Objective: Our goal was to evaluate the feasibility of using a mobile app to assist with PN services within cancer control programs.
Methods: Seven navigators in 6 geographically diverse PN programs evaluated the mobile app over a period of 5 to 9 months by using the app to track their daily activities. We evaluated the app’s capability for collecting and reporting core data elements, such as time spent on outreach, patient care, and administrative tasks, as well as standardized metrics for program evaluation and monitoring. We obtained qualitative data during calls with the navigators through weekly journals and in-depth interviews.
Results: The app was effective in tracking caseload, profiling patients’ health challenges and barriers to screening and treatment, and capturing PN activities performed during patient encounters. App limitations included an unreliable reporting function, a requirement for internet connectivity, patient privacy concerns, and evolving technology.
Discussion: Lessons learned from this evaluation will be useful in developing an app with more robust capabilities while retaining user-friendly features.
Conclusion: Mobile technology may reduce individual and health system barriers to accessing cancer care and treatment and support posttreatment cancer survivors while also assisting navigators in conducting their work efficiently and effectively.
Cancer patient navigation (PN) is a process that assists cancer patients and their families by reducing barriers and facilitating timely access to health and psychosocial care across the cancer continuum from screening through treatment, survivorship, and end of life.1,2 Patient navigators provide culturally sensitive services to provide health education, address patient barriers to care, and provide psychosocial support, particularly among the medically underserved.3 Patient navigators interact with a variety of individuals besides patients as they facilitate care and treatment. Patient navigators frequently engage with families of cancer patients to assess and mitigate care and treatment challenges. They also build and maintain a network of providers and services, coordinate care among them, and keep these entities apprised of the needs and concerns of the patient. PN is considered such an essential component of quality cancer care that it is required for accreditation by the American College of Surgeons Commission on Cancer.4
The Centers for Disease Control and Prevention (CDC) administers the National Comprehensive Cancer Control Program (NCCCP) to support US states, Pacific Island jurisdictions, territories, tribes, and tribal organizations in their comprehensive cancer control efforts.5 Through this funding, jurisdictions work to reduce health disparities across the cancer continuum by supporting cancer prevention and early detection efforts and to increase access to quality cancer care and quality-of-life programs and activities among cancer survivors.5,6 The NCCCP recognizes PN as an effective public health strategy to reduce cancer burden7; however, the field lacks a formalized and consistent infrastructure to conduct and measure navigator activities applicable to cancer prevention and control.
For PN to have increasing relevance in the field of cancer control and prevention, standardized data collection and concordant outcome measures to make meaningful comparisons across diverse programs and populations served are needed.8,9 Mobile technology has been increasingly used in chronic disease management10 and survivorship11 and can assist the field of PN in the collection of data related to standardized metrics, such as those identified and recommended by the Commission on Cancer, the Academy of Oncology Nurse & Patient Navigators, the National Navigation Roundtable, and the Oncology Nursing Society.4,12-14 A mobile application (herein, app) could benefit navigators by supporting communication with patients, care providers, and services, while also enabling access to the systems they need to conduct reporting. This potential to automate many of the tasks that take time away from interactions with patients may increase the productivity of patient navigators. In support of these needs, we collaborated with Project ECHO (Extension for Community Healthcare Outcomes) staff at the University of New Mexico to adapt a mobile app previously developed for use by community health workers within their endocrine program. The mobile app was adapted for this study to provide a data entry and reporting tool enabling oncology patient navigators to document, track, and report on basic health information, cancer continuum, barriers to care, and PN efficiency. The goal of this project was to evaluate the feasibility of using this adapted mobile app to assist with PN services within cancer control programs. We present the findings of this feasibility testing among 6 different cancer control programs in the United States.
Mobile App Design
The app, designed for use on a Google Nexus 9 (Android) tablet, contained 4 main sections: Education, Collaborate, Calendar, and Patients. The Education tab contained a variety of educational resources for both the patients and navigators. The Collaborate tab provided a link to videoconferencing, and the Calendar tab had a customizable Google calendar. Navigators entered patient information in the Patients tab. This tab contained several other patient forms, including a comprehensive patient assessment, an encounter form, a barrier/resolution list, and patient care plan.
