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. Author manuscript; available in PMC: 2025 Jan 1.
Published in final edited form as: Cancer J. 2024 Jan-Feb;30(1):2–7. doi: 10.1097/PPO.0000000000000694

Telehealth in cancer care: inequities, barriers, and opportunities

Ana Maria Lopez 1
PMCID: PMC10904017  NIHMSID: NIHMS1943260  PMID: 38265919

Abstract

Telecommunications technology began to be integrated into healthcare delivery by the mid 1900s with the goal of increasing access to care including access to cancer care. There have been at least three significant telehealth expansion periods with the most recent related to the COVID-19 pandemic. Technology uptake increased in the 1990s as quality improved, costs came down, and usability factors were addressed. As telehealth practice transitioned to use of personal devices, the COVID-19 pandemic arose, and necessity compelled widespread telehealth uptake. Most patients and clinicians entered the pandemic with little if any telehealth experience and often no training on using personal devices to access health care. Tele-oncology data reveal cancer care feasibility and acceptability with generally high levels of satisfaction for both patients and clinicians. Sustaining the progress made in telehealth uptake requires ongoing insurance coverage with parity in coverage, licensure facilitation, and ongoing development of technology that is easy to use. In addition, to tele-cancer care appointments, the technology may be used for care coordination, education, and increased access to cancer clinical trials.

Telemedicine is broadly defined as the use of technology in patient care1. The use of technology in healthcare has been part of the healthcare delivery menu since the 1950s. Telemedicine was primarily developed to increase access to clinical care. The advancement of telecommunications technology in health care has come in waves. This manuscript will outline lessons learned from these waves of evolution with a focus on the impact of the most recent wave—associated with the COVID-19 pandemic, on the care of persons with cancer, and on a looking forward to the opportunities that may lie ahead.

Terms and terminology

Most papers on telemedicine begin with definitions2. There are many terms, many definitions, and words matter. The Health Resources and Services Administration has defined telehealth3 as “the use of electronic information and telecommunication technologies to support long-distance clinical health care, patient and professional health-related education, health administration, and public health.” These technologies include bidirectional video and audio technology e.g., videoconferencing used for real-time teleconsultation, that is a fully interactive teleconsultation. Recording technology that “stores and forwards” the collected data as sounds, static images, and/or video images taken at a different time than the diagnostic interpretation may also be utilized. Real-time and store-forward technologies may also be complementary. For example, in cancer care, the patient may be seen for a real-time teleconsultation for a clinical trial evaluation while biopsy slides may have been digitized and transmitted for telepathology interpretation, diagnostic radiographic images may have been transmitted for teleradiology interpretation, and laboratory results “forwarded” for assessment.

Although often used interchangeably, telemedicine is specifically focused on the provision of clinical care. Telehealth is generally considered to be a broader term that encompasses remote monitoring, e-prescribing, and clinician-to-clinician communication and care coordination as delineated above4. To emphasize patient-centered care, the term tele-care is also used in this manuscript.

Telehealth waves of evolution

First Wave:

Some of the first recorded uses of telemedicine are documented to be the Nebraska Psychiatric Institute using videoconferencing technology to provide treatment and education by linking to a local state hospital5 in 1959, and the opening of the Logan International Airport-Massachusetts General Hospital Medical Station telediagnosis program as a bidirectional video clinic in 19686.

This first wave of telemedicine is instructive in that the rationale for tele-care is generally the same as we find today. The reason for the visit may be for second opinion, for diagnosis, for ongoing care, and for emergent or urgent care. The reason a virtual option is considered may be to address the geographic barriers to care that exist globally, the logistical difficulties in care access in urban settings, and the barriers in healthcare quality that these scenarios present to patients and families. Still, these first-generation programs did not enter mainstream clinical care. In retrospect, multiple factors likely contributed. Adopters acknowledged that technology could meet a need, but it was nascent, bulky, costly, and the images were not always of the best quality. In short, there were technical difficulties.

