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Telemedicine in Cancer Care
Abstract
Telemedicine uses telecommunications technology as a tool to deliver health care to populations with limited access to care. Telemedicine has been tested in multiple clinical settings, demonstrating at least equivalency to in-person care and high levels of patient and health professional satisfaction. Teleoncology has been demonstrated to improve access to care and decrease health care costs. Teleconsultations may take place in a synchronous, asynchronous, or blended format. Examples of successful teleoncology applications include cancer telegenetics, bundling of cancer-related teleapplications, remote chemotherapy supervision, symptom management, survivorship care, palliative care, and approaches to increase access to cancer clinical trials. Telepathology is critical to cancer care and may be accomplished synchronously and asynchronously for both cytology and tissue diagnoses. Mobile applications support symptom management, lifestyle modification, and medication adherence as a tool for home-based care. Telemedicine can support the oncologist with access to interactive tele-education. Teleoncology practice should maintain in-person professional standards, including documentation integrated into the patient’s electronic health record. Telemedicine training is essential to facilitate rapport, maximize engagement, and conduct an accurate virtual exam. With the appropriate attachments, the only limitation to the virtual exam is palpation. The national telehealth resource centers can provide interested clinicians with the latest information on telemedicine reimbursement, parity, and practice. To experience the gains of teleoncology, appropriate training, education, as well as paying close attention to gaps, such as those inherent in the digital divide, are essential.
PRACTICAL APPLICATIONS
Telemedicine is the use of telecommunications technology to deliver health care to populations with limited access to care.
Telemedicine has generally been demonstrated to be at least equivalent to in-person care, improve access, and decrease costs with high levels of patient and health professional satisfaction.
Telemedicine may take place synchronously, asynchronously, or blended with in-person care. The patient and the consultant may engage virtually via fully interactive video technology in real time or asynchronously by storing and forwarding clinical data elements, such as medical reports, images, and video recordings, to be interpreted at a later time.
Effective teleoncology interventions include cancer telegenetics, telepathology, bundling of cancer related teleapplications, remote chemotherapy supervision, symptom management, survivorship care, palliative care, and approaches to increase access to cancer clinical trials, some of which may use mobile technologies.
The national telehealth resource centers can provide interested clinicians with the latest information on telemedicine reimbursement, parity, and practice.
Telemedicine uses telecommunications technology as a tool to deliver health care to populations with limited access to care.1 Initially developed to assist in the care of astronauts in space, telemedicine technology was soon being adapted and studied to increase access to care for populations on Earth.2 Since the demonstration projects in the 1970s, access to telemedicine technology has expanded with greater portability, improved usability, lower costs, and higher quality. From the National Aeronautics and Space Administration’s singular STARPAHC Project to the myriad of small, large, freestanding, academic, commercial, direct-to-consumer telemedicine services available in the United States today, telemedicine has been tested in multiple clinical settings. Most studies demonstrate at least equivalency to in-person care and high levels of patient and health professional satisfaction.3,4 Some studies demonstrate improved outcomes compared with in-person care.5 These factors have fueled ongoing interest in improving health care delivery by integrating teleconsultations with traditional in-person clinical care.
Telemedicine services may use a variety of telecommunications technology to support clinical care. There are two primary approaches to telemedicine services: synchronous or asynchronous format. The patient and consultant may engage virtually and synchronously or asynchronously. The former uses fully interactive video technology in real time. The latter stores and forward or transmits clinical data elements, such as medical reports, images, and video recordings, to be interpreted at a later time. This latter approach is known as “store-forward.” Telemedicine services, including teleoncology, may use one or both of these formats with or without intermittent in-person consultations based on clinical needs. The physical exam may be accomplished virtually, with the exception of palpation, and/or data may be gathered by the local clinician and relayed to the teleconsultant or teleoncologist. Given the skills necessary for teleconsultation, team-based health professional education regarding the delivery of telemedicine services is essential for the teleconsultation team. Patient education and orientation regarding telemedicine and what to expect promote patient-centered care and engagement.6
The predicted shortage of oncologists in the United States,7 the greying of the population,8 and the well-documented oncology health care work force and population geographic mismatch9 provide specific rationale for implementation and expansion of teleoncology services. Telemedicine technology can serve to redistribute the oncology work force in a rational way, where needed. The convenience of teleoncology may serve to minimize the disruption that the disease can cause.10
Multiple aspects of teleoncology care have been studied. As an initial step, the technology was explored in real-time video format to increase access to oncology care in rural populations where the prior standard was for the oncologist and/or the oncology team to travel to the rural site. Doolittle and colleagues11-13 from the University of Kansas Medical Center demonstrated both clinical and cost effectiveness of this approach. Since then, others have confirmed the efficacy of this approach and identified high levels of patient satisfaction and improved access to clinical cancer services.14-16 Increased use of telemedicine is associated with improved cost efficacy.12,17
Because quality care of the patient with cancer requires multidisciplinary team–based care, telecommunications technology can support interprofessional care. Teleoncology lends itself well to bundling of services. At its simplest, most teleoncology visits are a blend of real-time and store-forward with the direct patient interaction taking place as a real-time videoconferencing session and with transmission of laboratory, imaging, and pathology data transmitted for store-forward review. Building on this experience, Lopez et al18,19 and Weinstein et al20,21 demonstrated the efficacy of bundling of teleradiology, telepathology, and teleoncology in breast cancer care, as had previously been accomplished for telediabetes care,22 to allow for enhanced access to quality care as a blend of in-person care (i.e., the clinical services available on site) and teleconsultative care.
