PATIENT VOICES, a project for the integration of the systematic assessment of patient reported outcomes and experiences within a comprehensive cancer center: a protocol for a mixed method feasibility study
Authors: Brunelli Cinzia , Borreani Claudia , Caraceni Augusto , Roli Anna , Bellazzi Marco , Lombi Linda , Zito Emanuela , Pellegrini Chiara , Spada Pierangelo , Kaasa Stein , Foschi Anna Maria , Apolone Giovanni ,   on behalf of the PATIENT VOICES study group, Apolone Giovanni , Bellazzi Marco , Belli Filiberto , Borreani Claudia , Brunelli Cinzia , Capri Giuseppe , Caraceni Augusto , Casali Paolo , Corradini Paolo , de Braud Filippo , Foschi Anna Maria , Folli Secondo , Garassino Marina , Licitra Lisa , Nicolai Nicola , Pellegrini Chiara , Platania Marco , Procopio Giuseppe , Roli Anna , Salvioni Roberto , Spada Pierangelo , Valdagni Riccardo , Zito Emanuela 
Published: July 2020

Abstract
Background
Listening to “patient voices” in terms of symptoms, emotional status and experiences with care, is crucial for patient empowerment in clinical practice. Despite convincing evidence that routine patient reported outcomes and experience measurements (PRMs) with rapid feed-back to oncologists can improve symptom control, patient well-being and cost effectiveness, PRMs are not commonly used in cancer care, due to barriers at various level. Part of these barriers may be overcome through electronic PRMs collection (ePRMs) integrated with the electronic medical record (EMR). The PATIENT VOICES initiative is aimed at achieving a stepwise integration of ePRMs assessment into routine cancer care. The feasibility project presented here is aimed at assessing the knowledge, use and attitudes toward PRMs in a comprehensive cancer centre; developing and assessing feasibility of a flexible system for ePRM assessment; identifying barriers to and developing strategies for implementation and integration of ePRMs clinical practice.

Methods
The project has been organized into four phases: a) pre-development; b) software development and piloting; c) feasibility assessment; d) post-development. A convergent mixed method design, based on concurrent quantitative and qualitative data collection will be applied. A web-survey on health care providers (HCPs), qualitative studies on patients and HCPs (semi-structured interviews and focus groups) as well as longitudinal and cross-sectional quantitative studies will be carried out. The quantitative studies will enroll 600 patients: 200 attending out-patient clinics (physical symptom assessement), 200 attending inpatient wards (psychological distress assessment) and 200 patients followed by multidisciplinary teams (patient experience with care assessment). The Edmonton symptom assessment scale, the Distress Thermometer, and a tool adapted from existing patient reported experience with cancer care questionnaires, will be used in quantitative studies. A multi-disciplinary stakeholder team including researchers, clinicians, health informatics professionals, health system administrators and patients will be involved in the development of potentially effective implementation strategies in the post development phase.

Discussion
The documentation of potential advantages and implementation barriers achieved within this feasibility project, will serve as a starting point for future and more focused interventions aimed at achieving effective ePRMs routine assessment in cancer care.

Trial registration
ClinicalTrials.gov (NCT03968718) May 30th, 2019.