Oncology Patients' Perspectives on Remote Patient Monitoring for COVID-19

PURPOSE:

Oncology patients are vulnerable to adverse outcomes associated with COVID-19, and clinical deterioration must be identified early. Several institutions launched remote patient monitoring programs (RPMPs) to care for patients with COVID-19. We describe patients' perspectives on a COVID-19 RPMP at a National Comprehensive Cancer Center.

METHODS:

Patients who tested positive for COVID-19 were eligible. Enrolled patients received a daily electronic COVID-19 symptom assessment, and a subset of high-risk patients also received a pulse oximeter. Monitoring was provided by a centralized team and was discontinued 14 days after a patient's positive test result and following 3 days without worsening symptoms. Patients who completed at least one assessment and exited the program were sent a patient engagement survey to evaluate the patient's experience with digital monitoring for COVID-19.

RESULTS:

The survey was distributed to 491 patients, and 257 responded (52% completion rate). The net promoter score was 85%. Most patients agreed that the RPMP was worthwhile, enabled better management of their COVID-19 symptoms, made them feel more connected to their healthcare team, and helped prevent emergency room visits. Identified themes regarding patient-perceived value of a RPMP included (1) security: a clinical safety net; (2) connection: a link to their clinical team during a period of isolation; and (3) empowerment: an education on the virus and symptom management.

CONCLUSION:

RPMPs are perceived to be of value to oncology patients with COVID-19. Policymakers should consider how these programs can be reimbursed to keep vulnerable patients at home and out of the acute care setting.

INTRODUCTION

The delivery of care to patients with cancer has been disrupted by the COVID-19 pandemic accelerating new care delivery approaches that leverage technology platforms. Patients with cancer are particularly vulnerable to this virus and require clinical vigilance to monitor for adverse outcomes.^1,2 In a study of patients with lung cancer and COVID-19 cared for at a National Comprehensive Cancer Center, 62% were hospitalized and 25% died.³ However, not all patients with cancer and COVID-19 require hospitalization; in a large cohort study of nearly 1,000 patients with cancer and COVID-19 from the United States, Canada, and Spain, 50% required hospitalization.⁴ Given their potential for adverse outcomes, patients with cancer and COVID-19 require careful monitoring to identify early deterioration and render higher level care when indicated with the goal of allowing patients to remain at home if clinically appropriate.

Remote patient monitoring programs (RPMPs) have been launched at a number of healthcare institutions to care for patients with COVID-19 during the pandemic.^5-10 Remote patient monitoring is defined as “assessing patients outside a typical clinical encounter”⁶ using a technology platform. The typical components of a COVID-19 RPMP are (1) identification of patients who tested positive for COVID-19 or were suspected to be infected, (2) an electronic patient-reported outcome (ePRO) questionnaire to assess symptoms, (3) a pulse oximeter or other device to monitor vital signs, (4) clinical alerts for severe or worsening symptoms, (5) a clinical workforce to respond to symptom alerts, and (6) a standardized response to symptom management. A RPMP offers the ability to identify and expedite care of infected patients whose condition is worsening, offload the burden of care from practices to a centralized team with expertise,⁸ reduce healthcare resource utilization, and prevent spread of the virus by keeping some patients in their homes. RPMPs are also thought to be a more cost-effective method of delivering care by potentially reducing acute care visits through proactive home-based interventions and shortening hospital stays by enabling clinicians to feel more confident discharging a patient with the understanding that they would be under monitoring in the home.⁶

The literature to date on COVID-19 RPMPs has focused on program and patient characteristics, implementation strategies, and the initial effect on healthcare resource utilization measures, such as acute care visits, hospital admissions, and length of stay.^5-10 We sought to add to this literature by describing patients' perspectives and satisfaction with a COVID-19 RPMP at a National Comprehensive Cancer Center.

METHODS

This study received a waiver of informed consent from the Memorial Sloan Kettering Cancer Center Institutional Review Board.

Patients and Program Eligibility

Eligible patients for the RPMP were cared for at Memorial Sloan Kettering Cancer Center and either tested positive for COVID-19 on an outpatient microbiology test for the virus or were discharged after hospitalization for the virus.

Program Components

Components of the program have been described elsewhere and were organized as three distinct care pathways: program onboarding, program monitoring, and program exit.¹⁰ Patients were onboarded by a nurse and provided an educational video.¹¹ The onboarding process provided a program overview, introduction to the technology interface, and emphasized the role of symptom assessments in patient care. Once onboarded, patients entered the monitoring phase and received a daily seven-question ePRO assessment of COVID-19 symptoms.

Questions included the following:

• Have you had any difficulty in breathing while not moving that is new or has gotten worse?

