Physician perspectives on clinician-to-clinician telemedical consultation for gynecologic cancers: A qualitative study

Highlights

• •Virtual consultation between clinicians has the potential to expand access to gynecologic cancer care.
• •Telemedical consultation needs to allow communication of detailed patient information.
• •The consultation system must reduce travel burdens for patients and facilitate appropriate pre-referral workup.
• •Clinician-to-clinician consultation must be easy to integrate into current clinical workflow.

Abstract

Objective

Approximately fifteen million women in the United States live > 50 miles from a gynecologic oncologist. Telemedical technology allows patients’ local physicians to consult with subspecialist gynecologic oncologists without burdening patients with unnecessary in-person visits. Although critical to adoption of this technology, physicians’ input into implementation of clinician-to-clinician consultation has not been sought. We therefore gathered feedback about experiences with referrals, communication, and openness to telemedical consultation from gynecologic oncologists, gynecologists, and medical oncologists.

Methods

We recruited gynecologic oncologists, gynecologists, and medical oncologists from practices serving rural patients to participate in semi-structured interviews. The Consolidated Framework for Implementation Research and the Theoretical Domains Framework guided the interviews. Questions focused on factors influencing adoption and implementation of clinician-to-clinician telemedicine. Interviews were conducted via WebEx, recorded, and transcribed. Two investigators coded interviews using the combined frameworks and identified salient themes.

Results

We conducted 11 interviews (6 gynecologic oncologists, 3 gynecologists, 2 medical oncologists) and identified themes encompassing communication burnout, barriers to sharing patient information, need for further logistical information, and potential benefits to patients.

Conclusions

Clinician-to-clinician telemedicine may improve access to gynecologic cancer care by decreasing barriers to subspecialty expertise while simultaneously benefiting referring and consultant clinicians through improved identification and workup of patients who may need in-person consultation. To optimize desired outcomes, telemedical consultation must allow for communication of relevant patient information and records and easy integration into clinical workflow. Importantly, clinicians must perceive the consultation as improving patients’ access to specialty care.

1. Introduction

Gynecologic cancers are among the most prevalent cancers in women, yet many patients do not receive guideline-concordant care, in part because of barriers to accessing gynecologic oncologists. In the United States, the standard of care for patients with gynecologic cancers includes consultation with a gynecologic oncologist (National Comprehensive Cancer Network, 2023, Wright and Bohlke, 2016, American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology. Practice Bulletin No. 174. 128. 2016:e210-e226.). However, 15 million women in the United States live > 50 miles from a gynecologic oncologist and may experience geographic barriers to care (Shalowitz and Vinograd, 2015, Stewart and Cooney, 2014). For example, 22 % of ovarian cancer patients have not seen a gynecologic oncologist, and 18 % may not receive standard-of-care surgery (Shalowitz and Epstein, 2016, Warren and Harlan, 2017). Geographic mismatch between women with gynecologic cancers and disease specialists leads to worse survival outcomes, disproportionately affecting women who live in rural areas (Shalowitz and Moore, 2020). There is therefore a critical need to utilize telemedical technology to allow patients the benefits of consultation with a gynecologic oncologist while minimizing the burdens of travel.

One promising application of telemedicine is clinician-to-clinician consultation (CCC), which allows clinicians to determine which patients require in-person referral and which patients can benefit from subspecialists’ input without incurring the burdens of travel for care. CCC between primary care and specialty clinicians has been formalized in some non-oncologic settings, (Association of American Medical Colleges. Project CORE, 2019, of New Mexico, 2019) yet virtual CCC for cancer care has been understudied and underutilized. Compared to clinician-to-patient virtual visits, CCC has multiple potential advantages, including the potential for asynchronous (i.e. store-and-forward) care, less burden on patients’ and clinicians’ time, and less direct cost to patients from the encounter.

To inform the development and testing of a telemedical intervention to link clinicians involved caring for rural patients with gynecologic cancers, we sought input from key stakeholders including gynecologic oncologists, obstetrician-gynecologists, and medical oncologists regarding the current communication environment among clinicians and factors influencing telemedicine adoption and implementation. We utilized qualitative methods for this inquiry to maximize the depth of engagement with stakeholders, to ensure our ability to explore barriers and facilitators raised by participants, and to avoid bias introduced through closed-ended survey questions in the absence of previously validated instruments on this topic. This qualitative study was exploratory and aimed to generate data to guide future studies on adoption of clinician-to-clinician telemedicine to improve access to gynecologic oncologists.

