Telemedicine in oncology: Virtual solution to a very real problem
Following the lead of businesses, consumer transactions, news dissemination and more, medicine — a profession rooted in a “hands-on” tradition — is evolving into the digital age.
Providers ultimately will need to adjust to this new approach to patient care or risk being left behind, according to Christian Otto, MD, MMSc, director of teleoncology at Memorial Sloan Kettering Cancer Center.
“Those who do not engage in virtual care are going to fall by the wayside, and those who do provide digital platforms will succeed,” he said. “The patients are going to go where the convenience is.”
In oncology, however, telemedicine promises much more than convenience.
ASCO projects that between 2016 and 2026, the number of cancer survivors will rise from 15.5 million to 20.3 million. This increased survivorship, combined with increasing rates of new cancer in the aging population, is expected to result in a 40% increase in cancer care demand.
This growing need for cancer care is expected to coincide with an estimated shortage of 2,200 oncologists, many of whom are aging out of the workforce.
Patients in rural or underserved areas are already feeling the strain. With no major academic medical centers close to home, these patients often must either endure lengthy travel or forgo treatment at a tier one center.
For these patients, telemedicine can serve as a lifeline to the care they need, according to Jennie Crews, MD, MMM, medical director of Seattle Cancer Care Alliance Network.
“It offers great promise in overcoming the disparities we’re now seeing around outcomes in this country based on where you live,” Crews told HemOnc Today. “Patients who live in rural areas do not have outcomes as good as those in urban centers. Telemedicine offers us an opportunity to reach those patients and bring better care to them. Your ZIP code should not dictate how well you survive your cancer.”
Telemedicine — also referred to as telehealth — is commonly associated with video health consultations, but it can also include online patient portals, patient wellness apps, remote monitoring, patient education, CME for providers and more, according to the American Telemedicine Association (ATA).
Telemedicine has an unusual and ambitious history, with the earliest patients not even on the planet.
“NASA has been one of the pioneers in telemedicine, beginning with the origins of the manned space program and the necessity for biomedical monitoring of crew members during space walks,” Otto said. “I spent 7 years as a lead scientist for one of NASA’s most pressing in-flight medical problems concerning elevated intracranial pressure and visual disturbances.”
Otto and colleagues collected real-time data from Mission Control on 13 crew members, including a cosmonaut. He said they also instructed nonmedical crew professionals on how to conduct medical tests, including intracranial Doppler, intraocular pressure and optical coherence tomography.
“We know that connecting with the patient in their environment has demonstrable beneficial impacts to their outcomes,” he said.
Today, these benefits can be attained in more routine settings.
“We use it for almost everything known to man, to be honest,” Judd E. Hollander, MD, associate dean for strategic health initiatives at Sidney Kimmel Medical College at Thomas Jefferson University, told HemOnc Today.
There are three main ways telemedicine is employed in oncology, Hollander said. These include for scheduled visits with providers, remote visits to the ED, and through apps, which, for Jefferson Health, is a direct-to-patient app, JeffConnect, that is continuously staffed.
Patients with cancer arriving at Jefferson’s ED are checked in through a “tele-intake” process. Patients are ushered into a private room, where they speak to a clinician via video within 10 to 12 minutes of arrival. The clinician can use digital devices to listen to the patient’s lungs or heart if necessary, and can order X-rays, blood tests and other screenings.
“We are able to speed up the process and decrease the amount of time the patient spends waiting in the ED, exposed to the various diseases that may exist there,” Hollander said.
Crews said patients’ images, such as X-rays or photographs of the skin, can be viewed through asynchronous “store-and-forward” technology.
Also, melanoma screening can be conducted in a real-time virtual visit by physically examining the patient through a platform similar to Skype or FaceTime, she said.
“There are really good optics clinicians can use when doing these consults,” she said. “Another way of diagnosing dermatologic conditions is to have a patient take a picture of a lesion and send it to the dermatologist for examination.”
Remote patient monitoring is another rapidly growing area of telemedicine.
