Is telemedicine a viable option for the treatment of patients with hematologic malignancies?
Telemedicine — which, in reality, could just be talking on the telephone with a patient — has gradually developed to include technological tools, such as internet access and live video, that can enhance the doctor-patient relationship.
Operationally, patients with hematologic malignancies frequently require aggressive therapy, during which they need to be seen at a facility that can manage them safely. So, the initial interaction with the patient must be face-to-face. However, midcycle visits, during which a patient does not get chemotherapy but is monitored for side effects, can occur by telemedicine. Most side effects can be easily managed remotely via telemedicine if there is a clinical laboratory and nurse practitioner nearby. Once patients have completed therapy and are in the observation phase, they can be seen by telemedicine every 3 months for the rest of their lives.
At our center, we have restricted telemedicine to midcycle and follow-up visits. The initial visit requires the patient come in to see us, so we can examine them and create that human relationship so essential for a functional doctor-patient experience. Once that connection is in place, then the patient may never have to leave their home area for a doctor visit. Patients can easily go to a local laboratory to get a blood count and then follow up with us remotely with the assistance of a local nurse practitioner or physician’s assistant. Future technology may enable us to perform some degree of a physical examination without the nurse practitioner or physician’s assistant, but we will always require laboratory work for follow-up.
Multiple telemedicine visits can occur with minimal impact on the doctor’s schedule, and it is a much more efficient use of the patient’s time. We consider it absolutely no risk to the patient who visits a laboratory and a trained and trusted nurse practitioner; however, without those elements in place, there may be too much risk in trying to make a medical decision. A telemedicine visit also makes it easier to safely triage a patient’s complaint. If they are sick, we can have an “eyeball visit” to determine whether we need to send an ambulance, recommend they go to the hospital, or have them take aspirin and call us in the morning.
Telemedicine requires a moderate investment. In California, rural facilities are already part of telehealth networks with large academic centers with which they have contracts for emergency room back-up. It requires a little software and IT staff to make sure the communication is HIPAA compliant. There may be financial advantages, too. Although we haven’t personally been able to measure savings to the health system, we’re pretty sure that it reduces emergency room visits.
Currently, using a common video platform like Skype is problematic because of privacy concerns. Smarter telemedicine consisting of interactions with the doctor from his/her home communicating with the patient directly at their home in a HIPAA-secure experience is likely the future. The only consistent patient complaint is, “Doc, I miss the hugs.”
Laurence J. Heifetz, MD, FACP, is medical director of Gene Upshaw Memorial Tahoe Forest Cancer Center. He can be reached at email@example.com. Disclosure: Helfetz reports no relevant financial disclosures.
Hospitals and doctors’ offices have employed telemedicine for patients with hematologic malignancies for decades, except not in a smart, efficient way. Phone calls back and forth between the patients and nurses or doctors are a primitive form of telemedicine; however, without the advantage of an electronic platform it was uncoordinated and inconsistent, and documentation was poor. So, it was hard to measure impact. Digital platforms have allowed us to make telemedicine communication, dialogue and patient assessment much more efficient and functional. The advantages of telemedicine are clear, and it is opening opportunities that were never available before.
There is an opportunity for more treatment education for the patient and family. Remote consent is becoming available online for clinical trials. Further, many patients get the bulk of their care from local physicians. Community oncologists are extremely proficient, but when it comes to rare diseases or highly complex malignancies, they might not have all the knowledge to be able to address patient questions in real time. Telemedicine can provide an opportunity for tele-consultations for both community physicians and patients. However, questions remain, including whether the impact on outcomes will be as significant as we hope. As we roll out these programs, it is important to have metrics to measure impact on patients and health care.
A very large proportion of patients we serve are elderly and, therefore, may not have access to digital platforms or be sufficiently computer literate. Another challenge is state licensing. At practices where the patient population comes from different states, institutions have to ensure physicians are licensed across all the states to practice medicine. So, a certain practical set of limitations remain to be addressed. Also, the landscape for payer reimbursement is not yet clear and, based on the metrics used now, it is hard to prove to payers the value of a professional telehealth encounter.
We must ensure these encounters are used in the most efficient way possible moving forward. It would be great if they were integrated with other digital health platforms to allow, for example, simple laboratory monitoring in real time. There is an entire industry right now focused on these digital health platforms, but it is a very dynamic landscape and the dust hasn’t settled yet on what is possible.
Telemedicine platforms are available and, if we can find a way to optimize their use and leverage telemedicine in the best way, it can transform all of health care. It’s a question of access, patient satisfaction and follow-ups that would otherwise be impossible to do. There are many benefits, but we have to address practical questions within the next few years.
Pierluigi Porcu, MD, is professor of medical oncology, dermatology and cutaneous biology at Thomas Jefferson University, and director of the division of hematologic malignancies and hematopoietic stem cell transplantation at Sidney Kimmel Cancer Center. He can be reached at firstname.lastname@example.org. Disclosure: Porcu reports funding or honoria from Innate Pharma, Kura Pharmaceuticals, Miragen, Seattle Genetics, Spectrum and Viracta.