Building a Sustainable Approach for Telemedicine in Cancer Care

Dr. Ana Maria Lopez, professor and vice chair Medical Oncology at the New Jersey division of the Sidney Kimmel Cancer Center – Jefferson Health, discusses the future of telemedicine in cancer care and how to make it sustainable and accessible to all patients and survivors. Transcript: ASCO Daily News: Welcome to the ASCO Daily News Podcast. I'm Geraldine Carroll, a reporter for the ASCO Daily News. My guest today is Dr. Ana Maria Lopez, a medical oncologist, professor, and Vice Chair of Medical Oncology of the New Jersey division of the Sidney Kimmel Cancer Center, at Jefferson Health.  Dr. Lopez is a member of ASCO's Telemedicine Working Group, and joins me to discuss the future of telemedicine in cancer care and how to make it sustainable in the years to come while striving for quality care for all patients and survivors. Dr. Lopez's full disclosures are available on the transcript of this episode, and disclosures relating to all episodes of the podcast can be found on our transcripts at ASCO.org/podcasts. Dr. Lopez, it's great to have you on the podcast today. Dr. Ana Maria Lopez: Thank you so much. Happy to be here. ASCO Daily News: Dr. Lopez, do you think that the COVID-19 pandemic and the increased use of telemedicine will permanently change the way patients with cancer are cared for? Dr. Ana Maria Lopez: You know, I hope so. And the reason I say that is because we've learned a lot. And we've learned that there are ways that we can care for people better at a distance. And so, what we've learned and what we can take forward, I do hope that we'll be able to do. So, for example, we know that a lot of the screening for a cancer clinical trial may be able to be done at a distance. And that way, when the patient actually comes for the appointment, there can be a more rapid entry into the trial. We know that patients may be able to stay at home safely at certain time points--perhaps at time points during survivorship, perhaps if they're doing very well with their treatment. Or if they need an acute assessment, something that needs to be done right away, the camera could be opened, and the conversation can be had. We also have some recent data that being able to care for patients at home may be able to pre-empt some hospitalizations. And to be able to do this with the benefit of telemonitoring, of visual monitoring--that all of these may be very helpful for patients, and may be able to improve their quality of life as well as let us help them with whatever the acute problem is at the time. ASCO Daily News: Absolutely. Those are very positive developments. I know you do have some concerns about disparities in care that emerged during the pandemic. You know, the COVID-19 pandemic exposed a host of disparities in cancer care, including access to telemedicine. During the 2021 ASCO Annual Meeting, you chaired an education session that assessed disparities in digital access and implications for telemedicine. Our listeners will find a link to the session in the transcript of this episode. So, Dr. Lopez, can you tell us about the major barriers to telemedicine that are of concern to you today? Dr. Ana Maria Lopez: Yes. It's really been such a learning experience. You know, telemedicine was really developed to increase access to care. And then to realize during the pandemic that in some situations, telemedicine, telehealth was really a barrier to care. And the reason for that is we used to do telemedicine--for example, a rural patient. The rural patient would go to the local clinic, the local clinic would have this incredible telemedicine setup that maybe included a tele-stethoscope, a tele-otoscope, so that you were really able to do the full exam virtually, with the exception of palpation. And everything was very well set up. But when telemedicine, during the pandemic, really translated--and this began before the pandemic as well, but not to the massive scale. But telemedicine really went to the patient's device. So, the patient needed to have some sort of a smartphone or a tablet, or some device that was connected, preferably, to broadband internet. And not everyone has that. And even if they're in an area where they might have access, it might be spotty in a certain part of the house. Or everybody is trying to get on the network for home schooling, for work. They may not have enough access, enough bandwidth, for the telemedicine appointment. So, access to broadband internet is critical. And then if people had access, their device might not have the right access, or they may not know quite how to get onto their device to get to the telemedicine visit. So digital literacy really came up. You know, we've always talked about literacy. We've talked about numeracy. But now, digital literacy. And we, as clinicians, really needed to advocate for our patients so that they would have the digital literacy to do the telemedicine visit. And I think, actually, also for us, as clinicians, and for the health care team, did education training on the technology, but also on how to engage. You know, there's so many questions that people will have. Well, can I really engage the patient well enough? Can I really make that connection with the patient, which is really what we treasure in the patient/physician relationship? Will I really be able to make that through this machine? And so how can we help people so that they can engage? And again, it may not be the same. But can it provide the care that both parties can really feel, yes, that meets the need at the time? So, I think all of those factors can be important. And they are all, I think, areas that can be overcome. ASCO Daily News: Absolutely. You spoke about access to broadband; you spoke about digital literacy. These things, of course, impact patients in rural settings, [and] older patients. So, it is very important for oncology practices and advocates to be thoroughly aware of best practices, and be knowledgeable about telemedicine tools moving forward to increase access for patients and to help stakeholders learn how to use the tools more effectively. Can you highlight best practices and ways to ensure that clinicians are using telemedicine to best serve the needs of patients and survivors? Dr. Ana Maria Lopez: There's so much in that question. So best practices, I think, we're still learning, which is one of the, I think, great