“Remote monitoring can involve surveilling a number of different attributes that are relevant to the health of patients outside clinic visits,” William A. Wood Jr., MD, MPH, associate professor at the School of Medicine of The University of North Carolina at Chapel Hill, and a HemOnc Today Editorial Board Member, said in an interview. “One category might involve the patients reporting their experience and symptoms, which could be done by web-based reporting, interactive voice response or other methods. In this way, a provider can gain understanding of worsening or severe symptoms, for which intervention or triage could be helpful to avoid adverse downstream health consequences.”
Remote patient monitoring is currently in the early stages of implementation, and is primarily focused on patient-reported outcomes, Otto said.
Patients undergoing treatment at Memorial Sloan Kettering are administered online surveys in which they provide information about their symptoms, side effects and complications, and overall satisfaction with their treatment.
A study of this approach — presented at ASCO Annual Meeting in 2017 — randomly assigned 700 patients to usual care or an electronic capture tool through which patients reported outcomes each week.
When patients in the intervention group reported serious or worsening outcomes, an email alert would be sent to a clinical care nurse involved in the patient’s care. The symptoms also would be reported to the patient’s clinician at the next visit. The usual care group called in with their concerns or worsening symptoms.
At a median follow-up of 7 years, researchers found that those in the intervention group survived 5 months longer than those in the usual care group.
Approaches to remote monitoring in oncology often go beyond what is quantifiable and tangible, Adam P. Dicker, MD, PhD, FASTRO, professor and chair of the department of radiation oncology, and director of Jefferson Center for Digital Health at Sidney Kimmel Medical College and Cancer Center, told HemOnc Today.
“There are a lot of things that can be done remotely, like talking with the patient, and observing, listening and examining,” he said. “It’s not the same as a patient who has a pacemaker that you can interrogate remotely. It’s a lot more nuanced.”
As telemedicine advances into patient-generated health data, remote monitoring can include tracking of physiologic information, Wood said.
“For example, sensors that measure heart rate or blood pressure or temperature might provide signals that require either direct attention or triage to avoid ED visits or hospitalizations,” he said. “Many of these devices have been developed for the overall consumer market, but several now provide relevant information that could be useful for patients and health care providers.”
Still, remote patient monitoring remains in its infancy.
“There is a lot of research going on in this space, including at our institution,” Dicker said, “but very few places are doing it as standard of care.”
Providing comfort, support
Psychiatry services for patients with cancer is one area of treatment that intuitively lends itself to telemedicine.
According to Otto, Memorial Sloan Kettering’s in-home psychiatry program, launched in 2018, has proved to be an incredibly valuable psychological resource for patients struggling with physical symptoms.
In a study published last year in Journal of Clinical Oncology, Otto and colleagues evaluated 38 patients who were undergoing active cancer treatment and had previously been seen at in-office visits. Many lived in areas with limited access to counseling services.
Five psychiatrists conducted remote patient visits over a period of 2 years, and 50% of patients completed a questionnaire after the experience. Most (96%) reported that telepsychiatry visits enabled easier access to care, and that the quality of care was equal to that received in person.
Patients also emphasized the benefits of avoiding long trips to Manhattan for care, easier scheduling and reduced appointment wait time.
The cancellation rate also was significantly lower among in-home patients.
“If a patient isn’t feeling well and doesn’t feel able to trek all the way to Manhattan, they still get to have the important psychiatric treatment they need,” Otto said.
Otto said the program — which soon will be expanded into palliative care — is approaching 500 remote visits. It boasts other impressive numbers as well, saving patients an estimated $155 per visit and sparing them 3 hours of travel.
Crews said Seattle Cancer Care Alliance is piloting a telemedicine project aimed at palliative care that involves conducting real-time virtual follow-up visits from the patient’s home. Through these visits, a palliative care physician assesses the patient’s needs and provides advice on symptom management.
“We’re meeting the patient where they are, at their convenience,” Crews said.