Second Wave:

In 1973, the STARPAHC (Space Technology Applied to Rural Papago Advanced Health Care) project opened its doors on what is now the Tohono O’odham reservation in Arizona7. NASA (The National Aeronautics and Space Agency) had sustained its interest in developing telemedicine technology, and as technology does, it gets better and less expensive. These improvements led to the resurgence of telemedicine in the 1990s—the second wave of telemedicine. At this time, several academic centers established telemedicine programs including the program that I have been closest to, the Arizona Telemedicine Program (ATP) at the University of Arizona8.

During this time, telemedicine expansion was determined to be predicated on multiple factors related to access. Access to the technology, in the 1990s, meant being able to get to a telemedicine center. At the telemedicine center, health professionals needed access to training on the use of the technology, access to licensure, and coverage and reimbursement, that is, telehealth parity. Advocacy advanced efforts on all these fronts.

As an example, ATP, a statewide telemedicine program developed as a multi-hub and spoke model that respected existing referral patterns and that incorporated extensive health professional education for the teleconsultation. Real-time in-person teleconsultations took place in dedicated ATP Telemedicine Suites which were maintained by a Telemedicine Coordinator. The ATP Telemedicine Coordinator was present at each hub and spoke site to collect data for store-forward review and to assist the clinician and the patient with the technical aspects of the in-person tele-visit. In the event that the referring clinician was present at the spoke site, the Telemedicine Coordinator would provide technical support for the referring clinician.

There was also an evolution regarding the impact of distance. Distance may mean the provision of rural or frontier clinical care. Distance may also be a barrier in urban settings where difficulty with parking and transportation limit access to healthcare on a regular basis.

Teleconsultation accessibility expanded with the use of internet-based, wireless, and mobile technologies. Whereas teleconsultants and patients previously had to travel to a specialized telemedicine site for a teleconsultation whether real-time or store-forward, the new technologies could be implemented on the clinician’s or patient’s desktop, laptop, tablet, or smartphone. We all joked that the latest telehealth technology was in everyone’s pocket, the smartphone.

With the transition to personal devices for technology access, the need for training persisted, yet seemed less necessary since the world just seemed more digitally knowledgeable. This apparent democratization of telehealth was the seed to the disparities that were to be noted in the next evolutionary step.

During this time, telehealth parity expanded although coverage and reimbursement parity were not both consistently achieved9. The status of telehealth parity by state is maintained by the Center for Connected Health Policy (CCHP) which is the federally designated National Telehealth Policy Resource Center10.

Efforts to facilitate state licensure for telemedicine practice led to the development of the Interstate Medical Licensure Compact. This voluntary agreement among US states and territories was initiated in 2013 when state medical boards began to discuss streamlining the medical licensure process. This Compact would make it easier for physicians to practice in multiple states, for patients to access care, and to leverage the benefits of technology for clinical care while preserving public protections by sharing information on licensees11.

Third Wave:

With the COVID-19 pandemic, the opportunity to limit spread of the infection while still providing patient care mainstreamed telemedicine care globally. This natural experiment engaged clinical teams without established telemedicine clinical workflows, with technical platforms that had been minimally tested, and with most practitioners not having had any training in telehealth12. Prior to the pandemic, patients would receive detailed hands-on instruction with their own device regarding what to expect during the teleconsultation, how to use the technology, and how to troubleshoot the technology. This step helped identify persons without sufficient internet speed for the teleconsultation and/or without the right device for the teleconsultation. It also provided the patient with the technical review and support needed for a successful teleconsultation.

With smartphone access increasing in the United States during the COVID-19 pandemic, telemedicine programs no longer needed to explain that telemedicine was like seeing your doctor on TV only that you’d be able to hear each other and see each other. People were familiar with the concept of a video call. By 2021, 85% of the population had a smartphone13. Many assumed that smartphone access meant that most people would ease into telemedicine use. With the explosion in telehealth use with the pandemic, there was insufficient hands-on technical support to facilitate access to the teleconsultation. Some developed videos or photos to guide patient use14. Without this support, it was difficult to identify and address technological needs proactively for persons without the technology and/or without the ability to use the technology effectively.