things. I often think of telemedicine as a translational science because we go to the engineers, you know, I've got this problem, and they work it out. And then we can take it back to the bedside, or as some people say, the website, and try it out, really develop these approaches so that they can really help our patients best. But I think what you're pointing to is the real importance of education and training for the clinical teams. Something as simple as, you know, when a patient comes in normally to an appointment, there are vital signs. And again, in the pandemic, in many settings, we didn't have a way to collect those vital signs. So how can we, now that we have our lessons learned, work together to develop processes so patients can do their vital signs at home? Do we send a blood pressure cuff? A pulse-ox often has the heart rate on it. So, do we send these as a little kit? Or do we give these test kits to patients, and educate them on how to take their vital signs at home, so that those data are not missing when we see our patients through telemedicine? I also think when we were talking about engaging earlier, we're taught, in medical school, how to engage with the patient who's sitting next to us. But how do we engage with the patient when our connection is the camera? How do I look at the camera so that the patient--it appears that I'm looking at them, as opposed to looking at their eyes on the screen? So that that's engaging of the patient? I may find myself speaking a little more slowly or pausing more often in order to facilitate that engagement through the telecommunications technology. So, I think there are best practices just from the how to use the technology piece that we need to think about. But also, we need to better understand. What are the areas where telemedicine is most apt? Where do I really feel confident that this is the application to use, and in what situations do I say, you know what? I really need a hands-on approach. And how do I educate so that--let's say I'm following a patient who has a skin lesion. How do I educate the patient to be able to transmit those images faithfully to me, so I can really get a good-quality image, so that my interpretation is clinically appropriate? I think the most important best practice is that we shouldn't think that we're settling. Telemedicine, the technology, has incredible capacity. And if we are ever in doubt as a clinician that, you know, I wish I could do x, or if I had such and such, I would be better able to make this interpretation, if that crosses my mind, then I should see the patient in person. The assessment that I am giving the patient at the time, as a clinician, I should be really comfortable in, whether it's telemedicine, in-person, medicine, telephone, it should really be--I should feel confident. And if I'm not confident, then I should do what I need to do to care for the patient. ASCO Daily News: Absolutely. Is it your sense that oncology practices, [and] smaller community practices, are hearing your call, so to speak, and putting proper trainings in place and follow-up, et cetera? Oncology practices are very busy places. What are your thoughts on this? Dr. Ana Maria Lopez: So, in the same way that--what I said to the med students, you know, is you'll always do the right thing if you put the patient first. Always. Because you'll read, if you're not sure. You'll go talk to a colleague. You'll do what you need to do if you keep your goal the best care of the patient. And similarly, here, if we are going to use telemedicine, then as a clinician, I want to be proficient. I want to do the best job that I can. And so, then I want to get the training that I need in order to get that done. One of the things that we're instituting is, really, new doctors come in. Whenever anybody comes in, you're accustomed to, there is a whole set of learnings that have to happen, right? Because every institution is a little different. And we have our telemedicine trainings that are a part of that. And I think that's really important, because that shows that the health system, that the University system, that the Cancer Center has, as its core, that we understand you may not be 100% proficient at all of this. We don't expect you to. But we expect you to take these learnings and boost your knowledge in this area. ASCO Daily News: Right. In that context, then, of quality care, putting the patient first, how do you think telemedicine will serve patients and survivors in the future? Do you see great improvements in technology? Building better platforms for patients? Do you see these technologies on the horizon? Dr. Ana Maria Lopez: Absolutely. I think we sometimes think, for example--so cancer care. Cancer is a disease, predominantly, of elders, in the sense that as we get older, we're at higher risk for the disease. And as we get older, for example, our eyes age, our hands may become arthritic. Any of these issues could happen to any one of us. And technologies are being developed so that these are easier--so it's easier to maneuver the keypad, so that the lighting is more appropriate. And I think that all patients have a keen interest--and certainly patients that have been diagnosed with cancer--have a keen interest in their health care, and have a keen interest in maximizing their health care. So, bringing to them, you know, here are ways where you can maximize your telemedicine visit is generally very welcome. That sort of education is generally very welcomed by patients. ASCO Daily News: Right. What do you see as the biggest challenges for telemedicine in oncology in the future? There's been the promise of federal funding for these things. What are your thoughts? What what's your checklist for the future? Dr. Ana Maria Lopez: So, one of the things that really helped telemedicine expand as widely as it did during the pandemic and currently is that telemedicine is reimbursed. Very simple. But it's something that we've been working towards for a long time. So, telemedicine reimbursement really needs to continue if telemedicine is to continue. So, advocacy. And ASCO, other professional associations, are certainly at the forefront in advocacy. Reimbursement, tele-education for patients, for clinicians. Broadband, we've talked about. But something that we need to do as a profession is really be able to say, in what way do we want telemedicine to be sustainable in the