Telemedicine in Cancer Care: So Far and Yet So Close
Kristine Barrows felt anxious about her visits to Cancer Treatment Centers of America (CTCA) in Chicago. Even with a family member behind the wheel, the four-hour round trip from Barrows’ home in Ingalls, Indiana, on top of medical exams and consultations with multiple specialists, left Barrows physically and mentally exhausted. Her anxiety mounted after the COVID-19 pandemic struck the United States in March.
Even though she knew CTCA was taking measures to protect patients’ health, Barrows, who received diagnoses of stage 1 breast cancer in 2010 at age 39, type 2 diabetes in 2012 and stage 4 breast cancer in 2016, would face a high risk of potentially fatal health complications if she contracted the virus.
When a nurse called to ask Barrows if she wanted a video visit with her doctor instead of an in-person appointment, Barrows eagerly said yes. “They talked me through how to download the software and even did a test session the day before my appointment to make sure I was comfortable using the technology,” she says.
During the video visit in April, Barrows’ endocrinologist assessed the effectiveness of her treatment plan by reviewing blood sugar readings accessed digitally through continuous glucose monitoring. With this system, a sensor implanted under the skin tests glucose frequently and sends results to a monitor. “My numbers looked good, and I wasn’t having any problems,” Barrows says.
That kind of diabetes follow-up usually occurs during a one- or two-day cluster of appointments at the cancer center that includes visits with experts in oncology, pain management, counseling and radiation, as well as integrative services such as acupuncture and massage, Barrows explains. This time, “the entire appointment took less than 20 minutes, and I didn’t have to sit through Chicago traffic afterward. It was great!” she says.
The idea of using technology to provide health care services, or telehealth, was first considered almost 100 years ago, when a 1924 Radio News magazine featured an illustration of a doctor using a futuristic audio-video device to diagnose a patient’s case. The actual first known use of telehealth took place a couple of decades later, in the 1940s, when radiology images were sent more than 20 miles over telephone lines.
Telehealth services gradually expanded over the years, focused primarily on video visits to make medical care more accessible to residents of rural communities. Still, physician-patient video visits have been slow to catch on, with lack of insurance reimbursements among the main drawbacks. Historically, private insurers, as well as Medicare and Medicaid, either would not cover services like video visits or offered substantially lower reimbursements. Some patients were also reluctant to use the technology because they believed that in-person care was the best care.
The unprecedented spread of COVID-19 and nationwide directives to stay home quickly changed many people’s perceptions of telehealth. “Health care facilities and providers had to adopt, accept and accelerate this new medium of care to meet the acute and chronic care needs of patients immediately,” says Elaine Smith, a licensed marriage and family therapist and manager of behavioral health for CTCA in Atlanta.
That has included providing insurance coverage for telemedicine where it didn’t exist before the pandemic and relaxing laws that restrict doctors from remotely treating patients located outside the states where they’re licensed, although those changes may be temporary, says Dr. Judd Hollander, associate dean of strategic health initiatives at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia.
The bottom line, according to Smith: “For people with cancer, it’s extremely important that there are no interruptions to treatments or other vital services.”
THE RISE OF TELEHEALTH IN CANCER CARE
Although often used interchangeably, the terms “telehealth” and “telemedicine” refer to slightly different concepts. “When we talk about telemedicine, we’re typically referring to two-way, audio-video communication between a patient and their clinician,” says Dr. Reggie Saldivar, director of telehealth for the supportive care service at Memorial Sloan Kettering Cancer Center (MSK) in New York. “‘Telehealth’ is an umbrella term that encompasses health-related services utilizing digital technologies. Telemedicine is a type of telehealth.”
Many individuals have been using telehealth services for years, perhaps without giving it much thought. Examples include a patient emailing a provider through a portal, Barrows using a medical device to send blood glucose readings to her endocrinologist and a doctor accessing test results stored securely in a patient’s personal electronic medical record.
