Article

Teleoncology Plays Integral Role in Cancer Care Delivery

Teleoncology, the application of telemedicine technology to cancer care delivery, is helping patients in any geographic location access high-quality treatment from oncologists and top specialists without the need to travel or wait for an appointment despite predicted physician shortages.1,2 Patients in the 70 percent of U.S. counties without an oncologist can benefit from the increased convenience of receiving treatment that was previously unavailable or too challenging to access.Included among the strategies showing the most promise are telegenetics, the bundling of cancer-related teleapplications, remote chemotherapy supervision, symptom management, survivorship care, palliative care, and efforts to increase access to cancer clinical trials.1 

Many roles for teleoncology

Oncologists are beginning to use teleoncology as a way to deliver clinical care and for remote consultations with specialists in distant locations.3 The patient-benefits include improved side-effects management and quality of life, and increased access to treatment, all hopefully leading to better outcomes.3

Appointments blend real-time video conferencing sessions with a "store-forward" format--where clinical data in the form of imaging studies, medical records, and pathology reports, are stored and forwarded for review and interpretation at a later time.1 Treatment may also include intermittent in-person exams based on individual needs by a nearby physician who then transmits data via teleconsult.1

The bundling of telemedicine services including teleradiology, telepathology, and teleoncology were reported as part of a proof-of-concept study designed to expedite breast care for women awaiting biopsy results.1 Patients were presented the results within three to five hours after the procedure on the same day, resulting in expressed relief from the avoidance of the stress that comes with long wait-times.1

Expanded cancer care access benefits all

By making it easier to stay connected, teleoncology video visits allow already overburdened cancer patients to report side effects, adhere to their treatment, receive care despite travel distances, and seek consults with the top expert on their particular cancer versus the oncologist who is closest.2,3

In addition to those benefits, physicians can treat more patients because teleoncology increases their availability and flexibility for adding in a patient video visit when there is a cancellation or empty appointment.3 This increase in access to care for more patients also increases efficiency, which can result in more profitable practices.3

Telegenetics services that identify genetic carriers are now being provided to chronically underserved urban and rural populations. A recent study in outlined the successful development and evaluation of a collaborative-care delivery approach to telegenetics in these communities for pediatric populations.1,4 Initial new-patient appointment wait times dropped from three to nine months to six weeks with high satisfaction reported by all patients.1,4

Another benefit of teleoncology technology is increased access to and reduction of time needed to enroll participants in clinical trials, including facilitation of eligibility assessment, consent, participation, and assessment and management of symptoms during follow up.1

Familiar barriers can be resolved

Advanced technology and care delivery barriers to expanding teleoncology fall into a few common categories, such as practice considerations, training, reimbursement, and the digital divide.1

In-person professional standards surrounding the integration of full documentation into patient electronic health records (EHR) are essential and should be maintained with teleoncology processes.1 An EHR-system supports the improved exchange of information and allows each patient to receive the right care at the right time.1 This can mean linking an EHR with the right diagnostic tools, including skin assessment software in portable cameras to evaluate radiation or chemotherapy changes and rashes and real-time symptom monitoring using computer-based interactive programs and devices.1 Teleoncology tools can also be equipped with corresponding patient education that is ready at the point of care.1

Teleoncology training is important for the oncologist as well as the entire virtual care delivery team.1 A teleoncology consultation is more than a video chat, and skills beyond those needed to operate the basic technology are needed. Physicians must develop rapport-building techniques that help maximize engagement and allow an accurate virtual exam to be conducted using the appropriate pathways.1 If done correctly, the only limitation to a virtual exam is palpation--a process that can be performed by a local clinician and the resulting data can then be uploaded to the patient's EHR. Additionally, patients can be prepared thorugh orientations that teach them what to expect and how to prepare, and support patient-focused care approaches and participation.1

More than 30 states now require health insurers to cover telehealth expenses, such as audio or video calls with physicians and nurses, prescription delivery, lab testing, and the cost of monitoring devices for the patient's home.2,5 Despite this, reimbursement remains a barrier to expanding teleoncology care delivery due to inconsistencies from state-to-state.1 For example, teleoncology consultations are more likely to be reimbursed by Medicare if a patient is located in an area with known oncologist shortages, such as those places only located near rural health clinics and federally qualified health centers.1

Leveraging digital technology in connected cancer care delivery

With a mission to turn teleoncology into a mainstream channel for cancer care, one leading cancer center established virtual programs with four regional sites. The center offered genetic counseling, psychiatry, and supportive care in order to prepare patients and caregivers as they progressed through each stage of care, and designed their tele-education and telesupport programs for delivery at home or work.6

Based on responses from 1,185 patients who participated in the virtual programs, 91 percent reported they were satisfied or extremely satisfied by the teleoncology experience, more than 94 percent with provider skill, and more than 86 percent with the ease of use of the technology.6