“We have providers very interested in doing this, and who are committed to taking care of patients and improving access to care,” she added. “But, from a practical standpoint, we have been able to do this because Washington state is very forward-thinking in their telehealth laws and allows the originating site to be anywhere the patient wants it to be.”
‘True payer partners’
As much as patients might seek the convenience of telemedicine and clinicians would like to offer it, regulatory constraints and limitations on coverage may complicate delivery of this service, Crews said.
“The barriers around reimbursement are twofold. One aspect is state-to-state requirements, which vary significantly depending on what state you’re in and govern how Medicaid and private payers are required to reimburse telehealth,” she said. “Then there are the Medicare requirements, and Medicare has had a lot of rules around what areas are eligible to bill for telehealth.”
In 2018, CMS proposed a Physician Fee Services rule that would expand coverage of telehealth services. The rule would enable reimbursement for a virtual check-in by phone or video chat (for patients with established relationships with the clinician), remote assessment of images and video sent by patients, and expanded originating sites, such as mobile stroke units and the homes of patients with end-stage kidney disease.
The telemedicine services are referred to as “virtual check-ins” because federal law prohibits Medicare reimbursement for telemedicine services that take the place of in-person visits, except in rural locations.
CMS acknowledged in its proposal that the rule would increase Medicare costs. Although the proposed rule has been met with differing opinions from clinicians, Crews said it ultimately will be a positive step for providers of telemedicine.
“It’s definitely an improvement,” she said.
Differences among states in the reimbursement and licensure of clinicians providing telemedicine services are another substantial barrier. Practicing telemedicine across state lines is particularly complicated and challenging.
“When providing telehealth services to a patient, you need to be licensed in the state where that patient resides,” Crews said. “There’s an interstate compact now that is in place to alleviate some of the burden of obtaining multiple licensure.”
The Interstate Medical Licensure Compact Commission has introduced a rule that would allow clinicians to acquire expedited licensure to practice in states that have entered the compact. According to the commission’s website, 24 states and one territory have passed laws to join the compact. The streamlined application process draws upon the physician’s existing information submitted in their state of principal licensure.
“It doesn’t preclude the need to be licensed,” Crews said. “It’s not a substitute for getting a license in each state, but it is an expedited way to obtain licensing in states that are participating in that compact.”
Another issue for telemedicine providers in some states is the lack of parity laws.
Although most states in the U.S. have adopted telemedicine parity laws — which require insurers to cover telemedicine visits — clinicians in states with no parity laws struggle with a lack of reimbursement for these valuable services.
Hollander — who practices in Pennsylvania, a state with no parity law — said he is appalled by this lack of coverage.
“If you’re an oncologist, your obligation is only to your patients, but if you’re a commercial payer and you’re a for-profit company, your obligation is to your shareholders,” he said. “So, although the commercial payers make their living by taking care of patients, they’re actually profit-making with an obligation to their shareholders. When they’re left with a choice, knowing that a place like Jefferson is going to take care of the payment anyway, their fiduciary obligation to the shareholders will cause them to delay paying as long as humanly possible.”
Although value-based programs may offer clinicians shared savings for finding new ways of providing care at lower cost, the payer does not share any of the costs attached to these innovations, Hollander added.
“Any business model where you could keep a fraction of the profit but incur 100% of the cost is going to be a failure,” he said. “What we really need are true payer partners who believe something will work and will share both the upside and the downside.”
Because Pennsylvania has no parity law regarding telehealth, Hollander said payers are not obligated by statute to cover telemedicine, even if it is for an oncology service they would cover in-office.
“Frankly, from a payer perspective, that’s a smart strategy,” he said. “From a patient perspective, it’s just mean-spirited. Why would they make a sick, vomiting patient get in the car, travel across town and be totally uncomfortable when they could get the same information in the comfort of their own home?”
Telemedicine after transplant
Care for patients undergoing bone marrow transplantation is one emerging area of telemedicine.
To date, Memorial Sloan Kettering has conducted 220 telemedicine visits for patients who have undergone a bone marrow transplant since starting its program in 2018, Otto said.