These telehealth services, as well as others, must meet Health Insurance Portability and Accountability Act (HIPAA) requirements to keep personal information secure and confidential. Electronic medical records have always been expected to meet these requirements. Zoom meetings with colleagues are probably not HIPAA compliant, but medical centers that turned to the webinar platform during the pandemic use HIPAA-secure versions to protect information; other HIPAA-compliant apps include Doxy.me and GoToMeeting.
The pandemic may have hastened the country’s use of telehealth services, but many medical and cancer centers have been developing and using these services for years. Here’s a look at a few recent telehealth innovations designed to protect the health of people with cancer.
Emergency room pre-screenings: In Philadelphia, Jefferson Health is using a modern triage approach to screen patients before they come to the emergency department. “They can use the JeffConnect app to have a video consultation directly with a physician anytime of the day or night,” Hollander says. The university is home to the National Academic Center for Telehealth, which focuses on improving the patient experience through technology.
“If a patient needs to be seen at the emergency department, we can take their medical history and symptoms during the video consultation, arrange to meet them at the door when they arrive and escort them directly into an isolated exam room. They don’t have to touch a door or check in at the front desk,” Hollander says. Patients also can go straight to the cancer center, avoiding the emergency department. In addition to reducing the risk of COVID-19 exposure, triage protects people with weakened immune systems from exposure to flu and cold viruses, as well as other germs.
Bedside communication: Patients admitted at Jefferson Health, especially those with COVID-19, receive a hospital- issued, sanitized computer tablet so they can stay in touch with their care team and even loved ones who aren’t allowed to visit. “Right now, while personal protective equipment is scarce, the tablet offers a way for providers to check in on infected patients without physically entering the room unless necessary,” Hollander says. Patients might miss the face-to-face connection, but they benefit from more timely communication with physicians. “Instead of waiting for your physician to make it to your room, you can talk to your physician from wherever they are in the hospital,” he says.
MSK is launching a similar approach using bedside televisions, Saldivar says: “Clinicians can do a video call directly to the patient’s bed, allowing for remote consultations.”
Clinical trials: Accessibility of clinical trials has always been an issue for people who don’t live near large medical centers, which offer the majority of trials and are usually situated in metropolitan areas. Strict protocols, including weekly physical examinations and the expectation that enrollees will pick up self-administered experimental drugs in person, make participation prohibitive for many noncity dwellers.
Although the pandemic put a temporary halt to some clinical trial enrollments, many studies already underway continued with slight adjustments. “Trial participants are now monitoring health stats like weight, blood pressure and heart rate at home. And we’ve switched to telemedicine, or video visits, to inquire about side effects and other concerns,” says Dr. Jordan Berlin, associate director of clinical research at Vanderbilt-Ingram Cancer Center (VICC) in Nashville.
During the pandemic, the Food and Drug Administration OK’d mailing self-administered experimental medications to trial participants. Should this change become permanent, more people who live in rural communities and states with limited health care resources could benefit from greater access to promising new therapies. “I believe that telemedicine has the potential to make clinical trials safer,” Berlin says. “Patients who monitor their numbers at home tend to pay more attention to the readings and are faster to alert us if something seems off. We’re actually monitoring participants more closely now, even though we’re physically seeing them less frequently.”
Remote patient monitoring: A total of 76% of hospitals use technology to keep tabs on patients at home, according to the American Hospital Association. For instance, last year, VICC launched a program that allows patients receiving chimeric antigen receptor-T cell infusions to get nightly telemedicine checkups at home (or a hotel room if the patient lives more than 30 miles from the hospital). Typically, these patients would be confined to the hospital for a week or longer, but under this program, they visit the hospital twice a day for checkups and then use hospital-grade equipment to take their own vitals during nightly telemedicine visits. VICC also offers a remote radiation oncology survivorship program: Patients go to a clinic in Clarksville, Tennessee, for routine evaluations; 50 miles away, at VICC, a health care provider uses a specially designed stethoscope to listen to their hearts and lungs and a video-enabled dermatology scope to examine skin affected by radiation treatments.