• Have you had any difficulty in breathing while walking short distances (such as room to room) that is new or has gotten worse?

• Have you been coughing?

• What is the highest temperature you had?

• Do you feel strong enough to get dressed, prepare meals, and bathe yourself?

• Have you had diarrhea (loose or watery poop)?

• Compared with yesterday, how do you feel?

Patients discharged from the hospital were considered high-risk and provided with a pulse oximeter to provide data on blood oxygen levels and heart rate. We developed an automated system that alerted the clinical team when patients reported a mild-to-moderate symptom (a yellow alert) or a severe symptom (a red alert). The pulse oximeter would also alert the clinical team if blood oxygen levels were below 93%. These alerts interfaced with the institution's electronic health record and were incorporated into clinical notes related to the management of enrolled patients.

Patients were monitored for at least 14 days after a positive test result and until worsening symptoms or fever were absent for 3 days. Once patients met these criteria, they were exited from the program. Thereafter, the responsibility for symptom monitoring and management returned to the primary team.

COVID-19 Cohort Management Team

A team of physicians, advanced practice providers, and oncology registered nurses, called the COVID-19 Cohort Management Team (CCMT), provided monitoring and symptom management for enrolled patients. The CCMT actively monitored patient responses to the ePROs and the pulse oximeter readings from 7 am to 7 pm 7 days per week. After-hours, an overnight support line was staffed by acute care clinicians to respond to patient concerns. Red alerts mandated a call by the clinical team, often within minutes, to determine if the patient required a higher level of care or the symptoms could be managed remotely. All care by the CCMT was documented within the electronic health record.

Patient Engagement Survey

A patient engagement survey was developed with the following goals:

1. To evaluate the patient experience with a RPMP for patients with cancer and a COVID-19 diagnosis.

2. To learn about the role of a centralized team in the patients' understanding and management of and coping with symptoms related to COVID-19.

3. To share our patients' insights about a RPMP with the broader cancer and healthcare community to improve future iterations of this and similar RPMPs.

The survey was developed in collaboration with clinical leaders of the CCMT and the Patient and Caregiver Engagement department, who have expertise in health literacy and question design. The survey was organized into four sections: (1) patient experience with program onboarding, (2) patient experience with program monitoring, (3) patient experience with program exit, and (4) patient-perceived program value. The survey consisted of 22 questions with 20 using a five-item Likert scale. A net promoter score was calculated on the basis of responses to the statement: I would recommend the COVID-19 Management Program to other patients like me. The percentage of respondents who disagreed or strongly disagreed (detractors) with this statement was subtracted from those who agreed or strongly agreed (promoters). The net promoter score has been used by a variety of companies and organizations both inside and outside of health care to assess customer satisfaction.^12-15 The question has been highlighted in the business literature for assessing customer experience with a program or product because it reflects a patient's willingness to recommend a program to someone else and thus has reputational implications for that individual.¹² There was one open-ended question and one question asking who completed the survey (patient or caregiver).

The survey was distributed to all patients who exited the program and completed at least one ePRO symptom assessment. Administered through the patient portal within 48 hours of exiting the program, the survey was available for 14 days. None of the questions were mandatory, and the patient could complete the survey only once.

Survey Analysis

The survey was distributed to eligible patients from May 26, 2020, to October 26, 2020. Survey results were examined descriptively for all respondents. Five investigators (B.D., T.S.L., C.B.W., C.E.G., and M.F.K.) reviewed open-ended responses using a grounded theory approach to extract themes associated with a patient's perceived value of remote monitoring.¹⁶ The open-ended query was Please tell us what you liked the most and least about the COVID-19 Management Program. Each response was inductively coded with one or two themes identifying the reason that the patient perceived or did not perceive value in the program. Investigators then compared thematic assignments and revised and refined the code list until saturation was achieved. When discrepancies in coding emerged, they were resolved through group discussion by the authors leading to consensus. Finally, meaningful patient responses that encapsulated the primary themes were categorized together to construct a conceptual model of oncology patients' perceived value of a RPMP for COVID-19.

RESULTS

A total of 491 patients were offered the patient engagement survey, with 257 (52%) providing responses. The median age of respondents was 59 years (Table 1; range, 15-91 years), 47% were female, 63% were White, 14% were Black or African American, and 9% were Asian. The most prevalent malignancy was hematologic (22%), followed by breast (18%) and GI (16%). Most respondents entered the RPMP through an outpatient microbiology positive test result for COVID-19 (78%). The remainder were those discharged from the hospital after an inpatient stay from complications secondary to a COVID-19 viral infection (22%); these patients were provided a pulse oximeter.

TABLE 1.