Building on the experience with telegenetics in pediatric populations, the Arizona Telemedicine Program23 and others24 began providing telegenetic services to urban and rural populations. The strong literature on phone consultations for genetics care provided a sound rationale for expansion to telemedicine services. The approach successfully identifies genetic carriers and yields high levels of patient satisfaction.25-27
Teleoncology services are exploring remote supervision of chemotherapy delivery.28,29 Limitations include physical exam assessment, which may be fully accomplished virtually with the exception of palpation. Training in the virtual physical exam is essential for success. Collaboration and communication with the referring clinician regarding physical exam findings can address the inability to palpate. Some programs rely fully on the local physical exam.30-32 Portable, home-based, and mobile technologies may be used for home health follow-up that may include wound care, symptom management, and palliative care (see Mobile Applications for Cancer Care section below).
Access to cancer clinical trials is often limited for patients living in nonurban areas. Even if patients are not traveling long distances for cancer care, the additional time requirements associated with cancer clinical trial enrollment can be a deterrent for participation.33 Telemedicine may be used to facilitate access to cancer clinical trials by facilitating trial eligibility assessment,34 consent,35 participation,36 and cancer clinical trial follow-up,37 including symptom assessment and management.38
In pathology, the microscopic examination of tissue on glass slides has historically necessitated tying the physical presence of people skilled in the microscopic examination with the microscopy equipment imaging the glass slides. Telepathology disrupts that paradigm by allowing remote viewing of microscopic images, essentially decoupling the physical requirement of people skilled in the microscopic examination with the glass slide.
One such pathology use case is telepathology for rapid on-site evaluation (ROSE). ROSE with cytology preparations plays a critical role in minimally invasive procedures. Achieving accurate diagnoses often requires ancillary immunohistochemical testing. Likewise, cytologic specimens need enough tissue for the performance of molecular analyses. Attaining accurate diagnoses and tissue sufficiency for molecular studies highlights the importance of ROSE in providing immediate feedback on triaging specimens obtained through minimally invasive procedures.
ROSE is traditionally performed by pathologists or cytotechnologists who must go on site where the procedure is performed. The number of ROSE procedures delivered is limited by the number of available cytotechnologists and pathologists to go on site. Some on-site locations lack available cytotechnologists and pathologists. With hard cases, time spent performing ROSE can extend to hours if the lesion is near inaccessible. The time expended on such cases creates an opportunity cost of availability. Pathologists or cytotechnologists caught up with such demanding procedures are no longer available for other procedures. Because of the immediacy of ROSE, synchronous real-time telecytology (TC) addresses all of those issues.
Memorial Sloan Kettering Cancer Center (MSKCC) has developed two large-scale models for synchronous real-time TC operations for ROSE. The first model addressed our on-site satellite locations, which lack available cytotechnologists and pathologists. MSKCC had established multiple satellite locations offering interventional radiology and endoscopy services. The volume of procedures, however, was not able to justify the physical on-site presence of a cytotechnologist. The solution created is TC through robotic microscopes.39
The second model addressed more centrally located high-volume locations that have available cytotechnologists and pathologists. The solution created is TC through streaming high-definition video microscopy. This framework for TC enabled for more efficient use of skilled resources to render ROSE.40
In the first model for synchronous real-time TC, cytotechnologists off site control robotic microscopes deployed to the satellite sites. Through a multidisciplinary effort of education and training, teams in laboratory medicine, interventional radiology, and endoscopy prepare the cytologic specimens through staining and loading of the robotic microscopes. Cytotechnologists are then able to control the robotic microscopes and communicate the results back to the on-site procedural teams.