Telehealth also offers a viable way for patients with cancer to meet with psychosocial support practitioners, from psychiatrists to social workers, without risking exposure to COVID-19, and to get genetic counseling.
Caregiver connections: COVID-19 put the kibosh on caregivers accompanying loved ones to medical appointments. This situation ratcheted up both patient and caregiver distress, but long-distance caregivers have always struggled with this problem. “Distance caregivers, or those who live more than 100 miles from the patient, report higher levels of anxiety and stress than local caregivers,” says Sara L. Douglas, a nurse practitioner who holds a doctorate in education and serves as the Gertrude Perkins Oliva Professor in Oncology Nursing and assistant dean of research at the Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland. “About one-third of people with cancer rely solely on distance caregivers to arrange transportation to medical appointments, schedule in-home care, order medications and medical equipment, and provide other critical care needs.”
Douglas is leading a National Institute of Nursing Research-funded study that explores how strategies including videoconferencing can ease this caregiver burden. Two-thirds of the participants used videoconference technology to attend a loved one’s in-person doctor appointment. “Video participants said they enjoyed getting to meet the doctor face-to-face, hearing information firsthand, having the ability to ask questions and being able to see their loved one at the appointment,” Douglas says. Patients said they felt reassured that their caregiver was present, if only on a screen, and felt less pressure to remember precisely what their doctor told them about their condition and treatment.
THE PROS AND CONS OF TELEHEALTH
Despite most hospitals using some type of technology to connect patients and providers, telehealth is an evolving field. “The research on telehealth for patients with cancer is currently in its infancy, but my guess is that these services will prove to be safe and effective for the majority of patients,” Saldivar says. Findings thus far highlight telehealth as a positive addition to care. In a 2019 review of 233 studies focused on telehealth for acute and chronic care consultations, Agency for Healthcare Research and Quality investigators found that virtual appointments either improved outcomes or were equal to in-person visits. Telemedicine reduced hospital mortality and time in the emergency department and may have shortened hospital stays and lowered costs, improved emergency care outcomes and reduced the number of outpatient visits, the agency found.
Not all medical care can be done remotely, of course, and not everyone is comfortable receiving care from a distance. For instance, those who live in remote areas and are most inconvenienced by long drives to medical facilities are the same people who are least likely to have reliable high-speed internet access.
Connectivity wasn’t an issue for Chuck Kreuzer, who lives near Waynesburg, Pennsylvania. The 55-mile drive to the University of Pittsburgh Medical Center Hillman Cancer Center often meant a full day away from the auto body shop he owns and manages. Kreuzer was 47 when he learned he has thrombocythemia, a rare blood disorder. Since receiving the diagnosis in 2016, Kreuzer gets blood tests every three months, followed by a visit with a hematologist.
In March, that visit took place via video. Kreuzer never had to leave his shop, and his wife, Lisa, joined the appointment and asked the doctor her prepared list of questions. “The video visit wasn’t rushed, but it didn’t feel quite as personable or natural as an in-person exam,” she says.
Although Kreuzer appreciated the convenience of not battling Pittsburgh’s traffic and the safety factor of not entering a medical setting during the start of a viral pandemic, he still wants to see and be seen in real time by his doctor. “If my numbers come back out of range, I would feel more comfortable discussing what that means with my doctor in person,” he says. “Also, because this cancer increases my risk for an enlarged spleen, I would feel more reassured if I had a physical exam at least every other visit.”
From the perspective of health care providers, the challenges involved with providing telehealth include choosing and learning to use a platform, making sure there is proper information technology support and figuring out how to deal with scheduling glitches, Saldivar says. It may take some time to work these issues out, but there will likely be continued innovation and expansion in this field.
Telehealth experts understand patients’ and doctors’ concerns and know that technology will never completely replace in-person medical care. “For patients undergoing cancer care who might be asked to come to a clinic multiple times a week, a telemedicine visit can save quite a bit of time, money and stress,” Saldivar says. “Ultimately, we want to be sure that the telehealth services we’re providing are safe, effective and just as good as an old- fashioned face-to-face visit.”