Telehealth, Telemedicine, and e-Health in Cancer Care
The essay aims to elucidate the application and use of e-Health in the patient-centred care of cancer patients. The terms telehealth, telemedicine and e-Health are used synonymously; however, they cover specific areas of interest (Young and Badowski 2017). Telemedicine signifies curing a patient from afar or remotely by using technology. Telehealth, on the other hand, is a much broader subject that encompasses telemedicine and other non-medical services like promotive and preventive care. Electronic health (e-Health) is much broader than the other two and summarises both. e-Health includes caring for a person remotely or in-person and comprises all services that apply information and communication technology to share, store, and exchange medical information for promoting treatment, prevention, diagnosis, education, monitoring, and administrative intent. The patient lies at the core of the e-Heath system and has the ability to enhance self-management by use of online communities, software applications, and patient portals. e-Health system revolves around healthcare delivery and monitoring through the tablet of mobile phone apps (Palos-Sánchez, Saura and Álvarez-García 2019). E-Health is not a new concept, although the increased dependency on e-Health has brought in a new age of patient-centred care of cancer patients that yonder past the conventional in-person treatment model to dynamic, instantaneous, and technology-abetted interventions and diagnosis. e-Health has the ability to improve the care delivery by enhancing the communication between the patient and the provider, improving toxicity assessment and symptom management, along with better patient engagement in the cancer-care spectrum. Many studies show that around 70% of patients with cancer seek medical guidance through the web and over 30% pursues support interventions to aid them cope with complicated challenges of cancer treatments. Since use of the web and internet to access health information and seek support interventions is on the rise, much consideration has been put to the evaluation and implementation of e-health based support programmes and educational programmes to target the oncology patients. In the USA, enhancements in detecting cancer at an early phase and treatment efficiency have directed to unparallel cases of survivors. A vital element of the e-Health system is documenting patient-reported outcomes (PROs) (Cella et al. 2015). E-Health technologies help facilitate access to care for the underprivileged, underserved communities and rural populations that experience barriers in acquiring regular in-person treatment or care. This paper will discuss the use of e-Health in patient-centred care to better the delivery of cancer care, management of symptoms and “health-related quality of life” (HRQOL).
There has been an increasing demand in implementing patient-reported outcomes or PROs in the care processes of cancer, with the identification of treating and assessing an individual’s symptoms, overall health-related quality of life (HRQOL), and economic status for bestowing quality care. The US Food and Drug Administration describes PROs as an assessment that the patients evaluate regarding their health status without any translation by a physician (Penedo et al. 2020). PROs include emotional functioning, physical symptoms, care satisfaction, treatment adherence, and HRQOL. Many researchers have assessed the link of PROs with medical information technology. PROs can be assessed and scored instantaneously and connected with information technology, with the results being immediately put into the e-Health records and information portals, providing instantaneous feedback to the physicians and patients. Computer-generated tests apply the theory of item response to quickly evaluate symptoms with fewer items, increasing the precision of measurement and minimising the patient burden. Hence, adapting computer-based testing to information technology can escalate the probability of patients completing the PRO assessments. The clinical results can be instantaneously combined with e-health records, which can prompt the physician when the reports show severe symptoms or toxic syndromes in the patient’s body, creating the possibility for immediate medical response. Many studies have approved the acceptability and practicability of such procedures of cancer care. It has been observed that patients are more likely to use health information mechanisation to inform or report their health progress, and physicians have been acknowledging these PRO data, directly endorsing the use of these computer-based programmes.
The Role of e-Health in Patient-Centered Care
Apart from having several symptoms and coping with the toxic side effects of the treatments, individuals with cancers also have concerns regarding prognosis, the impact of the sickness on their daily lives and wellbeing, and quality of life following the treatment. Hence, the period during which a person receives the treatment is vital for managing symptoms and the best time for psychosocial intervention. Using e-health for delivering the interventions will enhance the participation of the patients in the care process and reduce the physician’s burden. Clinicians will have ample time to offer their attention to severe cases instead of having to divide their attention and care with patients who do not require much clinical help. The growing use of e-Health programmes and mechanisation like phone applications to care for and manage patients having mild or moderate health symptoms can vastly reduce the burden of clinicians. Therefore, e-Health or mobile-health (m-Health) has the ability to impart the required relief to the healthcare infrastructure, which was much needed due to the increasing numbers of cancer survivors. With the growing use of smartphones and internet technologies, numerous studies have emerged assessing the efficacy and viability of using e-Health or m-health to impart evidence-based medical interventions during cancer therapy. A study found that, even though e-Health interventions vary, most interventions incorporate controlling symptoms that are side effects of chemotherapy, self-management education, propelling communication and customised information (Moradian et al. 2018). The paper reviews how the e-Health system is feasibly applied and used to manage symptoms of active cancer patients.