During this time, telemedicine was adopted, utilized, and widely disseminated. It is reported that at the Cleveland Clinic, outpatient tele-care visits increased from 2% to 75% of all outpatient clinical visits overall and to 90% for primary care outpatient visits15. In our own cancer center, the Sidney Kimmel Cancer Center at Thomas Jefferson University, outpatient tele-oncology consultations went from 1.9% pre-pandemic to nearly 80% at the height of the pandemic with a quarter of those visits being phone visits. A blend of videoconferencing and telephone consultations was typical in most practice settings16.

Telephone visits were more prevalent for patients who could not adequately access the teleconsultation via a computer, laptop, tablet, or smartphone. A demographic analysis revealed that these were often elders; persons whose native language was not English; persons without high-speed internet access, without a smartphone, with lower income, with Medicare and/or Medicaid coverage, with disabilities, from racially or ethnically diverse backgrounds, and from rural or frontier communities17. The same communities that were already experiencing care disparities experienced widening disparities compounded by the digital divide. As an example, the Indian Health Service reported that with limited broadband access, tribal communities experienced approximately 80% of their virtual visits early in the pandemic as telephone visits18. At the same time, the clinical value of a telephone call was recognized19–20. At the time of this writing, Medicare coverage of telephone visits will persist at minimum to the end of 2023, and at least 20 states have taken action to allow or require coverage for telephone visits21.

Care of persons with cancer

The care of persons with cancer is complex as is most clinical care in the world today. Cancer care begins with care for the at-risk well, that is, primary or secondary prevention efforts as well as early detection. This is followed by cancer diagnosis, treatment, symptom management/palliation, and survivorship. Cancer clinical trial enrollment can be a part of cancer care throughout the cancer care continuum (please see Figure 1). These aspects of cancer care extend across a person’s lifespan and may overlap and resurface e.g., the diagnosis of a second primary or a recurrence.

Figure 1.

Figure 1

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Telemedicine Interventions Across the Cancer Experience

The care of persons with cancer is also multidisciplinary in nature. It takes multiple health professionals and multiple disciplines within the health professions to support a person and their family throughout the cancer care experience. Team-based, interprofessional, and coordinated care is a hallmark of quality cancer care, as is, multidisciplinary care with medical oncology, radiation oncology, surgical oncology, pathology, radiology, and other medical specialties and subspecialties such as genetic counseling, nutrition, behavioral health, social workers, financial toxicity counselors, exercise physiologists, patient navigators, coaches, and community health workers. Insofar as these aspects of care may be achieved through verbal and/or visual communication, each of these elements of care can be facilitated through tele-care (1,22-23).

Consistent with historical data, patients with a diagnosis of cancer experiencing a teleconsultation during the COVID-19 pandemic have reported high levels of satisfaction24 with telehealth25–26 with nearly 20% in one study favoring having all future visits via telemedicine26.

More than a thousand oncologists belonging to the National Comprehensive Cancer Network (NCCN) responded to a survey in the Summer of 2020 to assess their experience with telehealth. Respondents included oncology specialists from 87% of NCCN member institutions (26 of the member institutions). They had generally not been telemedicine users (81%) prior to the pandemic. Tele-oncology was perceived to be safe. A serious adverse impact due to telemedicine use versus an in-person visit was reported to be never or rare by 93% of those surveyed. Video-based clinical visits were favorably to very favorably perceived by 87% of respondents, and respondents shared that nearly half (46%) of future oncology visits could be amenable to teleconsultation27.

Limitations to telehealth visits were reported among multiple cancer care clinicians as being difficulties with internet connectivity, difficulties with technology use, and inability to perform a physical exam28.

Although a generally accepted perception is that video-based visits are less able to support a strong patient-physician connection, data from a palliative care program revealed that, with training, effective goals of care conversations were accomplished via telemedicine29.

COVID-19 Lessons

Telehealth During COVID and Cancer:

Since persons with a diagnosis of cancer have an increased risk of adverse outcomes from COVID-19 infections, including increased intensive care admissions and mortality, the application of telehealth in cancer care has likely been of particular benefit to this population30–31.