Demographic and Clinical Characteristics of Enrolled Patients

Patient Experience With Program Onboarding

Ninety-seven percentage of respondents agreed (22%) or strongly agreed (75%) that they understood why they were in the COVID-19 management program, and 99% agreed (23%) or strongly agreed (76%) that they understood how to complete the daily symptom questionnaire.

Patient Experience With Program Monitoring

Patients were queried about the different mechanisms by which the clinical team interacted with them about symptoms during the monitoring period. Ninety-three percentage of respondents interacted with the clinical team through the patient portal, and of those, 91% found it helpful; 94% interacted through the telephone, and 88% found it helpful; finally, only 36% of respondents had a televisit (defined as a video visit), and 83% found it helpful. Of respondents who were given a home pulse oximeter, 94% found it helpful to monitor their oxygen level.

Patient Experience With Program Exit

Ninety-three percentage of respondents agreed (27%) or strongly agreed (66%) that they understood why they were no longer being cared for by the COVID-19 clinical team, and 91% agreed (34%) or strongly agreed (57%) that they understood who to contact if they developed any new or returning symptoms.

Patient-Perceived Program Value

Patients did not find it a burden to participate in a RPMP with 91% of respondents agreeing (25%) or strongly agreeing (66%) that the time and effort it took to report symptoms was worth it (Fig 1). From a symptomatology perspective, respondents felt that participation was an important part of their care for COVID-19 (87% agreed or strongly agreed), led to a feeling of being better able to manage their COVID-19 symptoms (76% agreed or strongly agreed), and helped them understand how their symptoms compare with others who have COVID-19 (66% agreed or strongly agreed). Beyond physical symptoms, patients also endorsed that the RPMP provided psychosocial benefits and helped them cope with their COVID-19 diagnosis (73% agreed or strongly agreed), made them feel connected and safe with the CCMT (87% agreed or strongly agreed), made them feel connected with the healthcare institution (87% agreed or strongly agreed), and made them feel their COVID-19 care was being coordinated with their oncology care (77% agreed or strongly agreed). From a healthcare resource utilization perspective, 59% of patients agreed (23%) or strongly agreed (36%) that participation in the RPMP helped prevent visits to the emergency room and urgent care center. Finally, the overall net promoter score was 85%.¹²

FIG 1.

Patient engagement survey: patient-perceived program value (N = 257). MSKCC, Memorial Sloan Kettering Cancer Center.

Qualitative Analysis

Qualitative analysis of free-text responses identified three primary themes regarding patient-perceived value of the RPMP. The identified themes were (1) security: patients appreciated that the RPMP provided a clinical safety net; (2) connection: patients appreciated the link to their clinical team during a period of isolation; and (3) empowerment: patients appreciated that the RPMP provided education on the virus and symptom management. These themes were used to construct a conceptual model of patient-perceived value with a RPMP for oncology patients with COVID-19 (Fig 2). The model presents these three themes as supporting value pillars and demonstrates how RPMPs can deliver enhanced care for patients by ensuring that they feel cared for, connected to their providers and healthcare institution, and activated or empowered in their symptom management.

FIG 2.

Conceptual model: three pillars of patient-perceived value of remote monitoring. MSKCC, Memorial Sloan Kettering Cancer Center; RPMP, remote patient monitoring program.

DISCUSSION

The COVID-19 pandemic created a unique confluence of circumstances that brought remote monitoring to the fore of care delivery. The early days of the pandemic were an especially potent time for RPMP innovation as there was much unknown about the virus, including its contagiousness, treatment, and lethality. However, for RPMPs to be effective in delivering real-time, dynamic, and technology-assisted interventions, patients must actively provide symptom information.¹⁷ We focused on three clinical care pathways to build our RPMP, which were onboarding, monitoring, and exiting. For patient engagement, it is critical that each of these phases of care is thoughtfully implemented. To continue to develop, scale, and innovate RPMPs, there is a need for stakeholders to better understand the patients' perceived satisfaction with these phases of care and the overall perceived value of remote monitoring.

Our RPMP had a high net promoter score, and patients endorsed agreement that by participating in the program they felt better able to manage their symptoms and, importantly, understand which symptoms were concerning. In addition, patients perceived value in the program serving as a source of support for coping with an often scary, unknown diagnosis. The RPMP helped patients feel connected at a time when they were socially isolated and when their diagnosis prohibited interactions with their usual caregiver or family. Finally, for patients dealing with not just the virus but also a cancer diagnosis, the respondents perceived that the program helped them avoid unnecessary acute care visits, which come at a considerable financial, emotional, and physical cost for this population.^18,19 The qualitative analysis highlighted these interlocking components of security, connection, and empowerment that underly the value proposition for patients of remote monitoring. These pillars are likely applicable outside of COVID-19 symptom monitoring and could serve as the foundation for building RPMPs for other clinical indications.