2. Methods

Sample and recruitment: Gynecologic oncologists, gynecologists, and medical oncologists were recruited from practices serving rural and non-rural patient populations to participate in semi-structured interviews. Potential participants were identified through the authors’ professional network. The project manager contacted potential participants via email to provide information on the study and to set up interviews. Incentives of $150 gift cards were offered to study participants. Goals for enrollment were representation from all three medical specialties and when thematic saturation was reached (Green and Thorogood, 2004). Thematic saturation is a foundational concept within qualitative analysis, based on grounded theory,(Glaser and Strauss, 1967) and specifies that data collection may conclude when the researcher is no longer generating new concepts related to the focus of study. Methodological literature for qualitative research suggests that the majority of new concepts become apparent within the first 6–16 interviews, (Hagaman and Wutich, 2017, Francis et al., 2010, Namey et al., 2016) and 80–92 % of all new concepts appear within the first 10 interviews (Morgan et al., 2002). Given these data, and based on our group’s experience conducting qualitative research related topics, we therefore anticipated enrolling approximately 15 clinicians, but planned to assess for thematic saturation from 10 interviews onward.

Procedure: As the adoption of telemedical interventions is influenced by factors at multiple levels, we based our semi-structured interview (Ritchie and Lewis, 2008) guide on two frequently combined implementation determinant frameworks: the Consolidated Framework for Implementation Research (CFIR) and the Theoretical Domains Framework (TDF) (Fig. 1) (Birken et al., 2017). CFIR focuses on the organizational level; domains include intervention characteristics, outer setting, inner setting, characteristics of individuals, and process of implementation (Damschroder et al., 2022). To elaborate on the attitudes, beliefs, and perceptions of clinicians regarding CCC, we used the TDF, which includes 14 domains aiming to identify individual clinician determinants of behavior (Atkins et al., 2017).

Fig. 1.

Sample CFIR/TDF constructs and domains related to implementation of provider-to-provider telemedical consultation.

Interview questions (Supplemental Material 1) focused on barriers and facilitators to clinician-to-clinician telemedicine consultation, covering the domains of both the CFIR and TDF frameworks. Questions elicited information regarding current experiences with, and perceptions of CCC, needs of clinicians and patients, experiences with existing communication methods, and attitudes toward potential changes to consultation methods. Participants were asked to consider both synchronous (i.e. face-to-face) and asynchronous (i.e. store-and-forward) applications of telemedicine. Interviews were conducted by CW, a qualitative methods expert with experience using the combined CFIR-TDF framework in implementation research (Birken et al., 2023). Interviews were conducted via videoconference, recorded, and transcribed verbatim. This study was approved by the [redacted for peer review] Institutional Review Board.

Analysis: We employed grounded theory to guide the analysis process (Glaser and Strauss, 1967). A combined CFIR-TDF framework was used to develop a codebook (Supplemental Material 1) using the domains and constructs from each framework. Two coders (CW & AR) co-coded two interviews to establish analytic reliability, identifying and reconciling coding discrepancies; we revised the codebook to document resulting clarifications. Subsequent interviews were independently coded and then reviewed by both coders. CW and AR identified salient themes, which were then reviewed by the study team, utilizing an iterative feedback and refinement process.

3. Results

Thematic saturation was judged to have been reached after 11 interviews with 6 gynecologic oncologists, 3 gynecologists, and 2 medical oncologists, representing community and academic practices in Arkansas, Maine, Massachusetts, Michigan, North Carolina, Tennessee, and Utah. Interviews lasted between 15 and 36 min. Six main themes were identified (Table 1).

Table 1.

Major Themes.

•Clinicians believe that formalized telemedicine consultation could build relationships between gynecologists and specialists. •Clinicians believe formalized telemedicine consultation could improve patient access to specialized care. •Clinicians are overwhelmed by existing communication channels (EHR, phone, fax, pagers, text) and are concerned about burnout, increased work volume, interruptions to workflow, and effectiveness of communication.

