Remote Monitoring in Oncology: From Evidence to Everyday Practice with Ethan Basch, MD, MSc

Ethan Basch, MD, MSc, is Chief of Oncology and Director of Cancer Outcomes Research at the University of North Carolina and Chairman of the Scientific Committee of Resilience Care. His research focuses on bringing patients’ perspectives into cancer research and routine care through patient-reported outcomes (PROs) and digital tools.⁠⁠

In this interview, he discusses the growing role of remote monitoring in oncology, from supporting patients receiving advanced therapies to preparing care teams and choosing the right technology.⁠

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Your trials showed that tracking symptoms remotely helps patients live longer and avoid the Emergency Room. Why should a community practice care about this today?

There is now substantial evidence of the benefits of remote monitoring with patient-reported outcomes (PROs), including improved symptom control, quality of life, reduced emergency and hospital visits, lengthened time on treatment, better patient satisfaction, and in some cases improved overall survival.  

Another advantage of remote monitoring that we are hearing more about, particularly in the community, is the ability to monitor advanced therapies, such as bispecifics or CAR-T, using electronic patient-reported outcomes. Moving these therapies into community and ambulatory settings requires a higher level of monitoring. Patient-reported outcomes and, in some cases, connected devices afford the ability to feel safe about monitoring these patients and escalating problems quickly through these systems.

For a community practice, there are many compelling reasons to start using patient-reported outcomes. This is becoming the standard of care in high-quality cancer care and will be an expected part of care. Well over one hundred community practices and large integrated health systems are now implementing PROs in the United States. PROs are increasingly being integrated with navigation and other supportive oncology services as a way to engage with patients and understand their status.

This is something every practice needs to be doing now.

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You talked about advanced therapies moving into community settings. What needs to be in place to monitor these patients safely once they go home?

Advanced therapies are rapidly moving into community and outpatient settings. However, a lot of providers understandably feel nervous when they begin using these treatments. Another complication is that these therapies often require coordination between inpatient and ambulatory care, including the transition between them. We need to make sure that the patient has smooth monitoring throughout that time and that we understand what's happening so we can identify potentially catastrophic toxicities early and begin steroids quickly.

The reality is that we simply do not have the workforce to remain in constant contact with patients. We also know that, even when we ask patients to reach out if they have difficulties, this often does not happen.

So remote monitoring is the ideal intervention to provide peace of mind when administering these therapies and enable their transition into community and outpatient settings.

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For a practice getting started with remote monitoring, what are the key ingredients for successful implementation?

For practices that have not had experience with remote monitoring with patient-reported outcomes, getting started can seem daunting. Of course, implementation involves changing several processes: introducing new technology, adjusting workflows, redefining some personnel roles and responsibilities, and engaging patients. Each of these is a little bit of a lift.

In oncology, however, we are accustomed to managing difficult things, such as bringing a new cytotoxic treatment on board or changing specialty pharmacy processes. Introducing complicated approaches and systems is something cancer services do well.

First, this needs to be an operational initiative across the entire practice. It has to come from leadership, with a clear commitment.

Second, because this is largely a nursing intervention, strong nursing engagement and good coordination between managers and nurses are essential so that nurses know what to expect on the ground.

One of our observations is that practices considering ePROs for remote symptom monitoring often encounter initial pushback from nursing teams. There is concern about a potential influx of patient messages and increased complexity in their work. Studies show, however, that these concerns subside after implementation.

At this year’s ASCO Quality meeting, data was presented from interviews with nurses at practice implementing PROs across the United States. Almost all reported significant fear and concern before implementation. Afterwards, those concerns had not only disappeared: the nurses also felt more confident in their ability to monitor patients.

Third, a key component is having the right technology and, ideally, a technology partner to help integrate remote monitoring into the practice’s workflow and culture, including how it triages messages and manages symptom-related issues.

If you consider these elements, including the nursing work, the workflow, the technology and the partnership with a software vendor or someone working within your EHR, I think the chances of success are very high.

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What should practices consider in terms of staffing when introducing remote monitoring?

Practices that seem to struggle to introduce these approaches and technologies are often those that are already understaffed at baseline or may have experienced significant turnover among clinic-based staff or navigators. This creates difficulties because turning on a PRO system brings patients’ unmet needs to light.

Practices looking to introduce these systems should review their nursing and navigation staffing and ensure that they are adequately staffed.

At a minimum, after turning on the system, practices should monitor the workload of nurses, navigators or whomever is on the front line receiving patient-reported information. They should then assess whether they need additional staff or should adjust the roles and responsibilities of existing staff.

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What should practices look for when choosing an ePRO platform for remote monitoring?

When a practice is considering technology for remote monitoring with PROs, there are several aspects to assess.

At the top of my list is the user interface, for both patients and providers. For patients, it needs to be simple, easy and accessible on their own devices, without complex passwords or high barriers to access, particularly for hard-to-reach patient populations. The software itself needs to be intuitive, fast, efficient and easy to use.

For clinicians and operational teams, integration with the EHR is helpful. I do not think it is absolutely necessary, but it helps considerably because so much of our work and internal messaging takes place within the EHR. Practices have also successfully used standalone systems, although we are increasingly seeing EHR integration.

In terms of provider functionality, alerts about patient-reported issues requiring immediate attention need to be escalated and conveyed to staff quickly, so they can identify what requires prompt action.

There should also be a dashboard showing everything patients have reported, including issues that may not require an immediate response but could be discussed at an upcoming visit or used to assess symptoms over time.

There needs to be a way to forward this information to other providers, as well as an audit function showing whether a provider has already addressed an issue so it can be cleared from the queue.

A future component will be AI. AI is rapidly moving into many aspects of care delivery, and patient-reported outcomes and remote monitoring are no exception. I think we will soon see AI approaches that can predict which patients may develop problems or help providers address escalated issues using templates or care pathways. We may even see AI beginning to address some patient issues, at least initially, as an adjunct to the provider.

These are key and future components of these systems, and any practice considering a PRO system can look at these different aspects.

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What is your message to practices still considering whether to adopt remote monitoring with patient-reported outcomes?

I think the research is now definitive. We have Level 1 evidence from randomized controlled trials showing the benefits of remote monitoring with patient-reported outcomes. We also know that it lowers costs, improves practice efficiency and increases patient satisfaction.

This has now moved from the research world to the real world. Uptake has been rapid, both in the United States and internationally. It is now time for every practice to consider bringing this into its own system.