January 10, 2023

Krupal B. Patel, MD, MSc^1,2; Kea Turner, PhD, MPH³; Amir Alishahi Tabriz, MD, PhD, MPH³; et alBrian D. Gonzalez, PhD³; Laura B. Oswald, PhD³; Oliver T. Nguyen, MSHI³; Young-Rock Hong, PhD, MPH⁴; Heather S. L. Jim, PhD³; Anthony C. Nichols, MD⁵; Xuefeng Wang, PhD⁶; Edmondo Robinson, MD, MBA^7,8; Cristina Naso, MEd⁹; Philippe E. Spiess, MD, MS^9,10

Author Affiliations Article Information

JAMA Netw Open. 2023;6(1):e2250211. doi:10.1001/jamanetworkopen.2022.50211

Key Points

Question  What are the estimated cost savings of using telehealth among patients with cancer?

Findings  This economic evaluation of cost savings from completed telehealth appointments included 11 688 patients younger than 65 years, with 25 496 telehealth visits at a National Cancer Institute–Designated Comprehensive Cancer Center from April 1, 2020, to June 30, 2021. According to cost models, the estimated mean total cost savings ranged from $147.4 to $186.1 per visit.

Meaning  These findings suggest that telehealth saves time, travel, and money for patients, which could improve care delivery and may reduce the financial toxicity of cancer care.

Abstract

Importance  Patients with cancer typically have greater financial hardships and time costs than individuals without cancer. The COVID-19 pandemic has exacerbated this, while posing substantial challenges to delivering cancer care and resulting in important changes in care-delivery models, including the rapid adoption of telehealth.

Objective  To estimate patient travel, time, and cost savings associated with telehealth for cancer care delivery.

Design, Setting, and Participants  An economic evaluation of cost savings from completed telehealth visits from April 1, 2020, to June 30, 2021, in a single-institution National Cancer Institute–Designated Comprehensive Cancer Center. All patients aged 18 to 65 years who completed telehealth visits within the designated time frame and had a Florida mailing address documented in their electronic medical record were included in the study cohort. Data were analyzed from April 2020 to June 2021.

Main Outcomes and Measures  The main outcome was estimated patient cost savings from telehealth, which included 2 components: costs of travel (defined as roundtrip distance saved from car travel) and potential loss of productivity due to the medical visit (defined as loss of income from roundtrip travel plus loss of income from in-person clinic visits). Two different models with a combination of 2 different mileage rates ($0.56 and $0.82 per mile) and census tract–level median hourly wages were used.

Results  The study included 25 496 telehealth visits with 11 688 patients. There were 4525 (3795 patients) new or established visits and 20 971 (10 049 patients) follow-up visits. Median (IQR) age was 55.0 (46.0-61.0) years among the telehealth visits, with 15 663 visits (61.4%) by women and 18 360 visits (72.0%) by Hispanic non-White patients. According to cost models, the estimated mean (SD) total cost savings ranged from $147.4 ($120.1) at $0.56/mile to $186.1 ($156.9) at $0.82/mile. For new or established visits, the mean (SD) total cost savings per visit ranged from $176.6 ($136.3) at $0.56/mile to $222.8 ($177.4) at $0.82/mile, and for follow-up visits, the mean (SD) total cost savings per visit was $141.1 ($115.3) at $0.56/mile to $178.1 ($150.9) at $0.82/mile.

Conclusions and Relevance  In this economic evaluation, telehealth was associated with savings in patients time and travel costs, which may reduce the financial toxicity of cancer care. Expansion of telehealth oncology services may be an effective strategy to reduce the financial burden among patients with cancer.

Introduction

Financial toxicity includes both objective financial burden (ie, costs) and subjective financial distress.^1,2 Costs of cancer care include: direct cost of care (cost sharing through higher deductibles, copayments, coinsurance, and even entire cost of care for uninsured patients) and indirect costs of care (lost productivity and cost of driving to and from appointments).^1,3 Patients with cancer have greater time-based costs than those without cancer (eg, time spent traveling back and forth to appointments and time spent receiving medical care).^4–6 Strategies are needed to reduce the direct and indirect costs of cancer care delivery.