A study by Somers et al. (2015) showed that pain is the most prevalent symptom of about half the cancer patients during the treatment period and about 65% on individuals in advanced stages of cancer. Research conducted by Duke University has marshalled m-Health programmes using e-health interventions for pain management among cancer patients, called mPCST, which assisted and trained the patients to cope with pain. The intervention was delivered through videoconferencing, and the intervention was acceptable and viable to the patients suffering from treatment-related and cancer-related pain. The benefits achieved were similar to the conventional in-person educational interventions, such as an increase in self-efficiency to manage pain and a decrease in sensitivity towards pain (Kelleher et al. 2019). The mPCST programme was developed for cancer patients who underwent “haemopoietic stem cell transplant” and had recurring pain after the process. The mPCST programme helped them with managing pain, enhanced self-efficacy, decreased pain, and reduced disability rendered by acute pain measured through the “pain disability index”. The programme allowed to bridge the gap between outpatient care and in-home care, thus permitting the progression of care, enhancing the relationship between patient and therapists, and contributing to the high efficacy, feasibility and acceptance of the e-health intervention. The creative use of e-Health to reduce the gap between inpatient and outpatient care have assisted in overcoming a major barrier in care procedures of cancer and might even expand to aid various other settings in future (such as post inpatient infusions and post-surgery care).
Importance of Patient-Reported Outcomes (PROs)
Another side effect of cancer treatment is fatigue which affects almost all cancer survivors. According to Seiler et al. (2017), e-Health mediation has the potential to manage fatigue and high fatigue-related disability among cancer patients and cancer survivors. Fatigue is one of the major adverse effects of targeted therapies like tyrosine kinase inhibitors, that enhances the rate of survival drastically among cancer patients, such as patients with acute myeloid leukaemia, although it also reduces the quality of life (HRQOL). In an initial study conducted by Jim et al. (2020), the authors recorded the efficacy and viability of intervention through a smartphone application to enhance fatigue management of patients suffering from acute myeloid leukaemia who have been receiving treatments and targeted therapies. Patients who have been on the waitlist for the programme received traditional care and were then moved to receive the intervention. Participants who received the intervention showed enhanced improvements in fatigue control and overall HRQOL. Therefore, e-Health and m-Health can be viable options to assist in symptom management for fatigue, which is a prevalent and persistent ill-effect of cancer and can be exercised as a key element in managing symptoms for recent types of cancer treatments and therapies.
Cognitive disability related to cancer impacts at least 15% to 75% of cancer survivors and is a more aggressive outcome in some therapies than others (Johns et al. 2016). For instance, the likelihood of cognitive disablement is doubly common among males with an advanced phase of prostate cancer who have been going through “androgen deprivation therapy” than those who do not undergo the said therapy (Gonzalez et al. 2015). In a study by Wu et al. (2018), a cognitive coaching intervention dispensed with the help of e-Health was contrasted with traditional care in males suffering from advanced phases of prostate cancer being treated with “androgen deprivation therapy”. The study showed mixed outcomes, and the intervention was proved viable and mostly acceptable by the patients who showed improvements in reaction-time but compromised memory. Therefore, the efficacy of the intervention can be said to be restricted to particular elements of cognitive functioning. The patients who participated had provided feedback to make the e-Health intervention more bearable and provided insights for developing and boosting this and future e-Health interventions. This e-Health intervention was self-conducted by the patients without the help of clinicians, unlike the previously discussed intervention of managing fatigue and pain, therefore creating ways to alleviate the burden of the clinicians. Initial level findings from research by Yanez et al. (2015) comprising a diverse group of males with advanced phases of prostate cancer undergoing “androgen deprivation therapy” revealed the viability and efficacy of a psychosocial programme conducted through e-Health system. Patients who participated in the intervention randomly reported a significant reduction in symptoms of depression and distress and controlling cognitive functions. A similar study showed that psychosocial interventions rendered by e-health technologies reduced symptoms related to anxiety and modulated the impact of anxiety post-treatment (Greer et al. 2017).