Telehealth Adoption Facilitators:

The rapid uptake of teleconsultations was not due to infrastructure expansion. The technologies and networks that were available at the start of the pandemic were essentially the same as pre-pandemic, yet pre-pandemic teleconsultations overall made up <1% of clinical encounters32.

The key factors widely accepted to have been essential to the adoption of tele-care are the same two factors identified by telemedicine advocates as critical for expansion pre-pandemic. These are parity in coverage and reimbursement and state licensure facilitation. These are the two factors that the Centers for Medicare and Medicaid Services (CMS) eliminated in March 202027. A third essential shift is attributed to necessity. For patients and clinicians, the pandemic offered us an opportunity to rethink what a clinical encounter can entail and to let go of our habituated perception that a clinical encounter required a one-on-one in-person visit with the clinician at the clinician’s office33.

Inequities in Telehealth Care:

The rapid implementation of tele-care applications, both audio- and video-based, disrupted usual clinical care, demonstrated the feasibility of telehealth integration, and lay bare pre-existing inequities in access to healthcare and telehealth uptake34. As discussed above, analyzing the considerable percent of telehealth consultations conducted by telephone revealed that the same resource deficits found in healthcare delivery overall were mirrored in telehealth care. Persons experiencing resource limitations were less likely to have the appropriate device with the necessary internet support and were less likely to know how to use the device for a teleconsultation18.

Those with less technical experience, not unexpectedly, were more likely to be less ready for telemedicine uptake. Multiple studies have documented elders, persons with less education, lower income, greater disadvantage, and greater co-morbidities to be less telemedicine ready26,35–36. In fact, several programs including our own provided patients without the appropriate technology with smartphones or tablets and supported technology skill development as needed37–38.

The Need for Technical Support:

Bidirectional video-based communication for teleconsultation is generally considered the “gold standard” for telehealth. Prior to the COVID-19 pandemic, technical support for patients and clinicians was a standard practice (please see Table 1). Patients and clinicians did a test-run with the telemedicine support team to prepare for the teleconsultation. In addition, training for the teleconsultant took place prior to the consultation with some programs requiring telemedicine training and providing certifications (please see Table 2). As outlined above, with the dramatic increase in virtual consultations, individualized technical support was no longer feasible. Given this shift, it would not be surprising to learn that some patients and clinicians felt inadequately prepared for telemedicine usability.

Table 1:

Technical support for the patient

Is your internet in the location where you plan to have your telemedicine visit sufficient to support the video technology?
Do you have access to the telemedicine platform on the device that you plan to use?
Can you get to the telemedicine platform?
Can you log on to your telemedicine platform?
Have you set up appropriate passwords? Are passwords working? If needed, can you reset your passwords?
Can you navigate to the appropriate site where the telemedicine visit would be conducted?
Do you know what needs to be done to troubleshoot? Can you refresh your screen?
Do you know how to get help during the tele-visit—a phone number to call? A chat function? An email?
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Table 2:

Technical support for the health professional

Have you completed specific telemedicine training that encompassed the use of the technology, how to conduct a tele-exam, documentation, and billing?
Is your internet in the location where you plan to have your telemedicine visit sufficient to support the video technology?
Do you have access to the telemedicine platform on the device that you plan to use?
Can you get to the telemedicine platform?
Can you log on to your telemedicine platform?
Have you set up appropriate passwords? Are passwords working? If needed, can you reset your passwords?
Can you navigate to the appropriate site where the telemedicine visit would be conducted?
Do you know what needs to be done to troubleshoot? Can you refresh your screen?
Do you know how to get help during the tele-visit—a phone number to call? A chat function? An email?
How do I use the technology when I am teaching students, residents, or fellows?
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Summary COVID-19 Lessons:

If we look at the history of technology dissemination and adoption, we see that disruption and disparities are part and parcel of this process39. When an innovation is introduced, those most likely to have earlier access and uptake are those with resources. Insofar as access to healthcare reflects social, economic, geographic, educational resources that have been well-documented to be unequally distributed in our society, access to healthcare innovations will mirror these inequities. Specifically, considering the digital technologies that were a necessity with the COVID-19 pandemic, health inequities related to lack of access to the necessary technology and/or lack of ability to use the technology effectively. Persons without the necessary health literacy, numeracy, digital literacy and/or e-literacy would not be able to ease into being a successful digital health user40. At the same time, all other disparities in care, such as those related to race, ethnicity, gender, geography, and age, persisted.

