ASyMS: Advanced Symptom Management System
Real-Time Symptom Monitoring System in Cancer Care
Kailesh Gopalbhai
Digital Health Innovation and Strategy Partner
1. Cancer Symptom Management Challenges
Cancer is set to become a major cause of morbidity and mortality in the coming decades in every region of the world (1). By 2030, there will be nearly 22.2 million new cases of cancer diagnosed annually and over 13.2 million deaths, an increase of 75% compared to 12.7 million new cases and 7.6 million deaths in 2008 (1).
Cancer treatments, such as chemotherapy, are increasingly being provided in an outpatient care setting (2). Patients are required to closely monitor and manage a range of potentially diverse and complicated side-effects (3), without readily available clinical support. Obtaining symptom information from patients is fundamental in high-quality cancer care. Improvements in symptoms demonstrate a therapy is effective, where worsening symptoms may reveal disease progression or an adverse event. Clinicians will maintain or reduce chemotherapy dosage on the basis of patient-reported symptoms (4). Yet, in-clinic reviews are inefficient and may not adequately detect symptoms for optimal or timely clinical actions (5). Intervention between visits reduces the odds that a patient will arrive for a visit with severe symptoms (4). Unlike chronic disease populations (6), few information technology applications for the remote monitoring of cancer patients have been reported (7). Utilizing such technology to create virtual care environments is urgently required for the increasing numbers of cancer patients.
2. The Advanced Symptom Management System (ASyMS)
In response to the unmet need to capture patient-reported symptom information (8–11), Kearney and colleagues developed the Advanced Symptom Management System (ASyMS), a real-time symptom monitoring system to better track and manage chemotherapy side-effects in patients with lung, breast or colorectal cancer (9, 12).
ASyMS enable patients to report their symptoms and receive an instant notification on their mobile phone with advice on how to manage these reported symptoms (11, 13). Symptom reports are sent via a secure, wireless connection to a central server hosting the risk-alerting algorithms. These algorithms enable the clinician to program acceptable measurement limits that are appropriate to a patient’s disease state. The alerts are then triggered when symptom level are not within the designated range for the individual patient. A web interface provides a clinical portal for nurses to screen and follow any alerts being triggered, as well as review patient-specific information (for example, questionnaire responses, cancer type and stage, co-morbidity information) to help them make an informed clinical decision. These reports can also be viewed by the patient on the phone as graphs, showing the pattern of symptoms over time. If symptoms are severe, a nurse is paged to contact the person to offer advice and support.
Figure 1. The ASyMS System (14).
Two levels of triage alert are integrated into the system (13): (i) an “amber alert” for symptoms of mild or moderate severity, which require a response within 4 h (or similarly appropriate time period) of the alert and (ii) a “red alert” for severe symptoms, which require a response within 30 min (or similarly appropriate time period) of receipt of the alert. An “amber alert” is used to indicate to clinicians that a patient is experiencing toxicities at home that are not severe or life-threatening but in which early intervention might prevent further symptom progression. This included combinations of mild or moderate symptom reports which result in significant symptom burden or for symptoms which are moderate in severity but had persisted over a period of 48–72 h. A “red alert” is used to indicate to clinicians that a patient is pyrexial and/or experiencing severe toxicities at home such as severe diarrhea.
3. Evolution of the Advanced Symptom Management System
Kearney and colleagues have conducted a significant body of work in relation to ASyMS over recent years (9–11, 13–15). The evolution of the system is evident both in terms of patient populations using the system and the complexities associated with the study design in which the feasibility, acceptability and impact on patient outcomes have been explored (8, 11). The symptom questionnaire was adapted to specific patient populations such as patients with palliative care needs (9) and teenagers and young adults receiving chemotherapy (10). Furthermore, ASyMS has demonstrated its potential to significantly impact on patient outcomes in a small scale randomized controlled trial study, in which decreased severity of fatigue and improved reporting of hand-foot syndrome was observed in the intervention group (11).
