Is home-based remote monitoring ready for prime time in oncology?
Click here to read the Cover Story, “Telemedicine in oncology: Virtual solution to a very real problem.”
About 20% of the oncology population lives in rural areas without close access to oncology care. The number of older oncology patients also is increasing and will acquire multiple medical comorbidities, so it is these patients who will have a particularly difficult time accessing care. Due to better therapeutics, patients with cancer are living longer and some are needing more active treatments, thus increasing the demand on access to care. There also is a predicted oncologist shortage, which will create a demand that might be more than the current oncology workforce can handle.
This is where the utility of telemedicine or telehealth comes in. Telehealth can provide care to those who don’t have easy access; telehealth can fill the gaps in care that result from lack of sufficient providers. Telemedicine enables the oncologist to provide cancer care to patients while remaining at the medical center. A telehealth visit typically mirrors a traditional face-to-face visit. The University of Utah has an active telehealth program, with telehealth services in cardiology, ICU and stroke, to name a few. Until recently, our oncologists were routinely travelling to Wyoming, Montana, Nevada and other areas of Utah to conduct in-person oncology visits. We have an interest in expanding telemedicine services and have recently started them at an affiliate center in Colorado. We perform virtual visits with patients who have been diagnosed with a blood cancer and have received a bone marrow transplant procedure. This has allowed patients to receive highly specialized care closer to their own home. We plan to expand these services to the rest of the Intermountain west population that we serve.
There are some data to support the use of tele-oncology. University of Kansas was one of the earliest centers to start doing telemedicine, where they deal with a large number of patients from rural areas. Gary Doolittle, MD, and colleagues showed that the quality of care was not compromised and that patient and physician satisfaction were very high. They also reported improved cost efficacy with telemedicine.
Since then, there have been other groups in Texas; Queensland, Australia; and British Columbia that have used telemedicine and reported similar satisfaction outcomes. Tele-oncology has also expanded to include associated services such as teleradiology, telepathology and palliative care services with symptom management. As an example, The University of Utah offers a type of telecommunications program where patients with cancer undergoing treatment can be remotely monitored for toxicities of treatment and are provided either self-management strategies by the system or contacted by a health care provider.
Although there are multiple small studies that have tested telehealth in oncology, to my knowledge, there is yet to be a randomized trial comparing tele-oncology to standard oncology care. However, in the areas of need, I don’t think a large, randomized clinical trial to prove tele-oncology to be noninferior or superior to standard-of-care treatment is necessary. If there’s a need — and, based on what we know so far about telemedicine, where it works for the population that needs it most — we should do it if the infrastructure allows.
Catherine J. Lee, MD, is associate professor of medicine in the division of hematology/BMT at Huntsman Cancer Center at The University of Utah. She can be reached at firstname.lastname@example.org. Disclosure: Lee reports no relevant financial disclosures.
There has been a lot of progress in home-based remote monitoring, and a lot of exciting research in this area. This includes clinical trials at Duke, such as our home-based hematopoietic stem cell transplant program, in which we mix house calls and physician-patient videoconferences to keep patients at home and out of the hospital, and our mobile health studies, in which we give patients iPhones and Apple Watches along with a custom app to track their health and activity. Other great studies include Project ECHO in hepatitis C, which is really advancing telemedicine, and Ethan Basch, MD, MSc, and colleagues’ study of electronic reporting of patient-recorded outcomes, which showed a significant survival advantage for patients with metastatic cancer. Home-based remote monitoring has tremendous potential.
At the same time, there is a large gap between an academic medical center utilizing home-based remote monitoring in a clinical trial, supported by an extensive research infrastructure, and implementing and disseminating these approaches in the wider practice of oncology. Even telemedicine, which has been practiced for decades, still grapples with several challenges, including reimbursement and licensure, as noted in the accompanying article. Further, there is a significant difference between a specialist providing a consultation to a patient sitting in their local provider’s office (the most common form of telemedicine currently) and providing telemedicine consultations directly to the patient in their home.
Additional challenges arise from other home-based remote monitoring systems. For example, if a patient takes their blood pressure at home and it transmits an alarming result to the provider’s office consistent with hypertensive urgency or emergency, how does the provider evaluate that? If this is done in a local provider’s office, someone can make sure the cuff is placed properly, confirm the result with a manual measurement, etc; however, if a patient is at home, who will validate the reading? Further, who will review all the data generated by these remote monitoring systems, both from the perspective of potential information overload (ie, time and data management) as well as from the perspective of covering these systems during the day, night and weekends, including responding to potential medical emergencies? What are the medical-legal implications if the monitoring system malfunctions or is itself not monitored? Could these systems lead to a false sense of security (eg, the patient thinks someone is monitoring their health but the data may not be reviewed in real time) or increased medical resource use (eg, ED trips from false alarms or from a sense of caution from untrained providers)?
Home-based remote monitoring has tremendous potential, and these challenges can be addressed. However, for home-based remote monitoring to truly fulfill its promise, to have that direct patient-to-provider interaction, we’ll need additional research.
Anthony D. Sung, MD, is a cell therapy and hematologic malignancies specialist at Duke Adult Blood and Marrow Transplant Clinic and assistant professor of medicine at Duke University School of Medicine. He can be reached at email@example.com. Disclosure: Sung reports no relevant financial disclosures.