Introduction:
Children with cancer experience distressing and severe symptoms, yet routine monitoring in young people is rare. As a result, symptoms are often undertreated. High symptom burden is associated with increased hospitalisation, lower quality-of-life, poor treatment adherence and long term problems including post-traumatic stress disorder. As part of a larger project that aims to empower and engage children using digital health solutions, the objective of this study was to explore the congruence of symptom burden identified by healthcare providers with child self-report.

Methods:
This exploratory study had two phases. A clinical advisory group agreed upon relevance and importance of 15 symptoms; 10 from the Symptoms Screening in Pediatrics tool and an additional five commonly occurring symptoms in children’s cancer. In phase one medical records for the first 12 weeks of cancer treatment were reviewed from newly diagnosed children (8-18 years). Data were extracted regarding healthcare provider assessment of symptom occurrence. In phase two, a convenience sample of children undergoing active cancer treatment were recruited during scheduled appointments for chemotherapy. Child and parent proxy completed a survey about the 15 symptoms. The types and severity of symptoms were compared between healthcare provider assessment, parent proxy and child self-report.

Results:
There were 3,909 documented assessments by medical (54%), nursing (32%) and allied health clinicians (14%) regarding 25 children. The most commonly assessed symptoms were changes in appetite, nausea, pain and constipation. These clinical assessments identified 1399 occurrences of the 15 symptoms. Most common were nausea, pain, appetite and rash. Least common were changes in taste, feeling cranky, cognition changes and mouth sores. Sixty-eight children were recruited to Phase 2. Child report of symptoms causing the most distress were fatigue, sleep and changes in taste. The symptom causing the least distress were diarrhoea, feeling scared and headache. Parent proxy for total symptom burden (13.80) was similar to child-report (13.43), although parents frequently over and underestimated many symptoms and interrater reliability was weak (0.37, 95%CI -0.36 to 0.70, p=0.12).

Discussion:
Child report of distress from symptoms differs to parent and healthcare provider assessment and perception of symptoms. This incongruence is likely to limit effective symptom management. The symptoms causing distress to children are amendable to intervention, but only if there is awareness of the prevalence of symptoms.

Conclusion:
New strategies are needed to help healthcare providers to support and encourage children and their parents to communicate about distress from symptoms. Harnessing the capabilities of digital technology to provide a child-centric, integrated and systematic mechanism to monitor, report and communicate about symptoms is a promising solution.

Lessons Learned:
This study highlighted the importance of asking children themselves about their symptoms. Use of patient reported outcomes with children is feasible and acceptable.

Limitations:
These results are not conclusive; the small sample size may have biased findings.

Suggestions for future research:
Research is required to integrate digital health solutions into clinical practice across the care trajectory. Such solutions may empower children and families to communicate about symptoms and promote decision making between specialist and community healthcare teams.

An introduction (comprising background and problem statement): New health information technologies (HIT) are being rapidly developed to improve the delivery of mental health care; however, a range of facilitators, barriers and contextual conditions can impact on the adoption and sustainment of these solutions. Our implementation science protocol systematically guides the implementation of HIT-enabled solutions in traditional face-to-face and online mental health services, allowing for revisions over time based on retrospective review and constructive feedback from the services in which the solutions are implemented.

Theory/Methods: The protocol is comprised of four phases. The primary objective of the scoping and feasibility phase (Phase 1) is to determine the alignment between the service partner and the quality improvement goals supported by the HIT-enabled solution. Phase 2, the local co-design and pre-implementation phase, aims to utilise co-design methodologies, including service pathway modelling, participatory design and user (acceptance) testing, to determine how the HIT-enabled solutions could be used to enhance the service. During implementation (Phase 3), the accepted HIT-enabled solution is embedded in the mental health service to achieve better outcomes for consumers and their families as well as health professionals and service managers. Using iterative evaluative processes, the solution is continuously developed, redesigned, and refined, adapting to the changing needs of the stakeholders, including consumers with lived experience and their families, and the service. This optimised HIT-enabled solution can then be maintained in a service during the sustainment and scalability phase (Phase 4) for the purposes of mental health services reform.

Results: Currently, the implementation science protocol has been initiated in nine primary youth mental health services, a counselling service for veterans and their families, and a helpline for individuals affected by eating disorders and negative body image issues, all of which are operating in Phase 3.

Discussions: The international goal of substantially improving the quality of mental health services is central to many technology-based innovation implementation efforts in mental health service delivery. The greater the gap between the innovation and conventional practice, the greater the implementation challenge. With the aim of avoiding obsolescence of the solutions, our implementation science protocol stresses the parallel and iterative evaluation of the effectiveness of the HIT-enabled solution alongside the success, or lack thereof, of the implementation.

Conclusions (comprising key findings): Putting in place a theoretically sound implementation science protocol is essential to facilitate the uptake of novel HIT-enabled solutions and evidenced-based practices into routine clinical practice for the purposes of improved outcomes.

Lessons learned: It is imperative to identify factors that predict the likelihood of implementation success as well as the development of strategies to proactively mitigate potential barriers to achieve better implementation outcomes.