Sergio A. Giralt, MD, chief of the adult bone marrow transplant service and Melvin Berlin family chair in multiple myeloma at Memorial Sloan Kettering, and a HemOnc Today Editorial Board Member, said these services are offered to patients at Hartford HealthCare, the first regional member site of the MSK Cancer Alliance, as well as to outpatients staying at Memorial Sloan Kettering’s 75th Street residence, which includes 20 apartments where outpatients recover from transplant and consult with various providers via telemedicine.
“Transplant patients are from all over the country, but transplant expertise is not available all over the country,” Giralt said in an interview. “Through telemedicine, patients recovering from transplant can consult with nutritionists, physical therapists and physicians. Clinicians can talk with patients about symptoms and side effects they may be experiencing and monitor them for potential graft-versus-host disease.”
Telemedicine in the transplant context allows patients to have convenient access to expertise and monitoring without needing to travel to the hospital, Giralt said, adding that telemedicine allows for a more direct and interactive way of conveying information about recovery.
“It potentially allows us to provide educational and health maintenance e-content in a sustainable way,” he said. “If you just provide a pamphlet, you can’t necessarily get a sense of whether they truly understand the information, but if you have a conversation by telemedicine, you have a much better chance of ensuring that the information is clearly communicated and understood.”
Services available via telemedicine in Sloan Kettering’s program include physical therapy, yoga, remote physician consults and visits, survivorship services and patient-reported outcome surveys.
Home-based telemedicine for patients recovering from bone marrow transplantation also is being closely evaluated by several cancer institutions.
Memorial Sloan Kettering is conducting a pilot study of 31 patients whose recovery took place entirely at home or in a “home-like environment.” Patients had access to home-monitoring telemedicine consults, and reported on their outcomes using various questionnaires, a video diary and a distress thermometer. The study’s primary outcome is readmission rate by 21 days posttransplant.
Giralt said results have not yet been reported of the study, which ended in January.
“The biggest challenge was the learning curve with the technology,” he said, “but the patients loved the program.”
Telemedicine will continue to become an increasingly important part of the way oncology is practiced, Giralt said, citing Kaiser Permanente’s recent success in conducting 50% of its patient interactions digitally.
“We can’t keep building more offices and increasing our infrastructure to treat more patients,” he said. “With telemedicine, I could be treating Mrs. Smith at the clinic at 9 a.m., and at 9:30 a.m. I could be treating Mr. Jones in Rhode Island, and it could be seamless.”
Second opinions via telemedicine
Many patients who are diagnosed with cancer seek a second opinion, either in hopes of hearing better news or to optimize their treatment plan.
Second opinions are especially valuable to patients living in rural communities, where regional hospitals may not have the diagnostic resources available to large urban hospitals. These patients may also be limited financially and physically in their ability to travel long distances for second opinions.
Telemedicine offers these patients expanded access to the most up-to-date diagnostic and treatment methods, while still being treated at their regional hospital.
Steven Brem, MD, co-director of the Penn Brain Tumor Center, director of neurosurgical oncology and professor of neurosurgery at Hospital of the University of Pennsylvania, said patients newly diagnosed with brain tumors must not only face the shocking reality of their disease, but they also must navigate an overwhelming number of treatment options.
University of Pennsylvania recently launched a telemedicine service that provides second opinions to patients diagnosed with brain tumors. The program — the first phase of an ongoing pilot project — will enable patients from across the country to have access to specialists at the Penn Brain Tumor Center.
“Given the recent explosion of technology, including innovations in genomics, surgery, radiation and targeted therapy, the treating hospital for a patient with cancer can make a huge difference in outcomes,” Brem said. “Some patients can receive targeted treatments based on their molecular and genomic profiles. Some patients can afford to fly and get second opinions at national centers of excellence, like Penn. But, for the vast majority, there are local and regional centers, with less extensive experience in treatment of brain tumors.”
The second-opinion telemedicine program at Penn is not designed to replace the fundamental care offered at these local and regional centers, Brem said.
