Telehealth Safely Connects Oncology Community During COVID-19 Crisis

Raymond Liu, MD, an oncologist at San Francisco Medical Center, Kaiser Permanente Northern California

Raymond Liu, MD

Social distancing is necessary to reduce the spread of the novel coronavirus (COVID-19) and telehealth serves as a key approach to continue the delivery of life-saving care for patients with cancer, while protecting patients and providers alike from infection, according to Raymond Liu, MD.

The pandemic continues to disproportionately affect patients with cancer. Through the use of digital and telecommunication tools, such as telephone, messages, and video technology, providers are able to manage patient care, health-related education, public health, and health administration.¹

Telehealth has allowed for providers to connect with patients in a way that was never considered to be possible before, according to Liu. For example, the ability to hold video visits has allowed for family members or caregivers who do not live in close proximity to the patient to still be involved in important decision-making processes. Many benefits exist with this approach on a provider level, as well. For example, with the use of telehealth, providers are able to connect with their colleagues to conduct virtual tumor boards, where they are able to review pathology or imaging reports and continue to provide quality care for patients.

Despite these benefits, significant challenges are still faced in that the lack of evidence-based practices, training, and experience can affect the ability of practices to rapidly implement telehealth. In a manuscript published in JCO Oncology Practice, Liu and colleagues describe current telehealth expansion efforts and offer concrete, action-oriented recommendations to inform providers, practices, institutions, and even health systems, irrespective of their settings or telehealth capabilities.²

“Telehealth is not going to go away in the near future and once patients understand the convenience and the flexibility of telehealth, I think they're going to want it and it will [allow us to] provide a very high level of care,” said Liu. “For us, [the challenge is] going to be to distinguish which patients like which type of telehealth visit, how to improve [this practice] over time, and then how to tie the payment models in to support patient-centered care. If we can do all of that, I think we can be top in the world in delivering care to our patients efficiently, in a value-based way, and also in a patient-centered way.”

In an interview with OncLive, Liu, an oncologist at San Francisco Medical Center, Kaiser Permanente Northern California, shed light on the benefits and challenges of utilizing telehealth in oncology and shared advice on how to implement this approach in practice.

OncLive: Could you provide a brief overview of how telehealth is being used as a way to support social distancing efforts to prevent the spread of COVID-19 ?

Liu: Around February/March, we started getting requests from patients who were worried about the COVID-19 virus. Our patients are especially vulnerable; they have cancer and they're often on chemotherapy or other immunosuppressive agents. Many of our patients are older adults. We very quickly had to come up with a pathway to improve social distancing and help flatten the curve, while also taking care of our patients. Oftentimes, the care is still urgent, and so we needed to find a way of providing that care without requiring them to come [into the clinic]. We’ve had years of experience with telehealth, so we immediately thought of [utilizing this] as an innovative way to help us improve social distancing and also help flatten the curve.

What are the benefits of telehealth for patients, caregivers, and providers?

One of the positive aspects that we've seen, especially on the patient side, has been that we have been able to connect in a way that we never thought we were able to before. We have patients connecting with us while mobile; for example, [they can connect with us] while in their cars or while traveling. Also, we shouldn't underestimate the power of a caregiver [for] patients with cancer. Caregivers may not be living with the patient and decision makers may not be living near the patient, especially with social distancing [efforts in place]. We have known for a very long time that our ability to conduct video visits with multiple folks in the family, as well as the patient, has provided us with the ability to connect families and bring them together in decision making processes. As such, video visits have provided many opportunities for improving patient care. Additionally, this is a time where people are losing their jobs and if a caregiver is needed to bring patients to an appointment, that could impact employment. To this end, we have found video visits to be very helpful for caregivers so that they don't have to take time off from work. We have also done video visit calls with patients [while they were] at work, as well. Because of the convenience, cost savings, and also the ability to bring people geographically from many, many places together, video visits are very, very powerful.

That being said, when we deal with our elderly population, and those who don't necessarily speak English, we are definitely faced with challenges [with this approach]. The way that we get around that is to ensure that we pay attention to those [challenges and] create an infrastructure; that's what a lot of this manuscript is about. We want to help the community and the nation figure out what the right infrastructure should be provided to ensure that all our patients get access to this care.

When we speak with our colleagues about it, there's a lot of satisfaction on telehealth and all the opportunities it can provide. However, we're also worried about ensuring that we design the right package for every single patient and taking a patient-centered approach.

Could you elaborate on some of the challenges faced with telehealth and the utilization of this effort in light of the pandemic?

There are many nuances to doing telehealth and we've explored these over the past several years. One of the challenges we've already noticed previously are that our elderly population finds it more difficult to engage with technology, especially in terms of the internet connectivity and video visits. As such, what we sought out to do, and we are collecting more information on this, is determine how to create a patient-centered approach with this.

The Medicare rules have changed to allow telehealth to be done and paid for but even though that's the right thing to do for the patients, we also need to understand emails and telephone and all the other ways that patients are engaging with us; that information can be helpful. We're also very interested in looking at healthcare disparities and figuring out how to reach those who don't have the technology or the internet bandwidth at home.

What are some of the efforts being made to expand telehealth to more patients and providers alike?

In our healthcare system, we have been able to do this in a very robust way. In the manuscript, we show that we were essentially doing telehealth for about 60% of our visits and we remain at nearly 100% of our visits in our San Francisco medical facility, for example. We’ve seen that change in oncology throughout our area. We have been able to implement this across the spectrum and we're finding very high patient satisfaction. [This approach allows for continued] connection with our oncologists and our care staff, which is super important in a situation where people can feel disconnected having been isolated in their homes. We have been able to do that, and we've also engaged our staff.