The rapid adoption of telehealth during the COVID-19 pandemic has allowed patients to receive care in a location that is convenient for them, which may reduce the costs of cancer care. To date, there has been limited research regarding the cost savings of telehealth among patients with cancer. The COVID-19 pandemic is providing a unique opportunity to estimate the potential cost savings of telehealth in oncology care.⁷ Although it is well established that patients with cancer experience substantial financial toxicity, few studies have explored the indirect costs that they face. Thus, this study focused specifically on an oncologic population from a comprehensive cancer center with a substantially large sample size to estimate the indirect cost savings (driving costs and lost productivity) from telehealth visits.

Methods

This was an economic evaluation estimating cost savings from completed telemedicine visits at Moffitt Cancer Center (MCC), the only National Cancer Institute (NCI) –Designated Comprehensive Cancer Center in Florida. Data from telehealth visits were collected from April 1, 2020, to June 30, 2021. All patients aged between 18 and 65 years who completed telehealth visits within the designated time frame and had a Florida mailing address documented in their electronic medical record were included in the study cohort. All patients were offered telehealth if deemed appropriate by the clinical team. Telehealth visits were not offered to patients who needed physical examinations beyond what can be assessed during a telehealth visit. Patients who presented in person for chemotherapy infusion and/or radiation treatment were excluded from the analysis. This study was exempt from MCC institutional review board approval with a waiver of informed consent from patients because the study was deemed low risk. This study used the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) reporting guideline.⁸

Due to the COVID-19 pandemic, implementation of telehealth at MCC was accelerated in March 2020. Telehealth was defined as care delivered through a videoconferencing platform in real time. Starting in April 2020, MCC instituted videoconferencing for their telehealth visits. Patient visits were defined as new, established, or follow-up. New patient visits were patients not having received any previous medical care from MCC; established patient visits had received care at MCC previously but were referred to a new subspecialty for consultation; and follow-up patient visits were seen at MCC for follow-up care by clinicians in the same subspecialty they had previously received care from.

Statistical Analysis

We assessed patient time, travel, and indirect cost savings from using telehealth for cancer care delivery (Figure 1). Analyses were guided by the framework recommended by Sanders and colleagues⁹ for assessing the time and transportation costs of patients. Time savings were calculated as the difference between the roundtrip time required to travel from each patient’s home address to an in-person consultation at MCC, plus in-person consultation time vs the time required to attend a telehealth visit from home (ie, time savings = roundtrip drive time + [time for in-person consultation – time for telehealth visit]). Travel savings were calculated as the roundtrip driving distance in miles from each patient’s home address to an in-person consultation at MCC. Indirect cost savings were calculated as the roundtrip costs associated with traveling from each patient’s home address to an in-person consultation at MCC. This included 2 components: the costs of travel and the potential loss of productivity due to the medical visit.

The American Community Survey (ACS)¹⁰ was used to determine census tract–level data for hourly median income per year. The census tract income data were then matched to the patient’s address. This analysis focused on patients younger than 65 years, because these patients were more likely to be employed full time than those aged 65 years or older.

Two different models were generated with a combination of 2 different mileage rates and hourly wage rates determined via ACS census tract level data. Driving distance traveled in miles was calculated in October 2021 by Buxton Company,¹¹ an analytics organization that uses Alteryx’s¹² analytic platform to provide geospatial data. Briefly, the locations are geocoded, and distance is calculated between the 2 geocoded locations by finding the route that results in the least amount of drive time between the 2 locations.

Calculations for different models were conducted using R (R Project for Statistical Computing).¹³ Details are available in the eMethods in Supplement 1. Data were analyzed from April 2020 to June 2021.

