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Going the distance: ‘Human factor’ remains key element of teleoncology
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Advancements in digital technology during the past 2 decades have helped clinicians and patients connect in ways they may never have imagined.
The missions of these initiatives span the spectrum of the health care continuum. Webcasts allow physicians to confer about challenging cases, whereas high-definition video cameras let them view the skin — or even the internal organs — of a patient who is thousands of miles away.
Most importantly, patients who live in remote areas or have limited access to high-quality care increasingly can benefit from the resources available at major cancer centers.
The evolution of teleoncology programs has come with some growing pains, many of which remain unresolved.
Technological glitches often top the list, and the reimbursement structure for such programs remains largely undefined. Licensing issues between states — and between countries — also have arisen.
Both doctors and patients who have participated in teleoncology endeavors have expressed satisfaction with the levels of care provided. Whether that translates into improved outcomes on a population level, however, remains to be seen.
Moreover, some researchers worry that, as large centers extend their reach far into the community, patients may no longer view their local doctors or hospitals as capable of providing adequate care.
Richard M. Goldberg
“In general, people have become more and more comfortable with getting what they need and want without a human touch,” Richard M. Goldberg, MD, physician-in-chief at The Ohio State University Comprehensive Cancer Center — Arthur G. James Cancer Hospital and Richard J. Solove Institute, told HemOnc Today. “Some form of technology-assisted interaction is likely the future of medicine. But to what extent we can do this in a way that’s safe, provides optimal care and is satisfying to both patients and providers is still up for discussion.”
Types of models
Thomas Jefferson University Hospitals in Philadelphia is designing a teleoncology program intended to strengthen its connection with affiliated local institutions.
“Patients will initially visit a clinician at one of these community centers,” Andrew Chapman, DO, FACP, clinical associate professor, director of the division of regional cancer care and co-director of the Jefferson Senior Adult Oncology Center, said in an interview. “If the clinician considers it to be a rare or difficult case, or if the patient desires a second opinion but is too far away or too frail to travel, a virtual visit can be arranged.”
In some cases, doctors at Jefferson’s main campus travel to those patients.
“We are helping to facilitate those decisions in any way we can,” Chapman said. “If the patient wants to get a consultation or re-visit, we can determine appropriateness of a referral. Otherwise, the work gets done locally.”
That type of model provides several benefits, Chapman said.
“We want to collaborate on clinical trials, provide support services, and provide added benefit or services to network-affiliated hospitals,” he said. “It is centered on benefiting local hospitals.”
Overall, teleoncology programs aid in the diversification of working relationships. However, too much focus on the business aspect may pose problems, he said.
“If interactions like these elevate the level of care in a community, it is a laudable program,” Goldberg said. “However, if communities purchase the name of an affiliated cancer center but do not get access to the expertise from that center, I feel differently.”
Some programs are similar to a consulting service, through which clinicians receive emails from all over the world that contain all of the necessary information about a patient’s case. This allows some patients to receive multiple expert opinions without having to make additional visits.
“Very well-to-do patients who I have worked with have put together a panel of 15 or more oncologists to get consensus opinions from experts collected from around the world,” Goldberg said. “An individual can spend $50,000 to $100,000 on such a service.”
Goldberg, who previously was affiliated with the University of North Carolina, said UNC has built an extensive network of video screens placed in conference rooms at other sites over the state, especially in remote locations. That allows physicians to attend UNC’s multidisciplinary tumor boards — which include multiple pathologists, medical and radiation oncologists, and radiologists — and participate in real-time consensus-reaching discussions about their patient’s management from their own office or local hospital. If needed, the patient can be sent to UNC.
In other parts of the country, programs have been created in which nurses or nurse practitioners carry out procedures directed by physicians elsewhere. As part of one such initiative in Alaska, team members decide when patients undergoing treatment in rural areas must fly to a larger center in Anchorage.
“Driven by immense distances and limited medical resources, Alaska has pioneered these services,” Goldberg said. “Their approach is an effective conduit to specialty consultation for people residing in remote regions.”
Crossing borders
Sandhya Pruthi
Sandhya Pruthi, MD, associate professor of medicine at Mayo Clinic in Rochester, Minn., has been involved in the program in Alaska since its inception in 2010.