future? And what will that require? So, for example, things like when patients, let's say, join a practice. Do they receive a telemedicine kit for vital signs? We know, for example, some practices in pediatrics--otitis media are a very common pediatric problem. Parents receive a little otoscope that they can be taught to use, and can have available should they need it. So, for us to really think, what do we need for sustainability? The camera on the phone is now, generally, a pretty high-quality camera. So, in what way can those tools be leveraged to be able to transmit more diagnostic-type images? That's probably not the right term, but images that are of higher quality that one can really make a better interpretation if that is something that's being looked at during a clinical exam. So, we really need to think of sustainability. As you may know, the numbers shot up during the COVID epidemic, the peak of it. We're not past the epidemic. And they have now--telemedicine has not decreased in use in many, many places. So, the easiest thing for us to do as clinical people, as patients, is to just go back to what we're used to. And then we would really lose all the lessons learned. So, I think it's really important to think proactively. Where are the benefits? How can we maximize them? How can we sustain them? ASCO Daily News: You mentioned sustainability. With sustainability in mind, would you agree that further research is necessary to leverage the best of telemedicine in oncology while making changes to improve the patient experience in a sustainable way? And are there any studies, any research, that you're keeping an eye on at the moment? Dr. Ana Maria Lopez: Yes. I think research is critically important to inform telemedicine sustainability, and to think about, really, what are the right applications for future care? And that these are ways, again, to increase access. Fundamentally, this will increase access. So, I think there are many studies to even think of what are the right metrics? What is it that we really are looking at, and what is it that we need to measure? There are things, for example, in cancer care. Cancer care is multidisciplinary by nature. So, there's teleradiology. There's telepathology. In what ways can those services be helpful to the patient, whether the patient is seen in person or at a distance? We've talked a little bit about the access to clinical trials. And again, in what ways can "tele" be integrated in order to increase access to clinical trials? And I think that area, will really blossom. That's an area, again, where hopefully, our lessons learned will not just retreat as something of historical interest. And then is there a right interval, for example, for seeing patients, whether in survivorship, or even during treatment, where you can do an assessment and feel comfortable that if you're doing a visual assessment or if you're doing an assessment that is at a distance with different tools that can do more of the traditional type of physical exam, that we can feel comfortable that that was the right exam? So, these are things that are very concrete, and are very studiable. And I'll give you an example. So, we could have a patient who is being treated for a malignancy. They could have an in-person exam, an in-person assessment, and then they could go into another room and receive a tele-exam, tele-visit, with another clinician. And then the assessments could be compared. Did we get to the same outcome? And is it maybe every other visit that would be comfortable to do at a distance? So, I just think these are really important questions to think about sustainability. And although they may seem very concrete, they're very important to think about how we will carry telemedicine into the future, as well as some of the aspects that we talked about--helping the telemedicine tools be more useful, be more, really, user-friendly for the patient population. And also, to take into consideration that there may be times where the patient, where the clinician, may say, you know, yes, we could do it through telemedicine, but I think it's time for us to see each other face-to-face. And so, too, there's the flexibility to honor the patient's preferences as well. ASCO Daily News: Absolutely. You've raised so many very important [and] interesting points today. Are there any other thoughts you'd like to share before we wrap up the podcast today, Dr. Lopez? Dr. Ana Maria Lopez: One of my favorite images--and I know it's a podcast, so you can't show the image--but there was a cartoon in the front of a magazine that was called “The Radio Doctor.” And I think it was from the 1920s. And I was always so impressed by this because it basically showed a telemedicine setup. And of course, telemedicine didn't happen until much later. And here we are, probably close to 100 years from that image in the front of that magazine, and we're tackling what was visualized, what was envisioned then. So, change, growth, takes time. So, I think that that's really important to remember, that things take time. So sometimes, we may get impatient. At the same time, we want to do it right. And we want to do it with the patient, really, at the center of all of this. So, I very much feel that we've learned a lot of lessons. I look forward to thinking about telemedicine sustainability in cancer care and in clinical care overall. And a part of that work really needs to be working with patients and hearing their voice, and hearing how we can work together so that the clinical experience is as good as [it can be], and there are some data that in certain settings, patients prefer the experience. So, to help us understand what feels better to them, then, and how we can improve the experience overall. So, it's an exciting time. And I look forward to what the future will bring. ASCO Daily News: Indeed. Well, thank you very much, Dr. Lopez, for shining a spotlight on the role of telemedicine in cancer care. Some interesting times ahead. Thank you, Dr. Lopez. Dr. Ana Maria Lopez: Thank you very much. Thank you. ASCO Daily News: And thank you to our listeners for your time today. If you enjoyed this episode, please take a moment to rate, review, and subscribe wherever you get your podcasts.   Disclosure: Dr. Ana Maria Lopez: None disclosed. Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care, and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.