Integrating Pros into the EHR

Patient-reported outcomes (PROs) are well-established in the context of clinical trials, providing important assessment of the individual during an intervention/study. However, their usage in routine clinical settings remains low, for any number of reasons, despite their utility and ability to provide important, quick information about treatment response. We are working with the UCLA Health Resident Informatics program is to assess the clinical utility of embedded electronic health record (EHR) reporting of PROs and health-related quality-of-life (HRQoL) metrics in the counseling of patients with thyroid nodules and low-risk thyroid cancer. We anticipate that evaluation and reporting of PROs and HRQoL in the EHR will allow physicians to identify potential barriers to communication in these patients, including anxiety, depression, and fatigue. Addressing these barriers and improving physician-patient communication has the potential to enhance the implementation of management strategies that reduce overdiagnosis and overtreatment of low-risk thyroid cancer.

Monitoring Febrile Neutropenia

Within the past several years, various consumer-level devices have been brought to market to provide real-time feedback about changes in patients’ status, including key vital signs that can impact clinical decision-making. Utilization of these technologies is critical to create new patient care efficiencies given ever rising healthcare costs and limited resources. To this end, we are validating a remote monitoring system for febrile neutropenia that includes a thermometer, blood pressure (BP) cuff, and smartwatch with intermittent (hourly) heartrate (HR) measurement. Upon measurement, each device wirelessly transmits data to a central hub via Bluetooth. This remote monitoring system is being validated in an inpatient setting against conventional vital signs measurements acquired by healthcare staff. Once the system accuracy has been validated, we plan to assess this approach for safety and efficiency of remote monitoring in lower-risk outpatient febrile neutropenia patients. Ideally, the system will decrease healthcare utilization by encouraging outpatient management of such low-risk patients with febrile neutropenia via improved monitoring while simultaneously supporting early intervention by providers and caregivers.

Enhancing Lung Cancer Screening

Lung cancer is the leading cause of cancer-related mortality in the United States and globally. A key issue has been that lung cancer diagnosis often occurs quite late and in its advanced stages, resulting in poor outcomes. Within the past decade, landmark randomized clinical trials including the National Lung Screening Trial (NLST) and more recent NELSON study, have demonstrated the efficacy of low-dose computed tomography (LDCT) for detecting lung cancer sufficiently early. Consequently, new lung cancer screening programs have launched, providing ongoing surveillance of individuals deemed at high risk for developing this disease. However, these programs face numerous pragmatic challenges, ranging from low enrollment and adherence to ongoing surveillance given a lack of patient and provider understanding about lung cancer and screening, through to costs and limited resources that need to be optimally utilized.

Alongside UCLA’s lung cancer screening experts, the Center for SMART Health is helping set the stage to improve screening by exploring several different strategies, including outreach through online patient portals and working with community partners to develop strategies that encourage enrollment and continuance with recommended imaging follow-up; developing novel ways to conduct risk stratification of at-risk individuals to optimize screening frequency; and seeking new ways to provide better patient engagement for cancer screening.

Improving Colon Cancer Screening

Colorectal cancer (CRC) is the second most common cause of cancer-related mortality, killing over 50,000 Americans each year – a number that is unwarranted as it many of these cases are preventable via screening and surveillance of high-risk abnormalities. For instance, many people with high-risk polyps that are detected during initial colonoscopies fail to follow-up in a timely manner.  Often such findings are not fully documented and/or issues exist with inconsistencies in reporting, making it challenging to definitively know which patients need to come back and when. Working with investigators in the Division of Digestive Diseases, the Center for SMART Health is helping to identify these individuals at UCLA through automated natural language processing (NLP) tools, looking to merge colonoscopy and pathology report observations in the electronic health record (EHR) into a comprehensive picture that can then be used to guide follow-up recommendations.

Understanding COVID-19 Risk Perception and Behaviors

Effective prevention of COVID-19’s spread is strongly predicated on adherence of the population to recommendations of health professionals. It is therefore critical that we identify the factors that contribute to an individual’s health decision-making with respect to adherence to the recommendations. We are developing two projects to help inform health policy and strategies around COVID-19:

  • National survey. We are creating a cross-sectional survey in collaboration with the Nationscape survey study (which is collecting 500,000 surveys through weekly interviews of Americans from July 2019 through December 2020) to identify and develop potential strategies to enhance compliance. Our survey will cover risk perception, factors influencing risk perception (e.g., primary sources of information, education; risk behaviors, factors influencing risk behaviors (e.g., demographics, health insurance), preexisting health beliefs and psychosocial factors (e.g., social isolation, anxiety, worry). The questions will help assess: 1) COVID-related behaviors (e.g., protective behaviors and high-risk behaviors); and 2) health preventive behaviors (e.g., increasing health maintenance). Results from this large study will be widely disseminated and will form the basis of a comparative effectiveness study for different preventative health interventions.
  • Cancer screening patients. The WISDOM Study involves an enrolled cohort of >25,000 women and already includes assessment around breast cancer risk, perception, and anxiety. We are proposing to extend this assessment with similar COVID-19 specific question in similar areas, gaging psychosocial measures of anxiety and depression within this group. Results from the cohort will be further contrasted with the results of the national survey, ad we will use these results to identify educational gaps and propose practical strategies to encourage preventative behaviors.

Improving Breast Screening

Can we provide better, individualized recommendations for screening? Guidelines for mammography indicate annual screening for most women, providing a “one-size-fits-all” approach to the detection of breast cancer. However, as our understanding of this disease has improved, a better picture of risk factors is now developing – some women have higher risk than others (and conversely, some have lower risk). As part of a PCORI-funded pragmatic trial, the WISDOM Study, the Center for SMART Health is helping to test different screening schedules (one based on risk, another based on age). The goals of the 100,000 subject study are to determine:

  • If the risk-based screening schedule helps decrease false alarms that lead to unneeded tests or treatments;
  • How women feel about using a risk-based screening schedule;
  • If the type of schedule affects how much women worry about breast cancer;
  • Whether women who learn that they are at high risk take other steps to reduce their chances of getting cancer; and
  • How well each screening schedule detects cancer.