Minneapolis VA Health Care System

Front row, from left, are Connie Jaenicke, NP and hematology-oncology nurse navigator, and Lara Carson, RN, Annie program manager and MyHealtheVet coordinator; back row, from left, are Daniel Greenwood, MS, RD and program director for Patient Education and Connected Health, and Beverly Foss, RN and hematology-oncology RN case manager.

Veterans with cancer who undergo aggressive therapies often endure adverse effects. The worst symptoms, however, usually happen at home following chemotherapy or other treatment. To provide these Veterans with increased support for symptom management, a team at the Minneapolis VA Medical Center in Minnesota decided to enlist the help of Annie – VA’s new automated text messaging system.

“Patients know they are experiencing symptoms, but they don’t always know when it’s too much or how to react,” explains Connie Jaenicke, NP, Nurse Navigator in the Minneapolis Hematology/Oncology Department. “We worry about patients not seeking treatment for these symptoms early enough to avoid a hospitalization. This can worsen a patient’s quality of life unnecessarily, and delay or preclude future chemotherapy.”

Two years ago, Minneapolis became one of the first VA locations to participate in a pilot program to test the Annie system. Connie says around the same time, scientific studies had been published citing evidence that online self-management tools resulted in reduced cancer symptom distress and improved quality of life.

From Idea to Protocol to Study

As the idea germinated that Annie could be leveraged similarly, a clinical team from the Oncology Department convened that included Connie, along with Clinical Nurse Specialist Kathleen Nelson, Oncologists Dr. Mark Klein and Dr. Evan Mariash, Registered Nurse Bev Foss, and Physician Assistant Kim Smith. They also enlisted the help of Lara Carson, RN, My HealtheVet Coordinator, and Dan Greenwood, Program Director for Patient Education and Connected Health, to collaborate on mapping out a message protocol for symptom self-management.

From there, the group worked with members of the Annie Connected Care team to develop the protocol and then recruit 15 Veterans to participate in an 8-month study period. The final report they compiled, “Use of Mobile Messaging System for Self-Management of Chemotherapy Symptoms in Patients with Advanced Cancer,” was recently published in the August 2019 Supplemental Edition of Federal Practitioner.

Here’s how the study protocol worked: Annie sent Veterans text messages twice daily, Monday through Friday, asking them to rate a symptom using a (0-4) severity scale: absent (0), mild (1), moderate (2), severe (3), or disabling (4). Symptoms included nausea/vomiting, mouth sores, fatigue, trouble breathing, appetite, constipation, diarrhea, numbness/tingling, and pain. Veterans were also instructed that they could input a particular symptom, even if Annie hadn’t asked about it that day. In addition, Annie asked whether they had a fever or not.

When Veterans replied to a symptom inquiry, Annie would next send an automated message response that correlated with the severity scale: offer positive affirmation that they were doing well (0), give advice for home management (1), refer them to an educational hyperlink (2), ask them to call a direct number to the clinic (3), or instruct them to report directly to the emergency department (4).

The Results and What’s Next

While none of the Veterans reported disabling symptoms, all replied with symptom ratings and received self-management guidance. In a follow-up participant survey, Veterans offered many positive responses. None reported technology challenges, all said it was easy to do, and many felt empowered by the texting advice for symptom self-management.

“The most unanticipated response was how many Veterans said they felt validated when Annie said they were doing well,” Connie says. “That’s a tribute to the messages Lara and Dan helped us craft, like ‘Good job’ and ‘Happy to hear you’re not experiencing nausea.’”

Annie is now available for use at VA facilities nationwide. A wide range of Annie message protocols have been tested and nationally approved for use in assisting Veterans with self-care. Along with an updated version of the oncology protocol, there are protocols for blood glucose monitoring, hypertension, medication reminders, weight management, anxiety and many others.

Lara, who has also assisted in the development of other Annie protocols, explains, “As we move toward using technology more often, our hope is that it becomes just as important as prescribing a walker or medicine to help the patient at home.”