What we think about is virtual rooming, which is going to a virtual house call where you can actually see the patient's living room and that's really, really wonderful; it gives you a context on the patient's care. On the other hand, they need to know that the staff is here to support their technology needs. As such, we do create the infrastructure that we describe in the manuscript to ensure that our medical assistants are actually virtually rooming the patients even before we start the visit to ensure that the patient is comfortable and that the technology issues are worked out. On the surface, it might be simple to do a call, but when you really think about it, as detailed in the paper, many little elements should be considered to ensure that the telehealth visit goes correctly.

What are some of the strategies and observations shared in your manuscript regarding the development of internal protocols to appropriately triage patients into telehealth visits versus personal encounters?

We have to hire staff to help us with that effort. What we do know is that when we offer patients a variety of choices, they'll pick the one that makes the most sense to them. Choice is really, really important in this aspect. So again, if the patient doesn't have the technology, we try to help them with it. However, if they don't have it and that's not their interest, we absolutely do what's right for the patient. I'd say the bottom line is the patient-centered side of all this. Our absolute goal is to meet the patient where they are and always find the right way to connect with them, payment issues aside. That’s what's important for telehealth. We really need to start doing the research and thinking about this, since we'll all be doing this a lot more in the future. How do we do it right and how do we do it when thinking about the patient?

There’s a section in the manuscript outlining steps to increase provider-level telehealth capacity. Could you expand on this?

Specifically, there are many ways we can do this on a provider level. This traces back to our health disparity question we answered earlier in that reaching out to rural areas becomes easier with telehealth because the patients can be wherever they are. They don't have to drive long distances. However, the other benefit is that provider-to-provider communication can sometimes be easy. We’ve had this system in place for several years, which is why we can do these virtual expert tumor boards, and we talk about that in the manuscript. Even for a rare cancer, we have 3 or 4 folks in the whole region of northern California, who are maybe hundreds and hundreds of miles away but are able to connect through these video conferences; they're able to look at the pathology or the imaging reports and develop expert quality care for patients and then send those recommendations locally. Virtual tumor boards are one way that providers and providers can help support each other in a virtual way to provide even higher quality care in the telemedicine era.

You mentioned that patients are open to this process. Could you expand on how both patients and providers feel about telehealth? Are they receptive, for the most part?

Time changes. If we perform a study evaluating telehealth satisfaction, it's really important to do the study over and over again. To this end, we are collecting data to help understand how trends are changing over time. What we do know is that there's a large variability to our ability to take up telehealth, and I do want to mention that telehealth in this situation is email, telephone, and video; it's basically all the work that we're doing that's not an in-person visit. As such, many times, when you see things about telehealth, they're really focusing on the video visit, which is what primarily we've talked about in terms of reimbursement. However, the whole body of work, again, if we’re talking a patient-centered approach, looks at [all of] that. Collecting data going forward it's going to be important to distinguish between those types of [telehealth], what patients prefer different types of telehealth, and then figuring out how we can tailor it to their preferences. We’re collecting that information now and it will be the subject of future manuscripts.

What is your advice for other health systems that are working on deploying patient-provider telehealth along the oncology care continuum? What are the key components needed to do that?

There are 2 sides to this; one is the provider side and the other is the patient side. We talked a lot about the patient side earlier in the interview and the importance of thinking about a patient-centered approach. Meeting the patients where they are, the virtual rooming, all those things are really designed to question what the patient preferences are, what kind of cancer do they have, and what kind of visit is needed, so we could do the right thing for the right patient.

On the provider side, many systems-related [issues that need to be addressed]. Do you have enough bandwidth for internet capability? We've rapidly expanded our video visits. If we’re doing 10,000 video visits per week, we’re going to need the internet bandwidth. An internet connectivity issue and infrastructure need to be considered. When your staff go remote, there's a communication issue that needs to be considered. In the past, people were doing in-person huddles. How do you convert that and create a sense of team to ensure that you maintain the health and wellness of your staff? On top of that, there's training that needs to happen because just like our patients might not be technologically trained, some of our staff or physicians might not be either. We have been working many, many years on the training aspect of this. Training is very, very important.

I would say the most important thing is to never give up, not just with regard to training or infrastructure, but understanding patient needs. I know that this is a very challenging and unusual time, but this is also a time that we can innovate; it's a time that we can look to using this opportunity to do the best that we can for our patients. Our system has many, many great things about it but we should also take every challenge as an opportunity; that's how we think about telehealth.

What is your take-home message?

We're all in this together: our patients, our staff, and our providers are all going through the same thing with shelter in place, with a need to connect with each other. Telehealth provides us with that opportunity in a way that we never had before in prior pandemics. Let’s all take this opportunity to work together to find solutions to share them to help our patients, our colleagues, and our society. We can all do our little part, and we all are doing our part, to shape the outcome of healthcare in the future.

References

1. Health Resources & Services Administration. Telehealth programs. Accessed May 26, 2020. bit.ly/2M33qAk.
2. Liu R, Sundaresan T, Reed ME, et al. Telehealth in oncology during the COVID-19 outbreak: bringing the house call back virtually. J Oncol Pract. Published online May 4, 2020. doi:10.1200/OP.20.00199