“A program like this is not new to Alaska because of the size of the area,” she said. “Anchorage has telemedicine built in, and it functions just fine. If it can work in a remote location like this, it can work anywhere. We can provide expert services to people who might not otherwise have access to them.”
Pruthi led a study of one Mayo-Alaska program that was published in January in Mayo Clinic Proceedings. The initiative, which includes interactive audio and video components, was established to help counsel underserved, high-risk women in Alaska on how to reduce their risk for breast cancer. This collaboration included a nurse navigator at the referring site and outreach coordinator at the providing site to help facilitate patient encounters by uploading patient records, as well as handling scheduling and billing.
The researchers analyzed data on 60 consultations, and the final analysis included a survey sample of 15 women. The overall patient satisfaction rate was 98%, and the physician satisfaction rate was 99%.
“In this telemedicine pilot study, we demonstrated the feasibility of a telemedicine program to provide integrated specialty care that resulted in a positive effect on patient satisfaction,” Pruthi and colleagues wrote. “This program has a sustainable business model, thus creating a new modality for health care delivery.”
The telemedicine program at St. Jude Children’s Research Hospital is a global endeavor.
Ibrahim Qaddoumi
“Our mission is based on the vision of our founder, Danny Thomas, that a fighting chance should be given to any child with cancer, so our efforts are centered on helping people who lack resources,” said Ibrahim Qaddoumi, MD, MS, an associate member of the department of oncology and director of telemedicine in the International Outreach Program at St. Jude.
The initiative came about after St. Jude started temporarily relocating physicians to low-income regions to ensure that some of the world’s poorest people receive the cancer care they desperately need.
“When those doctors left, there was no continuity of care and communication,” Qaddoumi said. “That’s why we began doing online or teleconference consultations.”
The International Outreach Program provides online meeting rooms through its Cure4Kids.org website that allow St. Jude staff to conduct real-time discussions with medical teams striving to improve cancer care of children in low-income countries. Those discussions are designed to improve the care of individual patients and also promote the development of best practice treatment guidelines and protocols.
“We try to empower local physicians,” Qaddoumi said. “When you bypass local doctors with direct doctor-to-patient communication, you may help a single patient, but those patients may lose trust in their local doctor. We want to help doctors in Latin America, Africa, Asia and other regions provide the same kind of care that patients would receive here.”
Results of a study by Santiago and colleagues published in Pediatric Blood & Cancer indicated that an educational outreach program focused on training in pediatric cancer and telepathology in the developing world yielded encouraging results.
“Overall concordance between the telepathology and original diagnoses was 90.6%,” the researchers wrote. “Brief, focused training in pediatric cancer histopathology can improve diagnostic accuracy.”
Treatment burdens
Sergio A. Giralt, MD, served as a second opinion consultant with The University of Texas MD Anderson Cancer Center’s telemedicine initiative.
Sergio A. Giralt, MD, chief of the Adult Bone Marrow Transplant Service at Memorial Sloan-Kettering Cancer Center, said teleoncology helps minimize the burdens of treatment and allows patients to remain near their support system of family and friends.
Source: Photo courtesy of Sergio A. Giralt, MD, reprinted with permission.
“The perception was that it was a glorified phone call, but these programs can have benefits in all different types of situations,” said Giralt, now the chief of the Adult Bone Marrow Transplant Service at Memorial Sloan-Kettering Cancer Center. “We realize that people in remote or rural areas have difficulty reaching treatment centers, but even those without economic means who live near urban areas face challenges.”
Travel to and within major cities can be costly. Patients who live just out of driving distance of New York, Chicago or other metropolitan areas may be required to stay overnight in a hotel, leading to concerns about cost and comfort, and hotel room availability may not match the schedules of busy clinicians.
“All of these factors are part of the burden of treatment,” Giralt said.
Teleoncology solves many of those problems, he said. It also allows patients to undergo chemotherapy and radiation in a familiar environment.
“The importance of receiving treatment at home or near the support system of family and friends cannot be underestimated,” Chapman said.
Sixth sense
The most significant drawback to teleoncology is that, without face-to-face or physical contact with patients, clinicians may not be able to effectively use the sixth sense that allows them to make diagnoses aided by intuition.
