Expansion, Implementation, and Evaluation of Electronic Health Record-Integrated Patient-Reported Symptom Screening in a Comprehensive Cancer Center

Patients with cancer have under-recognized physical and psychological symptoms and have supportive care needs that may interfere with their treatment and compromise their quality of life (QoL). Despite advances in early detection and treatment success, individuals often face debilitating cancer- and treatment-related symptoms and concerns. In addition to fatigue and pain, patients report unmet nutrition, transportation, and childcare needs. Studies evaluating clinical management and intervention programs for oncology patients are limited and not well integrated within most institutions, leading to a push to embed symptom screenings with a referral process in ambulatory cancer care.

The study team previously developed and piloted an electronic health record (EHR)-based patient-reported symptom and needs assessment called cPRO, for cancer patient-reported outcomes. This current study expanded the cPRO assessment implementation to oncology patients across the Northwestern Medicine healthcare system.

The specific aims of the research were as follows:

• Evaluation of expansion and implementation.
• Evaluation of effectiveness.
• Identification of implementation facilitators and barriers.

cPRO was implemented in ambulatory cancer clinics across three Northwestern Medicine regions. Patients completed assessments on pain, fatigue, physical function, depression, anxiety, and supportive care needs at home using the EHR patient portal, or in clinic prior to medical visits. Clinicians had access to cPRO results in the EHR and were triggered with an alert notification for severe reported symptoms or needs, allowing them to communicate with patients and make referrals and care decisions in real-time. cPRO’s impact on patient and system outcomes were evaluated over 12 months using both a quality improvement study and a human subjects study. Participants also completed measures on patient-reported healthcare utilization and quality, symptoms, and health-related QoL at baseline, six and 12 months. Finally, researchers identified facilitators and barriers to implementation using clinician, administrator, and patient feedback.

Patients found cPRO easy to navigate and value in its ability to monitor symptoms, facilitate reflection, boost self-efficacy, improve appointment efficiency, and strengthen sense of care quality. They also emphasized the importance of their care team acknowledging completed cPRO assessments instead of repeating the questions during the clinician visit. This study has resulted in a reproducible tool, models, strategies to implement EHR-integrated symptom and needs assessment, and referral for ambulatory oncology patients. The tools and cPRO protocols have since been leveraged to establish a similar bilingual program in another healthcare system.