•Clinicians find it difficult to share patient information with other clinicians not on the same EHR system.

•Specialists are frustrated by the lack of information sharing during informal consultations. •Clinicians want more information about accountability and compensation in using a formalized consultation platform.

3.1. Theme 1: Clinicians believe that formalized, telemedical CCC could build relationships between gynecologists and specialists

Some gynecologists may be hesitant to reach out to specialists with whom they or their practices do not have an existing relationship. “To be honest, I would be more comfortable if I either personally knew their provider and knew their practice style, [and] whether or not, I guess, they were trustworthy and an appropriate referral for my patient. Referring to a new individual, I would at least want to gather some information from either colleagues or their colleagues about whether or not it would be an appropriate provider to take care of one of my patients”.

Further, they may be reluctant to ask questions or send patients in fear of making an inappropriate referral. A gynecologist explained, “Well, you just don't wanna look dumb, right? You might ask your partners first, like, ‘Hey, I'm a little stuck here, does this seem reasonable to refer on or is it just gonna get bounced right back to me?’ or ‘Should I be referring this, and I'm worried because I'm not referring?’ There's just that little bit of fear of doing the wrong thing, and you don't wanna get a representation as a gynecologist of sending things that don't need to be sent or waiting too long to send things that should be sent.” Another gynecologist felt specialists were intolerant of their questions saying, “Other [specialists] are not as friendly or willing to tolerate some of our generalist questions”.

Clinicians felt a formalized consultation system could help them to build relationships. A gynecologist explained, “There are some [specialists] that I’m just not really comfortable messaging them and getting responses back that—but maybe the more that we interact with them, I think it could improve [our] relationship.” A medical oncologist agreed, saying, “If you don’t have relationships, then obviously, you need something as a facilitator”.

3.2. Theme 2: Clinicians believed formalized, telemedical CCC could improve patient access to specialized care

All three provider types reported potential positive implications of a formalized, asynchronous CCC system in streamlining referrals. Clinicians felt that by creating the opportunity to consult formally in a patient’s care treatment plan, a cloud-based consultation system would reduce the need to send patients to practices outside of their geographic region for testing that can be completed locally. A medical oncologist noted this system could assist patients by removing some of the travel burdens, “If there is an opportunity to collaborate where we do the chemo here and then see the specialist elsewhere, then that could really help the patient.” A gynecologist further explained, “A lot of the rural area, they do a lot of farming, so I think taking time off from that vocation and making it down to make several appointments, so not only do you have to have the consultation, and then you have to have surgery, and then the recovery, and then post-op. I think those are all barriers for our rural patients to get the care that they need.” Another gynecologist emphasized the need to reduce the travel burden for patients, “Saving them [patients] some transportation if we get the referral going, and I find out that they need more imaging or lab work. I can get that started. Then I think it’s also gonna save them time for … their pre-op workup, and then getting them their surgery faster if that’s what’s needed”.

3.3. Theme 3: Clinicians are overwhelmed by existing communication channels and are concerned about burnout, increased work volume, interruptions to workflow, and effectiveness of communication

When asked about their willingness to participate in virtual consultations with other clinicians, respondents consistently reported that they currently spend more time than desired checking and responding to messages across various platforms. A gynecologic oncologist explained:

“To be honest with you, it is very distressing to me and to my colleagues every time a new software platform or a new method of communication is introduced into our clinical workflow. Right now, I have a pager. I have a cellphone. I have six email addresses. I have Epic. I have Microsoft Teams. I have something called PerfectServe. I am reachable in like 20 different formats, and it's very fatiguing and frustrating to maintain all of those different lines of communication and to make sure that I'm not missing things, and that I haven't followed up on things. I think our profession, most of us are people who like to have check boxes and make sure that they are all checked so that people don't fall through the cracks.”

The large number of formats of communication makes it easier to miss information. One gynecologic oncologist said, “Nothing gets missed if it's all done in Epic. Sometimes the email stuff and the phone calls because there not formally in the charts. It can get missed or lost if the secretary has to follow up with it or whatever.” A gynecologist agreed that calls are particularly inefficient: “Again, it’s really doing it the old-fashioned way, calling, and having their office page them out, and then waiting. They could be in the OR and waiting to get that call back, and then you could be in the OR and getting pulled. Like, it’s just time. It’s really inconvenient, and I think that’s the biggest thing”.

