OnCare Connect


Towards a human-augmented chatbot to identify and support side-effects experienced by lung and head & neck cancer patients undergoing concurrent chemoradiation therapy.







Funded By

     

Phase 1
January 2019 - July 2019

Phase 2
September 2019 - Present


My Role
Design Strategist
Design Researcher
Project Manager


Phase 1 Team
Dr. Amardeep Grewal, Clinical Project Lead
Brenda Laventure, Radiation Department
Lauren Southwick, Research Manager
Carly Breen, Research Assistant
Dr. Raina Merchant, Director and Advisor
Dr. Jessica Gaulton, Advisor
Elissa Klinger, Advisor


The Problem


An estimated 3,000 cancer patients are treated a year at Penn Medicine’s Perelman Center for Advanced Medicine’s Abramson Cancer Center. For certain cancers and stages, concurrent chemoradiation therapy has the potential to improve oncologic outcomes. Despite these advantages, combining chemo and radiation therapy often leads to greater side effects in patients undergoing treatment for the 5-7 weeks of recommended treatment. Common side effects include dehydration, nausea, diarrhea, fatigue, and pain. Due to how toxicities are accrued over the course of treatment, side effects also persist for weeks after the completion of treatment. Post treatment, patient are also more likely to have an unplanned hospitalization, with over 50% of them occurring after a patient is no longer seeing their care teams on a daily basis.



How Might We


We began this project by asking how might we identify radiation-related symptoms in cancer patients undergoing concurrent radiation and chemotherapy earlier to prevent symptom progression and hospitalizations?


Design Strategy Overview


We developed OnCare Connect as an accessible text message platform to meet patients where they are and support them when they need it most. Through research and observation our team saw texting as a viable and sustainable platform for reaching and engaging patients throughout the course of their 5-7 week and course of treatment and 4 weeks after they’d completed treatment. We piloted an open text messaging program from 8am - 8pm.

The pilot program was managed and monitored by a research assistant, two non-clinical staff (including a researcher and myself), a patient scheduler, as well as a resident radiation oncologist. We enrolled a total of 20 patients (14 undergoing treatment and 6 who had recently completed treatment).

The team proatively checked in every three days to see if patients would share new symptoms or give updates on existing ones. We aimed to be a service for patients to share emergent changes before their weekly clinical visit, and created a continuous feedback loop with nurses, physicians and extended care teams (ie: social workers, speech and swallow therapists, medical oncologists, and dietician) to ensure all team members were on the same page. To do this, OnCare resident radiation oncologist made sure updates were included in a patients electronic health record (EHR) and that a secure message would out to care teams before clinical visits with patients to highlight symptoms presented over text and/or things a patient wanted wanted their care team to know.



Process


Design Research
  • Defining stakeholders and partnerships
  • Observing waiting areas for scheduling and intake processes
  • Shadowing nurses and physicians to map workflows
  • Pulling qualitative and quantitative data from electronic health record (EHRs)


Stakeholders
OnCare Connect is comprised of a team of multidisciplinary and cross departmental team. Initiated by Penn’s Center for Digital Health within the Center for Health Care Innovation, the project partnered with two disease site teams within the Radiation Oncology department at Penn Medicine to explore this challenge.

I worked closely with chief resident Amardeep Grewal to identify stakeholders that could inform contextual inquiry and serve as long term partners throughout the design process.





Building Capacity for Care Teams


We wanted to create a sustainable service that would build capacity for care teams and leverage a patient-centered approach to proactively identify and prevent treatment-related symptoms from progressing.

We knew that current clinical workflows only allowed for care teams to meet with patients one out of the five days per week they visited Penn’s Radiation Department for treatment. And despite having 7 weeks of daily weekday radiation treatments that totaled 35 visits to the hospital, patients only had 7 days scheduled to meet with her nurse and physician from the radiation department. With only 7 planned appointments, nurses and physicians were missing valuable data and feedback about a patients well-being between these once a week visits.

When we examined what this looked like in terms of care coverage, we found that in a given week, patients had about 6 scheduled hours (excluding wait times) of scheduled time in clinic for radiation treatment. By providing an active text support service between 8 am - 8 pm, 7 days a week, OnCare Connect was able to increase weekly real-time care coverage from 5% (9 hours) to 50% (84 hours).





