The COVID-19 Pandemic and Transition to Digital Health in Clinical Oncology Care.

BACKGROUND: Clinical oncology care is complex, and new technologies can improve efficiency, contribute to safe treatment delivery, and enhance care for the patient. The COVID-19 pandemic prompted a shift to the use of digital health technologies to provide care. Oncology care providers can ensure that technology is integrated with the patient's plan of care. OBJECTIVES: The aims of this review were to provide a survey of digital health technologies in oncology care and changes in practice resulting from the pandemic, as well as to highlight oncology nurses' and nursing leaders' roles in promoting digital health technology in clinical practice. METHODS: Current and emerging literature, frameworks, and real-world experiences were reviewed to provide an overview of digital health technology in oncology care. FINDINGS: Digital health technology has become an integral tool for the oncology care team and provides opportunities to improve the lives of patients. The pandemic accelerated the adoption of technology to provide safe and effective care. Oncology nurses play a role in identifying patients' needs and developing and implementing care strategies.

Access to Care: Using eHealth to Limit Location-Based Barriers for Patients With Cancer.

BACKGROUND: Rural and urban communities may encounter barriers to care, which can lead to delays in timely screening, diagnosis, and treatment. eHealth interventions, such as televisits and remote patient monitoring, are being used increasingly to improve patient access to quality clinical cancer care and to support patient-provider communication. OBJECTIVES: This article describes how eHealth can bridge gaps in patient access to cancer care and provides insight into successful eHealth program implementation. METHODS: Articles that evaluate access to care and eHealth program implementation were summarized. Two case studies illustrate eHealth as a strategy to improve care delivery and access. FINDINGS: Integrating eHealth into clinical practice can help to transform care delivery and improve patient access to quality cancer care by limiting barriers.

InSight Care Pilot Program: Redefining Seeing a Patient.

PURPOSE: Early detection and management of symptoms in patients with cancer improves outcomes. However, the optimal approach to symptom monitoring and management is unknown. InSight Care is a mobile health intervention that captures symptom data and facilitates patient-provider communication to mitigate symptom escalation. PATIENTS AND METHODS: Patients initiating antineoplastic treatment at a Memorial Sloan Kettering regional location were eligible. Technology supporting the program included the following: a predictive model that identified patient risk for a potentially preventable acute care visit; a secure patient portal enabling communication, televisits, and daily delivery of patient symptom assessments; alerts for concerning symptoms; and a symptom-trending application. The main outcomes of the pilot were feasibility and acceptability evaluated through enrollment and response rates and symptom alerts, and perceived value evaluated on the basis of qualitative patient and provider interviews. RESULTS: The pilot program enrolled 100 high-risk patients with solid tumors and lymphoma (29% of new treatment starts v goal of 25%). Over 6 months of follow-up, the daily symptom assessment response rate was 56% (the goal was 50%), and 93% of patients generated a severe symptom alert. Patients and providers perceived value in the program, and archetypes were developed for program improvement. Enrolled patients were less likely to use acute care than were other high-risk patients. CONCLUSION: InSight Care was feasible and holds the potential to improve patient care and decrease facility-based care. Future work should focus on optimizing the cadence of patient assessments, the workforce supporting remote symptom management, and the return of symptom data to patients and clinical teams.

Building a Clinically Relevant Risk Model: Predicting Risk of a Potentially Preventable Acute Care Visit for Patients Starting Antineoplastic Treatment.

