Oncologists turn to telehealth for an extra layer of patient care

Telehealth experienced explosive, unprecedented growth early in the pandemic. More than two years in, much of that uptick has slowed, hampered by reimbursement uncertainty and unknown returns on investment.

Still, some health systems have found an enduring use case for virtual care: oncology.

Although telehealth appointments aren’t a replacement for in-person therapies, oncologists say scheduling regular remote check-ins and constantly monitoring symptoms have helped them stay on top of their patients’ health, especially amid COVID-19-related delays in cancer treatments. Despite limits on efficacy data, organizations point to expanded access and reduced emergency department visits as early signs of success.

Some providers characterize remote monitoring technology and digital platforms as essential care delivery tools, even as physicians in other sectors return to in-person visits.

“What’s unique in oncology is that you see the persistent utilization of video visits, despite a trend toward normalcy for most of the healthcare system,” said Dr. Sumit Shah, medical oncologist and director of digital healthcare integration at Stanford Health Care.

“This is largely because oncology is well-suited for virtual care in the sense that most of our decision-making can be made based on objective criteria that are still available through video visits,” he said.

Long-distance checkups

Before 2020, Stanford Health Care in Palo Alto, California, mostly offered remote second opinions for clinicians, with virtual video visits as a potential option for patients traveling long distances, Shah said.

But during the pandemic, the health system found that video appointments allowed its most vulnerable cancer patients to receive necessary care without possible exposure to COVID-19. Virtual oncology visit rates soared, peaking at 80%.

Traditionally, cancer care has been mostly episodic, where patients may only see their oncologist three to four times a year to receive exams and discuss treatment plans, Shah said. By setting up video visits on an as-needed basis, physicians are able to have a better sense of a patient’s trajectory. They can arrange in-person or virtual medical assessments in response to patient requests; adjust prescriptions; or coordinate urgent care visits to offer patients fluids, anti-nausea drugs or pain medications.

Stanford oncologists have embraced telehealth, especially for advanced urologic, lung and gastrointestinal cancers, Shah said. Half of all oncology visits are now virtual, compared with other specialties at the hospital, where rates of remote visits have decreased to 10% or 15%.

When determining which technology to use for virtual care, Shah said it was important for Stanford Medicine to choose a platform that had full integration into its electronic health record. The health system opted to use Vidyo, which embeds directly into its Epic EHR.

So far, oncologists at Stanford have been able to widen the system’s geographic footprint and optimize the use of clinic rooms and other resources, Shah said.

“We are currently implementing an enterprise solution for remote patient monitoring to enable patients to use mobile health devices to gather patient-generated health data and transmit that information to their care teams,” Shah said. “We’re also in the process of launching on-demand services that would allow patients to access a provider through their phone to address an urgent matter.”

The health system plans to expand its telehealth focus to all advanced disease and post-surgical patients, Shah said. The broader scope will allow providers to discharge patients earlier for at-home recuperation.

In the meantime, Stanford is untangling some of telehealth’s ongoing logistical challenges.

“We’re still in the process of ‘hard-wiring’ virtual visits into our operations—knowing which visits are appropriate for virtual care versus which visits would necessitate an in-person evaluation,” Shah said. “Furthermore, while telemedicine can broaden our outreach, it’s important to ensure that we’re not widening inequalities in healthcare that can arise due to lack of access to internet, phones or computers.”

Mass General Cancer Center in Boston has also relied primarily on video visits to stay in touch with patients. Those who want to discuss their symptoms, treatment or other topics can see their physician in person, have a phone visit, or set up an appointment using the center’s Zoom platform embedded in its EHR system, said Dr. Steven Isakoff, medical oncologist and the center’s associate director for clinical research.

The flexible format allows providers from medical oncology, surgical oncology and radiation oncology to instantly join the conversation from wherever they are, Isakoff said.

The system is looking into using nonclinical employees, such as administrative and IT workers, to help coordinate remotely available interpreter services and technical support for patients.

“In the same way that we would have someone escort the patient into the exam room, we’re working on systems where we’re having an administrative person essentially escort the patient into the virtual room,” Isakoff said.

24/7 monitoring

Other health systems have focused more heavily on remote monitoring tools.

In addition to its multiple cancer centers providing outpatient and inpatient care, New Orleans-based Ochsner Health offers a virtual program called Chemotherapy Care Companion, which helps manage the health of patients placed on a chemotherapy regimen.

The program began as a way to identify and prevent risk factors in oncology patients that could lead to an ED visit. After a trial run, Ochsner leadership opted to expand the initiative in 2019 into a full virtual program and app, said Dr. Zoe Larned, system chair of hematology and oncology at Ochsner. The program provides patients with an iHealth blood-pressure cuff, weight scale and ear thermometer to be used twice daily. The Bluetooth-enabled devices are crucial ways to keep ahead of potential side effects of chemotherapy or the cancer itself, Larned said. Using personalized algorithms Ochsner developed in partnership with its EHR vendor, Epic, the devices send a digital alert to a patient’s physicians if their vital signs hit certain levels.