Across the health system, patients are encouraged to sign up for an online portal to allow for easy appointment scheduling and communication with care teams. The portal comes fully integrated with a patients electronic health records and has received positive feedback from patients and providers, but has often posed barriers for radiation patients with emergent issues and uncertainties.

Through observation and interviews it was clear that patients and caregivers wanted faster response times for the messages they sent through the patient portal. Patients often would create lists of questions that they’d wait to ask nurses and physicians during their weekly visits. Waiting to adderss emergent symptoms like dehydration (which would would lead to a preventable hospitalization) was also something nurses and physicians regularly observed. 

For nurses, without protected time to respond to messages they simply had no capacity alongside an overwhelming amount of charting (ie: a record of everything that was done regarding the patient's medical care) to address all the questions and needs on the patient portal.


Fast Real-Time Response


OnCare Connect was able to deliver answers 160x faster than the patient portal.  Patients “I thought it was a very good way to communicate- the speed at which the service got back to me was unprecedented. I loved it.”







Patient Experience


For patients and loved ones, the cancer journey is uncertain, scary, and filled with emotional and physical highs and lows. I met with over two dozen patients undergoing concurrent chemoradiation therapy over the course of OnCare Connects development and Lenora’s story was one I saw over and over again when reviewing patient charts and listening to patient experiences.


Lenora Smith


65 Year Old, Female

I met over a two dozen patients undergoing concurrent chemoradiation therapy over the course of OnCare Connects development. Lenora’s story was one I saw over and over in reviewing patient charts and listening to patient experiences.

Lenora had been recommended 7 weeks of concurrent chemoradiation therapy for stage III lung cancer. I met Lenora at consult and would follow her radiation journey for over 15 weeks.






 In addition to OTVs, within the last two years, the radiation department began implementing electronic Patient-Reported Outcome (PRO) surveys on tablets when patients check-in for their weekly clinical visits before treatment. A growing body of research has shown that PRO surveys can improve patient quality of life, reduce hospitalizations, and improve survival. Basch and colleagues (2016) found that patients who completed PRO survey questions for 12 common symptoms and had surveys monitored by members of a patient’s care team had a higher health-related quality of life (HRQoL) than usual care. Patients receiving monitored PRO intervention were less frequently admitted to the ED or hospitalized, remained on chemotherapy longer, and had a statistically significantly higher quality-adjusted survival with a mean of 8.7 in the intervention group compared to 8.0 months in the usual care group.


When we dug into the data, we found that even when we are listening, patient records are showing that we are missing key details. Lenora’s weight loss began around week 2 yet her PRO responses remained unchanged.

Based on Lenora’s story, we pursued a Quality Improvement (QI) Institutional Review Board (IRB) approval and partnered with Way to Health, a HIPAA-compliant technology platform to test an exploratory two way texting intervention. We investigated our challenge in two pilots, one focusing on patients who completed treatment and another with those currently starting concurrent chemoradition therapy. Understanding that toxicity is accrued over time, and that patients who had just completed were over 50% more at risk for an unplanned hospital visits, we strategically truncated the patient journey into on-treatment and post-treatment to glean insights from each phase. Both pilots were managed by a research assistant, two non-clinical staff, a radiation patient coordinator,  as well as a resident radiation oncologist. The team proactively checked in on patients three times a week, and line was open for them between the hours of 8am-8pm every day of the week for all emergent needs.


Metrics:


We enrolled 14 Head and Neck & Lung patients who underwent or were undergoing concurrent chemoradiation therapy treatment at the Abramson Cancer Center. In this early plase, we explored the feasibility, safety, and acceptability of this novel technology. Our success metrics were:


Feasibility


Since launching in April, OnCare Connect has sent and received over 1,759 text messages.




OnCare’s Future

After over three months of pilot testing, we found that we could not only catch and mitigate symptoms, but around 50% of the 681 text messages OnCare staff sent, could have been automated. These texts often included check-ins that asked patients to share how they were feeling or following up about a symptom they’d shared with their care providers earlier that week. We found that if we pursued automation, we could also provide supportive messages of encouragement aligned with forseeable symptoms during the course of a patients treatment to  help with psycho-social needs.

Now in its second phase of development, OnCare has grown its team, secured additional funding, and is working to pilot a human-augmented chatbot platform with the initial findings from phase 1 with patients, caregiviers, and clinical staff.









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