Optimizing the use of telemedicine in oncology care: post-pandemic opportunities

Abstract

Utilization of telehealth as part of the cancer care delivery continuum dramatically escalated in response to the COVID-19 pandemic at major cancer centers across the globe. The rapid shift toward telehealth visits for non-treatment cancer care provided immediate benefit through reducing unnecessary risk of exposure, overcoming transportation barriers faced by both patients and caregivers, and fast-tracking care transformation. As such, delineating the impact of telehealth on access, health equity, quality, and outcomes will be essential for refining the use of digital strategies and telehealth toward optimizing cancer care. Herein, experiences to date with telehealth usage for oncology care is reviewed, and priorities outlined for post-pandemic opportunities to improve the lives of cancer patients through telemedicine.

Introduction

The global COVID-19 pandemic led to a seismic shift in healthcare delivery, with rapid adoption and uptake of telemedicine across a wide variety of disciplines. By definition, telemedicine encompasses a broad variety of approaches for decentralized care that brings providers to the patient, and therein eliminates the need for travel. Telemedicine tools include telehealth visits that can be conducted through phone and or video, strategies for remote patient monitoring, and incorporation of home-based care visits. Implementation of telemedicine, particularly as realized by telehealth visits, rapidly escalated across the major cancer centers and oncology units during the pandemic, and was imperative to ensure continuity of cancer care. While telehealth implementation continues to evolve as of the time of writing, this perspective summarizes experiences to date at major centers across disparate geographies, and outlines key considerations toward optimizing telehealth as a core element of the cancer care continuum.

Across the United States, significant variances in telehealth readiness were observed in the pre-pandemic setting. As of 2017, the American Hospital Association reported that up to 76% of hospitals had either partial or full implementation of computerized telehealth capabilities (https://www.aha.org/factsheet/telehealth, Accessed Aug 29, 2020); despite these encouraging numbers, major barriers remained with regard to utilization. For example, study of a large commercially insured population in 2017 reported only 6.57 telehealth visits per 1000 members, reflective of the overall low uptake observed nationally¹. Prior to the pandemic, some emergency medicine departments had already begun to advocate for rigorous telehealth capabilities in the medical response to disasters, given the notable increase in events causing widespread loss of human life, ecological disruption, and/or significantly reduced access to traditional health services ². Nowhere is this more applicable than in cancer treatment, for which disruption in care for even short intervals has the potential to promote significant increases in cancer mortality. A number of reports have already begun to magnify this issue as a result of the COVID-19 pandemic. For example, at the University of New Mexico Comprehensive Cancer Center, a 62% reduction in screening mammography and a 48% reduction in Pap/PPV screening has been observed since March 2020. Assessment of cancer diagnosis and treatment encounters across 20 major healthcare institutions in USA observed precipitous decreases in both cancer screening and diagnosis of new cancers. Breast cancer screenings were reduced by more than 89%, and colorectal cancer screenings by 84%. Significant declines in new cancer diagnoses were robust across tumor types, with the highest declines observed in newly identified breast cancers, prostate cancers, and melanoma³. Accordingly, there is concern that deferred diagnoses will result in upstaging and worse prognosis. A study from the National Cancer Institute is predicting an increase of approximately 1% in cancer deaths attributed to deferment of breast and colorectal cancer screening alone during the period of the pandemic ⁴. Given these observations, it is critical to ensure that cancer screening and cancer care continue unencumbered, even in the backdrop of an international disaster, as facilitated by equitable access to telehealth.

Rapid, pandemic-induced escalation of telehealth as part of cancer care delivery

Restrictions on elective procedures, mandates for social distancing, stay-in-place orders, and in some cases reduced availability of personal protective equipment (PPE) each presented barriers for cancer care delivery during the pandemic. To circumnavigate this challenge, cancer centers with telehealth capability leveraged experience from their emergency medicine colleagues to enable rapid escalation. As has been well described in the emergency medicine literature⁵, use of “forward triage”, wherein telemedicine allows for patients to be efficiently screened offsite for evaluation of respiratory symptoms, travel history, exposure history, and development of specialized needs for in-person visits. Prior to the need for rapid escalation, it had been postulated in the telemedicine discipline that in-person visits would eventually become the second rather than first option, as aligned to goals for decentralized patient centric care and through refinement of high quality, non-visit care⁶. But how would this work in the cancer setting?

