Amye Tevaarwerk, MD, University of Wisconsin Carbone Cancer Center, discusses results from a survey exploring providers’ perspectives on the roles of phone- and video-based telemedicine in the oncology setting.
These results were presented at the 2021 virtual National Comprehensive Cancer Network (NCCN) Annual Conference.
Hi, my name is Amye Tevaarwerk. I'm an associate professor at the University of Wisconsin, Carbone Cancer Center. I'm both a physician informaticist as well as a breast cancer oncologist.
Early in the pandemic, in collaboration with a group based out of the NCCN, so the NCCN has an EHR Oncology Advisory Group, and a number of us physician informaticists were… not sitting around chatting because obviously this was during the pandemic… but we were all corresponding about telemedicine and how it was changing oncology care.
This was all in the very early phases of switching over to telemedicine due to the COVID‑19 pandemic. We were chatting about how patients with cancer are a unique population. They may be at higher risk for complications from SARS‑CoV‑2, but we didn't understand the risks or the benefit of using telemedicine for this population.
I'm not sure that we can say even after our survey that we do, but we decided to come up with a survey that we could send to the NCCN member institutions asking about oncologists' perspective on telemedicine use for patients with cancer.
We created a 20‑item web‑based survey using a review of the literature and then a consensus approach from all of our physician informaticists on the telemedicine workgroup.
The conversations happened in March and April. The survey started developing in about April, May, June of 2020. Then in July of 2020, we disseminated the survey via email.
The way we did that is we used the NCCN EHR Oncology Group. We asked each member of our group who was a member at one of the institutions to send it to a LISTSERV, hopefully, targeting oncologists broadly.
I say the term oncologist, and by that term, we meant anyone who was a clinician addressing the care of patients with malignancy. The survey was open from about July to August of 2020. Roughly a five‑week period in the end.
Our goal was to assess provider perspectives on the roles of phone and video‑based telemedicine in the oncology setting, both in current state at the time of the survey, but also their predicted, what did they think would be able to be sustained into the future?
Out of the 30 NCCN member institutions, 26 responded to us. We had a total of a thousand‑plus individuals responding. They were largely oncology attendings, either hematology and/or oncology. Most of them had been in practice for five or more years, based on the demographics, and most had had no prior telemedicine experience before the pandemic.
By the time of the survey, which is happening roughly July, August of 2020, 84% have participated in both phone and video‑based visits, largely because most member institutions had started with phone and then switched over to video relatively quickly as an additional option.
We were interested in a couple of key things. One, we wanted to know about serious adverse events that folks were attributing to the use of telemedicine.
I guess, it depends a little bit on your perspective as to whether you think 93% is a good number or not, but 93% of our respondents said that they had never or had rarely had an adverse outcome that they attributed to having conducted a visit as a telemedicine visit rather than an in‑person.
That does still leave roughly 6% saying it was happening occasionally, and then a very, very, very small percentage saying it was happening frequently.
Now, with this particular question, we didn't ask whether the telemedicine that had led to an adverse event was phone or video, but we did ask a series of questions about telemedicine and how it worked in a variety of common clinical scenarios.
We asked about telephone versus office and video versus office. We had a number of uncomplicated visit types and clinical scenarios that we discussed as well as more complicated things.
For instance, when we asked the question, "How well does a telemedicine visit conducted by phone work to review benign or reassuring data?" respondents overwhelmingly suggested that it was either as good or better than an office visit for both phone and video.
As the complexity of the task went up or the need for interpersonal relationships, for instance, the question of, "How well does phone or video work for establishing a personal connection with a patient and family?" the oncologists' respondents started to dramatically shift towards a preference for office visit.
There's a lot of complexity for what scenario what visit might be able to happen well using telemedicine. Although we didn't distinctly ask the question specifically for how video compared to phone for each of those circumstances, we do note that video is significantly outperforming phone in almost every question we ask.
As a follow‑up to those questions about how well telemedicine was performing, how often we were seeing adverse events, we also asked them in future state roughly what percentage of their future visits could be conducted via telemedicine.
We asked them, absent financial implications, because we all know that there's a lot of uncertainty about where reimbursement for telemedicine is going to go, but we said, "Hey, subtract that out of your head. What percentage of your patients could reasonably be seen via telemedicine versus in‑person visits after the pandemic resolves?" Whatever that means to the individual provider.
Roughly about 54% of the visits were felt to need to be in person. 33%, so a third of visits, they felt could be conducted by video.
A small percentage of visits, 13%, small but real, could actually still be conducted using telephone, which was an interesting perspective in terms of thinking, how much of what we're doing could we switch to telemedicine, potentially, in the future?
In terms of thinking about those findings, just to summarize them, our interpretation of the data was the telemedicine seems safe for appropriately selected patients.
I didn't tell you this at the beginning, but we do know that these respondents had indicated to us that patients were being selected for telemedicine visits on the basis of both the provider and the patient largely being comfortable with it. In that scenario, at least serious adverse events appeared to be uncommon.
Our provider respondents felt that there was utility in a future state for up to nearly half of patients. Although I don't have this data ‑‑ we haven't necessarily presented all of it ‑‑ I can tell you that there's a lot of comments about the need for clinical workflows to be established, best practices. A lot of comments about licensing and reimbursement, as you might expect.
Of course, one of the weaknesses is that, although we're providing a lot of data from a large number of oncologists, we don't have the patient perspective in thinking about, what would be acceptable to patients? What would not be acceptable? Where are the pros and the cons for conducting visits as telemedicine?
That only to be added by others given the limitations of what we can and can't do out of the NCCN network. That's a summary of what we did for this study.
It is important to think about the nuances of telemedicine and not just ask the blanket statement about, can telemedicine be used for patients with cancer? The answer hinges on the details of what you're asking providers to do with telemedicine for patients with cancer.
Tevaarwerk A, Osterman T, Arafat W, Smerage J, Polubriaginof FCG, Heinrichs T, Sugalski J, Martin D. Oncology Provider Perspectives on Telemedicine for Patients With Cancer: A National Comprehensive Cancer Network (NCCN®) Survey. Presented at: the NCCN 2021 Virtual Annual Conference; March 18-20, 2021. Abstract BIO21-011.
Dr Tevaarwerk reports no relevant financial relationships.