Discussion
PROM, tumor
MINOR, TUMOR
The IePRO model of care supports the detection and timely management of symptoms of patients treated with ICI. It represents a pragmatic research approach to the use of ePRO data in the context of two university hospitals that retain minor differences in resources and infrastructure, standard operating procedures, and care culture. It describes workflow changes that exist in parallel to usual care, complementing clinical activity and outlining a closed feedback loop between patients and care providers based on electronic monitoring of PRO data.We consider this model of care to have notable strengths. Due to the potential of symptomatic IrAEs to become chronic conditions, there is a need for forward-looking transformations in care delivery that focus on both short and long-term care [The model ensures patients receive tailored feedback every weekday they complete a questionnaire, without the requirement of a hospital visit. This closed feedback loop attempts to value the time patients invest in symptom reporting and encourage patients to continue self-monitoring.Some challenges relating to future implementation, patient engagement, the triage nurse role, and the clinical and technological burden remain. There are no CNS and nurse practitioners available in one of the sites, and thus, the triage nurses are likely to more often strictly rely on physician collaboration to manage symptoms. In the same site, physician teams are less differentiated across tumor types, which may simplify the flow of information with nurses. E-mail reports for mild to moderate symptoms may not facilitate as timely of an intervention as direct telephone or face-to-face contact. However, the care teams agreed it would be the most effective way to request multidisciplinary support and update all relevant parties on patient status. This may increase the burden on triage nurses to obtain a timely reply. An integrated system in the EHR could potentially save time and provide a clearer transfer of responsibility across the oncology team.The allocation of dedicated resources is recommended for successful implementation of PRO data in routine care, as there is the possibility of increased clinical burden [Features of electronic applications clearly play a role in patient engagement and compliance, with integrated communication with care providers and other patients being among the most desirable functionalities, which is included in the Kaiku Health app [Data collection concerning the acceptability of the model of care from the provider’s perspective will take place after the trial and will be analyzed and disseminated in a later stage of the project. It is unclear how patients will perceive the novel role of the triage nurse and how it may interfere in their relationship with other providers like the CNS. International guidelines for managing IrAE often require skills, such as prescribing medication and diagnostic tests that most nurses in Switzerland cannot autonomously enact. While close collaboration with physicians in symptom management is essential, the lack of autonomy increases the complexity of the workflow and introduces additional points of failure. Further standardization of practice and continued investment in advanced nursing practice roles may further optimize care delivery and improve the model. Because IrAE management guidelines do not primarily focus on self-management support, some variability in what interventions are put in place by triage nurses is likely. More comprehensive self-management support coverage in those guidelines would empower nurses and patients and further clarify how beneficial outcomes can be achieved [The development of this model benefited from the collaboration with a patient-representative to assess the tools and PROM used in its different components. This triggered deeper discussions with the care team, relating to symptom management and administrative challenges. As patients’ acceptability of the model of care is assessed, we believe future iterations also stand to gain significantly from deeper patient and public involvement.