Patients saved an average of 95 minutes of travel time per session, decreasing the added burdens of transportation, missed work, and caregiver requirements.6 Additional patient feedback included reports that teleoncology sessions made their cancer care easier to access and they were able to stay in their comfort zone with the support of loved ones.6 Physicians benefitted by improving adherence and expanding patient outreach.6

Results were based on more than 7,500 teleoncology visits across the four virtual programs serving 3,865 patients over 766 sessions that were evaluated for interaction quality, ease of use, quality of care, as well as satisfaction and future use.6 Sixty percent of virtual sessions were conducted with patients in their homes while 20 percent scheduled their visits while at work.6

Disrupting the pathology paradigm

Recently, a leading cancer center performed a telepathology study that evaluated two large-scale, real-time telecytology (TC) models.Intent on disrupting the conventional paradigm, their approach allowed for remote molecular studies.1

The first model included multiple satellite locations where interventional radiology and endoscopy were offered; given procedure volume, TC robotic microscopes were used without an on-site cytotechnologist.1 In the second model, on-site cytotechnologists and pathologists streamed high-definition video microscopy at a high-volume, centrally located cancer center facility.1

Results for the first TC model using robotic microscopes revealed a perfect correlation of nearly 93 percent in 407 out of 43 cases over 22 months.1 Real-time TC streaming high-definition video microscopy and evaluation by cytotechnologists in the second model also demonstrated a perfect correlation of 93 percent in 12,043 out of 12,949 cases over 26 months.1

Based on this positive outcome, an ambitious large-scale asynchronous telepathology project referred to as the pathology consultation portal is underway.1 Anyone, anywhere can upload digitally scanned slides to request secondary opinions for diagnosis no matter where they are located.1

Telehealth eliminates inconsistencies while cancer care expands

Rural patients continue to face a lack of access to qualified specialists that create inconsistent and variable quality care received.7 To transform care delivery for patients in a rural setting, one medical facility developed a proof-of-concept telemedicine program to eliminate both variations and inconsistencies system-wide that could also expand their specialty care.7

Physicians identified oncologic genetic and nutritional counseling as two areas that required a low overhead to establish a telemedicine practice and thus gain traction quickly; they would also provide the necessary feedback to refine and expand the program in the future.7 And based on the positive results, it was approved for expansion to an additional site.7

Over the three-month evaluation period, there was an average savings of $1,050.63 in combined mileage and travel wages, and more than 13 hours of patient time was not spent traveling for the 23 genetic counseling patient appointments conducted.7 In addition, appointment volumes increased from six to eight per month and wait times for appointments decreased from 23 to 16 days.7 Access to services grew from 8 hours to, on average,16 hours per month, and included availibility for immediate-needs appointments.7

Other services currently undergoing transformation by teleoncology approaches include the growth and development of teleimaging, with a special emphasis on telepathology, teleradiology, and telecardiology.1,2 The U.S. Air Force is increasingly advocating for practices that will improve patient care and treatment when multiple clinicians are invovled; specifically, the transmission, interpretation, and archiving of images and documents for access by any physician.2

Technology for telemedicine is a tool that may free the physician to focus on patient care, lower costs, save time, and make earlier disease detection a reality, all moving cancer treatment closer to individualized care.1

REFERENCES:

  1. Telemedicine in Cancer Care. ASCO Educational Book. http://ascopubs.org/doi/full/10.1200/EDBK_200141?utm_source=TrendMD&utm_medium=cpc&utm_campaign=ASCO_Ed_Book_TrendMD_0 (article reference http://ascopubs.org/doi/abs/10.1200/jco.2006.24.18_suppl.16023). Accessed 3/11/2019.
  2. Telehealth and Cancer Care. Healthcare Innovation. https://www.hcinnovationgroup.com/clinical-it/article/13030439/telehealth-and-cancer-care Accessed 3/11/2019.
  3. Telemedicine’s Role in Cancer Treatment. Chiron Health Telemedicine Services. https://chironhealth.com/blog/telemedicines-role-cancer-treatment/ Accessed 3/11/2019.
  4. A novel approach in pediatric telegenetic services: geneticist, pediatrician and genetic counselor team. Genetics in Medicine. https://www.nature.com/articles/gim201745 Accessed 3/11/2019.
  5. Telemedicine Facts and Figures. Chiron Health. https://chironhealth.com/blog/telemedicine-facts-may-surprise/ Accessed 3/11/2019.
  6. Tele-oncology at MSK: Delivering innovative, patient-centered care. Journal of Clinical Oncology, Meeting Abstracts. http://ascopubs.org/doi/abs/10.1200/JCO.2018.36.30_suppl.272 Accessed 3/11/2019.
  7. Telehealth for oncology genetic counseling: An Idaho experience. Journal of Clinical Oncology http://ascopubs.org/doi/10.1200/jco.2012.30.34_suppl.288 Accessed 3/11/2019.