How Remote Monitoring Reduces Cancer ED Visits and Improves Retention

Patient monitoring remains a critical challenge in cancer clinics to ensure successful treatments and toxicity management. In an interview with Targeted Oncology, Lauren Hughes, BSN, RN, director of infusion services at Highlands Oncology Group, discusses the successful plan implemented at her group to address this gap in care.

Highlands Oncology launched a remote therapeutic monitoring model in June 2020, utilizing a system developed by Canopy Care. This system, which started as a simple ticketing mechanism to categorize and route patient issues, evolved into a comprehensive platform for symptom management and was recognized with an Innovator Award at the Association of Cancer Care Centers (ACCC) 42nd National Oncology Conference. This approach allows for the early detection of toxicities and has resulted in impressive outcomes, including a 22% reduction in emergency department (ED) visits and up to a 45% increase in patients remaining on treatment at the 3-month mark.

Hughes provides invaluable insights into the benefits of this system, its implementation process, and key considerations for other practices looking to integrate remote therapeutic monitoring.

Targeted Oncology: Could you discuss some of the challenges regarding patient monitoring in cancer clinics?

Lauren Hughes, BSN, RN: When patients come in and are seen with their provider in clinic, that is the time where they you would call them their healthiest, if you will, because they are sharing what they've been going through, their current signs and symptoms, their ongoing signs and symptoms, their emotional state, etc, and the provider is able to give them real-time feedback. But then the patient goes home. Life goes on. They don't have another appointment with their physician until a month [later], and they start having different symptoms, and maybe they don't want to bother their provider, or they don't want to call and wait on a callback, or they don't think this is important enough, so they don't call in. Then, you have moments where they get bad enough that they are then in the [ED], and then the [ED] maybe starts them on a treatment or stops a treatment that they're on. By the time they get back to their medical oncologist, their care plan has been disrupted. Then, it can be as simple as giving a little shot to get the patient back on track, or it can be as egregious as having to pause and cancel the entire regimen.

Another big one is, does the patient have a reliable person in their life that can be there for them, for physical and emotional support? If we could have patients in front of us, 24 hours a day, always having a doctor in their pocket to let them know what's going on, patients would be at their healthiest all the time because they know exactly what to do. But that's just not the case. That's not the real world.

What is the model that Highlands Oncology has incorporated?

The model that Highlands launched in [about] June 2020 is remote therapeutic monitoring with a company called Canopy [Care]. It started simplistically where it was essentially a ticketing system. Instead of patients calling us or sending an email where maybe those get answered or maybe they went to the wrong person, this ticketing system categorizes issues as symptoms, billing issues, prior authorization, etc. The system then routes it to that department. The department takes turns picking the tickets and can track if a ticket gets resolved. Whoever's on the back end can see any tickets, who they're assigned to, how long they've been there, etc.

That alone was a huge game changer. There [have been] many times [as a nurse], I would have a billing question and have to take the time to find one of the 50 people in billing who I’m supposed to send it to. Now I can send the question to billing and know whoever is available is going to pick it up and resolve it without it getting lost in the fray.

What it then started turning into is a lot more symptom management. We do have nonclinical personnel that sit at our switchboard, and there are clinical pathways that are in this system. So if a patient calls in with stomach pain, our nonclinical switchboard operators can type “stomach pain” into the ticket, and it pulls up a pathway with more questions to ask, including pain level, other symptoms, etc. Then the ticket is submitted to our triage nurses, who have a better idea of what might be going on and have a lot more options on the ticket and more pathways. Then the triage nurse can call the patient, add more notes to the ticket, or change the pathway completely.

It's a cool mechanism to guide newer triage nurses that are not used to telephonic assessments as far as what to ask and what to be looking for, so that they can then pass on a full report to the provider team. For our more tenured triage nurses, the pathways are still helpful, but they've pretty much got it memorized. But there are new pathways being added every day. The bispecific antibody pathway was added recently, and the questions you ask for bispecifics are vastly different than what you might ask for a patient who is on a nonbispecific regimen.

What is also great about Canopy is patients can either actively submit a question or concern through the app themselves, or the provider or nurse can program it to where it will ping the patient every X number of days. Typically, if the patient is starting a brand new regimen, we'll set it up to ping them once a week, asking about symptoms, how they’re feeling, and if they want a callback from a provider. That's more of a passive interaction from the patient. But patients really love it, too, because they don't always want the callback, and they can look at their personal trends over time.

Are there any considerations that you would recommend to clinics or providers when trying to integrate a system like this into their practices?

There are several things that practices will need to consider, and things that, frankly, have stopped a lot of practices, or at least paused practices from moving into a system like this. There's the implementation lift and change management process to the company. It's another system to manage and keep locked down on the [information technology] side. You have to be able to staff it. Who's going to be answering the tickets? Is it going to be a dedicated department? Are you going to assign it to multiple departments? Then you have to do the training for those departments. How are you going to get your patients to enroll? There are a lot of different potential barriers that should be considered within a practice to determine if you're ready to take that on.

But practices such as Highlands that have already implemented this model recognize those barriers. We went through the barriers. We went through the growing pains. We want to help other practices as much as we can through those barriers and give them our wisdom and our lessons learned.

One of the barriers that the team started working through was getting more patients enrolled. One thing that we found highly successful is whenever we do our chemo teaching class with the patients, a big part of that class is talking about Canopy and showing them how to enroll. And then if they want to enroll, we help them enroll right there. Our enrollment rate significantly jumped up from there, and then the impact significantly jumped up.

Also, work with whatever company you're utilizing for some type of remote therapeutic monitoring. If you're paying them for the platform, they're going to want to help you make it successful.

Since 2020, Highlands and Canopy have contributed to 10 real-world studies on the impacts of electronic patient-reported outcomes, and the numbers are impressive. We've shown a 22% reduction in [ED] visits from our patients who utilize this. We've shown an up to 45% increase in patients still on treatment at 3 months, so their treatment did not get disrupted by that point, which is fantastic. And we have an 88% retention rate of patients on ePRO [electronic patient-reported outcome] at their 6-month mark. We have earlier detection of toxicities with things like bispecifics. The numbers, they really speak for themselves. It is a lift for practices to implement something like this, but it's a game-changer all the way around. Once you get through the hard parts, I think we can all say here at Highlands, it's a win, both for the clinic and for patients.