The app also sends patients daily questionnaires about symptoms such as nausea, dizziness or trouble eating. Physicians review the information daily.

Implementing the program was fairly seamless: Ochsner worked with its IT team and Epic to help clinicians understand the data and program software, Larned said. After signing up for Chemotherapy Care Companion online, patients are able to visit the “O Bar” at Ochsner’s cancer centers and receive their monitoring devices. Technicians help patients set up their devices and install the program’s app to ensure everything is working correctly.

Around 350 patients between the ages of 23 and 86 are enrolled in Ochsner’s virtual program, half of whom are advanced-stage cancer patients. The system sends reminders to participating patients, resulting in an estimated 75% compliance rate.

Larned said with a good IT support team, setting up a remote care platform is much easier than health systems might believe.

Smaller hospitals and care centers looking into telehealth options should consider partnering with larger health systems that already have a virtual system in place, Larned said. Facilities should also think about how to manage their workforce to ensure clinical staff are available to monitor and review data, while still having one-on-one interactions with patients.

In the near future, Ochsner plans to customize its program questionnaires to be more specific to certain cancer types and extend its Chemotherapy Care Companion program to patients receiving oral therapy and those undergoing experimental treatments, Larned said. As part of its growth, the cancer center will create discharge monitoring tools, use grant funding to expand access to internet-enabled technology and present outcomes data to insurance companies supporting future telehealth reimbursement.

“It gives (patients) real peace of mind that we’re watching behind the scenes, that those days that they’re away from us waiting for their next appointment or their next treatment cycle, that they still have communication and access to us,” Larned said. “They feel very confident that it’s providing an extra layer of care.”

Investors have responded to overall provider and patient interest in telehealth with an infusion of cash.

In 2021, 18 venture capital firms invested in remote care vendors, compared with seven in 2020 and four in 2019. So far in 2022, there have been five deals involving remote-care vendors.

When it comes to virtual cancer care, some vendors, such as Thyme Care and OncoHealth, partner with health systems to connect cancer patients with company-employed remote clinical teams. Others, like Memora Health, focus on remotely monitoring oncology patients using text messages and sorting through patient health data.

The telemedicine platform Outcomes4Me provides patients with broader education on how to live with cancer, offering information on nutrition, the latest news in oncology and how to connect with a network of others undergoing oncology treatment.

“The biggest benefit is convenience,” OncoHealth CEO Rick Dean said. “Meeting the patient where they are allows that patient to talk to an oncologist or a nurse anytime, or have their family member talk to a nurse about what’s going on, and do it in their home.”

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But is it effective?

Although more research on the effectiveness of telehealth in oncology and its different specialties is needed, some organizations and vendors have started gathering information on clinical outcomes.

At Ochsner’s South Shore, North Shore and Baton Rouge cancer centers, where the health system has implemented the Chemotherapy Care Companion program, preliminary data has shown ED visits and inpatient admissions have been reduced by 33%, Larned said.

On average, patients not enrolled in the virtual program visit the ED 4.9 times, compared with 3.3 times for enrolled patients, she said.

Other companies report optimistic patient-satisfaction rates. Around 75% of patients using Memora Health still engage with its app after 90 days, and 59% of users’ symptoms are managed without needing an in-person intervention, said Naomi Levinthal, vice president of strategy at Memora Health.

Three-fourths of oncology patients at Stanford have said they are likely to choose a video format for their next appointment over an in-person visit, Shah said.

Still, telemedicine can never fully replace in-office appointments, as most tests, scans and treatments can’t be done virtually. Physicians often want to be able to do things like feel a lymph node to determine if a patient is responding to treatment, or look at a wound and see if it’s healing well, Shah said.

“Sometimes a telehealth visit can underplay a potential symptom or side effect that a patient is having,” ​​Mass General’s Isakoff said. “You might miss that with a home visit if they’re sitting comfortably on the couch and not really moving around.”

The emotional connection also plays a role: Some providers continue to worry about being able to establish the same connection with patients made possible by in-person appointments.

“It’s the way that we’re able to hold a patient’s hand when delivering bad news, or give them a hug,” Shah said. “It certainly is challenging to be able to convey that same level of empathy over a video visit.”

But more providers in the healthcare industry are beginning to see virtual visits and remote patient monitoring as part of a larger health-at-home ecosystem, with broad potential applications, Shah said.

“Instead of having to come to a tertiary care infusion center, could patients actually receive either chemotherapy, immunotherapies or injectable medications in the home setting?” he said. “The ultimate goal is to deliver more care in a dispersed fashion.”