Results

A total of 25 496 telehealth visits for 11 688 patients were conducted for patients aged between 18 and 65 years during the study period. There were 4525 (3795 patients) new or established visits and 20 971 (10 049 patients) follow-up visits (Figure 2A). The eTable in Supplement 1 highlights the demographics of the telehealth visits. Median (IQR) age was 55.0 years (46.0-61.0) among the telehealth visits, with 15 663 visits (61.4%) being women, 18 443 visits (72.3%) having private insurance, and 18 360 (72.0%) visits by White non-Hispanic individuals. In travel, an estimated 3 789 963 roundtrip miles (804 969 for new or established visits and 2 984 994 for follow-up visits) were saved, equating to 75 055 hours (15 422 new or established visits and 59 633 for follow-up visits) of savings in total driving time. Per visit, telehealth was associated with mean (SD) savings of 148.6 (143.7) roundtrip travel miles and 2.9 (2.3) hours of roundtrip driving time (Table 1, Figure 2B and 2C). An additional 29 626 hours of in-clinic visits were saved by using telehealth with a mean (SD) savings of 1.2 (0.13) hours per visit (Figure 2D). For new or established visits, telehealth was associated with mean (SD) savings of 177.6 (161.6) roundtrip travel miles, 3.4 (2.6) hours of roundtrip driving time and 1.5 (0.0) hours of in-clinic time per visit (Figure 2B, 2C, and 2D). For follow-up visits, telehealth was associated with mean (SD) savings of 142.4 (138.8) roundtrip travel miles, 2.8 (2.3) hours of roundtrip driving time and 1.1 (0.0) hours of in-clinic time per visit (Figure 2B, 2C, and 2D).

Telehealth was associated with an estimated $1 170 160 savings in lost productivity (income) due to driving time, $467 247 savings in lost productivity due to visit time, and $1 637 407 total savings in lost productivity (Table 2, Figure 2B, 2C, and 2D). For new or established visits, the following savings were noted: $245 113 savings in lost productivity due to driving time, $104 522 savings in lost productivity due to visit time, and $349 655 total savings in lost productivity. For follow-up visits, the following savings were noted: $925 027 savings in lost productivity due to driving time, $362 725 savings in lost productivity due to visit time, and $1 287 752 total savings in lost productivity. Mean (SD) savings in lost productivity per visit due to driving time were $45.9 (41.5) per visit overall, and $54.1 (47.9) for new or established visits and $44.1 (39.7) for follow-up visits (Table 2, Figure 3A). Mean (SD) savings per visit in lost productivity due to visit time was $18.3 (5.9) per visit overall, and $23.1 (6.9) for new or established visits and $17.3 (5.1) for follow-up visits. Estimated mean (SD) total savings per visit from lost productivity was $64.2 (43.6) per visit overall, $77.2 (50.6) for new or established visits, and $61.4 (41.4) for follow-up visits. Total driving-cost savings ranged from $2 122 379 at $0.56/mile (Figure 3B) to $3 107 777 at $0.82/mile (Figure 3C). For new or established visits, total driving-cost savings were $450 782 at $0.56/mile to $660 074 at $0.82/mile, while for follow-up visits, total driving-cost savings were $1 671 597 at $0.56/mile to $2 447 695 at $0.82/mile. According to cost models, the mean (SD) driving cost savings per visit ranged from $83.2 ($80.5) at $0.56/mile to $122.0 ($118.0) at $0.82/mile (Table 2, Figure 3B and 3D). For new or established visits, the mean (SD) driving cost savings per visit ranged from $99.6 ($90.5) at $0.56/mile to $146.0 ($132.6) at $0.82/mile, and for follow-up visits, the mean (SD) cost savings per visit was $79.7 ($77.7) at $0.56/mile to $116.7 ($113.8) at $0.82/mile. According to cost models, the mean (SD) total cost savings per visit ranged from $147.4 ($120.1) at $0.56/mile to $186.1 ($156.9) at $0.82/mile (Table 2, Figure 3B and 3D). For new or established visits, the mean (SD) total cost savings per visit ranged from $176.6 ($136.3) at $0.56/mile to $222.8 ($177.4) at $0.82/mile, and for follow-up visits, the mean total cost savings per visit was $141.1 ($115.3) at $0.56/mile to $178.1 ($150.9) at $0.82/mile.

Discussion

This economic evaluation study uses a large data set collected at an NCI-Designated Comprehensive Cancer Center to estimate patients’ savings from using telehealth. From April 1, 2020, to June 30, 2021, a total of 25 496 telehealth visits were conducted. Telehealth was associated with a total savings of 3 789 963 roundtrip travel miles, which equates to traveling 152.2 times around the earth, and a total savings of 75 055 roundtrip drive hours, which equates to 8.6 calendar years. An additional 3.4 calendar years (29 626 hours) were saved in clinic visits by using telehealth. Depending on the visit types, mean savings in lost productivity per visit due to driving time ranged from $44.1 to $54.1, mean savings in lost productivity due to visit time ranged from $17.3 to $23.1, and mean total savings in lost productivity per visit ranged from $61.4 to $77.2. Mean driving cost savings per telehealth visits ranged from $79.71 to $146.0 depending on visit type and model used. Mean total cost savings per visit ranged from $141.1 to $222.8 depending on the visit type and model used.

Some of the main arguments for implementing telehealth are to increase access to care, patient convenience, and cost savings in outpatient clinics.¹⁴ Telehealth may also provide an opportunity to reduce emergency department visits, readmissions, and patient mortality.¹⁴ As patients’ financial costs of cancer care increase, telehealth may reduce their burden of travel including costs associated with parking and lodging, and lost income from missing work.

The burden of travel has been identified as an important factor that can change access to diagnosis, treatment of cancer and participation in clinical trials.^15,16 Transportation is a key determinant of health care access and has been identified as an important source of out-of-pocket nonmedical costs for patients receiving cancer care.¹⁷ Patients without adequate transportation are more likely to miss appointments and rely on emergency department care,¹⁵ and there is substantial variability in the estimated parking costs throughout cancer treatment.¹⁸ In addition, a recent study noted that the number of rural hospitals has decreased over the last decade, resulting in almost double the number of people living outside a 60-minute radius of major hospitals and longer drive times to receive care.¹⁹ Thus, telehealth could be beneficial among rural patients in particular.²⁰

In the models previously mentioned, we did not consider the cost savings of telehealth for cancer caregivers. Caregivers for patients with cancer spend substantial time and effort to coordinate and attend appointments with patients. In 2020, 53 million individuals were caregivers, 6% of whom were caregivers for patients with cancer. The vast majority of caregivers (80%) help with transportation; 18% report high financial strain; and 45% have experienced at least 1 financial impact as a result of caregiving.²¹ Although the current study was focused on indirect cost savings from patients’ perspectives, future studies should include caregivers’ indirect cost savings as often patients and caregivers function as a unit and share expenses. Therefore, savings from telehealth would be even higher if caregivers’ savings from lost productivity were accounted for, especially when telehealth has the ability for multiple caregivers to join the same appointment from various geographical locations.

Although telehealth offers considerable cost savings to patients with cancer, it is well documented that telehealth adoption is affected by the digital divide. Factors associated with financial toxicity (eg, age, insurance, race, and education) are also associated with the digital divide.²² Future studies are needed to address inequities in telehealth uptake. Additionally, telehealth requires substantial infrastructure costs and investments from health systems with buy-in from administrators and clinicians to ensure high patient satisfaction.²³

Limitations

Our study has several limitations. This analysis was retrospectively conducted at a tertiary/quaternary referral center, and so roundtrip travel distances may be higher than usual because this is a destination center for cancer care. Our assumption of employment rates and incomes for patients younger than 65 years may vary. Additionally, a percentage of patients on active treatment or following treatment may not be fully employed given their functional status, thus affecting the savings from lost productivity. Because we were unable to accurately capture employment among older adults, patients aged over 65 years were excluded; however, future studies should examine cost savings in this population. Cost savings due to lost productivity assumed that all patients are nonsalaried and the loss due to travel time and hours of visit time could not be made up for. Therefore, the savings in this study might be considered a maximum amount of lost productivity. This study only considered telehealth visits that were completed via synchronous videoconference, and the costs of electronic devices and internet access were not considered. This study also did not assess other factors likely to affect cost savings, such as rural vs urban residences, race, education, or insurance type, all of which should be explored in future studies. Finally, further data are needed if long-term oncologic outcomes with telehealth visits are equivalent to those seen in person, which can change costs of treatment.

Conclusions

Patients with cancer spend a substantial amount of time and money traveling to receive care. Using a large data set, we found that cancer care delivery via telehealth was associated with time, travel, and cost savings for patients with cancer, which may reduce the financial toxicity of cancer care. Future studies should explore other cost savings, such as the savings to cancer caregivers and how these vary for rural and urban patients with cancer.

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Article Information

Accepted for Publication: November 18, 2022.

Published: January 10, 2023. doi:10.1001/jamanetworkopen.2022.50211

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2023 Patel KB et al. JAMA Network Open.

Corresponding Author: Krupal B. Patel, MD, MSc, Department of Head and Neck and Endocrine Oncology, Moffitt Cancer Center, 12902 Magnolia Dr, Tampa, FL 33612 (krupal.patel@moffitt.org).

Author Contributions: Dr Patel had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Patel, Alishahi Tabriz, Gonzalez, Wang, Spiess.

Acquisition, analysis, or interpretation of data: Patel, Turner, Gonzalez, Oswald, Nguyen, Hong, Jim, Nichols, Wang, Robinson, Naso.

Drafting of the manuscript: Patel, Nichols.

Critical revision of the manuscript for important intellectual content: Patel, Turner, Alishahi Tabriz, Gonzalez, Oswald, Nguyen, Hong, Jim, Wang, Robinson, Naso, Spiess.

Statistical analysis: Patel, Wang, Naso.

Obtained funding: Patel.

Administrative, technical, or material support: Patel, Turner, Alishahi Tabriz, Gonzalez, Robinson, Naso.

Supervision: Patel, Gonzalez, Jim, Nichols.

Conflict of Interest Disclosures: Dr Gonzalez reported receiving personal fees from Sure Med Compliance and personal fees from Elly Health outside the submitted work. Dr Jim reported being a consultant for Janssen Scientific Affairs and Merck, and reported receiving grants from Kite Pharma outside the submitted work. Dr Spiess reported being the Vice Chair of the National Comprehensive Cancer Network Penile/Bladder Guidelines Panel, President of the Global Society of Rare GU Tumors, and a board member of the Societe of Internationale D’Urologie Journal outside the submitted work; none of these roles are compensated. No other disclosures were reported.

Data Sharing Statement: See Supplement 2.

Additional Contributions: The authors would like to acknowledge the members of Moffitt Cancer Center’s Planning and Market Data Analytics Department for their help with data curation and analysis, and April Manna, MS, for administrative assistance. Editorial assistance was provided by the Moffitt Cancer Center’s Office of Scientific Publishing by Gerard Hebert, MA, and Daley Drucker, BA. No compensation was given beyond their regular salaries. We would also like to thank donors to the COVID-19 Fund at Moffitt Cancer Center for their generous support, which helped to fund research to improve the quality and cost savings offered through Virtual Health.

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Soon after the COVID-19 pandemic hit, concerns regarding the sudden halt of in-person care grew. As hospitals swelled with novel coronavirus cases, many worried about chronic care needs not being met – especially among cancer patients.

These concerns were not unfounded. A study published in late November 2020 showed that the pandemic significantly delayed identifying new cancers and treatment delivery. A more recent study reveals that gaps remain in preventive cancer screenings.

But as in-person care restrictions proliferated, virtual care use grew. And though many providers were already leveraging virtual care strategies, like remote patient monitoring (RPM), the pandemic further spurred their use in the cancer care arena.

Some organizations were able to scale existing RPM programs for cancer care due to regulatory flexibilities that accompanied the pandemic, while others were able to stand up new programs through grants and new funding mechanisms.  

But implementing RPM efforts in the cancer care arena is not without its challenges, according to health system leaders who spoke with mHealthIntelligence. These challenges include a lack of technology access, clinician pushback, and nonexistent reimbursement structures.  

CANCER CARE PROVIDERS ARE USING RPM IN VARIOUS WAYS

Organizations that provide cancer care are employing RPM primarily to expand access to care and prevent adverse events.

At the University of Utah Health’s Huntsman Cancer Institute in Salt Lake City, RPM underpins several programs, including the symptom management and hospital-at-home programs.

Huntsman’s Symptom Care at Home program focuses on monitoring the symptoms of chemotherapy patients, said Kathi Mooney, PhD, co-leader of Cancer Control and Population Sciences at Huntsman Cancer Institute. Patients call an interactive voice response (IVR) system daily to report their symptoms and rate the severity. The system provides an automated response on managing the symptoms they are experiencing and alerts the care team if the symptoms become severe.