“We see this as completely complementary; it’s a service provided to the physician taking care of the patient with cancer,” he said. “It’s not as though I’m the Wizard of Oz behind a screen talking to the patients. We’re not looking to replace the primary care team.”
Instead, Brem works with the original physician, who will contact Penn through an online portal. The physician will send Brem information about the case, ask specific questions and discuss potential strategies.
“Then I’ll put together a formal report detailing what we would do at Penn,” he said, “I’ll use National Comprehensive Cancer Network guidelines, my own experience or discuss with colleagues. I’ll work to give an authoritative opinion based on best practices and evidence.”
Currently, the program is offered to clinicians and patients in Florida, Georgia, North Carolina, Pennsylvania, South Carolina, Virginia and Washington, and is expected to expand.
Brem said he formulates his report within a week, but given the time sensitivity of many brain tumor diagnoses, he often tries to work faster. He said the second-opinion process is very much a collaborative effort.
“It’s not just me — it’s our group. I might give my opinion, but I often will call one of our radiologists who are expert at brain tumors,” he said. “Or I’ll call one of my oncology colleagues for their advice. We also have a weekly formal brain tumor board, where we can review scans and develop a group consensus around best standard care or innovative options, such as novel clinical trials. So, if there’s something where there are multiple decision points, we can discuss it as a group in a timely fashion.”
A virtual future
Given the increased focus on convenience in medicine and the looming shortage of oncologists, telemedicine is likely to play an ongoing role in the future of cancer treatment.
Still, oncologists with whom HemOnc Today spoke had different levels of certainty regarding the extent of telemedicine’s role.
“It’s too early to say right now,” Wood said. “We’re going to see some examples of larger-scale implementation of telemedicine projects that are demonstrated to improve outcomes that matter to patients and clinicians. The existence of technology itself doesn’t justify its use; rather, the value in a technology comes from its ability to make a difference in the lives of patients.”
According to Dicker, properly executed telemedicine has secured its place in the future of oncology.
“When telemedicine is used correctly, patients are very appreciative,” he said. “There’s a fair bit of data that shows it has value. It affects the workflow and makes it more efficient. I think it’s here to stay.”
Brem likened telemedicine to NCCN guidelines, which have increased significantly in global use since 2006.
“There could ultimately be a pantheon of individuals doing [telemedicine], like the NCCN guidelines,” he said. “The guidelines are very broad, and they’re very principled. But individuals are like diamonds; everyone is different.”
Crews said she believes telemedicine will endure as a method of providing cancer care, not least of all because patients have responded favorably to it.
“There’s a lot of patient satisfaction data published in the primary care setting, where patients are very happy with telehealth,” she said. “There are less data in the oncology setting, but we did some patient satisfaction surveying at my previous location and had extremely favorable results. Patients appreciated not having to travel a long distance to receive their care. They were pleased with the experience.” – by Jennifer Byrne
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For more information:
Steven Brem, MD, can be reached at 3400 Spruce St., 3rd Floor Silverstein, Department of Neurosurgery, Philadelphia, PA 19104; email: email@example.com.
Jennie Crews, MD, MMM, can be reached at 825 Eastlake Ave. E, Seattle, WA 98109.
Adam P. Dicker, MD, PhD, FASTRO, can be reached at 111 South St., Bodine Center, Suite G-301, Philadelphia, PA 19107; email: firstname.lastname@example.org.
Sergio A. Giralt, MD, can be reached at 1275 York Ave., New York, NY 10065; email: email@example.com.
Judd E. Hollander, MD, can be reached at 1020 Sansom St., Thompson Building, Suite 239, Philadelphia, PA 19107.
Christian Otto, MD, MMSc, can be reached at 1275 York Ave., New York, NY 10065; email: firstname.lastname@example.org.
William A. Wood Jr., MD, MPH, can be reached at 860 Omni Blvd., Newport News, VA 23606; email: email@example.com.
Disclosures: Wood reports research funding from Pfizer. Berm, Crews, Dicker, Giralt, Hollander and Otto report no relevant financial disclosures.