COMMENTARY

Technology Will Transform the Oncologist's Day in Practice

Darshan G. Gandhi, MD, MBA

Disclosures

May 16, 2017

It is early Monday morning, and I drive into the parking lot of my hospital, prepared to encounter a long list of patients who were admitted or consulted upon over the weekend.

I walk into the hospital, and the electronic medical record (EMR) is down, undergoing routine maintenance—and, of course, there are no backup paper charts anymore. After spending an hour playing detective, I finish rounding on my patients and drive to the next stop: my outpatient office where I will spend the rest of the day.

I step into my office, log in to my desktop computer, and—after a painful array of password entries—open my outpatient clinical EMR, scheduling portal, email, inpatient EMR, and a few other browsers. At last I am now ready to do what I was trained to do: care for an actual oncology patient.

Does this situation sound familiar? If so, you're not alone in the quest to provide good patient care while maintaining your personal sanity.

As George Washington is quoted in Hamilton, "We are outgunned, outmanned, outnumbered, outplanned. We gotta make an all-out stand. Ayo, I'm gonna need a right-hand man."

A Right-Hand Man

Now imagine that there is a mobile application (app) that keeps an updated list of all of my patients; using Bluetooth connected to my car's speakers, it provides a synopsis of my patients' status as I drive into the hospital parking lot. A mobile rounding solution helps me round as I walk from room to room, taking notes and placing orders—my "virtual assistant."

I arrive at my office and place my right index finger on a scanner sitting next to my computer that logs me into the scheduling portal and all other browsers—within minutes, I am ready to see my first patient. This is the age of Apple's Siri, Amazon's Alexa, and Microsoft's Cordana entering the doctor's office.

Technology has serendipitously permeated each and every aspect of our life, faster and more deeply than we realize. It is now fair to say that technology has become a physician's right-hand man.

Oncology practice poses unique challenges not seen with most other specialties. It's a journey that starts with screening, making diagnoses, and staging with imaging and labs; then providing treatment options including systemic therapy (chemotherapy, targeted agents, and immunotherapy) and local therapy (surgery and radiation); and finally offering surveillance. An oncologist becomes a life-long friend—a caretaker of the cancer patient.

In addition to caring for a cancer patient, we are accountable to payers and hospitals, and we navigate the complex world of pathways and other regulatory nuances.

The Cancer Breakthroughs 2020 initiative by former Vice-President Joe Biden[1] and the 21st Century Cures Act[2] have provided much-needed awareness as well as the capital commitment to bring several technologies to the clinic with the potential to make life easier for both patients and providers.

So how exactly can technology help?

1. Data storage and beyond. The best-known and oldest use case is EMRs. The Health Insurance Portability and Accountability Act (HIPAA) in 1996 imposed requirements for the digitalization of health records.[3] The implementation of the Health Information Technology for Economic and Clinical Health (HITECH) Act supported this initiative, which resulted in increased demand for EMRs.

The EMR market has been dominated by companies like Epic, Cerner, Allscripts, NextGen, and eClinicalWorks.[4] Emerging companies like Practice Fusion, athenahealth, and others are disrupting the milieu by providing unique bells and whistles. Over the last decade, we have seen a transition from server-based EMRs to cloud-based EMRs, offering easier access and portability.

We are now in the era of "smart EMRs" where an intelligent engine can analyze patient data in real time and provide active guidance and recommendations to the treating physician. Examples include IBM Watson, AllegianceMD, and others. A smarter system using recurrent neural networks, called Doctor AI, is currently under development.[5]

2. Ease of access. Healthcare access transcends all boundaries—geographic and demographic—in the age of telemedicine. In 1996, Jim Reid first defined telemedicine as "the use of advanced telecommunications technologies to exchange health information and provide healthcare services across geographic, time, social, and cultural barriers."[6]

Some of the largest telemedicine companies are developing oncology-specific modules, including Teladoc, MDLIVE, and others. Varian's SomaVision has a radiation oncology-specific module that allows transmission of diagnostic images and dose prescriptions to the Palo Alto, California-based Varian's Eclipse and Helios software programs to develop treatment plans that map out beam angles, beam shapes, and exposure times needed to achieve desired intensity-modulated radiation therapy (IMRT) dose intensities.[7] These final plans can then be transmitted back to radiation oncologists in their offices.

