Telemedicine Holds Its Place in Oncology Care

Robin Zon, MD, FACP, FASCO

Telemedicine is reshaping health care, and regulators are beginning to shift focus to making telehealth a permanent and functioning component of oncology care. Recently, the American Society of Clinical Oncology (ASCO) released recommendations to help oncology clinicians and administrators navigate telemedicine.

To provide the recommendations, an expert panel conducted a systematic review of literature on telehealth in the oncology space. The review included the use of technologies and telecommunicating systems as well as the electronic methods of care delivery and how information is shared with patients. In addition, the expert panel provided opinions that contributed to the standards and guidance that ASCO released.

Overall, the recommendations provide a roadmap for how to best establish the doctor-patient relationship, the role of professionals in the multidisciplinary care team, and how to continue to conduct cancer research. One expert from the panel, Robin Zon, MD, FACP, FASCO, recently discussed the future of telemedicine during a presentation at the National Comprehensive Cancer Network (NCCN) Annual Conference 2022.

In an interview with Targeted Oncology^TM, Zon, a medical oncologist at Michiana Hematology Oncology, Advanced Centers for Cancer Care, discussed the role of telemedicine in oncology and how it continues to evolve to shape the future of the field.

TARGETED ONCOLOGY: How did telemedicine look 3 years ago and how has it transformed since the start of the COVID-19 pandemic?

Zon: With regards to the oncology world, telemedicine was very rarely used, at least in the domestic United States. Partially, it's because of the CMS restrictions in terms of who could do the telemedicine visit. Specifically, [it] was only for rural communities, and even then, the rural patients had to go to a health care facility to have that visit. So, it was very unusual, at least for the oncology world in the US, to use telemedicine.

Then comes along COVID and the pandemic, and with it, emergencies were declared, and CMS had lifted that site of origin and geographic restrictions. Therefore, it was much easier, for oncology be able to embrace telemedicine as a way to have contact with our patients. And of course, that was due in part because initially, when COVID started, we didn't have enough personal protective equipment [PPE], and vaccinations were not yet developed. As a result of the PHE initially there were travel restrictions and people did not want to be exposed to the virus unless they absolutely had to come into the doctor's office for emergent care. So, with that, across the board, there was this huge uptake of telemedicine.

By April of 2020, it was multiple-fold of what we had used in February. It was in the 80-times range, and then it declined and plateaued as time went on, partially because PPE became available, vaccinations became available, and we now had treatments for COVID. Since we were able to control COVID better the actual use of telemedicine declined but never went to zero. I believe that's because there's this beautiful role for telemedicine for chronic care management, as well as for taking care of patients that might have acute issues with regards to their therapies without having to come in.

In addition, what we've discovered with telemedicine is that it’s a way to be able to reach out to populations that may not have been compliant. Some patients didn’t historically come in to see us for a number of reasons -either because of transportation issues or because they didn't have access to caregivers or childcare, and etc.

So, it continues as a tool to continue to manage our patients. It is not to be the sole way that we manage our patients. I do believe that there will always be a role for in-person visits, but they can be used alternatively with telemedicine. I don't anticipate telemedicine is going to go away. The AMA recently released a survey in March 2022 that looked at a number of disciplines across all medical fields and everybody feels very strongly that there is a wonderful role to be able to use telemedicine in many different ways currently and in the future.

You were a part of the expert panel that developed the ASCO Standard and Practice Recommendations for Telehealth in 2021. Can you discuss those recommendations?

The expert panel was convened, based on the advice of ASCO and the request of members about how we should be using telemedicine for oncology. I do want to say that the AMA playbook for telemedicine in the American Association of Telemedicine did a beautiful job in providing everybody some basics on how to implement, operationalize, and use telemedicine in an effective and HIPAA-compliant way. But what we found for oncology patients is that maybe we should do more to be able to deliver recommendations and standards. And there were actually 6 questions that the expert panel [answered]. The first question was, which patient should be seen via telehealth versus in person? This is an important implementation consideration for oncologists, and that included mostly not just routine patients but possibly for new patients, especially in the beginning of the COVID pandemic.

The second question was how do we establish the physician-patient relationship within the context of telehealth in oncology? And the bottom line is that there should be an established doctor-patient relationship before we start seeing patients with telemedicine.

The third question was, what is the role of advanced practice providers and telehealth? What is meant by that is what is the potential role of physician assistants and nurse practitioners regarding telehealth provision of care?

The fourth question was, what about allied health professionals and can they be instrumental in oncology telehealth visits? The bottom line is, our allied health which includes mental health providers, geneticists, nutritionists, physical therapists, occupational therapists, etc, and these are very important to the overall multidisciplinary team of care for our patients. It may be difficult for patients to get to these experts, and telehealth may be a way in which they can help function and improve the care of our patients.