Along with monitoring, managing and facilitating cancer patients during active therapy and treatment, e-Health systems impart another important benefit of expanding the access to care widely to accommodate the inaccessible, defenceless and helpless populations, such as people from the rural and disadvantaged areas. While dispensing cancer care to patients through e-Health, communications can be either asynchronous (that is, pre-recorded and not in real-time) or synchronous (that is, occurring via video conferencing in real-time) or sometimes a mix of both. These combinations of approaches allow the services to be flexible, such as an asynchronous approach of dispensing medical information, followed by an interpretation and synchronous patient-physician or physician-physician discourse and consultation. e-Health mechanisation permits greater access to patients settled in rural areas for clinical trials, therefore benefiting a greater number of individuals directly and helping improve popularising the trials to a range of diverse populations. Additionally, e-Health uses in managing symptoms helps cancer patients with restricted access to supportive care, oncology clinics, and behavioural mediation. Therefore, learning and observing the use of e-Health in managing symptoms in underprivileged settings and making e-Health resources accessible to all should be considered precedence for researchers. e-Health might also help to connect local medical networks and systems with large-scale healthcare settings academic and specialist medical facilities. As for a noteworthy example, Project Extension for Community Healthcare Outcomes (ECHO), an initiative by the University of New Mexico collaborating education and management of healthcare model, connects healthcare providers in underprivileged and rural areas to promote training mentoring and provide resources to enhance patient management (Cheallaigh et al. 2017, McBain et al. 2019). ECHO now serves similar principles to care for cancer patients by partnering up with MA Anderson Cancer Centre in Texas, USA. Research has shown that the low-expense ECHO model is efficient for training service providers in disadvantaged areas regarding cancer treatment and screening. It is feasible to enhance the delivery of cancer care widely and minimise health differences among various populations by educating and empowering the healthcare providers.
Using e-Health for Symptom Management
Many symptoms of cancer can be acute, persistent, debilitating and aggravating even after a successful treatment span (such as pain, fatigue, cognitive disability) (Tewes et al. 2021). Additionally, cancer therapies can set about new devitalising symptoms and aggravation of existing symptoms like insomnia (Savard et al. 2015). Many researchers have established approaches and intervention plans to assist the patients and survivors, post-treatment and the application of e-Health system in this regard has growing importance. A common element of most studies that applies e-Health interventions for cancer survivors is a concurrent emphasis on several dominions of HRQOL, such as anxiety, fatigue, social support and depression (Kubo et al. 2019). Some e-Health interventions even focus on specific side-effects faced by the patients. As for instance, an e-Health programme structured for improving sleep among the patients and cancer survivors suffering from insomnia was linked to reduced severity of insomnia, enhanced quality of sleep, and increased levels of energy after waking up. In their pilot study by Baseman, Revere and Baldwin (2017), an e-Health phone app named SmartSurvivor was created to assist breast cancer survivors in implementing a survivorship blueprint. The pilot testing revealed that it was well received and accepted by the patients, while further studies are exploring the application’s efficacy among the disadvantaged population and rural environment. In the field of implementing care plans for patients with cancer and cancer survivors via e-Health tools, it is important to invest in further research. Particularly, it is to be considered by researchers on how to bridge the distance in care of cancer survivors’ transition to primary care from oncology team follow-ups by incorporating e-Health technology and health information systems.
