Long After COVID-19, Telemedicine Is Here to Stay in Oncology Practice

Andrew M. Evens, DO, MSc

Telemedicine has exploded in clinical practice across health care specialties following the coronavirus 2019 (COVID-19) pandemic. And as the format of virtual visits continues to be refined and a "telemedicine etiquette" starts to form, Andrew M. Evens, DO, MSc, explained that telemedicine is here for the long haul in oncology.

"This is a type of situation where we're almost building the airplane as it's flying. Not that it's incredibly complex, but there are some kinds of trades and hidden secrets [to doing telemedicine]," said Evens, the associate director for Clinical Services and director, Lymphoma Program, at Rutgers Cancer Institute of New Jersey (RCINJ). "At the end of the day, we just want the best and safest care for our patients."

In an interview with OncLive, Evens, who is also medical director of Oncology Service Line, Robert Wood Johnson (RWJ) Barnabas Health, and a professor of medicine at Rutgers RWJ Medical School, discussed the telemedicine initiatives that have been taken at RCINJ—even before the COVID-19 outbreak—as well as proper telemedicine etiquette and best practices for oncologists getting a handle on the new approach in clinical practice.

OncLive: Could you discuss how telemedicine has been used at RCINJ, even prior to the COVID-19 pandemic?

Evens: The times are challenging and fluid, and that is an understatement. We have been leveraging telemedicine quite a bit. We have a little bit of a leg up [with telemedicine], believe it or not. Last year, we started a telemedicine pilot program. We didn't really advertise it—it was more internally facing. However, we are RCINJ, which is as you know, is part of an 11-hospital health system of RWJBarnabas Health. This is the largest system in New Jersey and we have an Oncology Service Line, in which there are cancer programs at each of those centers, and RCINJ helps to coordinate and integrate all of those services.

We are more enriched with experts; we have 75 different oncology experts and whereas some of them are really robust, big community hospitals, such as Saint Barnabas in Livingston, New Jersey, others are smaller, such as Community Medical Center in Toms River, New Jersey where there are a handful of oncologists.

Last year, we set out to export some knowledge and so by working with Amwell, we kind of set up a second opinion, challenging cases program, and it went well. It was in a pilot phase, and it was [conducted in] patients who weren't at home, but they would go to the local medical facility. They would [be given] rooms, there was a nurse who would take their vital signs and history. I was [treating patients with] lymphoid malignancies, which is my specialty. We would do the consultation from afar and help kind of keep "Planet Cancer" here close to home, like we always say. That gave us a leg up, and then COVID-19 came and we just had to rapidly expand it, like many practices did.

When you quickly had to expand this program, how smooth was the transition to telemedicine? How did your patients react to it?

I would say that it was maybe a little bumpy in the beginning, but we were using a more lightweight, on-demand platform. It's one where it's almost like a "point and click," and it has a few "bells and whistles" to it where you can have multiple people come [on the screen] at once.

For example, if there's a family member, or the patient has someone in another state or another country [who wants to be part of the visit], they can come in, and you can share your screen with them. The platform we're using is HIPAA compliant.

Yes, it was a little bumpy to get more of the doctors to work it into the cadence of their schedule. There are some 1:1 rules: you shouldn't intermix telemedicine with an in-person clinic. You really want to block out times for it—half days or hours at the beginning and/or end of the day. Even though you think it's going to run smoothly, nothing ever runs on time—whether you are in person or through telemedicine.

Therefore, there is some telemedicine etiquette that we did some miniature training on, but it's pretty quick and it brings people up to speed, and the providers are obviously very smart. We have actually been able to bring up over 100 providers on this.

You mentioned telemedicine etiquette. Could you share some of the techniques or best practices that should be implemented with this approach?

Dress nicely. [You should include] a real background, not a virtual one. You want to have a good background; you don't want crazy posters and things like that in the background. You want to introduce yourself if there's not written consent ahead of time, and sometimes that's hard. We're working on a way to do that electronically; you need to garner verbal consent and double introduce yourself. It's really those kinds of basic, common sense stuff, and everyone was able to pick up on it quickly.

What challenges have you experienced with your patients as they adapt to this new method of visiting you? What obstacles have you or they faced?

It is new, because even though we had a pilot program, that comprised 1% of our patients. I can say, as of [early May], RCINJ was at about 85% of its usual volume but half of that volume comprised telemedicine visits. It is a huge component [that comprises] mostly our established patients, but we are starting to now even see new patients.

On the whole, it's been well embraced, especially when the epidemic was still heading towards the peak and was at the peak. Understandably, patients didn't want to take the risk of coming in, even though we have a very secure, stable environment. We have, like many places, a strict no visitor policy, we screened patients for COVID-19 before coming in, etc. They didn't want to come in [not just for fear of] infecting themselves, but they didn’t want to have their care providers get infected either. Just from that literal social distancing standpoint, it has been incredibly well embraced.