In the second model for synchronous real-time TC, cytotechnologists go to multiple on-site locations and leverage streaming high-definition video microscopy technology. Cytotechnologists and fellows go on site to prepare the cytologic specimens and drive the glass slides on the microscopes to selected critical regions of interest. The images, in turn, are streamed back to a cytopathologist centrally. The cytopathologist essentially validates and coordinates a distributed team of cytotechnologists via TC. Through this TC framework, a more efficient workflow is established to increase the scale and coverage of all incoming ROSE requests.
In the first model for synchronous real-time TC using robotic microscopes, over 22 months, 439 showed a perfect correlation of 92.7% (407 out of 439) of the cases. An adequacy upgrade (inadequate specimen becomes adequate) occurred in 6.6% (29 out of 439) of the cases. In an adequacy downgrade (adequate specimen becomes inadequate), the most relevant metric is near zero at 0.7% (3 out of 439) of the cases.39
In the second model for synchronous real-time TC using streaming high-definition video microscopy, over 26 months, 12,949 cases showed a perfect correlation of 93.0% (12,043 out of 12,949). An adequacy upgrade (inadequate specimen becomes adequate) occurred in 6.7% (867 out of 12,949). In an adequacy downgrade (adequate specimen becomes inadequate), the most relevant metric is near zero at 0.3% (39).41
Both TC models show adequacy downgrades (adequate specimen becomes inadequate) at a minimum. Adequacy downgrades are critical metrics because preliminary adequacy assessments incorrectly designated as adequate lead to premature finalizing of procedures without the accurate sampling of lesions. Adequacy downgrades result in either delay of diagnoses or need for repeat procedures.
ROSE is a successful use case of telepathology at our institution. With that success, our entire operation of cytologic preparations for ROSE is now entirely driven by TC. Furthermore, to our knowledge, our institution has the most extensive use of TC in the world.
ROSE TC illustrates one example of the value of synchronous telepathology. Implementation is now underway at our institution on an ambitious large-scale asynchronous telepathology initiative to render secondary opinions through digital slide-scanning technologies. Termed the pathology consultation portal, health care entities will be able to upload digitally scanned images of glass slides to receive secondary opinions for diagnosis. The immediacy and availability of such a portal will disrupt how pathology consultation is performed today by obviating the need for physical transport and manual handling of glass slides and patient information. International institutions will likely see the most benefit. There are savings in time by overcoming the barriers of long durations for physical transportation, and there is the circumvention of regulatory restrictions by some countries in not allowing glass slides to be sent outside their borders. Such technology expands the accessibility to anyone who desires a second pathology consultation.
Mobile health, or mHealth, is rapidly emerging as a critical tool for cancer care from prevention42 to palliation.43 Recognizing that patients with cancer seek to stay well and limit time in the outpatient and inpatient medical settings, mHealth’s goal is to help patients stay well while staying closer to home and living their lives. Portable, home-based, and mobile technologies may be used for home health follow-up that may include wound care, symptom management, and palliative care.
Wearable technologies can provide intermittent or continuous monitoring of vital signs. Temperature may be assessed continuously or intermittently through skin sensors that may provide early clues to neutropenic fever. Weight assessments may take place intermittently with results transmitted directly to the clinical team.
Often linked to smartphone applications, mHealth technologies may broadly include texting and messaging efforts that provide patients with ongoing engagement, support, and coaching.44,45 Smartphone applications have been developed to support lifestyle modification, wellness activities, and medication adherence. These assistive technologies may also target specific populations, such as the aging.46 Attachments to smartphones can provide the clinician with tools to assist with patient care. These interventions range from iPad-based group therapy visits for young adults47 with cancer to the use of smartphone digital images to assess the cervix after abnormal screening.48
If your practice is providing care to sites that are requiring considerable travel time, you may wish to consider a virtual solution. The saving of travel time may decrease your stress while supporting clinical productivity and well-being. The factors to consider are distance between the referring site and consulting site, frequency of travel, the savings in travel time for the clinical team and the patient/family, the service need, and your capacity to meet the need. Although the initial costs may seem high, remember that the more frequently the system is used, the lower the costs are per session.49
Teleoncology practice should maintain in-person professional standards, including supporting full documentation that is integrated into the patient’s electronic health record. With improvements in technology, depreciation, and cost efficiencies, using the best technology that you can afford will keep your practice closer to the leading edge as technology evolves. As you develop teleoncology clinical processes, consider your existing in-person processes. Developing similar processes will facilitate use, minimize errors, and improve patient care.
Because few practicing physicians are familiar with telemedicine technology, training is essential. A teleconsultation is not simply FaceTime with a patient. Training with the telemedicine technology is essential to facilitate rapport, maximize engagement, and conduct an accurate virtual exam. With the appropriate attachments, the only limitation to the virtual exam is palpation.