Altogether, these findings elucidate the prospective benefits of e-Health technology for improving and enhancing patient-centred health results among cancer survivors. Nevertheless, further research using bigger samples, extended follow-up, randomised trial plans, and assessment of clinical outcomes are required. Moreover, most studies do not include ethnic minorities and diversified races, rural populations, older patients needing palliative care, and patients who are not insured who have difficulty in obtaining cancer care or survivorship care. In this regard, an exception can be seen in the research conducted by Buscemi et al. (2019) and Yanez et al. (2020), who had created and implemented an e-Health application called My Guide for enhancing HRQOL among the breast cancer survivors of the Hispanic community. The 4-week long pilot testing of the app showed several advantages, such as enhanced knowledge of breast cancer and improvements in HRQOL. A 6-week long trial of the application was contrasted with another application for an attention-control trial that encouraged healthy lifestyle choices. Both the trials were connected with a reduction in symptom burden and decreased concerns related to breast cancer. Furthermore, among both applications, My Guide showed more acceptability and feasibility among the Hispanic cancer survivor community, therefore promoting the acceptability and viability of e-Health interventions in targeted populations that strongly experience challenges in accessing care interventions.
e-Health interventions present a potential to enhance patient-centred care of cancer patients and survivors. Several studies have started documenting and reporting the viability and acceptability of these programmes. Nevertheless, most of the studies and literature have studied short periods of follow-ups and small-scale samples that have no relevant outcomes, such as progression of the disease and disease activity. Moreover, much of the studies have reviewed issues related to external validity producing generic and universal outcomes, and only a few of them have incorporated e-Health interventions with health information systems like electronic health records and patient portals to help the patients with clinical conduct (Sirintrapun and Lopez 2018). However, these programmes and interventions have high reports of feasibility, and the patients have been reporting substantial levels of acceptance, suggesting that e-Health programmes gave a great impact on patient-centred cancer care, prompting future progressions of work in the field is assessed and developed.
M-Health and Pain Management Among Cancer Patients
With promising technological advancements in the medical field, e-Health interventions should move past feedback functions and semi-dynamic self-tracking to a state-of-art patient-centred interface. For instance, studies of gamification provide substantial evidence of incorporating gamification or the use of game design features in a non-game application with e-Health technology has the potential to increase patient engagement and adherence to oncology programmes (Floryan, Ritterband and Chow 2019). Substantial research is required on the advantages of gamification, including its application for encouraging adherence to recommended programmes, healthy lifestyle and symptom management activities. Incorporating user feedback in the e-Health portals and platforms is an evolving interest to increase patient engagement and ensure the right information is received by the patients. In initial e-Health platforms, all information was available to patients without personalisation which more than often resulted in inconvenient portals and platforms. The emphasis has now changed and moved towards customised messages and data individualised as per the patient’s treatment plan. It has been noted that patients also have been wanting a standard layout of the applications for ease of understanding and accessibility. Feedback from the patients and formal testing has the ability to help the developers to comprehend how to develop and implement applications considering all the user specifications. These implementations into the system will be helpful since newer platforms are created for the benefit of the patients. Researchers can also consider using Artificial Intelligence (AI) to combine correct diagnoses and patient data with overall clinical experience. AI tools can work with PRO data to impart current intervention since AI has been known to have a role in bioinformatics portable and wireless technology for many years. In the future development of the e-Health system, researchers might consider applying AI to refine the current algorithms that have been already created from PROs to recognise the individuals who require intervention. Furthermore, the application of AI in providing automated, high-quality clinical management of symptoms through e-Health. Ambient intelligence is another device or system that constantly observes and scans the health status of a patient in order to enhance health maintenance. Instances of ambient intelligence are constant observation of electroencephalograms, electrocardiograms, healing of wounds and respiration status. With the increase in the use of new technologies like sensor devices that gather instantaneous data, future research in this field should also consider how e-Health portals and programmes can be associated with sensor devices that are wearable and other kinds of ambient intelligence data related to health information systems (Dey and Ashour 2017). As for instance, wearable devices are helpful in collecting data like body temperature in order to observe symptoms of neutropenic fever (Wu and Luo 2019).
