The widespread availability of smartphones and their expanding capabilities have presented new opportunities for improving the delivery of healthcare. ONCOassist is an app designed to help oncology healthcare professionals in their day-to-day work. Its growing list of clinical decision support tools includes adjuvant chemotherapy calculators, AJCC staging information, CTCAE toxicity criteria, and prognostic and other useful clinical calculators. This information is designed to improve the efficiency of oncology clinicians. We now have 2,800 active users per month and Google Play and iTunes feedback has been very positive. For example 29 out of 30 gave ONCOassist 4 or 5 stars out of 5 on the Google Play Store.¹ Ongoing development will include the addition of an adjuvant breast cancer tool and new prognostic algorithms. ONCOassist can be downloaded through Apple or Google AppStores and is free of charge for Irish users once signed up.

Introduction

Since the launch of the iPhone in 2007, usage of smartphones has grown year on year. It is estimated that by 2021, 6.3 billion people will own a smartphone, representing 70% of the world’s population.² Just like PCs before them, the smartphone has now become a must have for those in the workplace. This has presented new opportunities for improving the delivery of healthcare, including that of increasing the efficiency and accuracy of oncology healthcare. 

A study from Manhattan Research in 2012³ reported that 87% of doctors now use smartphone apps on a daily basis when making medical decisions. More than 80% of these choose the iOS operating system (iPhone/iPad) as their preferred platform. 

In 2011, while we were studying for our Master of Electronic Business in UCC, there was an emphasis placed on healthcare and the need for innovation in this space. With an ageing population stretching the capacity of the healthcare system and those working in it, the current system will be unable to manage without expanded capacity.³ Innovation in digital health and telehealth was seen as a way to help bridge this gap and free up healthcare professionals’ time. 

After initial discussion with Dr Richard Bambury, who was a specialist registrar in medical oncology at the time, we identified a need for the development of a tool similar to Adjuvant! Online, but available in smartphone format. The specific use involved having the ability to access adjuvant calculators on a smartphone or tablet device, rather than having to find a computer, access the relevant website and print the result of the calculation before returning to the patient and showing it to them. This would result in clinicians saving time. 

This initial scope of the project was later developed and improved based on interaction and feedback from the Irish and international oncology community.  

Validation of unmet need

In order to validate the need in the market for an app like ONCOassist, we did initial research into the number of oncology professionals globally. We also reviewed the number of other oncology-related apps on the market. 

We estimated that there was a total of 100,000 oncologists in the world, ASCO (American Society of Clinical Oncology) membership was 35,000.⁴ Further research has shown us that the breakdown of medical oncologists in the EU5 is estimated as per Table 1. Although this could be considered a relatively small market compared to other products, we felt that the market need and opportunity was sufficient enough to warrant further development.  

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We also identified that, although apps like Epocrates and QxMD were on the market, they did not cater specifically for the needs of oncology healthcare professionals. We measured the popularity of these apps by examining AppStore ratings and by discussions with their users.

We carried out an initial survey to get direct feedback from Irish oncology professionals which confirmed the need among oncology healthcare professionals for a smartphone decision support calculator to help with decision-making. A total of 18 oncology professionals took part and the result of the survey showed an overwhelming positive response to the need for validated decision aids to help with adjuvant decision support. Only one of the 18 oncology professionals (5.6%) answered no to the query on whether a decision support tool with statistical information (eg. web-based tools) would help in making decisions.

We also found that the overwhelming majority of Irish oncology professionals were iPhone users in comparison to Android users (28 of 30 answering this question were iPhone users, two Android users). This reflected the global trend at the time. 

Initial beta development phase and pilots

Based on this initial background research we decided there was adequate interest to continue to develop ONCOassist. We therefore decided to go ahead and build an alpha version for early market testing. We developed this for the iOS platform only, based on our initial market research. 

We were accepted to the Ignite Business incubator programme in UCC where we planned to develop a beta version of ONCOassist. After a competitive application and interview process we were one of seven teams accepted to the Healthbox Accelerator programme in London. This three-month programme chooses promising early-phase healthcare start-up companies and provides them with funding, mentorship and networking opportunities.

The initial version of ONCOassist contained some prognostic algorithms, adjuvant tools for lung cancer and gastrointestinal stromal tumour (GIST), and useful oncology formulas. The plan was to launch ONCOassist, collect user feedback and further develop the app based on this. 

We launched initial pilots with oncology professionals in Ireland through Cancer Trials Ireland (then called ICORG) and in the UK through the Clatterbridge Cancer Centre. We worked with a student (Sinead Walsh) from the Master of Business Economics programme in UCC, to help with the set up and management of the pilot programme. ONCOassist was piloted by 48 oncology professionals and this was followed with a survey and interviews of pilot users. A total of 37 professionals downloaded ONCOassist and of these, 18 answered an anonymous survey comprising 23 questions. We also carried out five interviews.

This initial pilot confirmed the need for a tool like ONCOassist in oncology clinical practice, but also outlined the need for further features and tools to make it more useful to oncology professionals. This was confirmed by Sinead Walsh’s thesis: “The findings reveal that the app is in theory beneficial and the majority feel that they are ‘moderately informed’ regarding decision-making using the app. However, in order for it to be fully useful to the oncologists, the company needs to work on developing the app further to include a whole host of additional features that are used daily in the area of oncology.”⁶

Based on feedback from this survey, ONCOassist was further developed. By having a feedback tab prominently displayed in the app and by directly emailing those who downloaded the app we found the users who piloted ONCOassist were very forthcoming in giving feedback on how ONCOassist could be improved. 