ASyMS Cancer Studies
- ASyMS – C (Adults undergoing chemotherapy) (8, 11)
- ASyMS – YG (Young adults undergoing chemotherapy) (10, 16)
- ASyMS – P (Palliative Care) (9)
- ASyMS – R (Radiotherapy – lung cancer) (17)
- ASyMS – SERAT (side effect risk assessment tool) (15)
4. Patients and healthcare professionals experience of using ASyMS
New technology adoption needs to have a strong evidence base, including benefit to patients and acceptability of health professionals (8, 12, 16). Patient and nurse interviews in ASyMS studies reported that the system was easy to use (12, 14), enhanced communication between patients and clinicians (8, 9, 14), increased patient reassurance and support (10, 12, 14), promoted patient understanding of treatment (12, 14), assisted with symptom management (12), and promoted timely intervention (8, 9, 12). The alert notification feature of ASyMS was viewed positively by the clinicians (12), with the majority reporting that they felt that the alerts generated were relevant for real-time reporting of symptoms and in early detection and management of chemotherapy related side-effects. In addition, they experienced no problems in accessing patient symptom reports on the secure website and felt that it displayed all the relevant clinical information. Overall perceptions of using the ASyMS system included the prevention of hospitalizations, seeing patients better manage their cancer treatment side-effects, being able to reassure patients and being able to view patterns of emerging toxicities with real-time symptom information.
5. ASyMS Clinical and Healthcare System Outcomes
While the initial perceptions of using remote monitoring systems in cancer have been positive, it is still important to understand whether the use of such systems positively and significantly impact on both patient clinical outcomes, healthcare system usage and health system costs (Table 1) (18).
5.1 Clinical outcomes
Kearney et al. (11) found that patients in the mobile group reported less fatigue post chemotherapy in a randomized controlled trial. The significant reduction in fatigue suggests ASyMS provides more accurate reflection of chemotherapy related side-effects. However, the two study arms revealed no significant difference in symptoms of vomiting, nausea, diarrhea, sore mouth or throat. The authors also noted an unexplained decrease in prevalence, severity and distress caused by hand-foot syndrome in the non-mobile group.
5.2 Healthcare system outcomes
No ASyMS study provided any healthcare system outcome data based on cost-benefit, health economic analyses or usage of non-treatment hospital resources. This is possibly related to limitations in the medical record whereby all variables required to complete these complex evaluations may not have been consistently registered. These outcome studies are necessary if there is to be widespread uptake of this type of technology as healthcare administrators are unlikely to fund an intervention that does not have economic benefit. A study on the cost-effectiveness of remote patient monitoring (RPM) for heart failure reported $400 to $1,300 cost savings per patient (19). This compelling cost-effectiveness data and the clinical effectiveness of RPM should encourage its acceptance amongst clinicians and its consideration by third-party payers. In an asthma study (20, 21), however, patient self-monitoring using smartphones provided no cost saving or improvement of care. These findings suggest that there are some instances where remote monitoring has a significant advantage and some situations where there are none. The advantages in remote monitoring are stronger in more involved care such as with heart failure patients or diabetes (22).
6. Supporting Clinical Practice Decisions with Real-Time Patient-Reported Outcomes
As a growing number of tablet computers and mobile phones become Web-enabled, the outlook grows for real-time symptom monitoring to become a key part of standard clinical cancer care. Based on the implementation of patient-reported outcomes in clinical trials, a number of desirable system features have emerged (http://bit.ly/2hGoks0) (23). ASyMS already features the selection of symptom questions, functionalities of patient and healthcare professional interfaces, inclusion of notification/alert systems, and patient education. In the future, integration of such a real-time patient-reported symptom reporting with electronic health records (EHRs) will be essential for ensuring uptake by clinicians (24). The easier it is for clinicians to review patient-reported symptom information during their standard EHR documentation processes, the more likely this important information will play a prominent role.
Table 1. ASyMS overall strength and direction of evidence
|
Results |
Strength and direction of evidence |
| Patient-provider communication | ++ |
| Monitor treatment response | + |
| Detect unrecognized problems | ++ |
| Changes to patient health behavior | n/a |
| Changes to patient management | + |
| Improved patient satisfaction | n/a |
| Improved health outcomes | ++ |
| Strong & effective quality improvement | n/a |
| Better system performance (monitoring, planning, financing, evaluating, responding) | n/a |
Note: ++ strong effect; + some effect; n/a: not available.
7. References
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