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In Tech-Heavy World of Innovation, Communication Still Key

Amardeep Grewal, MD, and Brenda Laventure present their Center for Digital Health Incubator project OnCare Connect during the final report-out in early June.

In recent years, there have been many innovations for improving patient care, from CAR T therapy eradicating cancer cells to the therapy now known as Luxturna restoring eyesight. But sometimes it’s the very basics that can result in big gains in patient care. Sometimes, it just comes down to better communication.

That’s why it’s not surprising that communication plays a large role in all three projects of the Penn Medicine Center for Digital Health’s first-ever incubator class.

“In our current digital era, there is an increasing need to communicate with patients through the same channels that are used for everyday activities,” said Raina Merchant, MD, director of the Center for Digital Health. “All three incubator projects optimized ways of communicating with patients to address ease of scheduling, symptom identification, and post-op care.”

For five months, three incubator projects have been working on pilots in three different areas of the health system. This month, each will deliver a final report on their progress.

Thursday, Care Recovery Reimagined will present on their project, which deals with patients who received free flap reconstruction surgery, a procedure that allows wounds — particularly from the removal of tumors — to heal through the grafting of new tissue. The team hoped to reduce the high number of outpatient visits due to complications by implementing a texting platform that checks in with patients’ daily progress.

The two other incubator projects reported earlier this month, one working to detect bladder cancer earlier, and the other seeking to reduce unexpected hospitalizations of cancer patients receiving chemoradiation. Here, we detail how they improved communication to achieve remarkable care outcomes.

OnCare Connect: Enabling Patients to Speak Out on Their Cancer Journey

During the course of concurrent chemotherapy and radiation therapy, one in three patients will have an unplanned hospitalization. What’s especially distressing to Amardeep Grewal, MD, chief resident in Radiation Oncology, is that 50 percent of these hospitalizations could be prevented.

“We frequently see patients getting treated with chemotherapy and radiation therapy unexpectedly end up in the hospital due to treatment-related toxicity,” Grewal said. “This has a negative impact on a patient’s quality of life and can impact the delivery of their treatment.”

While doctors felt their patients were doing well due to patient reported outcome surveys they took once a week during their “on treatment visit days,” it turned out there was a significant gap — no questions in the survey directly asked about pain levels, a leading cause of unplanned hospital visits. So when clinical staff thought a patient was on track, they might be quietly moving toward a hospitalization.

And while patients often were seen by staff every day, sometimes 35 weekdays in a row, they were often not mentioning concerns until their scheduled treatment visit, meaning they missed opportunities to ask for help during the week.

With that in mind, Grewal teamed up with Brenda Laventure, a patient access coordinator in Radiation Oncology and a student at the Perelman School of Medicine, to propose what became OnCare Connect, a program that uses a texting platform to better monitor patients’ status and discern their concerns earlier.

The text platform uses an avatar named Caroline (chosen because “care” is in the name), to reach out to 20 patients receiving treatment for head and neck, or lung cancer. Behind Caroline were Grewal and others clinicians who responded to more than 600 text messages, averaging just three minutes in response time. These texts clued clinicians into their patients’ symptoms an average of three days before a scheduled treatment visit, allowing team members to jump in and manage treatment-related side effects in real time.

During the pilot, patient-reported toxicity significantly decreased, and the team was able to avoid preventable, unplanned hospital visits in some patients. 

“We were able to route patients to the correct individuals in their care team — such as nutritionists, social workers, nurses, or physicians — which they appreciated,” Grewal said. “Our goal is to take all that we learned and program Caroline into a chatbot to allow for many of the messages — which we found could be nearly half of them — to be automated so we can reach out and support more patients.”

Upstream: Getting the Importance of Early Bladder Cancer Detection Across

Initially, Daniel J. Lee, MD, an assistant professor of Urology, wanted to tackle the high complication rates associated with cystectomies, which are difficult procedures to remove the bladder due to invasive cancer.

“However, in the initial conversations with the incubator team, we realized that there were a lot of problems way earlier in the disease course,” Lee said. “So many of my patients had no idea that there could be serious problems associated with having blood in the urine, such as cancer.”

Blood in the urine, known as hematuria, is the most common symptom of bladder cancer, and having it means that patients have a 10 percent risk of bladder cancer, 25 percent if they smoke.

“A common theme among so many of my patients who already had bladder cancer was that there was a significant delay from the time they first had  symptoms to when it got worked up and diagnosed,” Lee explained. “A lot of them thought, ‘Microscopic blood isn’t a big deal.’”

So Lee and his team decided to start by communicating the seriousness of hematuria.

Importantly, the Upstream team determined that they couldn’t handle communication in the population they were targeting like other interventions. Since the at-risk patients skewed older, only about 30 percent had smartphones, with a similar percentage using email. That meant texting and e-notifications would likely go unseen.

“So many times we focus on the design and innovation aspects of projects without really taking into account what people value as being important — what they would want and how they would best receive the information,” Lee said.

The team decided to go old-school, mailing postcards to explain the dangers of hematuria and emphasize the importance of doing a full battery of testing for bladder cancer. In the pilot, the communications cut the appointment no-show rate in half.

Additionally, to improve communication within the health system itself, the Upstream team developed an algorithm that identified risk factors — like smoking and family histories — for patients who visited the emergency department (ED). The algorithm flagged patients for the ED doctors to recommend for testing with urology. This resulted in referrals of at-risk patients in the ED to skyrocket from 15 percent to 100 percent.

Moving forward, Lee wants to collaborate with primary care physicians to work on an alert and referral system for them. Additionally, he’s hoping that his team can learn more from the stories of patients they treated with bladder cancer and hematuria to discover additional early predictors of danger.

“One of the key reasons for the success of this pilot was how the team actually involved the patients in designing the interventions,” Lee said. “I think there are a lot of other, similar diseases with the same age ranges, especially for cancer, and hopefully future interventions for those can use a similar model to help engage and empower.”

Those in the health system interested in the Care Recovery Reimagined report-out may attend at 3:15 p.m., Thursday June 27. It will be held in the Plastic Surgery conference room, on the 14th floor of the South Tower of the Perelman Center for Advanced Medicine.

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