User-based development approach

Early on in development we decided to take a user-based approach to the development of ONCOassist, by regularly interviewing and surveying our userbase to drive innovation.

We followed a lean start-up approach, a derivative of the lean manufacturing model as developed by Steve Blank and popularised by Eric Reiss. 

This approach focuses on the needs of the end user and encourages developers to create a feedback loop between the end user and the development team; it encourages a continual process of ‘build-measure-learn’.⁷ This minimises the likelihood of developing features that won’t be used and is now considered a best practice in the development of software products.

CE approval – classification as medical device

ONCOassist was one of the first apps in the world to be CE approved. This is the European equivalent of FDA approval and means that ONCOassist is classified as a medical device.

This classification and its ongoing management took a number of months to complete. The process involved input from a technical, clinical and regulatory perspective. It included the writing of a clinical evidence report which underpins all of the tools and content we have in the app. 

Partnership with European Society of Medical Oncology

We began engaging with the European Society of Medical Oncology after an initial meeting at the ASCO Annual Congress in 2012. We were in regular contact with them and a product like ONCOassist had been requested by their members. 

In September 2014, we were invited to attend the ESMO Annual Conference in Madrid, Spain to demonstrate ONCOassist in the ESMO members lounge over a three-day period. After the demo, users were asked to complete an anonymous survey which was then submitted to ESMO. 

A total of 78 ESMO members were surveyed and the results were overwhelmingly positive. A total of 83% of those surveyed said ONCOassist would be ‘very useful’ or ‘extremely useful’ in their clinical practice (see Figure 1), while 59% said they would use it every day and 33% said they would use it once a week.

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As part of the survey we also asked what other tools were needed to meet the demands of oncology clinicians. The replies included the following: 

• An adjuvant breast cancer tool

• Additional units such as mg/dl for using calculators such as the Body Surface Area and Cockcroft-Gault calculator in a European setting

• Development of an Android version and a web app. It was found that there was a significant enough number of Android users to warrant the development of an Android version

• Addition of additional prognostic algorithms.

Based on this survey ONCOassist was licensed and endorsed by the European Society of Medical Oncology. In May 2015 it was distributed to 12,000 of their members globally.

Planned future developments and research

We are continuing to develop and improve ONCOassist based on feedback from our userbase. Over the coming months, we plan to add the following :

• A breast adjuvant tool. We have partnered with Cambridge University and will be using the Predict algorithm (www.predict.nhs.uk) in the development of this

• Ability to share results via PDF attachment to emails or printing

• Ability to personalise profile using a favourites section

• New prognostic algorithms including Barcelona Score, M-IPI score (mantle cell lymphoma), IPI for aggressive lymphomas 

• Information around genomic profiling of patients

• An interactive drug interaction checker.

A longer-term aim is to allow ONCOassist to seamlessly integrate with electronic health records. This would result in patient variables auto-populating our calculations and further speed up the process for healthcare professionals. 

We would also like to conduct a study that monitors the efficiency gains as a result of ONCOassist in the Irish oncology setting. This could be quantified based on time saved by healthcare professionals. We are currently looking for funding and a partner to work with us on this. 

Key findings

Based on our experience in the market we have identified a need for apps like ONCOassist. This has been validated by our growing userbase and AppStore feedback. We now have 2,800 active users per month and AppStore feedback has been very positive. With more tools we believe we can grow our userbase even more significantly over the coming years. 

In the development of software products like this a certain tipping point must be reached. Early versions of the product did not get significant traction – they were often rarely used and the importance of engaging with your userbase to get feedback to improve the app cannot be understated. 

We also realise that there is a never-ending scope for improvement. By continuously engaging with our userbase and getting feedback we will continue to improve ONCOassist over the coming years.

Apps like ONCOassist could be developed for other specialties and we have been approached by specialist clinicians in other areas. However, given our growing expertise in oncology we feel it is best to focus on ONCOassist for the foreseeable future. 

We would like to use this opportunity to extend a sincere thank you to the Irish oncology community for all your feedback and words of encouragement over the past number of years. 

If you have any questions about ONCOassist or anything mentioned in this article, please feel free to email us at
Email: feedback@oncoassist.com

References

1. Android. ONCOassist - Google Play Store. https://play.google.com/store/apps/details?id=com.oncoassist.core&hl=en (accessed 20 June 2016)
2. Ericsson. Ericsson Mobility Report. : ; 2016. https://www.ericsson.com/res/docs/2016/ericsson-mobility-report-2016.pdf (accessed 20 June 2016)
3. Google/Manhattan Research. Screen to Script The Doctor’s Digital Path to Treatment. U.S.; 2012. https://ssl.gstatic.com/think/docs/the-doctors-digital-path-to-treatment_research-studies.pdf (accessed 20 June 2016)
4. Harbourside Press. The ASCO Post - Rate Card . http://www.harborsidepress.com/wp-content/uploads/rate-cards/Rate_Card_TAP_2016_WEB.pdf (accessed 20 June 2016)
5. Campbell D. NHS cannot cope with ageing population, warns top doctor’, 
6. The Guardian: https://www.theguardian.com/society/2015/jan/19/nhs-we-have-not-fit-for-future-warns-top-doctor-bruce-keogh
7. de Azambujal E, Ameye L, Paesmans M, Zielinksi CC, Piccart-Gebhart M, Preusser M.
8. The landscape of Medical Oncology in Europe by 2020. Annals of Oncology, 2014
9. Walsh S. What is the users perception of ONCOassist and what benefits does it offer in the hospital setting.  Department of Economics, University College Cork, National University of Ireland. January 2013
10. Blank S. Why the lean Start-Up changes everything. Harvard Business Review. 2013, May