Improved patient management using eHealth tools: potential and pitfalls
2015; Future Medicine; Volume: 4; Issue: 1 Linguagem: Inglês
10.2217/bmt.14.53
ISSN1758-1931
AutoresNadia Harbeck, Rachel Wuerstlein, Time Schinkoethe,
Tópico(s)Bipolar Disorder and Treatment
ResumoBreast Cancer ManagementVol. 4, No. 1 EditorialFree AccessImproved patient management using eHealth tools: potential and pitfallsNadia Harbeck, Rachel Wuerstlein & Time SchinkoetheNadia Harbeck*Author for correspondence: E-mail Address: nadia.harbeck@med.uni-muenchen.de Breast Center, Department of OB&GYN, University of Munich, 81377 Munich, Germany, Rachel Wuerstlein Breast Center, Department of OB&GYN, University of Munich, 81377 Munich, Germany & Time Schinkoethe Breast Center, Department of OB&GYN, University of Munich, 81377 Munich, GermanyPublished Online:7 Jan 2015https://doi.org/10.2217/bmt.14.53AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinkedInRedditEmail Keywords: adherenceCANKADOeHealthgamificationpatient managementIncreased implementation of oral and subcutaneous medication for breast cancer and other oncological or hematological diseases has led to new challenges for patients and oncologists. Optimal and continuous communication as well as lack of adherence and compliance are huge problems potentially impacting not just quality of life but also patient outcome. Where conventional systems, as evaluated in the PACT program [1], failed, modern eHealth and web-based platforms could be a possible solution for improving compliance and the doctor–patient relationship. Novel eHealth technology offers great potential for improved patient management but also needs to take substantial legal restrictions into account before implementation.Lack of adherence to oral self-medication in oncologyOf cancer drugs currently under development, 25% are intended for oral self-medication [2]. This is in accordance with preferences of cancer patients since a majority of 54–89% prefer oral medication [3]. However, the change from intravenous administration to oral self-medication leads to a loss of control of the physician while the patient's individual responsibility increases substantially. Consequently, lack of therapy adherence is the main problem. Depending on tumor entity and therapy, up to 84% of all cancer patients are not adequately adherent [4].WHO already dealt with this subject 10 years ago and systematically summarized potential causes for lack of adherence regarding long-term therapies in general and oncology in particular [5]. At that time, palliative cancer therapy was reviewed taking into account the medication available. In the WHO report, the causes for lack of adherence were divided into five sectors: socio-economic factors, healthcare team-/health system-related factors, condition-related factors, therapy-related factors and patient-related factors.Recently, as part of a systematic review, Verbrugghe and colleagues examined the factors which influence the adherence to oral medication [3]. These authors also grouped the factors, and ended up with the following division: patient-related factors, therapy-related factors, disease-related factors, health system-related factors, as well as social and economic factors.As far as patient-related factors in view of inadequate adherence are concerned, they can be divided into conscious and unconscious factors. The conscious factors are reduced awareness of the necessity of medication [6], no perceived usefulness of medication [6], an attitude that missed medication does not make a difference [7] and reduced quality of life due to medication [8]. The unconscious factors include forgetting to take the medication [7,9] or the accidental ingestion of too many pills [7]. When it comes to therapy-related factors, conscious and unconscious factors, side effects [6–7,9–11] and an often rather long treatment duration [8,12] can be considered as the main causes. But also a long break in drug ingestion [13] and ingestion of more than one drug can [14] have a negative impact on the adherence.Nevertheless, there are also factors that have a positive impact on the adherence. First of all, these include an increased degree of attentiveness of the physician and the patient's better understanding of disease as well as treatment [8].How to encourage behavior: gamificationAs demonstrated by the PACT study in early breast cancer, simple brochures and increased information albeit by well-known healthcare professionals and patient advocates do not increase adherence in oncology [1]. A new approach aimed at encouraging and sustaining behavioral changes is gamification. Gamification means using game elements in a nonplayful context. Thus, the desired behavior is encouraged by playful elements [15]. The game or the playful level depends both on the target group and the approach. At present, most of the gamification approaches are aimed at children and teenagers. A study showed that 50% of teenagers suffering from diabetes Type