Given the relatively low utilization rates pre-pandemic, there is much yet to be learned about how to optimize telehealth for the cancer patient, incorporating the most effective form of virtual patient visit. However, early indications portend an auspicious role for telemedicine in cancer care. A retrospective study of video telehealth visits for surgical patients over a 9-month period revealed an unexpectedly low 30-day post-operative re-admission rate (4 of 152 patients), and a high degree of satisfaction for patients who completed telehealth visits⁷. A follow-up study specific to surgical oncology reported that post-operative telehealth visits reduced both emergency department visits and readmission, which was also associated with enhanced patient satisfaction⁸.

Individual reports on the impact of telehealth escalated significantly during the pandemic. Although analysis of the impact on outcomes has yet to reach full maturity, preliminarily data reflect an important role for telehealth. Several major National Cancer Institute (NCI)-designated cancer centers publicly reported significant increases in telehealth utilization during the course of the pandemic. For example, the UT San Antonio Mays Cancer Center reported as of August 2020 that 40% of cancer patient visits are now occurring by telehealth⁹. Approximately one third of the total visits at the Virginia Commonwealth University Massey Cancer Center, were made up of telehealth visits. At the University of New Mexico Comprehensive Cancer Center, ~35% of patient visits were converted to telehealth and all interventional protocols were adjusted to consent patients virtually. The Sidney Kimmel Cancer Center at Jefferson (SKCC) encompasses cancer services for a 14 hospital academic health system in Greater Philadelphia, covering a 2-state region. SKCC’s operation in midtown Philadelphia, the only NCI designated cancer center in Center City Philadelphia, is housed in Center City’s safety-net hospital (Thomas Jefferson University Hospital). At this site alone, 146 patients were seen via telehealth from March-July of 2019, compared to 6,853 over the same period in 2020, reflecting an increase of 4693%. International assessments have also begun reporting out across the nation’s most affected by COVID-19. A survey including 30 oncology centers in 12 of the most affected countries in Europe and United States show that telemedicine was implemented in 76.2% of the centers¹⁰. Thus, it is evident that organic, need-based implementation of telehealth has rapidly become an integral component of cancer care delivery.

While the overall impact of the telehealth visit on cancer outcomes remains the focus of the current investigation, early reports indicatte that patients are largely satisfied with telehealth as a means to connect with the care team during non-treatment visits. In a study examining hematologic malignancy patients, use of telehealth increased from ~2% to 50% of all visits within a matter of weeks, a survey showed that 99% of patients were satisfied with their telehealth visit, 94% said they would use telehealth again, and 87% felt that telehealth provided the same level of care as an in person visit¹¹. Telehealth can also be used for informed consent for treatment and research¹² wherein even pre-pandemic data suggest that patients are largely satisfied with tele-consent as a mechanism¹³. As was discussed at the 2020 AACR Virtual Meeting: COVID-19 and Cancer Conference Telehealth Forum, cancer centers from across the United States reported telehealth utilization for pre-treatment screening, non-treatment visits, and follow-up visits, with each anecdotally reporting a high degree of patient and provider satisfaction¹⁴. Finally, it should be underscored that telehealth can also provide an effective means for continuity of cancer survivorship programs, thus providing a mechanism to address the psychological challenges for cancer survivors during the pandemic¹⁵.