Site Selection and Recruitment
Seven navigators in 6 geographically diverse PN programs evaluated the mobile app (Figure). Of the 6 programs, 3 were specifically focused on assisting medically underserved populations: 2 programs served tribal organizations, and 1 program was located in the Appalachian region. For this project, the navigators worked with individuals to access breast, cervical, or colorectal cancer screening and/or treatment; however, navigator roles and workplace settings varied.
Data Collection and Analysis
For the purposes of the evaluation, app data were stored on servers at Project ECHO. Therefore, to protect their patients’ personally identifiable information (PII), navigators entered deidentified patient data and PN activity data into the app over a period of 5 to 9 months. Throughout the evaluation, the investigators (with expertise in PN, research, evaluation, epidemiology, and public health) reviewed the data entered into the app by the navigators to evaluate the app’s capability of collecting and reporting core data elements and standardized metrics for program evaluation and monitoring across programs, including time spent on outreach, patient care, and administrative tasks, and the types of encounters navigators engage in (phone, home visits, clinic visits, etc). DeLone and McLean15 provide a framework for measuring information systems success that includes 6 interrelated dimensions of information systems success: system quality, information quality, information use, user satisfaction, individual impact, and organizational impact. In our evaluation, we gathered data to assess the app in terms of these criteria. We obtained qualitative data through monthly check-in calls, weekly journal entries, and in-depth interviews with navigators at the end of the pilot period. The interviews included a mix of closed- and open-ended questions. Additionally, the project team assessed the app for its ability to aggregate data across programs, ease of use, customizability, and overall usefulness for navigators, administrators, re searchers, and evaluators. The evaluation was deemed public health practice and exempt from review by CDC and Westat institutional review boards. Analysis of qualitative data was descriptive. We reviewed interview transcripts, meeting notes, and journal entries to explore emerging themes and discussed appropriate coding among the project team.
Table 2 delineates specific app capabilities and the benefits and limitations in the areas of patient care and management, program management, app functionality, and data security. Navigators described navigating through the app as being intuitive and user-friendly. Specific benefits included tracking of patient barriers, access to resources, portability, security of the tablet, and the paperless nature of the app.
The app enabled navigators to characterize time spent with patients, effectively drawing attention to areas where the patient needed care. Several navigators noted that using the app was better than the existing mode of documentation (1 or multiple Excel spreadsheets) in their programs. For these navigators, especially, the app provided significant improvement for organization and planning. Navigators stated that a calendar dedicated to navigation activities in the app was helpful to track daily appointments and time spent throughout the month. The app allowed navigators to set reminders, “invite” patients to appointments, link to Google Maps to provide directions, and categorize activities at a higher level (clinic visit, community visit, pre-visit work, etc). PN program managers noted that capturing time spent, PN activity codes (codes related to the PN activity or activities performed during an encounter or calendar event), and encounter types improved documentation of activities. Program managers stated that documentation, for example, showing a reduction in time between diagnosis and treatment or showing that fewer patients missed or rescheduled appointments, could provide evidence of the utility of PN when reporting to grant funders or program administrators.
In terms of app functionality, accessibility in both online and off-line modes was a useful feature of the app. On the other hand, there were several noteworthy problems navigators identified with functionality. Some navigators experienced technical challenges to data entry (repetitive fields, duplicated ID numbers, etc). Navigators described being unable to print resources or reports from the tablet, lack of connectivity to electronic medical records (EMRs), and wireless Internet connectivity issues as the most significant limitations to their use of the app.
To enhance data security, the app required a secure log-in and PIN access. The app also contained an automatic log-out feature after 2 minutes of inactivity to ensure patient data were secure. Navigators, however, found the 2-minute window of the automatic log-out feature to be too short, given the nature of their interactions with patients. (This feature was not modifiable.)