The fifth question had to do with the use of virtual multidisciplinary cancer conferences. Another phrase we use for this is tumor boards. And even though we weren't having face-to-face tumor boards, I know my practice and many practices across the country, both community and academic based, were meeting virtually. So, there's guidance on how to accomplish this important aspect of patient care.

Finally, the sixth question had to do with the incorporation of telehealth in cancer clinical trials. Certainly, cancer research has suffered as a result of the pandemic. And what we have learned from that is that there's some concept called decentralization that can occur with clinical trials, which in fact, was embraced in part during COVID, to be able to allow patients to continue participation in clinical trial research. But looking forward, how can we use that same concept so we can continue to reach out to areas that might not otherwise have access to clinical trials?

So, the recommendation list is very long, it answers those above questions.

What lessons do you think oncologists learned from the past few years that can be applied to the future of telemedicine?

Part of the lessons that we're going to learn will be based on collecting data from those who had been using telemedicine and getting an understanding of what physicians’ perception were. Also, what were the actual numbers? [For example], in terms of how telehealth helped reductions in emergency room visits, hospital length of stays, and acute care visits, as well as what the patient perception was. There are surveys out there being done by groups such as the Patient Advocacy Foundation, and then there's other surveys being done, including with ASCO, collecting data, with regard to utilization.

What I can tell you is that the perception is, and there are some small reports coming out now showing that, in fact, there was a reduction in acute care visits to the ERs, which was important, r because during COVID, the ERs were swamped with COVID patients. We wanted to try to keep our non-COVID patients, especially our immunocompromised patients, from entering into that acute environment. So, there ended up being a reduction because we're able to manage things better, we're able to manage side effects before they became a problem, or we didn't send patients automatically to the ER. So it is imperative to acknowledge and that lifting of the site of origin and geographic restrictions for where the care was delivered was so important to allow that [to] occur.

I think the lessons learned is that telemedicine is certainly to be considered part of the tools that we can use to very maximally, and effectively, take care of our patients. This is not only in the acute care setting but also for chronic management. So, for example, many of us have learned that our patients weren't always telling us in between our visits that they were having some problems with medications. They were waiting to come, which meant they were on very expensive therapies that may not have been working anymore. But they didn't call the office. Well now, with telehealth we were able to do some more frequent virtual check ins, and we’re able to determine earlier, rather than later, that there is a problem, so we can effectively manage their care.

The establishment of guidelines was a good starting point for telehealth. What I'd like to see in the future is continued data and models looking at how we can better use telehealth, especially [in] outreach to our underserved populations, which includes not just the rural populations, but also populations that may be in such socioeconomic circumstances that they can't see their clinician as much as possible, even though they may live just 20 minutes down the road from the office. And there may be other ways in which we can use telemedicine to better educate our patients, as well as be able to use patient-monitoring devices. And there's all this wonderful opportunity there, that we can look forward to, now that we've had a glimpse, in an emergency situation of how something that was out there and existed can be utilized. How can we expand that and make it an important tool in our care, and subsequently improve the care of our patients?

You discussed telemedicine during a presentation at the NCCN Annual Conference 2022. What are the key takeaways from your talk?

Similar to what I’ve discussed so far, telehealth clearly is playing a much larger role in care delivery, but we need to do a lot of work when it comes to increasing access. There arelegislative issues and regulatory issues. There are barriers that have been identified, such as digital intelligence, broadband access, and other technology access. Those all need to be addressed.

There are legislative acts that are currently in Congress . So, we're certainly hoping that those get passed, because that will certainly help advance technology and help advance telemedicine.

The other important takeaway is about the Public Health Emergency extension, which is five months and takes us to July 1st. We're hoping that the originating and geographic site restrictions remain delayed, and it becomes permanent. Based on my recent participation with NCCN, I know payers actually are understanding the value of telemedicine and these are private payers who are very interested in continuing this because they see the value. I think there's some other concern, including payment models and how do we reimburse for telehealth.

There's been debate about whether telehealth should be audiovisual only. Well, there's a problem with that, right? If somebody doesn't have a technology to do audiovisual, they don't have broadband access, then we end up again, leaving out that population that may need this most. So, we need to be able to have audio only as an option for telemedicine. Also, we certainly don't want fraud and abuse. And I think that's come up to least from Congress, but I think we just need to monitor just like we would anything else. We have payment models, and we have standards that we follow, and our focus in oncology should be on giving high quality, good care. I think data collection looking at research in the past as well as research going forward will help answer our lingering question.

So, my conclusion is that telemedicine is here to stay. We have an AMA survey that suggests a strong feeling amongst all specialty providers including oncologists, no matter what their site of services (academic or community). We need to be looking at research opportunities and questions to answer how to best utilize telemedicine in the future.

_REFERENCE

_{Zon RT, Kennedy EB, Adelson K, et al. Telehealth in Oncology: ASCO standards and practice recommendations. JCO Oncol Pract. 2021;17(9):546-564. doi: 10.1200/OP.21.00438.}