3.4. Theme 4: Clinicians find it difficult to share patient information with other clinicians using different electronic health records (EHRs)

Communication challenges between referring clinicians and specialists are magnified when clinicians do not share an EHR system. In these cases, there is increased reliance on phone communication, which clinicians report takes too much time and affords fewer opportunities to review data. A gynecologic oncologist said, “…it's cumbersome when you rely on Epic to communicate about care with somebody and they are not part of that healthcare system.” Another gynecologic oncologist explained how not sharing the same system results in a delay in referrals, “In situations where they don't share our [EHR], it can be difficult to records in a timely fashion, and then get the communication back to that whatever doctor that they're gonna see”.

When using the same EHR system, sharing patient records is relatively easy. However, for providers using different systems or for clinics not using an EHR, sharing patient imaging, testing results, and histories becomes difficult. This is particularly salient in rural locations with more discrepancies in patient record-keeping systems. A gynecologic oncologist explained, “…for our community oncologists, it's hard sometimes to figure out what has happened to the patient since you saw them last, what treatments have they received, and what doses. It's sometimes difficult to track that information down in real time if it hasn't been communicated ahead of time”.

3.5. Theme 5: Specialists are frustrated by the lack of information sharing during informal consultations

Due to limitations of methods of communication primarily used for consultations (text, phone calls) specialists often do not have results available for review when providing recommendations, which limits the recommendations a specialist can provide. The current informal nature of many clinician-to-clinician consultations limits information sharing. This is largely due to reliance on phone-based communication, during which it is either not possible or secure to share protected health information. A gynecologic oncologist explained, “I’m often managing patients who are six to eight hours away and don’t have access to any labs, imaging.” Another gynecologic oncologist found consulting to be difficult due to the lack of information stating, “[Consulting is] a huge burden, because you’re giving medical advice without the information that you would normally have and without the tools at your disposal”.

Specialists feel that some patients are referred to them inappropriately, and that if they were provided with more information, referring clinician could be directed to more appropriate resources. A gynecologic oncologist explained, “For instance, all these curbside consults…these cases that we’re being asked to do consults on that are completely inappropriate consults and don’t need a consultation. It just needs to be a case-based discussion of how to manage things…I get phone calls and, you know, ‘This is actually something we’re discussing next month at our conference. Let me send you the link and you can log on. You don’t need to send your patient’”.

Similarly, CCC might help avoid frustration from lack of appropriate testing prior to referral to a gynecologic oncologist. A gynecologist explained, “I'll order a CT and a chest x-ray and tumor markers before I send them just to help speed up the process—or if you send a message to the GYN oncologists they'll respond and say, ‘Okay, I'll see them, but in the meantime can you order X, Y, and Z?’ That's always helpful to communicate with them first which I don't think all clinicians do, some will just send the patient after they get the tissue biopsy.”.

3.6. Theme 6: Clinicians want more information about liability and compensation in using formal, telemedical CCC

If clinicians were to adopt virtual, asynchronous CCC, participants suggested that they would need clarity about the legal liability associated with teleconsultation: “I think that [formalized consultations] would be very useful. Not only from a provider standpoint but also from a medical-legal standpoint, having that official conversation documented in a way that you potentially could even go back and you see that discussion”.

Currently, informal “curbside” consultations happen whenever clinicians can fit in a quick phone call; time spent is generally not compensated. Overall, clinicians were not happy with “curbside” consultations, as they represent an unpaid additional time burden. A gynecologic oncologist explained about the current consultation system, “…from a financial, from a business standpoint, that’s two hours of time with no compensation. That’s two hours of time that I could’ve been spending doing something else that relates to patient care or academic endeavors. It needs to be improved upon, not just in terms of how it’s done, but also the compensation for it”.

Clinicians felt that formalized CCC should be billable, and did not want to commit their time without receiving compensation. A gynecologist explained, “It depends on how much time [formalized consultation] takes, so if this system would take longer and take more effort than just sending a referral with the cover letter and the patient's chart, then of course there might be some need for compensation for that time, but it depends on how the process would work”.

