Digital Health Navigation: An Enabling Infrastructure for Optimizing and Integrating Virtual Care Into Oncology Practice

As technological advances over the past decade have led to the miniaturization and affordability of consumerfacing wearables and digital wellness applications, these tools have taken on an increasing role in care delivery. The social distancing and self-quarantine requirements of the COVID-19 pandemic have significantly accelerated this trend. For example, consumer wearables, as well as other remote monitoring devices, have been increasingly implemented over the past year to remotely detect COVID-19 infections through continual physiologic data and temperature monitoring. However, it is imperative to ensure the quality of these aforementioned devices and applications, as inaccuracies can negatively affect clinical decision making and patient outcomes.


Introduction
As technological advances over the past decade have led to the miniaturization and affordability of consumerfacing wearables and digital wellness applications, these tools have taken on an increasing role in care delivery. The social distancing and self-quarantine requirements of the COVID-19 pandemic have significantly accelerated this trend. 1 For example, consumer wearables, as well as other remote monitoring devices, have been increasingly implemented over the past year to remotely detect COVID-19 infections through continual physiologic data and temperature monitoring. 2,3 However, it is imperative to ensure the quality of these aforementioned devices and applications, as inaccuracies can negatively affect clinical decision making and patient outcomes. 4 The impetus is that these devices will augment traditional health care services by enhancing patient access while simultaneously engendering self-care and patient activation. However, there remains considerable room for improvement with respect to the provision of virtual care services within the context of oncology. Specifically, there is a need for thoughtful implementation of the clinical workflows supporting these technology solutions, more robust frontline provider education, and consideration around primary access barriers for marginalized communities. The latter is salient because vulnerable populations (ie, low socioeconomic status, racial minorities, and rural settings) are characterized by poor broadband access, limited English proficiency, low income, and minimal health or technological literacy. 5,6 Furthermore, the existing evidence base for the effectiveness of digital health interventions (DHIs), such as telehealth, remote patient monitoring, and digital phenotyping, has been limited and yet to be scaled in oncology clinical practice. [7][8][9] We posit that the development of a new provider role within the oncology ecosystem, termed a digital health navigator (DHN), will help address many of the aforementioned concerns and harness the full potential of virtual care in oncology. Such a role has been previously described for behavioral health services in psychiatric patients 10 ; however, to the best of our knowledge, it has not been contextualized to oncology. Through the implementation of this role, we believe that digital inclusion for all patients with cancer is attainable, regardless of their background or knowledge level. This role will also help drive a digital therapeutic alliance between patients and the oncology care team that improves outcomes, patient experience, and reduces health care costs.

Job Description
The utility of DHN was first identified by Ben-Zeev and Drake in a 2015 article, wherein they outlined such patient-facing functions as providing education on the basic operation of devices, delivering culturally competent feedback on the data abstracted from these devices (ie, vital signs, patient reported outcomes, and sleep patterns), and identifying any follow-up action. 11 The intent, limitations, strengths, supporting evidence, and associated costs of these technologies will also be provided. 11 DHNs can help assess patient preferences, interest, literacy, and dexterity around these tools. 11 Of note, patients with cancer are a unique population who may face additional obstacles such as fragmented care, complicated treatment regimens, and inadequate communication with providers. [12][13][14][15] For example, Kitamura et al 16 found that many patients reported anxiety regarding the use of new technology, as well as a reluctance or difficulty to communicate with their providers, when using telehealth services for oncologic consultations.
For providers, DHNs can leverage up-to-date practical and regulatory knowledge to support and train the oncology care team. They will help streamline clinical workflows, troubleshoot implementation bottlenecks, personalize user interfaces, facilitate technological navigation (ie, patient portal access and utilization), and disseminate best practice, all with an eye toward maximizing the productivity associated with virtual care paradigms. Finally, it is highly plausible that a spillover effect of DHN utilization may improve provider wellbeing, and this is because of their ability to offset many nonpatient care elements of the clinical team's workload, often cited as a point of frustration, anxiety, and dissatisfaction. 17,18 DHNs should ideally be embedded within a comprehensive cancer care team, and this alignment best enables them to coordinate the provision of DHIs, address barriers to timely receipt of virtual care throughout all phases of the cancer care continuum, and gather data on trends in DHI utilization. DHNs can serve as a critical link between patients and providers, able to right-size DHIs for both stakeholder groups. Qualifications should be flexible, site-specific, and underpinned by a dynamic curriculum of continuous education on emerging technology platforms and digital tools (Table 1). Consistent with the scope of the role, antecedent professional backgrounds can be broad including but not limited to clinicians, nursing, case management, office staff, and medical assistants. 1 However, a history of working collaboratively with clinicians, administrators, and patients is essential along with emotional intelligence, experience with electronic medical records, and familiarity with medical terminology and standard clinical practices. Other core competencies should be informed by the skills necessary to drive DHI adoption, within a particular use case, by patients and clinicians as a one-size-fits-all approach is impractical ( Table 1).