Mobile health, or mHealth, can assist oncologists to monitor their patients outside the confines of the office environment. Basic use would be to track vital signs like respiratory rate, blood pressure, and heart rate. The "Internet of things" technology is bolstering home monitoring of other specific parameters like skin rash, gastrointestinal side effects like diarrhea and nausea, and cardiac monitoring (EKG), among others.

3. Credible information. Medical and healthcare information platforms like Medscape and UpToDate are increasing the accessibility of information about various medical conditions, and that may also help physicians gain the knowledge to make further decisions in patient management. Organizational sources like National Comprehensive Cancer Network (NCCN), American Society of Clinical Oncology (ASCO), American Society of Hematology (ASH), and European Society for Medical Oncology have rich information on oncology—most of them available on one's portable device.

4. Precision medicine. Bolstered by novel biotechnology concepts and less invasive surgical techniques like the robotic da Vinci® Surgical System, procedural complications are declining while precision and specificity improve.[8]

Wearable technologies are not just helping document findings, they are also personalizing therapy. The consumer market is flush with sophisticated gadgets like Bluetooth ring "magic wands," Scanadu Scout®, Google Glass™, and Ekso Bionics®.[9,10]

5. Cost efficiency. The US healthcare expenditure has reached $2.9 trillion and is forecast to reach a record-breaking $3.78 trillion by 2018.[11] Technological advancement in healthcare may help to reduce the cost of healthcare services. The primary pillar is to improve the level of precision and accuracy of treatment in order to hopefully reduce chances of further complications and also decrease the need for further treatment. Point-of-care testing continues to revolutionize medicine in many aspects and offers cheaper care.

If this future vision is to be believed, then self-diagnosing blood and serum analyzers are going to be a day-to-day part of our household lives, reducing the need for further clinical diagnoses in some cases.

6. Regulatory/population health. Here we delve into big data analytics. The idea of big data analytics is now "in vogue" among hospitals, clinics, and other healthcare organizations due to the implementation of the Affordable Care Act in 2010.[12]

All electronic health records and EMRs stored in the systems of healthcare organizations are gold mines of information that can be used for the research and development of more efficient treatments and better drugs. Big data analytics may also help to design improved clinical trials for more effective and efficient drug testing that can fast-track the drug-approval process.

Big data analytics also helps in analyzing and predicting patterns for diseases, and it can be used for in silico drug discovery.[13] Big data analytics can be a great help for the realization of personalized medicine by aiding pharmacogenomics.

A subset of big data is smart data analytics. As the national healthcare expenditure skyrockets, and an enormous amount of healthcare data continues to pile up, there is an imminent need for better solutions to help with data management.

7. Security. The implementation of the final HIPAA Omnibus Rule by the US Department of Health and Human Services elevated the penalty for a health data security breach and has caused healthcare organizations to increase their data security.[14] As evidenced by recent security breaches into the Veterans Health Administration system and others, the need of the hour is to create robust firewalls and protocols to protect confidential information.

The future focus of healthcare technology will revolve around finding new data security solutions using information technology. Recent advances in data security services, like HIPAA-compliant cloud computing services and high-level security encryption, may reduce the risk to a certain extent.

The following chart summarizes some of the technology's value propositions:

After apprising myself of the various technologies, let's return back to the clinic where I am seeing patients.

I am about to see a 35-year-old woman with newly diagnosed breast cancer. She presents with multiple family members; and, as expected, they're all devastated by the news. The first question I am asked is where there are any screening tools that could be used by her family members to detect cancer before it has started.

"Prevention is better than cure"—an age-old dictum ever more widely quoted. Unfortunately, establishing any survival difference with screening as prevention takes years of clinical research and trials. We are on the verge of complementing the traditional screening procedures—colonoscopy, mammogram, and PAP smears, as examples) with more sophisticated tools. Several companies including Veracyte, Biocept, and Guardant360 have developed versions of liquid biopsy, or blood test, that could someday replace expensive and sometimes harmful tissue biopsies.[15,16,17] Circulating tumor cell assays developed by Janssen and Biocept are gaining traction as well. Pathway Genomics has launched a blood test kit—CancerIntercept™ Detect—for early detection in high-risk individuals.[18]

One of the family members then asks about any newer technologies that could help with early and accurate cancer detection.