Mobile technology can provide infrastructure for tracking PN processes and outcomes. The adapted app used in this study provided navigators with the capability to track their work, educational tools for use with patients, and project management tools such as aggregating data and running reports.
Navigators liked using the app because it was easy to use and captured data that were useful in their practice and for programmatic needs. Streamlining of the data collected in the app and connecting that information to data from the EMR would add significant value by reducing the data entry burden on navigators. Prepopulating fields across different parts of the app would help to ensure complete and accurate data. Because this app did not interface with EMRs and the data from one area of the app did not prepopulate to other areas, the feasibility of wide-scale implementation of this app in its current state is limited. It could, however, be useful to navigators without access to another patient tracking/data system, for example, navigators located in the community (like those associated with a public health program such as the NCCCP), rather than at a particular healthcare institution.
Our findings indicate the ability to create customizable reports is essential. Aggregated data on patient navigator–reported barriers, activities performed, time spent, contact type, and patient outcomes are important for PN program planning. These data could help PN program administrators and supervisors determine appropriate staffing, identify the PN activities and contact methods that yield the best outcomes, and identify areas where navigators need additional training. Aggregating PN data across cancer programs could help to better understand the needs of the larger community, such as access to transportation, translation assistance, and social support. Linking activities to outcomes may also help to provide justification to ensure program sustainability. In addition, these data may inform the NCCCP and other public health programs as they focus resources to particular populations. Finally, data aggregated across programs and regions could provide data for researchers to identify geographic disparities and share best practices with other PN programs.
Long-term compatibility with evolving technology will present challenges in future app development.16,17
As user behaviors, needs, and technology change, the app must be responsive to those changes. Creating an app compatible with multiple device types such as an iPhone, iPad, Android, or Windows device could increase flexibility and PN uptake. Access to a secure Wi-Fi or mobile network is essential for the app to work at its fullest potential; however, since not all areas of the country have this type of access, consideration should be given to the type of mobile device chosen and availability of Wi-Fi or other high-speed Internet access.
Security of PII is a priority, particularly when addressing the navigators’ most frequent suggestion, linking the app to their organizations’ EMR. App data are stored via a cloud/server that is maintained by a particular organization. Determining which organization should maintain PII and protecting the privacy of patients across multiple healthcare systems will continue to be a challenge. Enhanced security measures, such as a mobile device management service that provides improved security for mobile devices, may be considered to better protect PII.
In recent years, interest in improving and refining the PN process through the use of technology has increased, and several tools have been developed to accomplish this.11,18,19 However, at this time, free, publicly available systems that meet the needs of all cancer navigation programs with functionality to support all roles within and outside the program (patient navigators, outreach workers, program administrators, evaluators) do not exist. Other commercially available tools for conducting PN are available and include OncoNav20 and NurseNav Oncology,21 but these may be cost prohibitive in public health practice.
This evaluation is limited by the small sample size (7 navigators). In accordance with the Information Collection and Paperwork Reduction Act,22 we recruited 9 navigators to the pilot. Several of the navigators originally recruited could not complete the 8-month trial of the app because they left the jobs or roles they had at the start of the pilot. While we recruited navigators to replace the attrition, some of those navigators also had to drop out before using the app long enough to assess it. On the other hand, this pilot included navigators and programs representing geographic and programmatic diversity, allowing for responses from many different perspectives.
The need for standardized metrics to measure the effectiveness of PN programs and the desire for easy-to-use tools to assist navigators in conducting their work efficiently and effectively can be enhanced by mobile technology. A mobile app could help navigators reduce individual and health system barriers to accessing timely cancer care and treatment. The app may also assist navigators with tracking posttreatment cancer survivors needing support.
Based on these evaluation findings, it is important that future iterations of such publicly available technology be easy to use, have a customizable interface, and the ability to produce robust, customizable reports. Additional issues to address to make this technology more robust include compatibility with data systems navigators may already use, data safeguarding, secure storage of PII, long-term compatibility with evolving technology, and mobile connectivity.