“We find that to be very helpful in terms of cancer symptom management,” Mooney said in a phone interview. “You may see them in the clinic on a Tuesday and Wednesday morning, [but later] they wake up with something, and they’re in the emergency department. So, the ability to remotely have the patient know what they’re experiencing at home and be able to respond in the moment to that helps decrease the symptom burden and therefore decreases the escalations.”

But all escalations cannot be avoided, and cancer is known to progress rapidly. To expand access to acute care and avoid emergency department (ED) visits and re-hospitalizations, the cancer institute launched a hospital-at-home program in 2018.

Through the program, patients receive on-site and telehealth-enabled nurse practitioner visits and on-site registered nurse and physical therapy visits. It also includes remote cardiovascular monitoring. Since its inception, 2,000 patients have been treated through the program.

According to Mooney, the program has helped extend hospital-level care to cancer patients around the state, which is largely rural. Further, a study by Huntsman evaluating the program showed that the odds of unplanned hospitalizations in the hospital-at-home group dropped by 55 percent compared to patients who received standard care in the hospital.

Like Huntsman, Ochsner Health System in New Orleans implemented RPM to support cancer patients undergoing chemotherapy. Launched in 2019, the program provides patients with various devices, including a blood pressure cuff and thermometer, Erin Pierce, nurse practitioner and manager of precision cancer therapies at Ochsner Cancer Institute, told mHealthIntelligence.

Patients pick up the devices for free from the O-bar, Ochsner digital technology hub, where technicians help them set up and use the devices. Patients submit vital signs twice daily through the health system’s app. Clinicians intervene when needed to help patients before they find themselves back in the hospital.

“Our whole goal for all of this was really to decrease hospitalizations and ER visits and really keep people out of the hospital as much as possible because it’s the last place cancer patients want to be,” Pierce said in a phone interview.

The health system collected preliminary data on the program from January 2020 to December 2021, which showed a 33 percent decrease in ED visits and hospitalizations among program participants. The program won Ochsner a 2022 Association of Community Cancer Centers Innovator Award.

“The thing is, we know cancer patients are going to go to the emergency room, we know they’re going to get hospitalized, they’re prone to these things,” Pierce said. “But again, what we wanted to do was see if we could decrease that amount, and that’s what we were able to show.”

Unlike Ochsner and Huntsman, Mount Sinai Health System in New York City began using RPM in cancer care last year after applying for and winning a grant from the Federal Communications Commission.

The health system’s program provides wearable devices to cancer patients in the ambulatory setting who are receiving some form of cancer-related treatment, typically chemotherapy or immunotherapy, said Cardinale Smith, MD, PhD, chief quality officer for cancer at Mount Sinai Health System and system associate professor of medicine, hematology, and medical oncology.

The devices include arm cuffs that can track temperature and oxygen saturation, blood pressure cuffs, and tablets to connect patients with the care team and facilitate data exchange. The tablet has built-in internet access, helping the health system overcome one aspect of the digital divide.

“As we think about the digital divide and what some of the challenges are for certain populations to be able to use and access technology and novel devices…having tablets so that they can engage [in]and do video visits or communicate with their clinicians in real time was something that was important to for me,” Smith said in a phone interview.

In addition to reducing unnecessary ED visits and hospitalizations, RPM use has enabled Mount Sinai to leverage patient-reported data to improve mortality risk.

“[RPM use] may improve survival because we’re helping manage patients’ symptoms more appropriately,” she said. “And so, this is a way to reengage patients in real time about their symptoms as opposed to waiting until symptoms become severe.”

OVERCOMING CHALLENGES TO ADOPTION AND USE

While deploying RPM strategies for cancer patients, providers faced various hurdles.

For Ochsner, the primary challenges were the high cost of devices and some patients’ inability to understand and use technology.

To address the first hurdle, Pierce and her team relied on philanthropy funding and the Ochsner Excellence Grant, which provided $25,000, to buy the bulk of the RPM kits.

“We really strongly feel that this should be something that every cancer patient is offered, and we really want to be able to continue [providing these devices for free], so we’re continuing to try to find funding,” she said.

Though digital literacy has grown significantly, especially amid the pandemic, some patients still struggle with technology. Ochsner leveraged its O-bar – like Apple’s Genius Bar, but for patients in Ochsner’s care – to show patients how to use the technology and provide troubleshooting support if they have issues with the devices after taking them home, Pierce said.