I checked their blood sugar level more often due to a gamification smartphone app [16]. Yet, also older adults can be reached with gamification approaches. The online card game GoWish is aimed at people who cannot find the right way to prepare their environment for an inescapable fate, mostly their own death [17]. Appel and colleagues were able to show that internet telecare systems also work for people over 50 years of age. This three-arm study included 415 people with an average body-mass index of 36.6 and an average age of 54 years. The control group was left to itself and the other two groups were either cared for personally or by a web portal. The web portal included a learning module, a part of self-documentation including graphical representation and an online feedback system. After an observation period of 2 years, the two cared groups showed the same significant advantage over the control group [18].A successful example for gamification is the company Next Jump, NY, USA. When Next Jump offered its employees an own fitness studio, the demand was somewhat restrained. However, the demand increased to 12% after the company decided to reward those employees who joined the fitness studio. However, only after introducing the gamification approach, the number of active members could be sustainably increased to 70% [19]. Gamification is gaining increasing significance in macroeconomic terms. The renowned Gartner Institute assumes that in 2014 approximately 70% of the top 2000 international companies will use at least one gamification application [20].In an issue dedicated to the special subject of disease prevention, the Journal Science raised the question how one could change human behavior and what needs to be considered. The key findings were as follows: mere knowledge of the consequences of one's actions does not lead to a change in behavior. Often competing desires are able to influence people's actions (e.g., craving for cake vs maintaining one's weight). In order to obtain a desired behavior, the desired behavior has to be easier and it needs to be rewarded. Moreover, desired actions have to be automated [21]. Successful gamification approaches combine all of these aspects. At present, most of the successful systems are so-called lifestyle solutions. The applications of the lifestyle sector focus on exercise, nutrition and weight-loss. Successful systems in healthcare/fitness including gamification are (data from [22]): MayMyRun (rank 2, free), Nike+ (rank 3, free), RunKeeper (rank 4, free), Lose It! (rank 5, free), Runtastic (rank 6, free), Zombies, Run! (rank 6, paid), Fitbit (rank 8, free). All of these approaches have in common that one can set oneself personal goals that can be achieved in a playful manner. By achieving goals, scoring top marks or by a virtual competition one directly receives recognition from the respective system. Systems such as RunKeeper or Runtastic focus on the virtual recognition and the motivation of the user while systems such as Zombies Run! place the user in a game where he has to run away from zombies by jogging and thus the virtual and real world becomes one. Systems such as Fitbit combine self-tracking measuring devices (exercise, sleep, weight) with gamification approaches and thus enforce the automation of the desired behavior by regular wear of the measuring devices. Regarding web applications, Superbetter.com is very successful at present. Superbetter.com was developed to meet personal challenges (e.g., injuries, psychological problems, weight control) in a playful manner. Tasks in the categories Mental, Emotional, Social and Psychological are set and have to be accomplished. By successful accomplishment of the tasks, the user can collect points which will bring him to the next level of the system.Gamification in oncologyGamification for cancer patients has already been discussed within the American Society of Clinical Oncology (ASCO). Dr Fisch, M.D. Anderson, assumes that gamification in oncology can be used to solve general problems of patient care [23]. There are already various approaches in Canada: The Pain Squad system aims at pediatric oncology patients. Pain Squad's objective is to make patients keep a daily pain diary during therapy. To encourage this desired behavior, the game participants are placed in a 'special unit' and can win awards or prizes if they document their pain levels regularly. If they continue their documentation, they will advance to the next level and will be placed in an 'elite unit'. The intensity of the pain does not have an impact on the game participants' success [24]. The initiative Rethink Breast Cancer also comes from Canada. Their APP 'your man reminder' primarily aims at younger women. Showing various videos with young, sporty and lightly dressed men, women are motivated to participate in breast cancer prevention and regularly reminded to attend consultations [25].The clear demarcation between gamification and computer games is very important. Gamification focuses on achieving the desired behavior in the real world while computer games focus on the virtual play. For example, Syrum by Boehringer Ingelheim is a mere computer game, even if marketing messages are to be conveyed [26]. An unusual approach is the Foldit Project. It is an online puzzle where real crystallographic data have to be transferred into a folding model [27]. This project attracted a lot of attention when within 15 days only the folding of retropepsin of the Mason-Pfizer monkey virus was found. For almost 10 years one had tried in vain to decode the protein folding process by conventional means [28]. However, since playing the game itself takes priority for the user, this is not gamification in the narrow sense.CANKADO: a novel tool for web-based communicationWe have evaluated actual use of internet and modern media in breast cancer patients and their healthcare professionals in order to better understand the needs of patients and oncologists participating in breast cancer treatment. The vast majority of patients and almost all physicians use the internet for health related issue. Even at an age of 70 years and above, more than half of all patients have access to the internet. About half of the patients would be interested in implementing an online support system during their cancer treatment. This wide-spread routine use of internet and modern media as well as the trust in new interactive communication tools in patients as well as physicians may enable improvements in doctor–patient relationship, compliance and adherence and suggest that eHealth tools may have a promising future in communication and treatment in oncology.CANKADO [29] is an eSupport system aiming at increased therapy success in oncology. The system expands the range of care services of the physician and provides an opportunity to interact with the patients apart from personal meetings. In addition, CANKADO offers patients, physicians and their assistants various support measures with separate access. As an effort to improve therapy adherence, CANKADO's approach focuses on those reasons that are related to the patient or therapy itself.Physicians can register themselves and, when verified, can freely work within the system. The physician in charge or his employees can put their patients in the system. However, the access will only be activated if the patient decides to use the system and activates his personal access himself. After logging in, physicians get a real-time overview of their patients (dashboard). Patients only have access to their own personal data and also get an overview of their data in a dashboard. Based on the therapy chosen by the physician, the patient is reminded of taking the medication and to document the actual medication doses. The major difference to the currently available pill reminders is the fact that CANKADO includes an interaction between physician and patient and that the physician activates the medication in the system while the patient can only choose personal preferences in the context of medical prescriptions (e.g., preferred time of day). The physician also gets feedback on the documented medication and is thus informed about the progress in therapy in real-time. Next to documentation of medication intake, the second pillar of CANKADO is documentation of side effects. Patients are asked to document their personal side effects on a daily basis. The system offers a fixed selection of the side effects that are already known and have been confirmed to be caused by the medication according to official documentation. No other side effects cannot be entered; patients are asked to consult the physician instead. Patients thus get an overview of their own therapy progress and are able to better assess certain developments. Depending on the side effects, the system offers tips and advice if medical intervention is not required. Physicians will be informed via email about occurrences with their patients which need to be further followed up. For data protection, no patient-related data will be included in the emails.CANKADO's gamification concept is based on the principles of cognitive behavioral therapy. Cognitive behavioral therapy builds on the theory that during the course of his life, every human being learns typical behavioral pattern, attitudes and emotional modes of response through personal experience and imitation. In therapy, problematic behavior, thought patterns and attitudes are tackled and changed. In general, therapy consists of three phases: The first phase is meant to communicate information and to develop alternative behavior. In the second phase, the alternative behavior is to be further developed and behavioral corrections in critical situations are implemented (corrections of dysfunctional attitudes). The third phase focuses on stabilization of the alternative behavior, the assessment of the situation and the relapse analysis [30]. Gamification concepts on the basis of cognitive behavioral therapy have been developed and clinically evaluated for mental illnesses. As part of a clinical study, Doherty and colleagues showed its benefits for patients suffering from depression. The interaction between software and real therapist is of utmost importance when using computer systems to implement cognitive behavioral therapy [31].CANKADO assumes that therapy adherence brings about the healthy behavior while a lack of adherence shows the learned problematic behavioral patterns. CANKADO is meant to lead the patient from a lack of adherence to adherence by using both conventional elements of cognitive behavioral therapy and playful elements. Based on Doherty's approach [31], CANKADO provides patient care by means of a combined system of computer application and therapists where the physician in charge takes on the role of the therapist. CANKADO is designed according to the three phases of cognitive behavioral therapy. Special focus is placed on communication of information relating to disease, therapy and side effects. In addition, the therapy calendar together with its reminder functions conveys the desired alternative behavior (therapy compliance). The alternative behavior is further developed by the gamification approaches. The patient gets rewards for correct behavior on various levels. Behavioral corrections in critical situations (e.g., lack of ingestion of medication or documentation compliance, side effects) are done by feedback in the system and information transfer to the physician as well as consequent personal interaction. The alternative behavior is stabilized by an increasing range of incentives and the expansion of the gamification portfolio. Assessment of the situation and relapse analysis are achieved by static preparation and graphical representation of patient behavior and its development. Gamification is also offered for physicians using virtual competitions among peers, personal feedback and rewards. Elements of competition are entirely qualitative and not quantitative factors. Outstanding achievements are highlighted and virtually rewarded.eHealth as an essential part of future oncological managementIn conclusion, initial experiences show that cancer patients and their physicians are open for new web-based systems to support their communication and thus potentially enhance therapy adherence. Web-based eHealth tools for physician–patient interaction carry great promise but need to take numerous legal aspects into account. Next to individual countries' legislation, the European data protection directive for electronic communication 2002/58/EG needs to be observed. Moreover, data security, pharmacovigilance, therapeutics advertising act and medical devices act have to be considered. Once these issue are solved, novel eHealth will become essential parts of future oncological management. In order not just to capture patients' and physicians' interest temporarily but also to maintain this interest during therapy, mere information provision is not sufficient. Intelligent tools will need to apply gamification in order to succeed in clinical practice.Financial & competing interests disclosureThe authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.No writing assistance was utilized in the production of this manuscript.References1 Hadji P, Blettner M, Harbeck N et al. The Patient's Anastrozole Compliance to Therapy (PACT) Program: a randomized, in-practice study on the impact of a standardized information program on persistence and compliance to adjuvant endocrine therapy in postmenopausal women with early breast cancer. Ann. Oncol. 24(6), 1505–1512 (2013).Crossref, Medline, CAS, Google Scholar2 Banna GL, Collova E, Gebbia V et al. 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ACM (2012).Crossref, Google ScholarFiguresReferencesRelatedDetailsCited ByPRECYCLE: multicenter, randomized phase IV intergroup trial to evaluate the impact of eHealth-based patient-reported outcome (PRO) assessment on quality of life in patients with hormone receptor positive, HER2 negative locally advanced or metastatic breast cancer treated with palbociclib and an aromatase inhibitor or palbociclib and fulvestrant17 May 2023 | Trials, Vol. 24, No. 1The technological intervention in e-health management: evidence from Thailand18 October 2022 | International Journal of Human Rights in Healthcare, Vol. 51eHealth solutions for therapy management in oncologyTanja K Eggersmann, Nadia Harbeck, Timo Schinkoethe & Christoph Riese2 February 2018 | Breast Cancer Management, Vol. 6, No. 3 Vol. 4, No. 1 STAY CONNECTED Metrics History Published online 7 January 2015 Published in print January 2015 Information© Future Medicine LtdKeywordsadherenceCANKADOeHealthgamificationpatient managementFinancial & competing interests disclosureThe authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.No writing assistance was utilized in the production of this manuscript.PDF download
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