Pandemic proves telehealth ‘works in saving lives’ and ‘that we have an inequitable system’
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Over the last decade, “telehealth” became a buzzword in conversations about health care innovation.
During the first months of the COVID-19 pandemic, it became the only avenue to care for many patients with cancer and other diseases.
In 2020, Medicare visits by way of telehealth increased 63-fold, from approximately 840,000 in 2019 to 52.7 million, according to a report from the U.S. Department of Health and Human Services.
“It became mainstream ... all of the things blocking it got smushed away,” Stephen K. Klasko, MD, MBA, executive in residence, general catalyst and former president and CEO of Thomas Jefferson University and Jefferson Health, told Healio. “Those of us who had unlimited supply, like Jefferson and Penn [Medicine], finally had the demand to catch up to supply. Jefferson's cancer visits went from 1% telehealth to more than 52% of all visits to Sidney Kimmel Cancer Center.”
In-person care has since returned as the primary form of health care and the number of telehealth patients per day has leveled off.
But the pandemic highlighted the many advantages of telehealth — as a tool of convenience for most patients, especially those raised in a digital age, and a gateway to access for people who don’t live close to major oncology centers but have a digital device and a strong internet connection — as well as disparities in access and use.
Healio spoke with oncologists and leaders in the health care industry about the state of telehealth following its introduction into the mainstream during the pandemic, how it can and should be implemented going forward, and paths toward accessibility and equity.
Sorting the telehealth ‘toolbox’
Adam P. Dicker, MD, PhD, FASTRO, FASCO, director of Jefferson Center for Digital Health and professor and chair of the radiation oncology department at Sidney Kimmel Medical College and Cancer Center, has ample professional experience to educate clinicians and laypeople alike on the usefulness of telehealth as part of digital health, and created a course for medical and graduate students at Jefferson.
A personal experience, however, helped Dicker see one of its more important aspects as a health care modality.
Dicker’s father died in January. His admission to the ICU in December coincided with the peak of the omicron variant, so Dicker’s family could not visit him in person. Initially, they communicated through Facetime before Dicker began using his Jefferson Health Zoom account for regular, virtual conversations with his dad that included children, grandchildren, great-grandchildren and the ability to screen-share photos and memories from over 60 years ago. Thankfully for Dicker and his family, restrictions lifted in time for the family to be together, physically, in the final 12 hours of his father’s life.
The ordeal made Dicker think of telehealth as an asset in palliative care.
“If someone needs palliative care and they live an hour or two away by car, these folks are not exactly in the best shape to be spending 2 to 4 hours traveling,” Dicker told Healio. “Telehealth is a superb way of trying to deliver expertise when it doesn’t exist locally.”
Dicker said the ways modern technology can complement health care are seemingly endless, whether it’s talking with a physician on the other side of the country through a video call, communicating with a physician’s office via MyChart or using a smartphone to keep track of your heart rate. But harnessing it and determining when and how it should be used remain challenges.
“There are different tools in the toolbox, and the real goal is to figure out which is the right tool,” Dicker said. “Is the right tool a phone call? A video chat? Bluetooth-connected devices? Patient-reported outcomes?”
With technologies, telecommunication systems and health care changing rapidly, ASCO created standards and practice recommendations to guide use of telehealth in oncology.
The comprehensive guidance, published last summer, aimed to give oncologists, nurses, advanced practice providers, allied health professionals and administrators involved in the delivery of cancer care a better compass to navigate telehealth.
“Telemedicine has been an incredible tool throughout the pandemic to serve patients with cancer, but we want to make sure it is delivered in alignment with quality-based guidelines,” ASCO panel member Debra Patt, MD, PhD, MBA, FASCO, executive vice president of Texas Oncology, told Healio last year. “When people don’t use it in the way it was intended, its usefulness is diminished. So, we wanted to establish guidance and standards to ensure oncologists have a consistent way to use telehealth.”
Patients with cancer stand to benefit as much as anyone from the convenience of telehealth. Even after treatment, cancer survivors know they need to schedule follow-ups and keep close tabs on their health.
“Having that 24/7 tele-reassurance, cancer care at any address, is going to be the way to do it. ... Almost everything can be done at home,” Klasko said. “You get on the app — ‘What’s the problem? Click here.’ — you know if you can't solve it there, then somebody comes on your mobile phone and says, ‘We can look at it remotely and tell you what's going on.’”
The pandemic not only forced telehealth adoption more quickly than expected, but also showed the cancer care community how essential it could be.