Despite the rapid progress in incorporating telehealth as part of Cancer care delivery, significant gaps remain toward equitable implementation, and monitoring the impact of usage. Immediate needs include the following major areas of ongoing investigation:

Addressing barriers due to variances in digital literacy

Variances in digital literacy amongst cancer patient and caregiver populations present significant challenges toward routine implementation of telehealth. Data to date have identified disparities in digital health literacy across numerous demographics, including individuals with a lower socioeconomic status, individuals identifying as a racial or ethnic minority, and older patients ¹⁶. These observations are critical to address, as patients with the lower health literacy overall are less likely to participate in shared decision-making with regard to medical care ^17,18.

Previous reports found that both age and race disparities influence telehealth utilization. For example, in assessing access to an inpatient portal, patients over the age of 60 and especially over the age of 70 showed significantly decreased usage as compared to patients from a younger demographic (45.3% and 36.7% difference, respectively). This same study showed that African American patients used the portal with significantly reduced frequency as compared to White patients (40.4% difference) ¹⁹. Challenges can be further exacerbated in the older adult oncology patient. Compared to younger patients, older cancer patients have been reported to show reduced digital health literacy, are less likely to have an email address or own a smart phone, and are less likely to use an online portal to communicate with their oncology care team ²⁰. Other factors likely also contribute, which at present maybe underappreciated and understudied. For example, a retrospective study which linked insurance claims with patient-reported data suggested that age, marital status, geographic location, urban location, as well as anxiety or depression were significant predictors of having a telehealth encounter. Interestingly, in this study the impact of race did not reach statistical significance, indicating that unique drivers of telehealth usage and or barriers to telehealth likely exists in different regions ²¹. On balance, these pre-pandemic observations underscore the need to understand and mitigate variances digital health literacy amongst at-risk cancer patient populations.

Variances in access

Equally challenging to variances in digital literacy are significant variances in access across diverse and at-risk populations. This unmet need has been further magnified by current experience of major cancer series centers during the pandemic. As reported at the 2020 AACR Virtual Meeting: COVID-19 and Cancer Conference Telehealth Forum, which included representation from geographic and demographically diverse Cancer Centers, while many patients have access to smart phones and similar technologies that in theory enable telehealth, major barriers existed with regard to utilization. It was reported that a significant fraction of patients with smart phones lack the ability to download applications required for telehealth video visit, or did not have an email address, which is required in many of the many electronic health record systems to complete a telehealth visit. As a result, social work teams were deployed to assist patients in obtaining email addresses, learning how to download applications, and in some cases providing used phones to patients at low cost in order to facilitate continuity of care. Overall, it was noted that telehealth was strongly desired by patients, and is a powerful tool for overcoming yet another barrier to cancer care that is associated with lack of transportation (common in urban centers), or eliminating the need to travel long distances for a cancer care visit (common in rural centers), but that opportunities remain to ensure equitable access.

Rural centers reported additional challenges, augmented by an overall limitation in broadband availability in outlying areas, and limited cell phone minutes for telephonic cancer care visits. At present, data suggest that patients living in the Northeast, West, or Midwestern area of the United States showed a 29.8%−34.1% increased likelihood of having a telehealth visit as compared to individuals living in the southern United States. In addition, individuals living in urban areas were much higher likelihood of having a telehealth encounter (54.3% more likely) as compared to individuals in rural areas²¹. Indeed, whereas 97% of Americans living in urban areas have access to high speed Internet service, only 65% of those in rural areas and 60% of those in tribal lands have similar access, according to the latest information from the Federal Communications Commission (FCC)²². It is noteworthy that emergency FCC funding was given to increase broadband coverage as part of the COVID-19 Telehealth program²³, yet durable solutions to the issue of the geographic digital divide will likely be essential for equitable cancer care delivery of the future, given access challenges in both urban and rural populations.

Durable telehealth business modeling: the case for parity in reimbursement

Critically, sustained utilization of telehealth as part of cancer care delivery in the United States will require durable parity for reimbursement as compared to an in-person visit. Prior to the pandemic, only one in five states required payment parity for telehealth versus in person visits²⁴. The Centers for Medicare and Medicaid Services and selected commercial payer have modified reimbursement policies in response to the pandemic, but it is unclear whether are these policies will be sustained in the post-pandemic setting, and whether other large commercial payers will follow suit. It is notable that telehealth visits have been tested prior to the pandemic, and in multiple clinical settings has been shown to have at least equivalency to in-person care, and as noted throughout is associated with high levels of both patient and provider satisfaction²⁵.