“Telemedicine is like robotic surgery,” Goldberg said. “You can see the patient, but you can’t necessarily feel everything. You can be effective, but the experience seems different. So much of what we do in medicine involves the presence of patient and physician, the ability to adapt what you are saying to how it is being received.”
In some cases, physicians who perform teleoncology consultations do not even see the patients they are trying to help.
“In some situations, it is possible to render an opinion from slides or X-rays, but treatment planning should center on a conversation with a patient,” Chapman said. “It is difficult to measure certain non-verbal aspects of patient care or appreciate the dynamics of how, for example, toxicity levels might impact certain individuals.”
Clinicians also are not longitudinally involved in treating a patient.
“In terms of overall care, there is somewhat of a disconnect,” Chapman said.
Face-to-face communication with family members is imperative, particularly when it comes to treatment planning.
“Often the family members are as important in the decision-making process as the patient,” Chapman said. “If they are not present, we lose something.”
Technological component
Most clinicians involved with teleoncology agree that the concerns associated with the field will subside as technology improves.
Mayo Clinic’s program has already eliminated some of these obstacles, Pruthi said.
“With the state-of-the-art technology we have, we can look in the ear, listen to the heart and evaluate the skin,” she said. “With face-to-face video screens, the clarity is perfect. Eye contact is critical in building relationships and trust, and we have that. I am often asked after the telemedicine consultation by patients if they can return to meet with me again via telemedicine.”
Goldberg said the video technology he uses provides a good way to read signals in a patient.
“We can feel the patient’s response so much better using visual and audio feedback than just talking over the phone,” he said. “Since we can now see inside the belly with our scans, that is often a more objective look at what is happening than doing a physical exam of the abdomen.”
Still, there is continuing pressure from physicians and patients for the technology to evolve.
In fact, many physicians have yet to be convinced of the merits of teleoncology, Giralt said.
“They are not against it by definition, but there are technology issues that need to be considered,” he said. “We are still learning about lighting and stethoscope technology and proper ways to view the skin, among other things.”
St. Jude has used resources to ensure that the technology is advanced and maintained so that communication with local physicians is as smooth and consistent as possible, Qaddoumi said. However, spending too much time on this aspect of the process could detract from outcomes, he added.
“Our first focus is on patient care, rather than the technology itself or funding,” Qaddoumi said. “Fortunately, our institutional mission allows this to be the case, but I understand that other centers do not have this luxury.”
A study conducted by Qaddoumi and colleagues, published in Pediatric Blood & Cancer, evaluated videoconferencing between clinicians in Canada and Jordan who were diagnosing children with brain tumors. Results indicated that this method of communication was associated with significant changes to treatment plans for 36% of the patients. The altered treatment strategy was pursued in 91% of those patients, with positive results.
“Videoconferencing is a feasible and practical twinning tool in pediatric neuro-oncology with a potentially major impact on patient care,” Qaddoumi and colleagues wrote.
Another study in the same journal, which evaluated online static consultations between clinicians in Jordan and St. Jude for children with eye tumors, showed a similar outcome. The study also demonstrated an improved learning curve over time for the local team.
Finance and law
Another key barrier is reimbursement.
“With the exception of some rural areas, there is currently no real reimbursement strategy for this,” Giralt said. “If the reimbursement issue is not resolved, it won’t move forward — period.”
Goldberg said centers in California and Arizona are trying to force the issue of reimbursement, but other states are moving slower.
“At the moment, [teleoncology] is generally looked at as a freebie,” Goldberg said. “We are footing the bill ourselves. This is going to change, but how it is going to change also remains to be seen.”
The Mayo-Alaska program set up a subscription billing model with the local hospital, Pruthi said.
“The local hospital decides how they are going to recover the cost from the insurance carrier,” she said.
If the Agency for Healthcare Research and Quality or CMS decides to reimburse teleoncology programs, a clinical trial likely will happen, Giralt said.
“We need a randomized trial to see if telemedicine has the same effect as face-to-face visits,” he said. “However, a trial is a $5 million endeavor, and given the current economic situation, that money may very well go to other things.”
Licensing issues also have arisen with the program in Alaska.
“The physicians participating in telehealth are licensed in the state of Alaska and credentialed at the local hospital, but some licensing issues don’t apply in certain states,” Pruthi said. “This needs to be taken into account when developing a program.”
Other obstacles
Teleoncology initiatives also can create workflow challenges.
