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Innovating the Study of Symptom Monitoring with a Texas Two-Step

Publication: Dallas Medical Journal

Among patients receiving chemotherapy, symptom monitoring with electronic patient-reported outcomes (ePROs) is associated with improved clinical outcomes, satisfaction, and compliance with therapy. Standard approaches for ePRO implementation are not established, however, warranting evaluation in community cancer practices to improve the patient experience and optimize real time symptom management.

We turned to some time-honored footwork to implement and evaluate the effectiveness of ePROs for patients with cancer: the Texas Two-Step.

Step One

This two-part (hybrid) implementation-effectiveness evaluation of ePROs starts with “Implementation of Electronic Patient-Reported Outcomes (ePROs) for Symptom Monitoring in a Large Multi-Site Community Oncology Practice,” a study we published in JCO Clinical Cancer Informatics no. 5 (2021).

Patient symptom management optimization can facilitate reduced toxicity, improved quality of life, improved medication adherence, and improved overall survival. Patient-reported outcomes (PROs) have been a way to characterize patient-reported symptom burden, but the growth of electronic PROs (ePROs) provides opportunities for real-time symptom control.

ePROs have been shown to improve duration of cancer therapy and overall survival in the PRO-Common Terminology Criteria Adverse Events (CTCAE) trial at a large academic cancer center, and small studies in multicenter trials have found this approach feasible. However, broader implementation across community oncology clinics is yet to be evaluated. To study the use of ePROs, we implemented them in a large, multi-site community oncology practice, Texas Oncology, to assess both patient-level and organization-level outcomes according to the RE-AIM framework—reach, effectiveness, adoption, implementation, and maintenance.

Doing the Dance

Patients initiating a new systemic therapy at one of 210 Texas Oncology practice sites from July through December of 2020 were invited to use the Navigating Cancer ePRO platform, Health Tracker.

Health Tracker was developed by Navigating Cancer to enable frequent and regular remote symptom reporting for patients on active cancer therapy. These patient-reported records are available immediately to a care coordination dashboard and stratified by level of risk, enabling triage nurses and other healthcare providers to provide immediate care to their patients who are at high risk and require interventions. Health Tracker's symptom questionnaire is a modified version of the National Cancer Institute’s PRO-CTCAE instrument, which asks patients to report on 14 common symptom or toxicities, with the ability for patients to add additional symptom information in a free-form text field.

Participating patients received a weekly prompt by SMS text message or email (patient choice) to self-report common symptoms and well-being via computer or smartphone. Severe self-reported symptoms triggered a real-time notification alert to a triage nurse to address the symptom.


  • More than 4,000 cancer patients initiating systemic therapy enrolled in the program throughout the study period with 25% of patients living more than 20 miles from their clinic.
  • Of the patients who were enrolled in the platform, 73% completed at least one ePRO assessment, and among these individuals, 65% of all available weekly ePRO assessments were completed.
  • SMS (89%) was strongly preferred over email (6%) or clinic collect (5%). SMS was also associated with the highest participation rate (77%) vs. email (54%) or clinic collect (45%).

In this first part of the Texas Two-Step study, it was found that utilization of the ePRO tool can help provide just-in-time symptom management. The data shows that digital healthcare systems like Health Tracker can help clinicians manage patients’ symptoms quickly and efficiently, potentially leading to improved clinical outcomes, fewer visits to emergency departments, higher patient satisfaction, and compliance with therapy. For cancer patients especially, response time is critical, and this technology allows care teams to monitor a patient’s symptoms in real-time and swiftly respond to patients who are in need and require symptom control. It also gives clinicians better insight on compliance with oral therapies.

Also, despite the challenges of the global COVID-19 pandemic on cancer practices, implementation of ePROs for digital symptom monitoring across a large multi-site statewide cancer practice is feasible, and compliance is high.

Step Two

Demonstration of clinical utility in the real-world setting must incorporate patient and provider perspectives of ePRO programs to ensure successful implementation, so we sought to understand perceptions among patients and clinicians in ePRO digital symptom monitoring program. The results from step two were presented at the 2021 American Society of Clinical Oncology Quality Care Symposium in September 2021.

In the second step of this ongoing hybrid implementation-effectiveness study of Navigating Cancer’s ePRO digital monitoring program at Texas Oncology, patients initiating new systemic therapy for their cancer diagnosis were introduced to the program by their oncologist and enrolled by nursing staff for weekly reporting of symptoms. Feedback surveys were administered to both patients and clinic staff after six months of implementation of the program to evaluate their overall experience, and 1,040 (23.5%) patients and 215 (12.4%) clinicians completed the feedback survey.


  • Of the patient responders, 90% found the program very or somewhat easy for reporting symptoms, 85% moderately-extremely beneficial for having symptoms addressed, and 84% moderately-extremely interested in utilizing the program for future treatments.
  • Of the clinician responders, 73% indicated that that they had a good understanding of the benefit of the program; 70.6% felt confident in their ability to interpret patients’ ePRO responses; 80.3% felt confident in their ability to discuss the program with patients; 71.2% confident in their ability to counsel patients based on ePRO responses; and 55.3% felt the program enhanced communication with patients. Additionally, 59% of clinicians felt the program was beneficial for patients.

Big Finale

We found that patients have a more favorable perception of the benefit of the ePRO program than clinicians. Methods to reduce staff burden and reinforcement of program benefits during training and implementation are imperative to improve clinical utility and will be studied further as the program is optimized.

The COVID-19 pandemic certainly affected the ability to optimally implement the symptom management tool and might have affected its utilization and performance in several ways. Process workflows were altered substantially during the COVID-19 pandemic to maintain compliance with CDC guidelines. Staff were tasked with implementing screening protocols, enforcing social distancing, prioritizing and rescheduling patient visits, and treatment. Patients usually attended in-person appointments alone without caregivers to achieve lower volumes in clinic and maintain social distancing, a practice that introduced stress to patients and posed challenges in patient education.

During the pandemic, attention to symptom tracker follow-up was likely deprioritized in the wake of competing priorities because of the increased work burden from the global pandemic. Texas Oncology also robustly implemented telemedicine, further altering process workflow and increasing staff work burden in the clinic during the study period. It is also possible that the pandemic might have increased patient preference for using the tool over the normal process of interacting directly with clinicians because of disruptions in normal processes in the clinic or fears of presenting to the clinic in person.

The Texas Two-Step has been insightful, as this dance has already led to two key takeaways:

  1. Electronic remote symptom monitoring technology may provide security and empowerment to cancer patients.
  2. Implementing electronic remote symptom monitoring is likely to require additional resources.

Future evaluation will focus on the impact ePROs have on healthcare resource utilization, time on therapy, and symptom control. While more study is needed, this work demonstrates that ePROs is a promising tool that we will continue to use to improve the cancer patient experience and symptom control.

This article appeared in the November 2021 issue of Dallas Medical Journal.

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