In spite of the prospective advantages of innovative and newly evolving technological advances, the challenges and barriers of executing and implementing the incorporation of PRO data with health information systems are also to be kept in mind. In cancer care, successful implementation of such technologies is a complex process, and the reasons for the dearth of successful implementation are busy workflows in the clinical environment, for example, IT support and burden on the providers, and knowledge of ways to interpret the PRO data and knowing how to respond to the data. Additionally, patient triage happens within a clinical environment with a handful of available e-Health options for delivering care and self-help programmes. Hence, acquiring materials and resources is a problematic factor. To address such challenges, researchers should include the stakeholders (such as administrators, clinicians, and IT support) in their study to develop the monitoring programmes of the PROs. By incorporating the stakeholders in the implementation procedure, challenges and disruptions in the existing clinical workflow can be reduced. Guidance for establishing an e-portal for PRO, reviewing the established PRO systems, score interpretations and factors for choosing PROs are all helpful aspects that might be considered. Between completely providing the e-Health service providers with clinical data and gathering large amounts, causing overwhelming reactions among the clinicians, there is a fine line. Hence, integrating data of patients into a single e-Health system will require deliberation of understanding ways to replace existing practices that were time-consuming, low-value and ineffective with optimised e-Health solutions to assist in clinical practices and care delivery. E-Health systems have the potential to handle large amounts of information and data aiding in analysing big data in shorter time spans (Belle et al. 2015). These data help in creating algorithms to recognise patients who are at risk, like poor HRQOL, toxic impacts after cancer therapy, non-adherence and increase the optimisation of effective care. Massive health information interpretation and analyses require knowledge that the clinicians lack. Hence, healthcare teams should be provided with resources and the necessary expertise in bioinformatics to handle and interpret bigger data. Additionally, to enhance the engagement of the stakeholders in gathering patient-related data, clinical administrators and clinicians should understand the increase in value of patient-centred care as a direct outcome of e-Health technologies.
Barrier-Free Access to e-Health for Underserved Communities
An important and persisting limitation and barrier that can also be interpreted as a vital opportunity for future research of e-Health in delivering cancer care is the lack of attention to the diverse range of patient population, especially considering the different ethnicities, races, geographical locations and socioeconomic status. Developing programmes that are culturally informed, addressing the requirements of diverse populations, reaching cancer survivors and active cancer patients in remote areas or in disadvantaged areas where access to care is not possible and interpreting the platforms to non-English speakers should be the focus of future studies and research in this field (Kim et al. 2019). Most research corroborating e-Health interventions have been emphasised on English-speaking white population groups, popularising and implementing the interventions on a wide scale are yet to be achieved. Moreover, health information programmes are mostly incorporated into well-resourced clinics and healthcare settings through e-Health records. Efforts and considerations should be made in implementing e-Health programmes in unconventional settings like the rural community clinics and primary oncology care centres, focussing on treating and caring for a diverse range of patients in order to minimise health disparities and promote equity (Rezapour, Hosseinijebeli and Faradonbeh 2021). As the development of e-health technologies continue to grow, heterogenous communities with difficulty in accessing care should be incorporated into the studies in this field. Another limitation is the dearth of conceptual frameworks incorporating theory-based strategy; for instance, the accountability model of e-Health suggests that adherence to e-health programmes can be improved through encouraging accountability (such as goal setting, social presence and monitoring) and lawfulness (such as trustworthiness, reciprocity and proficiency) (Borrelli and Ritterband 2015). The amalgamation of these principles into the e-Health interventions that depends on automated operations is a problem.
Conclusion
Therefore, the essay concludes that expansion and implementation of e-Health to regular patient care bestows an oncology care centre and the patients several potential advantages. Patients who are located in remote areas and far away from a oncology care centre can access care interventions through e-Health systems. The potential to impart care to cancer patients located at far away greatly expands the geographical impression of healthcare system. Implementing e-Health services enables greater management of both survivors of cancer and active cancer patients. Implementation of such services and programmes enhances systems-level results like hospital readmission, decrease in emergency department visits and other cost-generating services, along with enhancing the patient outcomes. The paper provides a review of different existing research in the field of e-Health system in improving patient-centred care of cancer patients and survivors, managing symptoms and PROs and HRQOL. The essay reviews studies that have been selected based on representativeness and relevance of the study field. The studies highlight recent e-Health strategies and interventions in different groups of patients documenting the outcomes and the viability and acceptability of the e-Health programmes. The reviews complement the current meta-analytical and systematic reviews of the chosen field of research, which narrates the prospective of e-Health interventions in enhancing cancer outcomes and documents the gaps and obstacles in the interventions, including managing and incorporating electronic data, external acceptance, customising e-Health programmes making it disease-specific and patient-specific. The paper also discusses the opportunities and challenges for implementation, patient access and scalability of such technologies and concludes with a discussion regarding future prospects in the field.
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