could be a really huge connected ecosystem within your own home and also potentially at your workplace and other places that you might visit. These would be in places embedded in a way that you might not even know that all these things are collecting and generating data about you. That's going to generate large volumes of data that we've never really had before both in general, but also in the healthcare context. So lots of work needs to be done in this area to harness the potential for these patient-generated data.

As Melissa alluded to, we'll start to see more software services where we can start to use advanced computational methods like machine learning, artificial intelligence, much like how Amazon magically knows what book you might like based on previous purchases. So much of that I think we'll start to see more healthcare use cases around that being developed, and the next few years is definitely going to be a very exciting time. We're going to see a lot of movement and acceleration in this market, and it's just a really nice time to be in medicine and in informatics.

Dr. Fisch: Well, it's amazing. Thank you for describing that, and I certainly hope that some of these things that you're describing will connect not just to Amazon per se, but to the EHR, so that the healthcare teams are able to bring this information to life, as you have well described.

So other areas for future cancer care delivery research include improvement of content, dissemination and implementation of cancer survivorship care plans, EHR triggers aimed at improving adherence to medication in both patient and physician levels, and EHR education alerts to help providers adhere to best practice guidelines. So many opportunities exist to improve the quality of care among patients with cancer, especially in this important realm of improving treatment adherence and reducing healthcare disparities. So EHRs and other digital technologies are clearly valuable tools in this regard and are becoming part of our daily practice and part of the daily structure of our research. So thank you very much, and please view our article online. You can go to asco.org/edbook for a more in-depth discussion of this topic.

ASCO: Thank you Dr. Fisch, Dr. Accordino, and Dr. Chung. Please visit asco.org/edbook to read the full article. And for more expert interviews and stories from people living with cancer, visit the Cancer.Net Blog at www.cancer.net/blog.

Cancer.Net is supported by the Conquer Cancer Foundation, which is working to create a world free from the fear of cancer by funding breakthrough research, sharing knowledge with physicians and patients worldwide, and supporting initiatives to ensure that all people have access to high-quality cancer care. Thank you for listening to this Cancer.Net Podcast.

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