The development and implementation of the Clinician Report service for patients with advanced cancer was a dynamic process that involved iterative clinician feedback and system redesign. The current pilot, informal evaluation study provides insight into beneficial features that such systems can provide, identifies desiderata that challenge current system capabilities, and indicates areas for future development and research.
Application of the Readiness for IHCS Implementation Model
The Readiness for IHCS Implementation Model 46
identifies seven factors to address in the implementation of such systems: organizational environment; organizational motivation; technology usefulness; promotion; implementation process; department-technology fit; and key personnel awareness and support. The project team summarizes below the study findings regarding CR acceptability and utility in the context of these factors.
For the CR, the organizational environment included the nature of the clinics in which the system was implemented. The CR had to address security, privacy, and confidentiality issues. The CHESS system (including CR) collected and provided clinical data through a secure, password-protected website. To protect each individual's confidentiality, the patient and caregiver logged in separately to the system to respond to the check-in questions. Nevertheless, clinicians who received both patient and caregiver comments saw merit in doing so, but they expressed concerns about how to address caregiver reports that were not substantiated by the patient. Some contentious issues remained, including whether the CR should become part of the patient record, and whether to initiate patient contact based on information provided by the caregiver.
Healthcare, and cancer care in particular, benefits from the ability to intervene early in patients' problems, at a time when preventive actions might avert critical situations escalating into a crisis. As the CR enabled earlier interventions on key symptom-related problems, it fulfilled the organizational motivation to improve communication with patients and families to intervene in their problems earlier.
The CR demonstrated a degree of technological usefulness. The threshold levels for symptoms to generate alerts resulted in an appropriate volume of alerts, which the team believed was appropriate for notification about patient concerns. In contrast, clinicians raised concerns regarding the usefulness of numerically scaled symptom reports. The interim addition of a text box for describing symptoms in greater detail provided some benefit. Nevertheless, planned additional improvements must add more detailed operational assessment capabilities (e.g., “Have not had a bowel movement in the last three days despite taking medicine to help with bowel movements.”). Overall, the CR study provided the clinics an affordable and easy way to test a new communication tool with patients and caregivers. Challenges identified included a desire for greater depth of patients' problem details, such as those that could only be obtained via interactive telephone conversations or direct person-to-person dialogues.
Despite staff, patient, and caregiver training regarding use of the CR, the ongoing promotion of the system presented many challenges. Clinicians perceived the system as primarily used by caregivers rather than patients, and thus less useful. Lack of direct use by patients with advanced stage cancers may occur because patients are physically less able to use information systems like CHESS (due to severe symptoms that inhibit sitting at the computer), or they may be less motivated because they are too sick or feel helpless in the face of a poor prognosis. Future innovative approaches may overcome such hurdles and enhance cancer care.
While the customizability of the CR system (i.e., clinicians choose who received reports, as well as online and/or print capabilities) facilitated the implementation process, challenges arose due to the inability of CR to adapt to existing practices in the clinic. For example, the CR required clinicians to log into a separate website rather than to link out to CR during review of a patient's information in the familiar EMR or paper chart. Thus, using CR required additional steps for the clinical team during an already busy day. Furthermore, due to eligibility criteria of the clinical trial, each clinician had only a small portion of their patient population utilizing the CR system. The clinicians might have adapted to CR more easily if it had been implemented uniformly across their practice.
The CR demonstrated good department-technology fit
by positively impacting care providers' activities. Consistent with previous IHCS research 39,43–45
clinicians found that the Clinician Report better prepared them to address patient concerns during clinic visits. The CR also enhanced communication among clinicians, patients and caregivers. Although the CR could not provide real-time patient-clinician dialog regarding patients' symptoms, it at least alerted the clinical team earlier to issues that might require further attention. While such alerts might cause clinical staff to initiate telephone contacts with patients, inconsequential alerts could inflate clinicians' workloads in an already busy clinical setting.
The successful implementation of IHCS like the CR requires the awareness and support of key personnel. The CR implementation required clinician, patient and caregiver involvement. Within the clinic, nursing staff were primary users of the CR, but physician support for the CHESS research study and use of the CR was a critical factor for the CR implementation.
Limitations and Future Directions
The current study provides initial impressions from early implementation of a clinician reporting system for patients with advanced cancer. It occurred in the context of a large scale clinical trial examining the impact of an internet-based information and support system for cancer patients and their informal caregivers. Because the current study design was not a formal implementation evaluation, limitations occurred in the analysis of the CR. The small number of clinicians, representing a small sample of organizational roles, who provided feedback decreased study generalizability. Each organization has its own unique environment, motivation, and other factors that will affect implementation of a system like a CR. Despite these limitations, the current study attempted to identify essential factors to consider when implementing CR-like systems in other healthcare organizations.
Future CR-like system implementations should consider the clinician feedback reported here as potentially relevant. One such finding was that CR systems should be integrated within existing medical record system frameworks in an organization, not as a standalone system—clinicians should be able to access the CR seamlessly from the EMR. In addition, presentation design, such as graphics, should be consistent with existing frameworks with which clinicians are familiar. Additional desiderata include the ability to tailor how patients' symptoms are measured and reported, based on the needs of an individual clinic or patient population. Accordingly, criteria for when clinicians receive reports or alerts should follow from the symptoms they indicate are useful in their specific practices. Future CR systems should provide more specific, objective threshold criteria that allow clinicians to customize cutoffs for each patient. The ongoing CHESS clinical trials are collecting patient, caregiver and clinician login data that will better characterize the exact nature of CR system use (i.e., who used it, how often, and in correlation with what specific events) to further inform CR system development.