Telehealth has emerged as a means of improving access and reducing cost for medical oncology care, but new research finds that oncology health professionals still have differing opinions regarding the barriers to and benefits of video visits.
The qualitative study, published recently in JAMA Network Open, entailed interviews conducted, prior to the COVID-19 pandemic, of 29 medical oncology health professionals at Thomas Jefferson University Hospital in Philadelphia. The findings showed that although oncologists disagreed on the scope of a virtual physical examination and the financial impact of video visits, most recognized the benefit of eliminating travel and the challenge of delivering serious or bad news. What’s more, many reported concern regarding the health professional–patient relationship and their limited ability to comfort patients in a virtual setting.
The researchers noted that telehealth has promise for patients with cancer, where concerns regarding access, cost, and experience are common. A randomized controlled trial of video vs in-person visits for follow-up after radical prostatectomy demonstrated equivalent efficiency, similar satisfaction, and significantly lower cost for the video visits, they said, referencing a 2015 study. In addition, multiple studies have demonstrated that telehealth can improve access to cancer care for patients in rural settings while achieving equal or better patient satisfaction and generating cost savings when compared with in-person visits, they stated.
In 2015, Jefferson launched JeffConnect, an enterprise-wide telehealth program that facilitates video visits for patients across a variety of use cases, including both scheduled visits and on-demand visits. Health professionals received training in the use of JeffConnect with both personalized guidance and online training modules. All Jefferson health professionals, including those in medical oncology, were incentivized (with relative value unit equivalents and an end-of-year bonus for high usage) to utilize video visits, the researchers explained.
The findings showed that respondents had divergent thoughts on the clinical effectiveness of telehealth for oncologic care. Specifically, health professionals had opposing opinions on the capabilities of a virtual physical examination. Some reported they could not examine a sore throat, graft vs host disease, or shortness of breath via telehealth; others stated that they could assess the mouth and skin, as well as respiratory distress.
Health professionals who noted the limitations of physical examinations on telehealth cited the dependency on patient knowledge, and raised concerns that the discordance between the physical examination and patient history could cause potentially important missed findings.
Further, respondents noted that the lack of effective physical examinations made telehealth inappropriate for a number of visit types, including first appointments, patients who are seen only every six months to one year, multiple successive encounters, and patients who are symptomatic or sick. Another practical limitation recognized by one respondent was the inability to provide written information explaining complex treatments, referrals, and labs slips.
At the same time, other respondents found merits in the clinical effectiveness of telehealth. Some believed telehealth would allow for increased frequency of patient interactions, noting that for particularly high-risk patients, telehealth could be utilized to anticipate potential emergency department visits or hospital admissions. One respondent noted the potential use of telehealth for patients with communicable diseases, such as shingles, which may pose a risk to other patients in the office setting. Another respondent pointed out the utility of telehealth because laboratory tests were typically performed the day prior to the video visit, which allowed for results to be discussed at the time of the visit. This is in contrast to in-person encounters, where tests were often obtained by a phlebotomist immediately prior to examination, the researchers said.
Related to patient experience, meanwhile, many respondents expressed concern, noting that the relationship between health professionals and patients as uniquely important in oncology. Respondents frequently shared concern that a decreased ability to bond with and support a patient through telehealth is a disservice. Another concern was that patients may experience difficulty comprehending complex treatment discussions that may be better facilitated through an in-person interaction. Several respondents noted that it was not feasible to have discussions regarding serious or bad news through telehealth.
Conversely, some respondents found telehealth to augment the patient experience as it provided more frequent follow-up and enhanced convenience, particularly regarding transportation difficulties or when follow-up questions arose after an in-person encounter.
There was consensus that tele-oncology improved access to care. One respondent noted that for patients living far from large, comprehensive cancer centers, telehealth allowed them to receive treatment locally while remaining under the care of experts who specialize in their type of cancer.
Respondents did have starkly different opinions regarding the financial impact of care. Some reported that the copayment for a telehealth visit was unacceptable to patients who did not view video visits as “real” or equal to in-person appointments. Others felt as though the costs eliminated by telehealth visits, such as parking, gas, tolls, and lost work time made them cost-beneficial for patients. Overall, the ambiguity of insurance coverage status for telehealth and the inability to accurately estimate the copayment cost were negative aspects of video visits identified by several respondents.
The researchers concluded, “Our results emphasize the need to address oncology patients’ access to telehealth technology, especially for older populations, and the acceptability of delivering serious or bad news as telehealth continues to change the landscape of patient-health professional interactions. This is especially relevant during the COVID-19 pandemic, as many institutions worldwide have needed to create or expand telehealth programs.”