Cancer Care and Tele-Care: Looking Forward

Tele-Oncology:

The efficacy of tele-care for cancer care has been documented in the literature since the 1990s both in the US41 and internationally42. Tele-oncology approaches have included direct patient care, supportive care modalities, such as, pain and nutritional consultations, tumor board presentations, education43, cancer clinical trial screening44, and sub-specialty oncology care45–46. The most recent evolution of telehealth has confirmed overall patient and clinician satisfaction with the technology25–27.

Bringing back the housecall:

In the NCCN study cited above27, free text comments included psychosocial benefits of the telehealth consultation.

Oncologists noted that video visits:

“provide a window into the patient’s life—you visibly see the environment they live in and possibly the challenges of day to day,”

“video visits provide a better interpersonal connection because of not having to wear masks—ability to smile, appreciate facial expressions both good and bad.”

Regarding phone visits, respondents noted a benefit as well.

“My experience is that patients are more relaxed and easy to talk with when they are at home and contacted by phone. Even patients I have known for years seem very different in their demeanor when talking with them by phone from a telephone visit conducted from home.”

Sustainability:

To consider how best to maintain these benefits for our patients, we need to explore the multiple settings that impact care. There is the clinical practice where the patient and the health professional(s) meet to receive and provide care respectively. The clinical practice may sit within a cancer center and/or health system. These are impacted by the technology available, the practice guidelines for clinical care, and the healthcare policies that regulate care. With all these factors, existing within a community.

For the clinic, workflows to support and integrate telehealth visits into the oncology practice are needed for both the outpatient and the inpatient setting. These workflows would optimally be developed with the users—patients, caregivers, and the healthcare teams. In the outpatient telehealth setting, these may include virtual check-in and check-out processes, vital sign assessments, medication updates, Review of Systems reporting, follow-up appointment scheduling, timing of in-person and tele-visits (video and phone), and training and educating of patients as needed for successful visits. In the in-patient telehealth setting, teleconsultations may enhance oncology access by limiting the oncologist’s need for driving to multiple hospitals. Processes may include those to increase tele-presence, increase access to sub-specialists, and facilitate multi-disciplinary team meetings that can include the patient and family. With bidirectional technology, clinical workflows may virtually connect family members to daily in-patient rounds, to discharge planning conferences, to the discharge itself where discharge instructions and plans are delivered, and to the post-discharge oncology appointment which the family member may join virtually whether the patient’s appointment is in-person or virtual.

For the health system and for the cancer center, there is opportunity for integration and optimization. Multiple electronic tools are available. Making sense of when and which to use in a coordinated manner is a critical need. Health systems can support the digitization of health care by sharing successful approaches that may involve linking electronic records, diagnostic tools with still or video digital cameras, and apps and remote monitors that support symptom management and patient and caregiver education. The coordination of digital tools can support patient care, patient education, and clinician education.

Health systems may support and participate in models developed to bring health professionals together virtually for skill development. The Project ECHO model has demonstrated success in tele-mentoring in many specialties including cancer care. ECHO models have been documented to improve both learning and practice. A ten-year scoping review in cancer care has recently been published and demonstrated engagement, learning, and practice change47.

For technology development, telehealth technologies, like telemedicine workflows, should be developed with the engagement of the users48. All users are the same. An application that is easily adopted by tech savvy users may be cast aside by those less technologically familiar despite touted benefits. Developing technology with a variety of user perspectives can ease successful uptake. A resounding message from both patients and clinicians is the need for ease of use. Technologies developed with an emphasis on the technology and without sufficient engagement or consideration on usability and acceptability by those using the technology, often meet unexpected barriers when implemented.