Limitations: A complete implementation comprised of all four phases has yet to be completed, limiting data-driven refinement of the protocol.

Suggestions for future research: It will be important to validate the implementation science protocol in diverse healthcare organisations as a means by which to address key challenges to facilitate HIT-enabled reform.

Introduction

The use of mHealth tools in health care is increasing. However the understanding of their development and effective use is generally poor in the medical profession. Guidelines for effective impact evaluation of technology in Australia are scarce. There is also limited appreciation of the mechanisms by which technology enhances care co-ordination and health outcomes for the individual.

The creation of the Me & My Family phone application within the Healthy Homes and Neighbourhoods program (HHAN) has aimed to explore the development of a health and social care platform that will enable consumers to increase their health knowledge and health literacy in order to develop autonomous navigation of the health care system for themselves and their family. This is supported with evidence-based and sustainable health and social care information that has been developed within the program with a focus on health literacy and the utilisation of existing health materials from government and independent organisations. We describe the initial approach to development and the challenges experienced in this process.

Methods

A development plan was established prior to the commencement of the project. The development stages were divided into Exploration, Consultation, Design and Co-Collaboration, Consumer Testing, Modification and Re-test. Currently the development is in the Consumer Testing phase. The development plan outlined the aims of the application for use for both the health care worker (HCW) and consumer. Published literature, State and National guidelines were sought to inform the plan and the development process.

Results
Initial consumer and health care worker testing has shown that the application produced is user friendly and increases the confidence of the consumer in the reliability of the information they receive and ability to plan the health care for themselves and their family.

Discussions
mHealth applications encourage the individual to access and control their personal health information and health education. Integration of multiple health care resources and providers in one reliable platform allows the consumer to initiate health and social care needs.

The traditional trust in the health care provider has changed due to access to alternative sources of information that often conflicts with advice that is given. Utilising digital technology in an approachable manner allows this mistrust to be countered and the individual to develop better autonomy with personal health and social care. A consistent message is likely to improve health care engagement and outcomes.

A collaborative development model with HCW, management, consumers and designers allows the incorporation of tools that improve consumer engagement and the ability of the HCW to understand unmet needs and deficiencies in the health care system.

Conclusions
- A planned collaborative approach allows development of a product that will fulfil its aims.
- Consumers want technology that increases their health knowledge and control.
- Privacy of health care data is an important concern for both the health industry and consumer.

Lessons learned
A clear development plan and understanding of the consumer needs are integral to the production of a mHealth application.

1. Introduction
Healthcare spending represents 9.1% of GDP in Australia. A significant proportion of healthcare spending focusses on chronic diseases. In Australia, cardiovascular, chronic obstructive pulmonary disease, cancer and diabetes cost up to $27billion (36% of allocated health expenditure) in 2008-09. This number is only set to increase due to the ageing population.

2. Practice change implemented
The healthcare needs of those suffering from chronic diseases are complex and often require a multidisciplinary team approach. A patient-centred and community based management requires multiple medical specialities and allied health professionals to collaborate. Such a model has shifted healthcare into relying on digital means to ensure efficient communication between care providers and provide access for rural populations.

3. Aim and theory of change
While digital health is an emerging area of healthcare, concerns on all stakeholders lie with data privacy. Connecting diverse members of a patient’s care team across the whole health care sector requires a mobile-first, patient-focused cloud-based platform that can provide a safe and secure platform for collecting and sharing all relevant clinical information to facilitate multidisciplinary team meetings (MDT).

The aim was to fully digitise and shorten the MDT process from an average of 27 days per meeting to under 10 days, as well as provide significant cost savings of an estimated $1,000 per meeting associated with staff time, collecting and distributing information.

4. Targeted population and stakeholders
Initially, the platform is aimed at multidisciplinary care teams in oncology, given that it has been recognised and established workflow in cancer care.

5. Timeline
From June 2018 to January 2019, we co-designed with the MDT coordinator and clinicians, a workflow that allows them to manage all aspects of onsite and remote multidisciplinary team meetings in a mobile environment.

6. Highlights
The web-based MDT platform manages invitations, collecting and sharing of information from different sources, online presentation of information, instant sharing of results and archiving of summary records directly into the patient’s medical records.

The module was tightly integrated with the existing secure messaging platform, allowing clinicians to switch between a formal MDT meeting and ad hoc secure clinical information sharing.

7. Comments on sustainability
While most multidisciplinary teams (MDT’s) are run face-to-face, the ability to extend to virtual participation increases efficiency and leads to better patient outcomes by facilitating a seamless end-to-end digital approach.

8. Comments on transferability
The platform advocates a multidisciplinary model beyond cancer care, with early application in virtual discharge management, aged care and the wider chronic disease management in the primary and allied health sector.

9. Conclusions
The roll-out of the platform cut time to arrange and manage MDT meetings by 50%. A proactive user onboarding strategy helped the introduction of a new workflow.

10. Discussions
The success of this project was due to active co-design and constant feedback from clinicians in all phases from conception, design, implementation and optimisation.

11. Lessons learned
We observed that for existing MDTs it was important to first ensure the clinicians were fully comfortable with the new workflow, before they were open to virtual meetings.