Telehealth and outcomes: current state and future directions

At the time of writing, the pandemic continues to facilitate escalation and utilization of telehealth for cancer care delivery. As we look toward the future, where do we go from here? As described by Binder et al¹¹, patient-centered cancer care by definition includes an unprecedented element of decentralization, and expands the precision medicine algorithm of “The right treatment, for the right patient, at the right time” to include “in the right place”. Given this major disruption in cancer care delivery, there is much yet to be understood and key questions that should be addressed through oncology research.

First, how can inequalities in access, acceptability, and or receipt of telehealth services be mitigated?

Designing telehealth services to meet the specialized needs the population is utmost urgency; as described above, significant and unacceptable variances exist with regard to telehealth access and success in utilization as result of factors including geography, age, and sociodemographic. Equitable cancer care must be a priority, but achieving this will require use of supportive strategies for which the financial model is uncertain (e.g. patient navigators and/or hardware to circumnavigate barriers). Development of a simple, streamlined portal that is highly compatible with multiple operating systems for accessing telehealth is an opportunity for partnership with the technology sector.

Second, how can telehealth be optimized to improve the patient care experience and to enhance cancer patient provider communications?

Given this ‘new normal’, providers will need to prepare for and adapt to variances in telehealth capability across demographics and geographies, and ensure that telehealth visits maximize opportunity for delivery of high-quality care. Developing strategies to improve patient knowledge and skill when using telehealth services is likely to be a new and essential function for oncology care teams.

Third, what is the impact of telehealth on outcomes, including clinical outcome, patient reported outcomes, and health care utilization?

New models for risk stratification will need to be developed, built on longitudinal data tracking these critical endpoints for patients who engage in telehealth encounters. Accompanying these promising lines of investigation, incorporation of wearable and tracking devices as part of the telehealth experience is already emerging as part of the cancer care model of the future. As such, ensuring that telehealth platforms are capable of tracking these novel technologies will be important for coalescing data into the most effective possible telehealth visit.

Fourth, what is the impact of telehealth on cancer clinical trials?

Recent changes to the conduct of clinical trials which facilitated aspects of telehealth and decentralized trials should be adopted permanently with the goal of improving outcomes for patients in the cancer community at large. Remote consent, video follow-up visits, symptom capture applications, home drug delivery, and use of local labs for blood draw for eligible patients will greatly increase cancer clinical trial access, enrollment, and the pace of advancing new knowledge into clinical benefit.

Fifth, it will be imperative to address the ‘human-ness factor’ of telehealth delivery.

It is essential to further understand the impact of telehealth on both patient and provider satisfaction, stress levels, and preferences. It has been postulated that reduction in the human to human connection as a result of telehealth maybe a barrier that has not been sufficiently considered ²⁶.

In closing, it is without question that telehealth represents an innovative, and durable change to cancer care that will transform patient access to treatments; as such, it is critical that we as a cancer community strive to prevent this new technology from increasing cancer health disparities, and to optimize usage toward improving the lives of all cancer patients and their families.

Translational Relevance:

Rapid adaptation of telemedicine during the COVID pandemic disrupted cancer care models across a wide breadth of nations. Experience to date (described in the review herein), revealed varying readiness on the part of patients, caregivers, oncology providers, and health systems to successfully and equitably incorporate telehealth into the cancer care continuum. Moreover, distinct challenges have been realized as a function of geography, demographic, and level of digital literacy which require mitigation. Understanding the overall impact of telehealth on cancer outcomes, quality of care delivery, and access to care will be critical for optimizing implementation of telehealth as part of the cancer care continuum in the post-pandemic setting.