Mobile-deployed care management based on standardized ePRO and computer-interpretable guideline engine for Chinese lymphoma patients.

1 Background: To effectively assist lymphoma patients and their care-givers after their hospital discharge, a standard follow-up guideline for lymphoma patients was designed and encoded through a computer-interpret-able-guideline (CiG) engine and deployed through mobile-Web and mobile-Apps to ensure continuous care throughout the treatment and recovery processes. Methods: Scheduled tasks including ePRO questionnaires and requests for test results were sent for completion, and a virtual care management team was assigned to ensure compliance and respond to automatic triggered alerts. Attending oncologists also were given mobile-Apps to access the patients’ securely uploaded records and consult remotely to manage side-effects after discharge. The out-of-hospital record management and care coordination enabled the adjustment of treatment plans and the optimized unitilization of clinical resources. Results: During 2018, 1012 patients or their caregivers interacted with our team through the mobile platform after discharge. 856 individual patients uploaded enough information to be initiated in the mobile follow-up program. Approximately 30% of these patients were Beijing residents while the rest came from all over China. About half of these patients had follow-up tests done in other 387 hospitals or 52 clinics. Based on ePRO questionnaires submitted, 218 patients had 616 side-effect-symptom alerts triggered and followed up, in addition to patient-initiated mobile consultation with their attending oncologists. Lab results especially white blood cell counts, platelet counts, and neutrophil counts, contributed to the majority of test alerts managed by our team. Analysis of 8000+ anonymized questions identified clinical processes in need of optimization. A new patient education manual addressing frequently asked questions, and new processes such as chemo-regime scheduling were put in place. Conclusions: We have demonstrated the feasibility of a mobile-deployed care management process after discharge for lymphoma patients and their caregivers. We have initiated retrospective studies of impacts on our patients’ treatment compliance and quality of life.