“Some clinicians view telemedicine visits as a burden or a distraction from their other responsibilities,” said Erdeta Bani, a project manager who leads telehealth initiatives at Memorial Sloan-Kettering Cancer Center. “It feels like extra work. We need to make it feel like it is part of their regular work flow.”
One way to ease that burden is to group televisits together.
“Instead of going from a televisit to a regular visit and back again through the day, we need to cluster them so clinicians can dedicate a full morning or afternoon to telemedicine,” Bani said.
Two different medical records exist for any given patient, Pruthi said.
“One is at the referring site, and the documentation from the providing site needs to be available to the referring provider,” she said. “The telehealth platform known as AFHCAN (Alaska Federal Health Care Access Network) was used to share health care records, support the clinical workflow and ensure secure transmission of Health Insurance Portability and Accountability Act information.”
For international programs such as the one at St. Jude, scheduling across time zones has sometimes been a challenge.
“We focus on being flexible because the most important factor in telemedicine is the human factor,” Qaddoumi said.
Challenges must not hinder the delivery of quality care, Giralt said.
“Health care is a service industry,” he said. “We need to provide the best service possible with the least intrusion on day-to-day life of other physicians and the patients we treat.”
The manner in which that goal is reached likely will vary from one institution to another, Qaddoumi said.
“We have to be careful about a uniform approach,” Qaddoumi said. “Each program should be tailored to the institution that is helping, tailored to the institution receiving the help, and tailored to the disease. This definitely will present challenges, but if we take this approach, in the end, we will likely see better patient outcomes.” – by Rob Volansky
References:
Pruthi S. Mayo Clin Proc. 2013;88:68-73.
Qaddoumi I. Pediatr Blood Cancer. 2007;48:39-43.
Santiago TC. Pediatr Blood Cancer. 2012;59:221-225.
For more information:
Erdeta Bani can be reached at Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10021; email: banie@mskcc.org.
Andrew Chapman, DO, FACP, can be reached at 925 Chestnut St., Fourth floor, Philadelphia, PA 19107; email: andrew.chapman@jefferson.edu.
Sergio A. Giralt, MD, can be reached at Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10021; email: giralts@mskcc.org.
Richard M. Goldberg, MD, can be reached at The James Cancer Hospital, 300 W. 10th Ave., Columbus, OH 43210; email: richard.goldberg@osumc.edu.
Sandhya Pruthi, MD, can be reached at 200 First St. SW, c/o Gonda Building, Breast Diagnostic Clinic, Mayo Clinic, Rochester, MN 55905; email: pruthi.sandhya@mayo.edu.
Ibrahim Qaddoumi, MD, MS, can be reached at Neuro Oncology, MS 260, Room C6025, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105-3678; email: ibrahim.qaddoumi@stjude.org.
Disclosure: Goldberg reports research funding from Bayer, Myriad and Sanofi; honoraria from Lilly and Pfizer; and speaking fees from Fresenius Kabi and Yakult. Bani, Chapman, Giralt, Pruthi and Qaddoumi report no relevant financial disclosures.
Perspective
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Jonathan Linkous
The physician should be licensed in the one state where he or she practices and no other state.We have a need for doctors to be delivering care to patients in remote or underserved regions. Specifically, there is a need for specialists. Communities and hospitals are unable to support the growing number of subspecialties, as well as the number of patients who require the services of subspecialists. Thus, the need for specialists to deliver care to patients outside of their geographic region is growing by leaps and bounds.
However, state licenses cost a lot of money. We estimate that it costs about $300 million per year for doctors to be licensed in more than one state, and that cost is going up dramatically. In addition, there is a lot of time and paperwork and bureaucratic red tape to deal with. This is a huge burden on our health care system.
Today’s technology has allowed health care to be transportable. We need to find a way to facilitate this without spending the kind of time and money we are spending on it now.
There are a number of possible ways to resolve this problem, two of which have become most plausible. The first is to develop an interstate compact, whereby states agree to acknowledge the licenses of other states. Another possible solution is to develop a national licensure system.
There are political obstacles to both of these solutions. However, the passage of the STEP Act in 2011 — which allows military doctors who treat service members via telemedicine bypass individual state licensing requirements, provided they are licensed by the Defense Department — signifies that these barriers may be coming down.
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