Tools are being developed using artificial intelligence algorithms for cancer detection. The Stanford Artificial Intelligence Laboratory recently published their research in which an artificially intelligent diagnosis algorithm matches the performance of dermatologists in diagnosing skin cancers like melanomas.[19] They use convoluted neural networks, a technology that capitalizes on deep neural networks and that is beginning to gain traction in all walks of oncology care. Another prominent player is IBM Watson using Avicenna technology.[20]

The patient is also frustrated by the lack of sensitivity of mammogram in young women. Are there any better options where advanced technology could help? Indeed. Radiologists now have additional resources at their disposal. Enlitic has developed software that uses a deep learning algorithm to study masses and lumps in radiology images and assist with detecting cancer. IBM Watson has studied terabytes of data to compare a particular patient's image with a repository of billions of archived images to provide risk stratification.

Unfortunately, our patient had to undergo breast biopsy twice as the first test was "inconclusive." What if the radiologist/breast surgeon was able to use an intelligent surgical knife—the iKnife? It was developed at the Imperial College of London to utilize a mass spectrometer to detect specific chemicals in the biological sample.[21] This technology has the potential to reduce the need for second-visit biopsies and provide diagnosis on-site.

I complete staging for this patient and move to a multidisciplinary conference where we start discussing treatment options. As usual, I would refer to the NCCN and ASCO guidelines or use clinical pathways. While these pathways are rich and evidence-based, some might argue that they are not specific to a particular patient. Watson Genomic Analytics, a proprietary, cloud-based solution from IBM, can look for variations in the full human genome and then examine various data sources including basic research, clinical studies and published articles, treatment guidelines, and, most importantly, patient health records to produce a report and data visualization of the patient's case, including evidence-based insights on potential therapies.[22]

What started as a natural language question-answering computer system (used in Jeopardy) has metamorphosed into a decision-making tool that could assist oncologists making cancer treatment decisions.[23] It was used first for utilization management in lung cancer at Memorial Sloan Kettering Cancer Center. They recently entered a collaborative agreement with 14 large cancer centers to provide "treatment-advisor" services.

No treatment decision is complete without talking about the cost of drugs! As recommended by the US Centers for Medicare & Medicaid Innovation Oncology Care Model and several payer guidelines, we now consider the cost of drugs with patients.[24] The astronomical costs of drugs are no mystery, especially targeted agents and immunotherapies. Will there ever be a respite? One of the many factors behind these high costs is the long and arduous process of drug development and the phenomenon of attrition. On average, a state-of-the-art oncologic agent would cost about $2 billion in development.[25] Technology could help by using in silico trials. An in silico clinical trial is an individualized computer simulation used in the development or regulatory evaluation of a drug. This is done using advanced biological networks, or the organs-on-a-chip technique. This allows for the analysis of thousands of potential drugs on millions of physiologic models with super computers, expediting drug discovery.

The patient finally starts her systemic therapy. I would like to make sure that she is getting the appropriate dose for her genetic makeup and body weight. One solution is the PGxOne™ Plus test from Admera Health, a pharmacogenomics test that predicts how patients will respond to drug therapy based on their individual genetic makeup.[26] Differences between individuals can affect drug absorption, metabolism, or activity. Therefore, while one treatment regimen may work well for one individual, the same regimen may cause adverse effects for other individuals. Fortunately, the patient does well, and we start her on chemotherapy.

My nurse makes a cycle 1, day 1 phone call to check on the patient to ensure that there were no immediate side effects. Unfortunately, despite multiple attempts, we are unable to reach her. How do I monitor her if she develops neutropenic fever? Or a rash? Or some other major side effect?

Sensors are being developed that could be placed on patient's skin that could constantly measure body temperature and notify the patient if maximum temperature reaches 100.5 F. The sensor uses Internet of things technology to transmit that information to me or a colleague on call using her home Wi-Fi. Patient apps could be used to take pictures of a rash and upload it to a teleoncology portal that would transmit the data to the physician's office.

Technology and medicine—often felt to be distinct disciplines—are actually more akin to pieces of a jigsaw puzzle. They complete and complement each other. Medicine, like all other industries, requires innovation and upgrades. According to Paul Drouin, MD, "The tree of medicine must be transplanted into a new soil, where its roots can deepen and intertwine to reach a more complex source of healing knowledge and bring together all traditions of healing, ancient and modern." Technology can provide the "soil" in this context.

In truth, we have just started to scratch the surface of potential technologies available to oncologists. In my next article, I'll discuss technologies available to your cancer patients, the consumer, in a discussion of the consumerization of oncology care.

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