Areas for technology development are myriad. As noted earlier, technology that allows for multiple persons to join facilitates team-based care and medical education and supports the patient experience by engaging families and interpreters. Technology that integrates communication tools, such as, the ability to share a screen makes it easier to review documents and reports together. Being able to share a blank screen that allows for writing and drawing can support patient and professional education and engages visual learners. Tools that take into consideration human factors, such as, impaired hearing, limited vision, arthritic fingers, and changes in cognitive function facilitate use of the technology for more users and, therefore, enhance access to care. Digital tools that are interactive may provide the opportunity to tailor messaging in the person’s preferred language and aligned with the person’s values, culture, and literacy1. As our electronic healthcare tools and apps are integrating generative artificial intelligence, ethical considerations and respect for privacy and autonomy for all who engage with the technology is essential.

Practice guidelines for telehealth practice are needed. The American Telemedicine Association had historically brought clinical experts together to develop clinical guidelines49. Some topics addressed included tele-behavioral health, tele-dermatology, and tele-home health guidelines. With the COVID-19 pandemic, many specialty societies drafted telemedicine practice recommendations. Both the American Society for Clinical Oncology (ASCO)50 and the Society for Integrative Oncology51 published telehealth practice recommendations. The American College of Physicians52 has developed telehealth guidance and resources that include information regarding video and telephone visits, remote monitoring, and health care apps. The American Medical Association (AMA)53 has published multiple telemedicine resources. Research to support guideline development in the current telehealth practice state is needed.

The expansion of telehealth took place with many clinicians having minimal training and experience. Education regarding tele-care, what can or cannot be done, and how best to do so is critical both during formal professional education e.g., health professional school and post-graduate training as well as part of continuing education. The Association of American Medical Colleges (AAMC) has issued developmental telemedicine competencies54. Many health systems have developed internal and external educational programming for all members of the healthcare team55– 56.

In the policy arena, telehealth parity and licensure regulatory issues remain fundamental areas to address57. The expansion of telemedicine during the pandemic is broadly attributed to the implementation of policy to support telehealth insurance coverage and reimbursement. As noted above, multiple states have initiated processes towards telehealth parity in coverage and reimbursement. Licensure efforts through the Interstate Medical Licensure Compact are intended to make multi-state licensure for telemedicine easier. Some states have implemented telehealth only licenses whose scope of practice varies from state to state58.

The NCCN survey and other reports of clinician and patient experiences argue for supporting policy to maintain phone consultations for its flexibility and clinical efficacy. The clinical benefits of telephone consultations have been well-documented59 historically and during this most recent telehealth expansion.

In the community, enhancing digital access is fundamental for access to health moving forward. Identified barriers to telehealth have been access to broadband internet, not having the appropriate tool for the teleconsultation, and limited digital literacy—not knowing how to use the tool for teleconsultation. Community-based education is essential. Factors to consider include literacy, numeracy, and culture. Education to support digital fluency will ease and support the uptake and use of the technology for telehealth.

Community based efforts with the professional community and with the community-at-large may include advocacy education. Advocacy education for e.g., broadband access can be part of health system’s and cancer center’s community partnership efforts60. Advocacy education for clinical teams has been documented to support well-being61.

Conclusions:

Implementing new treatment approaches takes time. Dissemination of technology, of innovation, takes time. Early concepts of what we now call telehealth emerged in the 1920s62. Concrete progress was made in the 1950s and 60s. With the improvements in technology, the seeds planted began to blossom in the 1990s and early part of this century. During the transition, that was promised to be the great leap forward—the ability to conduct tele-visits from a personal device—the COVID-19 pandemic hit. Although the technology to conduct tele-visits from a personal device was available, it was not available to all. Still, progress, that may have otherwise taken a couple of generations to achieve, was made. Coverage and licensure cannot be sufficiently stressed as essential for sustainability and future progress.

Tele-cancer care has demonstrated feasibility, efficacy, and acceptability. Given the team-based nature of our work and the predicted shortages in cancer health professionals, telehealth may provide its greatest benefit in access to subspecialty care, in keeping the team connected, in care coordination and education, and in access to cancer clinical trials. As we have all become more facile with digital technology, telehealth adoption will require ease of use. As easy as what we are used to, the in-person visit.

References:

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