Telemedicine reimbursement is not uniform across the country and remains a barrier to wider clinical implementation. Reimbursement may serve as either a deterrent or a facilitator depending on your state. It is important to explore and learn the rules in your own state.
For example, Medicare considers where the patient is located (that is, where the teleconsultation is originating) in its reimbursement decision. Patients located in a health professional shortage area are more likely to have teleconsultations covered by Medicare. Health professional shortage areas may include critical access hospitals, rural health clinics, and federally qualified health centers. Although the teleconsultant bills for the consultation, the originating site may bill a facility fee. The latter may require the presence of a health professional at the originating site. Each state’s Medicaid requirements may differ. Become familiar with your own state requirements regarding services covered, clinicians covered, and any specific documentation that may need to be specified in the progress note. Always check the patient’s own insurance regulations. Even though some payers, especially large payers, may cover telemedicine services, the patient’s own insurance plan may not.
Some states have enacted telemedicine parity. Please see the American Telemedicine Association’s website for a list of the states that have passed telemedicine parity laws (www.americantelemed.org/policy-page/state-policy-resource-center). Most telemedicine services will require specific codes for reimbursement. It is important to confirm the proper code or modifier to use when billing for medical services. In some states, nonphysician clinicians may also be able to provide reimbursable services. If the clinician chooses to bypass insurance coverage and bill the patient directly, the patient may need to sign a waiver.
The national telehealth resource centers can provide interested clinicians with the latest information on telemedicine reimbursement (www.telehealthresourcecenter.org).
Telemedicine can also serve to support the oncologist in the rural area by supporting access to tele-education, camaraderie, and support. Using technology for distance education is well established. Similar to the clinical experience, education may be synchronous, asynchronous, or blended. To support camaraderie, blended or synchronous approaches may be most effective. A blended educational program may include viewing of a recorded session, followed by an interactive question-and-answer session. Educational support is not only needed in rural or remote areas. With the ever-changing landscape of care, tele-education may serve the essential function of helping to build and support the oncology workforce in both urban and rural settings and in multidisciplinary settings (e.g., oncology, behavioral health, and primary care) in partnership with interprofessional colleagues (e.g., physicians, nurses, genetic counselors, pharmacologists, and others).
Both disease-specific and molecular tumor boards serve to bring together health professionals to review, discuss, and prepare a treatment plan for a patient. Although generally accomplished on site, the technology can be used to bridge distances for some disciplines. For example, the pathology and/or radiology may be “beamed in” with telepathology and teleradiology, respectively. Some tumor boards are considering including the patient and family in the discussion.
The potential that technology brings to facilitate care is tremendous. In cancer care, services may be bundled with a blend of in-person and virtual options. Clinicians may be brought together virtually for the benefit of the patient, providing not only the necessary multidisciplinary care but also the necessary interprofessional care. Telecommunications technology enables patients to receive more care at home as the point of care shifts away from the hospital and the medical office. Like other telemedicine interventions, teleoncology is generally found to be equivalent to in-person care and demonstrate costs savings and patient satisfaction.
Barriers to dissemination remain and include technology costs, inconsistent billing and reimbursement regulations, data security risks, and state licensure requirements for clinicians. Although smartphones, internet access, and cell phones are fairly ubiquitous in the United States and globally, as clinicians seeking to provide quality care to all of our patients, we must remember that there is a digital divide related to access and use.50 The digital divide limits access to these innovations and limits the ability to study and understand the impact of these innovations in some populations—generally, the most vulnerable.51
The digitalization of health records holds the promise of better exchange of health information to achieve the right care at the right time for all people. The virtual linking of the electronic health record with diagnostic tools may include portable cameras equipped with secure software to assess skin changes and rashes associated with chemotherapy or radiation, as well as computer-based interactive tools that assess symptoms related to cancer care in real time. These diagnostic tools may be linked to appropriate patient education materials for health education at the point of need. Ultimately, this technology may develop to the point at which the educational materials automatically modify to patient literacy based on speech recognition.
The ability to exchange de-identified health information electronically may yield unprecedented access to population-based data. Discerning which data matter, which difference makes a difference, may ultimately be defined by the linkage of electronic records to artificial intelligence tools that can support clinical decision-making.52
The opportunity of big data analytics may soon be evident along the spectrum of health care. As our ability to analyze data and predict outcomes improves, personalized treatment approaches will be uncovered and tested in real time.
Technology is a tool that may free the physician to focus on patient care. We may see improved coordination of cancer care with lower costs, time savings, early disease detection, and increased access to care, education, and individualized care. To see these successes, we must focus on appropriate training, education, and reimbursement as well as paying close attention to gaps such as those inherent in the digital divide.
The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc.
No relationship to disclose
No relationship to disclose
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