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Disclosures: Jennings reports no relevant financial disclosures.
September 25, 2020
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APP-provided telehealth can ‘help fill gaps’ in cancer care during pandemic

Source/Disclosures
Disclosures: Jennings reports no relevant financial disclosures.
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With the advent of the novel coronavirus, the delivery of health care has dramatically changed across the spectrum, requiring physicians, pharmacists and nurses to get creative with patient care.

APPs also have faced these challenges, utilizing webcams, phone calls and email to deliver the care their patients need.

Reach of telehealth

The original goal of telehealth aimed to increase access to basic primary care for patient populations in rural and underserved areas, but as its merits have become more widely demonstrated, telehealth has been routinely incorporated in specialties such as psychiatry and asthma/allergy care, even prior to the COVID-19 era.

David L. Jennings II, MSN, RN, AGPCNP-BC
David L. Jennings II

Telehealth helps reduce the need for single- and multiuse personal protective equipment (PPE) by patients and health care workers. PPE is costly and sometimes unavailable due to panic-fueled stockpiling, and conservation should occur whenever possible. Alternate care delivery eliminates the need for patients to leave their homes for appointments at hospitals and clinics, thus lowering exposure to infection for both the patient and the health care team.

Further, telemedicine allows for triage of patients with COVID-19 symptoms without requiring face-to-face visits to help direct next steps for testing and treatment.

Telehealth can be effectively incorporated into oncology care — provided thoughtful and appropriate measures are taken.

To help determine which type of visit is appropriate, Elkaddoum and colleagues suggested stratifying patients with cancer into the following three categories: patients with a new cancer diagnosis currently receiving curative treatment, patients with metastatic disease receiving palliative treatment, and stable patients in surveillance or receiving oral therapy.

The European Society for Medical Oncology has proposed additional recommendations to prioritize patients based on their specific needs, such as offering a virtual visit for individuals with new side effects or symptoms regardless of disease trajectory.

Guidelines like these can be useful, but nothing can replace evidence-based clinical judgment and sound comprehensive triage. Virtual consults do not equate with clinical patient-facing visits in many situations.

Etiquette for virtual visits

A certain level of professional etiquette should be employed throughout the duration of a virtual visit.

Standards set forth by HIPAA for virtual and phone visits are no different than for in-person visits, and the same applies to use of multimedia technology and mobile health applications.

Background noise and distractions should be minimized whenever possible. The camera should be properly positioned so that the provider can easily be seen and heard.

Eye contact should be maintained, because typing notes or looking away from the camera might be perceived as apathy or boredom. Conveying empathy can be difficult via virtual visit, but some clinicians find they can effectively achieve this through eye contact, body posture and tactful word choice. It’s important to allow for frequent pauses and shorten the duration of phrasing to ensure the intended message is received. Also, you can assess the patient’s understanding of your recommendations by using the teach-back method and allotting time for questions.

Conversations with patients with cancer are often emotionally challenging for both parties, and the inability to conduct difficult conversations face to face can compound those feelings. Proper virtual etiquette can minimize conversational missteps and allow for genuine therapeutic communication.

In my experience, it’s been valuable to establish the goal of the virtual visit (ie, chemotherapy teaching, symptom management, etc) at the beginning, so that expectations are met and that time is used efficiently. Also, it’s important to clearly define the next steps regarding follow-up visits and lab work, etc. We can utilize online patient portals whenever possible to touch base between visits.

Disadvantages, legal implications

Although telehealth can improve patient outcomes and engagement, access to care and provider efficiency, while also reducing health care costs, it is not without its disadvantages.

For instance, physical examinations can be difficult and inadequate.

Even for the most tech-savvy, technical issues can be frustrating for both patient and provider and can require extensive troubleshooting. This can give way to a general distrust of telemedicine by both parties, as there is a potential for a breach of secure information, which must be safeguarded against. Technological trial runs to verify that the audio/video equipment is working properly can save frustration and valuable clinic time.

Although the AMA approved the use of telemedicine in 2016 and offered ethical guidance regarding its use for physicians, standards for nurse practitioners (NPs) can vary widely among states. NPs must familiarize themselves with their state’s legal requirements to ensure they are practicing within their scope.

Nearly all Medicare and Medicaid programs offer reimbursement for some form of telehealth visits, as their coverage has been outlined at both the federal and state levels.

As with scopes of practice for NPs, individual states dictate insurance coverage and reimbursement for provision of telehealth, and most states, as well as the District of Columbia, have passed legislation that requires coverage of telehealth by private payers. Reimbursement can fluctuate, as no two states’ regulations are exactly alike, so it is essential that NPs have complete understanding of their state’s policies.

Lastly, be sure to note the duration of each encounter for appropriate billing.

Evolving health care

Although I was skeptical (and somewhat resistant) at first, virtual visits and telephone check-in visits have become invaluable in my own practice and complement in-person visits quite effectively. I suspect these care delivery methods are here to stay for the foreseeable future.

Safe and thoughtful adoption of comprehensive telehealth can help fill gaps in care delivery efficiently even in the face of global pandemic, and clinicians should recognize that patience and persistence will be necessary as health care delivery continues to evolve.

References:

American Academy of Family Physicians. 10 communication tips for physician phone visits during COVID-19. Available at: www.aafp.org/journals/fpm/blogs/inpractice/entry/telephone_visit_tips_2.html. Accessed Sept. 3, 2020.

Balestra M. J Nurse Pract. 2017;doi:10.1016/j.nurpra.2017.10.003.

Elkaddoum R, et al. Future Oncol. 2020;doi:10.2217/fon-2020-0324.

ESMO. Guidelines: Cancer patient management during the COVID-19 pandemic. Available at: www.esmo.org/guidelines/cancer-patient-management-during-the-covid-19-pandemic. Accessed Aug. 31, 2020.

Rutledge CM, et al. Adv Med Educ Pract. 2017;doi:10.2147/AMEP.S116071.