Financial Disclosure: The authors have no financial disclosures to report.
Conflicts of Interest: The authors declare no conflicts of interest.
Human Participant Compliance Statement: This study was deemed public health practice and exempt from review by the CDC and Westat institutional review boards.
Disclaimer: The findings and conclusions of this paper are those of the authors and do not necessarily represent the official position of the CDC.
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- Oncology Nursing Society; Association of Oncology Social Work; National Association of Social Workers. Oncology Nursing Society, the Association of Oncology Social Work, and the National Association of Social Workers joint position on the role of oncology nursing and oncology social work in patient navigation. Oncol Nurs Forum. 2010;37:251-252.
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- American College of Surgeons. Commission on Cancer. Cancer Program Standards: Ensuring Patient-Centered Care. 2016 Edition. Chicago, IL: American College of Surgeons; 2015. www.facs.org/~/media/files/quali ty%20programs/cancer/coc/2016%20coc%20standards%20manual_inter active%20pdf.ashx. Accessed June 14, 2018.
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- Stewart SL, Lakhani N, Brown PM, et al. Gynecologic cancer prevention and control in the National Comprehensive Cancer Control Program: progress, current activities, and future directions. J Womens Health (Larchmt). 2013;22:651-657.
- Centers for Disease Control and Prevention. National Comprehensive Cancer Control Program (NCCCP). Increasing the Implementation of Evidence-Based Cancer Survivorship Interventions to Increase Quality and Duration of Life Among Cancer Patients. www.cdc.gov/cancer/ncccp/dp15-1501.htm. Updated April 12, 2016. Accessed August 14, 2018.
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- Battaglia TA, Burhansstipanov L, Murrell SS, et al. Assessing the impact of patient navigation: prevention and early detection metrics. Cancer. 2011;117(15 Suppl):3553-3564.
- Community Preventive Services Task Force. Diabetes Management: Mobile Phone Applications Used Within Healthcare Systems for Type 2 Diabetes Self-Management. www.thecommunityguide.org/sites/default/files/assets/Diabetes-Management-Mobile-App-Type-2.pdf. Updated March 14, 2018. Accessed June 14, 2018.
- Gehrke A, Lee SS, Hilton K, et al. Development of the Cancer Survivor Profile-Breast Cancer (CSPro-BC) app: patient and nurse perspectives on a new navigation tool. J Cancer Surviv. 2018;12:291-305.
- Strusowski T, Sein E, Johnston D, et al. Standardized evidence-based oncology navigation metrics for all models: a powerful tool in assessing the value and impact of navigation programs. Journal of Oncology Navigation & Survivorship. 2017;8(5):220-243.
- National Navigation Roundtable. Collective Action to Advance Patient Navigation. http://navigationroundtable.org. Accessed December 11, 2018.
- Oncology Nursing Society. 2017 Oncology Nurse Navigator Core Competencies. www.ons.org/sites/default/files/2017ONNcompetencies.pdf. Accessed December 11, 2018.
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- GW Cancer Center. Patient Navigation Barriers and Outcomes Tool (PN-BOT). https://smhs.gwu.edu/gwci/BarriersTool. Updated August 18, 2016. Accessed June 14, 2018.
- Highfield L, Ottenweller C, Pfanz A, Hanks J. Interactive web-based portals to improve patient navigation and connect patients with primary care and specialty services in underserved communities. Perspect Health Inf Manag. 2014;11:1e.
- OncoNav. Oncology Nurse Navigation Software. www.onco-nav.com/products/nurse-navigation-software. Accessed June 14, 2018.
- Oncology Navigation Software. Nursenav. www.nursenav.com. Accessed June 14, 2018.
- US Department of Health & Human Services. Information Collection and Paperwork Reduction Act (PRA) Overview. www.usability.gov/how-to-and-tools/guidance/pra-overview.html. Accessed December 14, 2018.