To further widen access to RPM during the pandemic, Ochsner changed the type of data collected in the program. Instead of enrolling patients before they started chemotherapy so clinicians could collect baseline vitals for each patient, the health system began enrolling patients at any point in their treatment journey and moved to a threshold system to assess the data.

“We went from those baseline vitals from the individual and went ahead to just threshold vitals,” Pierce said. “So, for instance, if blood pressure was at a certain range, or their heart rate, or their temperature, that’s when a notification would fire to [clinicians]…compared to [firing when there were] deviations from the patient’s original blood pressure.”

The health system was able to enroll more patients in the program by making this switch, she added.

Though the availability of real-time data and alerts are some of the biggest boons of using RPM, they can also become a barrier.

“We, in this pandemic world, are dealing with workforce shortages, people who are tired, and the idea of having to monitor another thing is challenging for folks,” said Mount Sinai’s Smith.

Leaders may face pushback on RPM efforts from their clinicians, who are worried about adding to their workload. Clinicians may also worry about liability if they do not respond to an alert in time or if the device malfunctions and they act on the wrong data.  

“We really had conversations with our regulatory and legal groups to understand some of the other things that came up for physicians, specifically around liability,” Smith said. “We had an initial rollout where we had the interested parties, who could speak to all of this, come and talk about it and what it meant.”

And it’s not just providers; patients may also have their own reservations, especially those uncomfortable with technology. Like Ochsner, Mount Sinai provided patients with additional support through oncology coordinators, who helped patients set up and use the devices, Smith said.

Huntsman Cancer Institute’s symptom management program incorporated the IVR telephone system primarily to address technology access and use issues among its patients.

“That’s one of the reasons we started with the IVR system because it decreased the disparity of not having access to a smartphone,” Mooney said. “We also have added now an app and web[site], so that we’re responsive to patients who said, ”I’d rather not use telephone audio,’ [and said], ‘I would rather just put it in through a text kind of method.'”

With the hospital-at-home program, Huntsman focused on breaking down barriers related to patients’ social determinants of health. The institute partnered with community organizations, including cleaning services and food banks, to curtail sanitation and food security problems while acute care is provided in people’s homes.

“We have tried to be very careful about not arbitrarily saying we couldn’t provide service to a patient because there is the benefit of not disrupting them, of keeping them in the home, of not asking them to travel a distance in order to get care,” Mooney said. “We have, for example, taken care of patients in mobile homes, in conditions where there was poverty.” 

Further, Huntsman worked closely with the home health agency they contracted with for the hospital-at-home program to ensure the home healthcare workers were adequately trained to provide acute care in the home.

According to Mooney, the institute helped train the staff on conducting critical assessments and other treatments outside the traditional home healthcare services arena.

BARRIERS TO ONGOING RPM USE IN CANCER CARE

As healthcare providers increasingly apply RPM strategies to cancer care, they are facing challenges in the broader healthcare landscape that may hinder more significant progress.

Perhaps the most pressing issue is the uncertainty regarding reimbursement for RPM-based programs.

“The issue is, with new models of care such as remote symptom management or hospital-at-home, they are new modalities that don’t have a structure within existing healthcare, and therefore there aren’t payment models,” Mooney said.

Within cancer care, the only type of established home healthcare reimbursement model is related to hospice services, spurring the need for new payment models for RPM programs that support other aspects of cancer care, she added.

Pierce echoed Mooney, saying that health insurance companies also need to look at expanding coverage to ensure that the high cost of devices does not deter patients from participating in these programs.

“I think it goes back to if this was more affordable, more people would be doing it,” she said. “We know the benefit is there; it’s just finding the coverage that we need, which is really why we need to get insurance involved with this.”

One way to encourage the development of payment models and prompt coverage expansion is to collect data showing the clinical and financial benefits of leveraging RPM for cancer care. According to Mooney, gathering and sharing this data can support the wider use of RPM, which can ultimately expand cancer care beyond the hospital.

“I think it’s very exciting with technology what we can do in the home,” she said. “And I think we are demonstrating a number of ways to do it and do it safely. And it is just now the implementation of that. How do we scale it with appropriate reimbursements and regulations that are supportive to care being provided in the home?”

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