“Prior to the global pandemic, people used telehealth predominantly for acute care visits with providers other than their established clinicians,” Patt said. “What we’ve learned from the pandemic is that the real service to patients is in longitudinal care in chronic diseases such as cancer, where patients can have telemedicine visits with their providers and we can perform medication changes, acute care visits and other support virtually and take care of patients where they are. So, that’s the big message — making sure we use it appropriately so we can continue to provide this incredibly useful tool to the patients we serve.”
Addressing ‘the digital divide’
Just as telehealth has opened the door to health care access for many patients, Dicker said it has also created disparities.
“I have a friend who spends time on Indian reservations, and there are some significant challenges there with broadband access and technology. There are even people within 10 miles of Jefferson in Philadelphia who may not have broadband access,” said Dicker, who has studied this with colleagues in Philadelphia.
Dicker said ways to reduce disparities in telehealth use include getting communication devices into the hands of patients in need, educating community health care workers on assisting in that practice, and creating a system that serves areas “where there’s a digital divide and health literacy.”
In a research letter published in JAMA Oncology in November, investigators reported that telemedicine capabilities may be insufficient to reduce and potentially could widen disparities in cancer care.
The researchers pooled data from the HealthCore Integrated Research Database on 16,006 patients (53% men; 50.7% aged 18 to 64 years) with newly diagnosed breast, lung, prostate or colorectal cancer during the first 8 months of 2020. The findings revealed socioeconomic status differences in the patterns of telemedicine uptake, with approximately 66.9% of patients in the highest socioeconomic status index quartile having a telemedicine visit within 30 days of cancer diagnosis, compared with 47.4% to 48.6% of patients in the lower socioeconomic quartiles. Additionally, patients in the highest socioeconomic status index quartile had 31% higher odds of telemedicine use within 30 days of cancer diagnosis when compared with patients in the lowest socioeconomic status index quartile.
“Unequal utilization of telemedicine among [patients with cancer] across the U.S. may widen cancer disparities,” Ronald C. Chen, MD, MPH, FASCO, FASTRO, Joe and Jean Brandmeyer endowed professor and chair of the department of radiation oncology at University of Kansas Cancer Center, told Healio after publication of the letter. “Additional studies can examine whether less telemedicine use is associated with delayed cancer care and worse outcomes for certain groups of patients.”
In October, two other studies presented at the virtual American College of Surgeons Clinical Congress also showcased disparities in telehealth availability and use among patients with cancer during the pandemic.
The first study set out to determine whether breast centers across the country offered telehealth services. The analysis included 371 Commission on Cancer-accredited centers throughout the U.S.
Among the findings, researchers reported geographic location (P = .004) as the only independent predictor of telehealth access. Specifically, centers located in the West offered telehealth six times more often than those in other regions, including the Northeast (OR = 6.38; 95% CI, 1.27-32).
“While several hospital characteristics affected the availability of telehealth visits, significant geographic disparities persisted independent of these factors,” Anees B. Chagpar, MD, MSc, MPH, MA, MBA, FRCS(C), FACS, professor in the department of surgery at Yale University School of Medicine, told Healio last year. “This interesting and somewhat unexpected finding suggests that some regions of the country were better able to offer telehealth visits, all else being equal.”
In the second study, researchers compared patient socioecological factors for 60,718 outpatient cancer clinic visits (84.4% in-person, 15.6% via telehealth) at the only NCI-designated cancer center in Alabama between March and December 2020.
Among their findings:
- Patients who used telehealth visits tended to be white (70.3%) and female (63.7%).
- Telephone vs. video visits appeared more common among patients who were Black (25.8% vs. 18.4%; P < .001), older (mean age, 62 years vs. 57.3 years; P < .001) and of lower-income ZIP codes ($52,297 vs. $56,343; P < .001).
- Predictors of lower video use included age (OR per 10 years = 0.82; 95% CI, 0.79-0.86) and Black race (OR = 0.6; 95% CI, 0.5-0.72).
“Telemedicine is here to stay and ensuring our patients can access the health care system equitably ensures we do not continue to broaden the chasm the digital divide has created," Connie C. Shao, MD, general surgery resident at The University of Alabama at Birmingham, told Healio last year.
A future of ‘health care at any address’
Klasko has been invested in the future of health care for some time, according to colleagues.
“He said in 2014 that telehealth was the future and set up a telehealth program [at Jefferson],” Karen E. Knudsen, PhD, MBA, CEO of American Cancer Society and American Cancer Society Cancer Action Network, and former executive vice president of oncology services and enterprise director for Sidney Kimmel Cancer Center at Jefferson Health, told Healio during an interview last year.