PURPOSE: To create a risk prediction model that identifies patients at high risk for a potentially preventable acute care visit (PPACV). PATIENTS AND METHODS: We developed a risk model that used electronic medical record data from initial visit to first antineoplastic administration for new patients at Memorial Sloan Kettering Cancer Center from January 2014 to September 2018. The final time-weighted least absolute shrinkage and selection operator model was chosen on the basis of clinical and statistical significance. The model was refined to predict risk on the basis of 270 clinically relevant data features spanning sociodemographics, malignancy and treatment characteristics, laboratory results, medical and social history, medications, and prior acute care encounters. The binary dependent variable was occurrence of a PPACV within the first 6 months of treatment. There were 8,067 observations for new-start antineoplastic therapy in our training set, 1,211 in the validation set, and 1,294 in the testing set. RESULTS: A total of 3,727 patients experienced a PPACV within 6 months of treatment start. Specific features that determined risk were surfaced in a web application, riskExplorer, to enable clinician review of patient-specific risk. The positive predictive value of a PPACV among patients in the top quartile of model risk was 42%. This quartile accounted for 35% of patients with PPACVs and 51% of potentially preventable inpatient bed days. The model C-statistic was 0.65. CONCLUSION: Our clinically relevant model identified the patients responsible for 35% of PPACVs and more than half of the inpatient beds used by the cohort. Additional research is needed to determine whether targeting these high-risk patients with symptom management interventions could improve care delivery by reducing PPACVs.

Misery Loves Company: Presenting Symptom Clusters to Urgent Care by Patients Receiving Antineoplastic Therapy.

PURPOSE: The Centers for Medicare & Medicaid Services (CMS) identifies suboptimal management of treatment toxicities as a care gap and proposes the measurement of hospital performance on the basis of emergency department visits for 10 common symptoms. Current management strategies do not address symptom co-occurrence. METHODS: We evaluated symptom co-occurrence in three patient cohorts that presented to a cancer hospital urgent care center in 2016. We examined both the CMS-identified symptoms and an expanded clinician-identified set defined as symptoms that could be safely managed in the outpatient setting if identified early and managed proactively. The cohorts included patients who presented with a CMS-defined symptom within 30 days of treatment, patients who presented within 30 days of treatment with a symptom from the expanded set, and patients who presented with a symptom from the expanded set within 30 days of treatment start. Symptom co-occurrence was measured by Jaccard index. A community detection algorithm was used to identify symptom clusters on the basis of a random walk process, and network visualizations were used to illustrate symptom dynamics. RESULTS: There were 6,429 presentations in the CMS symptom-defined cohort. The network analysis identified two distinct symptom clusters centered around pain and fever. In the expanded symptom cohort, there were 5,731 visits and six symptom clusters centered around fever, emesis/nausea, fatigue, deep vein thrombosis, pain, and ascites. For patients who newly initiated treatment, there were 1,154 visits and four symptom clusters centered around fever, nausea/emesis, fatigue, and deep vein thrombosis. CONCLUSION: Uncontrolled symptoms are associated with unplanned acute care. Recognition of the complexity of symptom co-occurrence can drive improved management strategies.

Safe and Effective Standards of Care: Supporting the Administration of T-VEC for Patients With Advanced Melanoma in the Outpatient Oncology Setting
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BACKGROUND: Talimogene laherparepvec (T-VEC) is the first oncolytic virus (OV) to demonstrate therapeutic benefit for the treatment of advanced melanoma. As a live virus, the use of T-VEC in medical and surgical outpatient clinics posed challenges. 
. OBJECTIVES: The purpose of this article is to describe the challenges faced when introducing an OV treatment into outpatient clinics and the processes implemented to ensure safety for patients, caregivers, and staff across the care continuum. 
. METHODS: An interdisciplinary team of experts developed and implemented new practices and workflows to support the administration of T-VEC in the outpatient setting. Clinical staff were educated on this new treatment, its indications and side effects, and the practice standards created to support its use. 
. FINDINGS: T-VEC posed safety and logistical challenges that were successfully addressed and implemented. To date, 16 patients with locoregionally advanced melanoma have been treated with T-VEC. No adverse events occurred related to preparation or administration, which opens the door for similar therapies in the future.

Immunotherapy Administration: Oncology Nursing Society Recommendations
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As the use of immunotherapeutic agents increases in single-agent and multimodality treatment regimens, oncology nurses face the challenge of administering and caring for patients receiving new and unique agents. Oncology Nursing Society clinical staff and clinical nurses collaborated to produce a set of recommendations to educate nurses involved with the monitoring of patients receiving immunotherapy on administration procedures and safe handling of these agents to ensure patient and staff safety and to reduce risk of error. The recommendations are meant to provide clinical nurses with a framework on which to build policies and procedures for administering new treatment modalities.
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