The generalizability of the study findings is limited in that the RPMP was based at one institution and characteristics of the program, including technology and workflow processes regarding onboarding, monitoring, and exiting patients, might differ at other organizations resulting in differences in patient-perceived value. In addition, other organizations may monitor their patients with COVID-19 using other biometric devices, such as digital thermometers or automated blood pressure cuffs, which could also affect perceived value.²⁰ Finally, we had a centralized team providing the patient monitoring 12 hours per day, 7 days per week; this resource expenditure might not be feasible at smaller or more resource-constrained institutions.

Given the value that patients perceive in remote monitoring, policy steps should be taken to ensure that remote monitoring can continue in the right clinical circumstances after the public health emergency and that innovation for technology-assisted care at home can thrive. Areas in cancer care where remote patient monitoring could yield value include patients returning home after hospital discharge who are at high risk for readmission, patients on combined modality therapy at high risk for symptom toxicity, and following oncologic surgery.²¹ Innovation is currently limited by constraints on reimbursement for remote patient monitoring. Concrete steps that policymakers can take to ensure that patients can continue to participate in these programs and enable these programs to better meet patient needs are as follows:

1. Provide greater flexibility in the definition of remote patient monitoring: The current procedural terminology guideline for remote patient monitoring requires the use of a medical device as defined by Section 201(h) of the Federal Food, Drug, and Cosmetic Act.²² This device must automatically collect and upload physiologic data, and data cannot be self-reported by the patient.²² However, it has been demonstrated that patient self-report through ePROs alone can result in improvements in quality of life, reduced acute care visits, and extended survival.^23-25 Although devices can be helpful for remote monitoring in certain cases, remote monitoring enables patients to report potentially concerning symptoms as they arise, whether they arise from a device or other avenue. Limiting RPMPs to instances where an automated device is required is a missed opportunity to effectively intervene before symptoms escalate. It could also limit innovation in novel ways of eliciting symptoms such as interactive chatbots and adaptive questioning.

2. Provide greater flexibility in the time period for remote monitoring: Current guidance provides that to bill the requisite remote monitoring current procedural terminology codes 99453 and 99454, the monitoring must occur for no fewer than 16 days of a 30-day period.²⁶ There are clinical scenarios when a shorter period of monitoring might be indicated. For example, the median time to readmission for a medical oncology patient is 10 days postdischarge, and thus, an organization might deem this the high-risk period to provide monitoring.^27,28 The time period should be based on the clinical scenario for which the monitoring is taking place. This flexibility has been allowed during the public health emergency and should be a permanent change.

3. Provide federal research funding to robustly evaluate RPMPs: As remote patient monitoring expands, there is a crucial need for research to answer questions such as (1) which cohorts of patients benefit most from remote monitoring? (2) What technology platforms are best deployed to provide that monitoring and how are these platforms evaluated? (3) How long should patients be monitored for a given clinical episode? and (4) What is the optimal clinical workforce to provide that monitoring? The Agency for Healthcare Research and Quality and the National Institutes of Health should make rigorous evaluation of RPMPs a funding priority.

In conclusion, removing the administrative barriers to remote monitoring reimbursement will allow these programs to grow and evolve. This may result in more care for patients in the home, which is often of lower cost and results in higher patient satisfaction. Policymakers should create an environment that allows for innovation in RPMPs by addressing barriers in reimbursement and funding rigorous evaluation studies.²⁹ The lessons learned from the crisis in care delivery caused by COVID-19 should serve as fertile ground to grow and harvest the next generation of technology-enabled care delivery.

AUTHOR CONTRIBUTIONS

Conception and design: Bobby Daly, Tara S. Lauria, Jessie C. Holland, Jericho Garcia, Jibran Majeed, Chasity B. Walters, Melissa Zablocki, Caitlin E. Giles, Meghan F. Kelly, Rori Salvaggio, Mark E. Robson, Diane L. Reidy-Lagunes

Collection and assembly of data: Bobby Daly, Tara S. Lauria, Jessie C. Holland, Jericho Garcia, Kimberly Chow, Olga Strachna, Caitlin E. Giles, Ashley Housen, Maryanne Canavan, Nina M. Maresca, Rori Salvaggio, Mark E. Robson, Diane L. Reidy-Lagunes

Data analysis and interpretation: Bobby Daly, Tara S. Lauria, Jessie C. Holland, Jericho Garcia, Chasity B. Walters, Kimberly Chow, Olga Strachna, Meghan F. Kelly, Ray Baser, Rori Salvaggio, Mark E. Robson, Diane L. Reidy-Lagunes

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Oncology Patients' Perspectives on Remote Patient Monitoring for COVID-19

The following represents disclosure information provided by the authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/op/authors/author-center.

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