“He asked every provider to conduct one telehealth visit per month, irrespective of reimbursement. So, my oncology team not only had that muscle memory of what to do with telehealth, but also was licensed across multiple states,” Knudsen said.
Klasko trained under innovative minds. About 20 years ago, he served as an adviser at Apple, “when they were moving from a computer company to a digital lifestyle company.”
“Steve Jobs’ genius was recognizing that just participating in the computer and operating system game and assuming that 10 years from now we’ll just have core laptops and better operating systems didn't make any sense. We needed to think about what could change things,” Klasko said. “Now when on my computer, I’m on my iPad or my iPhone ... it's all just a mobile device, right? That tells us the word ‘telehealth’ will become an anachronism.”
He prefers the concept of “health care at any address.” During the height of the pandemic 2 years ago, everyone got a sneak peek of what the future could look like.
“I think with COVID, we were able to push the envelope of things we could diagnose correctly,” Klasko said. “Now, you have to think about what technologies are coming down the pike that are going to make that even easier.”
The current and future technologies that fuel telehealth must work for not only providers, but also for their patients. Chagpar wants to pursue more research examining telehealth from that perspective.
“We recently published a study that showed that certain segments of the population were less likely to avail themselves of telehealth prior to the pandemic, in part due to lack of computer and/or internet access,” Chagpar told Healio last year. “The pandemic has taught us the need for people to be digitally connected, and it would be interesting to see what we, as a society, have done to overcome some of those disparities to make telehealth more widely available, particularly to the most vulnerable for whom there may be considerable obstacles to accessing care otherwise.”
In navigating a path forward, Klasko said oncologists and the institutions they work for can use the lessons learned through the COVID-19 pandemic. They can devise plans to build a system that works for everyone. They can utilize new technologies when they become available and plan for the future.
“Sebastian Thun, the founder of Google X, said the problem with American health care isn't that we aim too high and fail, it's that we aim too low and exactly hit the mark. And I think that's the story of telehealth,” Klasko said. “The pandemic proved telehealth works in saving lives, by literally getting care to folks who couldn't come to the hospital because of the pandemic. It also proved that we have an inequitable system.
“I tell people I want our health system to be like Target or Walmart. When you need to come into the store, we want to be a great place to shop, but most of the time you don't need to come into the store. That's the future of telehealth.”
References:
Doernberg H, et al. Factors affecting telehealth availability amongst breast centers during the pandemic. Presented at: American College of Surgeons Clinical Congress (virtual meeting); Oct. 23-27, 2021.
Katz AJ, et al. JAMA Oncol. 2021;doi:10.1001/jamaoncol.2021.5784.
Leader AE, et al. JCO Clin Cancer Inform. 2021;doi:10.1200/CCI.21.00039.
New HHS study shows 63-fold increase in Medicare telehealth utilization during the pandemic. www.hhs.gov/about/news/2021/12/03/new-hhs-study-shows-63-fold-increase-in-medicare-telehealth-utilization-during-pandemic.html. Published Dec. 3, 2021. Accessed Feb. 11, 2022.
Shao C, et al. Age exacerbates inequity in telemedicine use during the COVID-19 pandemic for cancer patients in the Deep South. Presented at: American College of Surgeons Clinical Congress (virtual meeting); Oct. 23-27, 2021.
Zon RT, et al. JCO Oncol Pract. 2021;doi:10.1200/OP.21.00438.
For more information:
Anees B. Chagpar, MD, MSc, MPH, MA, MBA, FRCS(C), FACS, can be reached at Department of Surgery, Yale University, 310 Cedar St, 118 Lauder Hall, New Haven, CT, 06510; email: anees.chagpar@yale.edu.
Ronald C. Chen, MD, MPH, FASCO, FASTRO, can be reached at University of Kansas Cancer Center, Richard and Annette Bloch Cancer Care Pavilion, 2650 Shawnee Mission Parkway, Westwood, KS 66205.
Adam P. Dicker, MD, PhD, FASTRO, FASCO, can be reached at Thomas Jefferson University, 1020 Walnut St., Philadelphia, PA 19107; email: adam.dicker@jefferson.edu.
Stephen K. Klasko, MD, MBA, can be reached at stephenklasko@gmail.com.
Karen E. Knudsen, MBA, PhD, can be reached at American Cancer Society, 1818 Market St., Philadelphia, PA 19103.
Debra Patt, MD, PhD, MBA, FASCO, can be reached at Texas Oncology, 204 Balcones Drive, Austin, TX 78731; email: debra.patt@usoncology.com.
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