Metrics of Success
The magnitude of success in the coordination of DHIs through DHNs can be assessed through a variety of patientrelated outcomes, ideally tailored to the specific use case. Examples include patient retention, improvements in health-related quality of life, patient engagement and selfcare, and reductions in acute care visits and treatment disruptions. These measures will need to be examined in future studies to promote widespread utilization of DHNs. For example, future researchers may prospectively assess the impact of the implementation of the DHN role on patientreported outcomes such as EuroQol-5 Dimensions, Patient Activation Measure, Functional Assessment of Cancer Therapy-General, and MD Anderson Symptom Inventory. Additionally, associated variation in the rates of acute care utilization (emergency room visits and hospitalizations) and total health care spending on an episode-of-care basis (30or 90-day episode) can also be assessed in a randomized or matched case-control basis. In addition to remote patient monitoring and technical support, DHNs will also be responsible for tracking patient adherence to clinician recommendations around DHI use. Finally, it will be crucial to also evaluate the long-term financial impacts associated with the DHN role, as it is highly unlikely to be directly reimbursed. The workload and number of patients taken on by each DHN will be greatly dependent on the health care setting (ie, clinic v hospital) and practice-based needs, and thus, it will need to be assessed on a case-by-case basis as this will factor into long-term financial costs. A useful benchmark to consider might be the published caseload for a layperson patient navigator, which is approximately 152 patients per quarter. 20 Approaches such as time-driven activity-based costing and cost-effectiveness analysis via decision trees and Markov simulation models will be beneficial in articulating a sustainable value proposition for DHNs to hospital or clinical practice administration.

Job Requirements Example of Navigator Roles
Associate or bachelor's degree in communications, business, healthcare administration, public relations, marketing, or relevant work experience equivalent 1-2 years of experience with health care clinical operations Strong understanding of cultural competency with the target population EHR experience Ability to work collaboratively with clinicians, administrators, staff and external third-party entities; bilingual (English and Spanish) preferred Computer and technology literacy. This includes core smartphone skills (Android and iOS) and basic technology trouble-shooting (application downloading, application data summarization, wifi connectivity, unknown ID and/or password, Bluetooth connection with wearables) Exposure to patients in a health-related field is preferred Excellent listening and communication skills. Ability to engage with patients in order to maintain application utilization. Assist with the maintenance of trust and transparency in order to aid in the technology-assisted care delivery process Excellent time management skills and ability to multitask Empathetic attitude with an ability to offer emotional support Preferred certifications: project management professional, certified associate in project management, professional in project management Patient eligibility and identification: Assessing digital health literacy and technology experience and delivery of education Robust education and onboarding of patients and caregivers to a particular technology platform Technical support, troubleshooting, and outreach as needed Monitoring patient adherence with technological platform Track and report appropriate patient-level quality outcomes (specifically quality of life) for technology program monitoring and evaluation Attend relevant stakeholder meetings to support the implementation, sustainment, and evaluation of technology platform or digital health intervention. Attend necessary conferences, seminars, and development opportunities that expand expertise and inform best practice Maintain appropriate documentation for regulatory compliance and reporting requirements with respect to a digital health technology platform Maintain compliance with relevant clinical departmental policies and procedures, such as JC standards, patient access to patient's own health information, patient safety, patient experience, and HIPAA privacy standards Ensure the implementation of a framework for digital inclusion with respect to access to services. As needed, recommend and connect patients and caregivers to community resources related to digital equity that can help overcome barriers Facilitate patient utilization of electronic medical record portal Abbreviations: EHR, electronic health record; HIPAA, Health Insurance Portability and Accountability Act; JC, Joint Commission. a Table contents are conceptualized on the basis of the patient navigator job description by the District of Columbia Primary Care Association. 19

Path Forward
To ensure successful execution of the DHN position within the health care system, staffing models and scope of practice must be clearly defined. Similarly, the training process needs to be standardized. Wisniewski et al 1 have previously proposed a 10-hour training and certification process that may be used as a framework in enacting this new role in an oncologic context. Much like traditional patient navigators who address barriers to clinical access and serve to reduce health disparities in marginalized communities, DHNs can similarly play an integral role in improving access and quality of care. As health systems continue to rapidly evolve with respect to the incorporation of digital health services within patient care, DHNs are uniquely positioned to promote health equity and patientcentered care. Given the tremendous potential for DHNs in oncology, it will be imperative to apply both change management methodologies and implementation science principles to better guide the durable deployment of this new health care role.
In conclusion, DHIs can provide a cost-effective, efficient, and safer way to remotely monitor and meaningfully engage with patients with cancer. Prior research has demonstrated that telehealth interventions may be beneficial within oncologic patients as these interventions can help reduce treatment burden and minimize disruption to these patients' lives. 21 Therefore, DHNs are an avenue toward realizing and maximizing the benefits of DHIs in oncology. The thoughtful implementation of digital health navigation will allow all patients with cancer to navigate the ongoing digital transformation of oncology care successfully and confidently.