Obviously, you lose some of the figurative and literal personal touch; you're obviously not able to do a physical exam. However, you can do some things. You can assess someone's fitness, you can have them walk around, you can ask them to take their temperature, [and have them take their blood pressure] if they have a blood pressure cuff.

We are even working on the future. You can have Bluetooth almost like a care package. You can ship patients a tablet and a stethoscope with a monitor, both of which are Bluetooth [compatible]. Many people think that telemedicine is here to stay. I don't think it will be at these volumes, and not irrespective of COVID-19; I think patients like it for the most part.

With that said, there is a small percent of patients, maybe 10% to 20%, and perhaps an older population who don't have audiovisual. They don't have a smartphone or even a computer. Due to the national federal regulations, phone calls [are permitted]. They're called check-ins—telephone check-ins—and they used to be garnered a much lower rate. However, you can now do a telephone check-in at the same kind of ability—so to speak, for billing and purposes—as video. We think that will probably go away and you'll need to do audiovisual, because it does add a lot [of value] to do the audiovisual component. Most patients, honestly, love it.

You mentioned that telemedicine is here to stay. Once more restrictions have lifted from COVID-19, in what other ways will oncologists continue to incorporate telemedicine as part of their daily practice?

That is an important point. [Telemedicine certainly can't be used for everything]; you can't do brain surgery through telemedicine. We have leveraged it, not so much for right during the pandemic, but for survivorship patients who are outside of treatment, kind of years down the road, and in a much more stable environment. With that said, sometimes we need to get labs. However, we can do it with a local LabCorp; it syncs with our medical records. Therefore, patients don't have to come to our center to do labs. Frankly, we probably check too many labs to begin with.

[Telemedicine can be used for] more patients later in their care. With that said, too, we have also used it in cases where a patient is on therapy—let's say they're getting treated every 3 weeks for 6 treatments or 6 cycles—and something might come up in between. Not so much like a fever, but they might have a symptom related to their treatment. Therefore, we can say, "Hey, let's pop on telemedicine. I don't want to make you drive 1.5 hours for a 5-minute visit, or even a 20-minute visit." Even in those kinds of acute instances, I would say, most times, you're able to reconcile the issue at hand through telemedicine.

What other adaptions or refinements can be made for the elderly population or those who don't have a form of audiovisual? How can they continued to be cared for in a safe and appropriate way?

There are disparities, as you could imagine, partly related to that for telemedicine, and as I alluded to before, there are even some age disparities. We want to make it as easy as possible. A lot of times it comes down to technology, and there are these standard operating principles [and/or questions] of: how do you do that via telemedicine?

In other words, just like you would in an in-person visit, you would have patients check-in at the front desk, get their insurance information, a medical health technician might greet them and do vital signs, and put them in the "room." We have a large nurse navigation program, and there are clinicians who might do a system assessment. What we are trying to do is almost emulate that [in-person experience] identically, as much as possible, and [talk to them] telephonically or through audiovisual. We call it "virtual rooming."

Before the day of the visit, [the patient has to] make sure the technology works. Perhaps we will be in a place where a patient says, "You know what, I still can't figure it out." Perhaps we then ship them something, or we try to figure out a way to bring [the technology] to them. Some patients need that help and we also need to do pre-screening and discuss new medication. Therefore, we're trying to do it where we literally are "virtually rooming" the patient. It's not just the provider; our team members are [all part of] that whole patient visit.

How has the experience of delivering a cancer diagnosis to a patient over telemedicine been? How have those conversations changed?

Literally, 1 hour ago, I did telemedicine with a young man who is not newly diagnosed, but he has relapsed. He just had a video-assisted thoracoscopic biopsy and has relapsed Hodgkin lymphoma. [Delivering that information] is a limitation [with telemedicine]. Obviously, we have to be very, very sensitive to those types of delicate conversations. I have had a preexisting relationship with him for almost 1 year, and so I had this sense that he would be OK with this [visit over telemedicine]. Frankly, it actually worked out fine. Even though it's a delicate, sensitive conversation—he is relapsing and is going to need a stem cell transplant—we did the [virtual] visit. He was at home, and Mom and Dad were on the couch with him. He's younger, in his 20s. I didn't do a "before and after" survey, but I still think something is lost. You're not able to reach out or [console the patient] and those type of things.

However, if he had come to the clinic, his parents wouldn't have been allowed in the room. We would have been masked, and it would have been a more aseptic environment. I still like to have those conversations in person if possible, especially if there's not a preexisting relationship. I can't imagine telling someone, "You have cancer" for the very first time through [telemedicine]. Perhaps it will happen in the future. However, we are still open for business, and we were even during the worst of COVID-19, with very heavy precautions and screenings.