Clinicians were unsure if billing for time spent doing consultations would be possible under current insurance rules. “I would love to be reimbursed for all of the time I spend on the phone and via email and in performing informal consultations for people, but I'm not sure based on insurance standards if you are able to bill for those informal processes, even if they’re documented and discoverable in the patient record. If you have not personally evaluated and consulted a patient, I don't believe that you can bill for those encounters.” Some of these assumptions and concerns around billing were a result of previous barriers to billing for telehealth visits with patients. “Just getting started with telehealth visits was really difficult, one, because insurance companies didn’t wanna pay for them, and, two, like, if they’re not gonna pay for them, we’re setting up these platforms and spending this money to make this available, but we’re not gonna get reimbursed for it.” Clinicians also did not want the expense burden to fall on patients, “I think the billing part is always hard because we don’t ever want to introduce financial toxicity to our patients”.

4. Discussion

Gynecologic oncologists, gynecologists, and medical oncologists are likely to support the potential of clinician-to-clinician telemedical consultation to improve patients’ access to subspecialty cancer care. Likewise, clinicians recognize telemedicine’s potential to improve relationships and coordination among care providers. However, we identified several major challenges that should be addressed to ensure that virtual consultation programs can be sustainably adopted.

To be perceived as useful, telemedical CCC will need to allow communication of relevant patient information, including imaging for review, and ensure bidirectional ability to ask and answer questions. Most importantly, clinicians must perceive the consultation system as permitting patients to avoid unnecessary travel burdens for in-person referrals and facilitating appropriate pre-referral workup for patients likely to need in-person evaluation. Clinicians also appropriately raised concerns about ensuring that patient care activities—including virtual patient care—are compensated appropriately. Fortunately, CCC is a billable service and can generate direct revenue as well as indirect revenue by ensuring that patients receive needed cancer care in the most appropriate location (American Academy of Pediatrics. 2 New Codes Developed for Interprofessional Consultation., 2023). We have previously comprehensively outlined the expected value-on-investment (VOI) of CCC; adoption will depend on persuading care providers and health systems administrators of the value of this critical access intervention (Shalowitz et al., 2023). We also recommend including in future studies an assessment of the impact of CCC on strengthening relationships between referring clinicians and consultants to improve care coordination.

Clinicians must also perceive CCC as easy to integrate into their current clinical workflow. In part, ease of use can be addressed through the consultation system itself, for example, by incorporating user-based software design techniques and relying on asynchronous rather than synchronous interaction to avoid scheduling challenges. More difficult, however, is addressing clinicians’ overextension and burnout associated with using multiple communications platforms for clinical care. We recommend identifying opportunities to implement parsimonious communication solutions that maximize benefit for patients and clinicians and de-implement lower value or duplicative platforms.

Although interviews reached thematic saturation, there may be additional factors determining clinicians’ willingness to adopt telemedical CCC. Additionally, the needs of specific urban, suburban, or rural clinicians may differ from our clinician sample, which was not representative of all geographic regions. Future work should therefore ensure that CCC implementation is sensitive to the needs of local clinicians.

Virtual consultation between clinicians has the potential to improve and expand access to gynecologic cancer care by decreasing barriers to subspecialty expertise while simultaneously benefiting referring and consultant clinicians through improved identification and workup of patients who may need in-person consultation. Sustainable adoption of virtual consultation platforms requires careful attention to the consultation platform, the clinicians who use it, and the care environment in which consultation occurs, to ensure that improvements in access to care are transformative and long-lasting.

Funding

This project was supported by the Foundation for Women’s Cancer Research Grant in Memory of Peggy A. Yates.

CRediT authorship contribution statement

Cheyenne Wagi: Writing – review & editing, Writing – original draft, Investigation, Formal analysis, Conceptualization. David I. Shalowitz: Writing – review & editing, Writing – original draft, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Aliza Randazzo: Writing – review & editing, Formal analysis, Data curation. Alexandra Peluso: Writing – review & editing, Project administration. Sarah Birken: Writing – review & editing, Supervision, Project administration, Methodology, Investigation, Data curation, Conceptualization.

Declaration of Competing Interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: [David Shalowitz – Past consulting fees (2022) from Nimble, LLC (telemedicine service provider). All other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper].

Appendix A. Supplementary data

The following are the Supplementary data to this article: