Advancing Telemedicine Outreach within a Comprehensive Cancer Center: Lessons Learned from Rapid Transformation of Care Practice and Operational Changes Associated with the COVID-19 Pandemic

April 2021 Vol 12, No 4
Nicholas Jaidar, FACHE, MHA
University of Maryland Marlene & Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD
Heather Thomas, CMA (AAMA)
University of Maryland Marlene & Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD
Eun-Shim Nahm, PhD, RN, FAAN
University of Maryland, Baltimore, School of Nursing

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Background: The COVID-19 pandemic has brought significant changes to the delivery of healthcare while increasing care needs in certain areas. To decrease the risk of transmitting the novel coronavirus to patients and healthcare workers, care providers have had to make major changes in their practice, such as increased use of telemedicine services. Many cancer centers also had to modify their cancer care while adopting telemedicine in a very short time.

Objectives: To present the 4-week journey that our comprehensive cancer center underwent to implement telemedicine service during the pandemic, lessons learned from the process, and future directions for telemedicine use in cancer care.

Methods: The telemedicine implementation process used in our cancer center was consistent with the steps suggested by the American Medical Association. The main steps included a needs assessment, identification and purchase of software and hardware, development of workflow and documentation mechanisms, preparation of clinicians and other team members, and patient education, as well as follow-up of implementation services, such as volume statistics, patient satisfaction surveys, and opportunities for improvement.

Results: During the first 6 months of telemedicine service, the number of outpatient visits via televisit increased significantly, from 0 to 2156 visits by the end of September 2020. Feedback from patient satisfaction surveys was positive. The most appreciated aspect of telemedicine visits for patients was the ability to connect with their providers from home. No major complaints from patients or resistance from providers and staff were reported. Telemedicine service in our center has been undergoing continuous enhancements, and the service coverage has been increasing, including survivorship care appointments, social work interventions, caregiver support, and advance care planning.

Conclusion: Telemedicine is likely here to stay, with increasing capacity in the current eHealth ecosystem. Further efforts must be made to generate evidence for its effectiveness in improving patient outcomes and experiences while establishing best practice approaches.


The United States is undergoing an unprecedented public health emergency, and the nation has been grappling with the surge of patients infected with the highly contagious virus SARS-COV-2, which has caused serious health conditions and many deaths. As of September 30, 2020, the Centers for Disease Control and Prevention reported 7,168,077 cases and 205,372 deaths.1 The majority of American citizens experienced government-ordered lockdowns for the first time in history—and many also experienced a second lockdown. The government mandated multiple measures to contain new cases, including masking, physical distancing, and avoiding group gatherings.2 In a very short time, the pandemic has affected every aspect of citizens’ lives and the ways business is conducted in society. The health impact has been devastating to many individuals, in many cases resulting in death. Individuals of any age can contract COVID-19; however, older age and specific underlying medical conditions, such as chronic kidney disease or heart disease, have shown to increase the risk for severe COVID-19–associated illness.3,4 Cancer patients and survivors are especially vulnerable to developing serious conditions associated with COVID-19, as the majority of them are older than 65 years and have multiple comorbid conditions.5

In an effort to monitor and understand the impact of the COVID-19 pandemic on vulnerable cancer patients and survivors, the American Cancer Society Cancer Action Network conducted a national survey in April 2020 (N = 1200+).6 The survey results revealed many challenges to cancer patients and survivors during the pandemic. The majority (87%) of respondents reported some changes, delays, or disruption to their healthcare, including regular and preventive healthcare (80%), care related to their cancer (62%), and follow-up care to manage other chronic or ongoing conditions (68%). Nearly half (46%) of cancer patients and survivors reported a change to their financial situation that affected their ability to pay for care.

From the healthcare delivery perspective, the COVID-19 pandemic has had an enormous impact on healthcare.7 Although there has been an enormous increase in care needs in specific areas of acute care hospitals, the number of visits to ambulatory practices fell nearly 60% by early April 2020 before rebounding. Unless urgent situations presented, many scheduled follow-up visits, preventive screening tests, and elective surgeries were postponed. In addition, a number of people became uninsured and had to forgo preventive or scheduled follow-up care due to loss of jobs. In an effort to decrease the risk of transmitting the novel coronavirus, healthcare practices had to implement major provisions, such as use of rigorous safety precautions and increased use of telemedicine. Prior to the pandemic, telemedicine services had been used in practice, but only in a limited scope. Some of the major challenges for using telemedicine included lack of reimbursement and limitations in technology platforms, often requiring additional hardware and software.8 However, these barriers have been significantly eased during the pandemic.9 Special provisions for reimbursement of televisit services were granted by the Centers for Medicare & Medicaid Services (CMS) and other insurance payers.9 In addition, in the current digital era, technology barriers have been significantly lowered, as several easy-to-use and affordable Health Insurance Portability and Accountability Act (HIPAA)-compliant conferencing programs are available to practices and patients.3,4

The use of telemedicine has skyrocketed since the COVID-19 pandemic started. Based on the national claim data, overall telemedicine use among American adults increased from 0.15% in 2019 to 13% in April 2020.10 The greatest increase was in older adults, as nearly half (43.5%) of Medicare primary care visits were provided via telemedicine in April compared with less than 1% before the pandemic in February 2020 (0.1%). The active use of televisit services during the pandemic highlights the potential for using telemedicine for vulnerable cancer survivors, such as older adults and those who manage multiple chronic conditions.3,4 For example, telemedicine has been shown to be an effective care delivery mechanism not only to protect older patients from infectious agents but also to actively check on their well-being.11,12 Many cancer centers adopted telemedicine practice in a very short time, which required significant changes in clinical and operational practices. In this article, we present the 4-week journey that our comprehensive cancer center underwent to implement telemedicine service as well as lessons learned from the process.

Telemedicine Implementation in a Comprehensive Cancer Center: Sprint from “Start Line” to “1000-Plus Visits”

Overview of the Team and the Project

The cancer center presented in this article is a National Cancer Institute–designated comprehensive cancer center in Maryland. The Maryland stay-at-home order went into effect on March 30, 2020, and our cancer center expedited its preparation for the lockdown situation in early March. In a very short time, the center’s COVID-19 Response Team, comprised of clinicians and staff from administration and Information Service and Technology (IS&T) supportive services, mobilized a plan to identify patients who were not receiving active treatment who could be seen remotely or in treatment locations away from the cancer center.

Implementation of Safety Practice in the Cancer Center

At the beginning of the COVID-19 pandemic, the center introduced rigorous screening and safety precautions. These measures included universal masking, temperature checks of employees and patients, and cleaning policies (implemented before the safety precautions were broadly required at the healthcare system level). In addition, we embedded screening questions into the patient appointment reminder system that asked patients about potential COVID-19 exposure and symptoms. Patients who reported potential (or covert) exposure or symptoms were directed to contact the triage nurse prior to coming onsite to the clinic. A few outpatient clinics were designated for examination and holding of patients who presented with symptoms to mitigate exposure to the rest of the patient population and staff.

Modifications in the Delivery of Care

Following the implementation of a number of safety and screening measures, the COVID-19 Response Team had to identify alternative methods to care for patients because of the need to rapidly reduce face-to-face appointments in clinics to meet physical distancing guidelines. In addition, patients were wary of coming to clinics due to concerns about exposure to COVID-19. The regulatory milestone that allowed the center to drastically modify its operations went into effect on March 6, 2020, when the CMS lowered barriers associated with reimbursement of telemedicine services through the expansion of the 1135 waiver, allowing hospitals and clinics to provide care via televisits across the country.9

Telemedicine Implementation Processes: Challenges and Strategies

The implementation process to establish the new telehealth service within the cancer center had to occur quickly in March 2020 due to the urgent need to start offering this alternative care delivery service as early as possible (the goal was early April 2020). The process was consistent with the implementation steps suggested by the American Medical Association in the Telemedicine Implementation Playbook.3

Prior to the implementation, the cancer center conducted needs assessments from the operational and providers’ readiness perspectives. Analysis was conducted with the number of patients who were scheduled for visits against the number of visits that the cancer center could safely accommodate due to physical distancing guidelines. We also evaluated the types of scheduled visits to identify the patients who needed in-person visits and those whose visits could take place virtually. The findings showed that approximately 25% of visits could be done using telemedicine. Concurrently, stakeholders (ie, providers, faculty, and staff) were asked about their perspectives on the need for implementing the telemedicine service. There was consensus on the necessity of implementing telemedicine as soon as possible during the COVID-19 pandemic. Overall, the needs assessment showed that the provision of telehealth options was inevitable and had the full support of all cancer center stakeholders.

Upon completion of the needs assessment, the COVID-19 Response Team established a Cancer Center Telemedicine Implementation Team that included various stakeholders, such as providers from each type of cancer service line, center operational administrators, and the IS&T team. Once the telemedicine team was formed, the first steps of the implementation process were to select a telemedicine platform, identify and purchase hardware (eg, laptops, webcams, and headsets), and assess the need for environmental changes, such as renovations for designated telehealth rooms. The team chose HIPAA-compliant Zoom for Healthcare13 as a platform because most of our providers were familiar with the Zoom meeting platform, and Zoom for Healthcare does not require specific hardware other than standard computer or mobile devices. An important stakeholder for this decision was the healthcare system–level telemedicine department, as the cancer center is an entity that uses telehealth service through the medical system. The team expected that hardware availability for both patients and providers (eg, secure laptops for providers’ use at home) could be an issue and purchased laptops, iPads, and webcams for providers to allow them to see patients via telemedicine at home or in their office. Initially the team discussed modifying the main conference room to a telemedicine room; however, Zoom for Healthcare does not require a separate telemedicine room, as telemedicine visits can be held in clinic offices or providers’ home settings. As a procedure for telemedicine visits, providers and patients were reminded of the importance of maintaining privacy and confidentiality.

Workflow Development

While waiting for the arrival of devices, the telemedicine team worked on developing and implementing a uniform documentation format for televisits and the televisit workflow in collaboration with clinical, registration, compliance, and billing services. The telemedicine team adopted a uniform progress note that captured all key elements for provider documentation required by payers to receive reimbursement for services. In addition, the team developed a consent form for televisits, which was incorporated into Epic EHR (electronic health records) using smart phrases. We included physician leaders in all cancer types while we were developing document forms and workflows. This strategy helped to ensure quality of care and obtaining buy-in from providers.

The implementation team spent considerable time with the scheduling, nursing, and provider staff members to develop optimal workflows and associated tip sheets for telemedicine service. Once developed, they were validated by the training team to ensure an efficient workflow for each department and for the entire telemedicine visit. Following is a list of steps for the development of telemedicine workflow.

  • Development of the workflow for introducing telemedicine visits to patients, to be used by the scheduling coordinators. The workflow includes introducing the Zoom for Healthcare platform and informing patients of the unique meeting URL and password information for the virtual meeting with the provider, as well as the help desk contact information
  • Development of step-by-step instructions for providers about how to conduct telemedicine visits and how to document each visit in the patient’s EHR. During the development of this workflow, although we provided specific attention to the differences in practice workflow for each cancer type, we ensured harmonizing the telemedicine workflow and the documentation format across cancer types
  • Run test from start to finish with selected providers and staff to solicit feedback on the process and to incorporate necessary changes. During the test run, audit of mock-up charts was conducted to ensure that documentation of the visits met the requirements for billing and compliance regulations

Preparation of Clinicians and Other Care Team Members

Proper preparation of providers and staff (eg, schedulers and billers) for the delivery of telemedicine services is vital for the success of the program and minimizes their frustration. The telemedicine team hosted multiple demonstration sessions during faculty and staff meetings, distributed tip sheets, and sent out e-mails with brief information. Educational content included instructions on telemedicine workflow and the use of the Zoom for Healthcare program, as well as information on different types of televisits (eg, video- vs audio-enabled visits) and the supporting documentation requirements for reimbursement. Education of scheduling coordinators focused on scheduling different types of televisit appointments based on the protocol, introducing televisits to patients, and asking patients whether they have the appropriate devices and software components needed for the televisit.

Education of Patients

To launch a successful telemedicine program, patients must be aware of televisit options and empowered to use them. For example, to be able to use video-enabled telemedicine visits, patients may need to download an app and understand the visit process and payment/billing options for the service. Our telemedicine team carefully considered several approaches to providing education to patients. We began the preparation process by assessing the patient population we serve. More than half (65%) of patients in our cancer center, located in an inner-city area in Maryland, are black, and many of them are members of underserved populations. Although the majority of patients (65%-70%) have smartphones, it is important to provide them with different options for remote visits. Fortunately, Medicare approves of 3 types of virtual services (Medicare telehealth visits, virtual check-ins, and e-visits), and virtual check-ins can be conducted over a telephone without video conferencing.14 We ensured that scheduling staff allocate sufficient time for patients who are eligible for Medicare telehealth visits but who are not technology savvy on the Zoom for Healthcare platform. Patients are informed of what to expect from the visit, and consent forms are obtained. Prior to the visits, patients receive instructions on downloading the Zoom for Healthcare app and checking their video/audio settings. The cancer center also developed a telemedicine web page for patients to learn more about the service and billing, and to schedule appointments.

Current Status and Outlook of Telemedicine Opportunities

As in many other cancer centers, the telemedicine service was implemented during the public health emergency, and the entire implementation process had to be completed rapidly. Fortunately, the telemedicine services have been delivered smoothly without major complaints from patients or resistance from providers and other care team members. During the first 6 months of telemedicine service, the number of outpatient visits via video- or audio-enabled televisits increased significantly, as noted in the Figure. Patients’ experiences with telemedicine visits were captured through qualitative comments included in the cancer center’s patient satisfaction surveys and the feedback to providers and staff members. The aspect of telemedicine visits patients appreciated most was the ability to connect with their providers from home. Examples of commonly reported positive comments were “I appreciate being able to stay home for this visit” and “This is better than dealing with downtown parking.”

The telemedicine service in our center has been undergoing continuous enhancements based on suggestions from the stakeholders, including patients. For example, we are evaluating a telemedicine platform that does not require downloading an app and are refining the providers’ documentation process within the EHR. The scope of telemedicine service within the cancer center is also expanding. In addition to appointments with physicians and nurse practitioners, the cancer center is using the televisits to conduct survivorship appointments with nurse navigators and plans to expand their use to provide other services, such as pretransplant education, social work interventions, caregiver support, advance care planning, and integrative medicine services (eg, physical therapists offering breathing/mindfulness techniques remotely).

Future of Telemedicine in Cancer Centers

During the COVID-19 pandemic, the expansion of the 1135 waiver has generated tremendous possibilities for using telemedicine services while creating significant changes to the delivery of outpatient care.7 Findings from the Commonwealth study showed that as of late April 2020, the number of visits to ambulatory care practices had declined by nearly 60%, whereas telemedicine visits had increased significantly. However, as the restrictions on travel and nonessential services lifted, the frequency of telehealth visits began to drop.15 In general, the findings so far have showed the effectiveness of telemedicine as a vital healthcare delivery option during the current COVID-19 pandemic as well as for other future outbreaks, and there is a strong emphasis on moving forward with telehealth on a global level.16

Use of telemedicine for cancer patients has also been shown to be promising.15 In a survey of cancer patients’ (n = 468) and radiation oncologists’ (n = 158) perspectives on telehealth, patients responded that video consultations would be an important addition to medical care during radiation therapy (RT) courses (59.9%) and after the completion of RT (63.4%). Similarly, radiation oncologists believed that video consultations would be useful or extremely useful for patients undergoing RT (61.1%) and for patients in the follow-up setting (63.9%). Rapidly advancing telemedicine platforms have made televisits more usable and accessible, and telemedicine can be especially helpful for reaching out to cancer survivors who have limited means for transportation, especially those residing in rural areas and in need of frequent follow-ups.3,4

While offering the telemedicine service, our team also noted excellent opportunities for using the televisit platform for multidisciplinary survivorship care. Currently, oncology nurse navigators are expanding the use of telemedicine visits, and this practice has been especially helpful for patients who live far from the cancer center. In addition, using this platform, nurse navigators can provide more patient-centered care as the appointments can be timelier and more convenient for patients. This platform can also effectively facilitate multidisciplinary oncology care models, overcoming challenges with physical visits with several care team members. On the other hand, our team strongly supports patients’ preferences for type of visit (eg, in person vs televisits) and their comfort levels with using technology. We found that once patients had a positive experience from the initial televisit, they preferred to use televisits unless their physical presence was required, such as for laboratory tests.

Conclusion

During the COVID-19 pandemic, the CMS removed many financial barriers, and rapidly advancing health information technology lowered technology barriers. With the emergence of 5G connectivity, challenges to telemedicine access will be lowered further. Many prior findings showed the effectiveness of telemedicine and patients’ and providers’ increasing adoption. Telemedicine is likely here to stay, with increasing capacity in the current eHealth ecosystem. Further efforts must be made to generate evidence for its effectiveness in improving patient outcomes and experiences while establishing best practice approaches. These findings can then inform policy and help to determine how to best incorporate telemedicine to benefit patients and advanced clinical practice.

References

  1. Centers for Disease Control and Prevention. COVID Data Tracker. https://covid.cdc.gov/covid-data-tracker/#cases_casesinlast7days. January 21, 2020. Accessed November 30, 2020.
  2. Centers for Disease Control and Prevention. COVID-19. www.cdc.gov/coronavirus/2019-ncov/index.html. 2020. Accessed November 30, 2020.
  3. American Medical Association. Telehealth Implementation Playbook. www.ama-assn.org/system/files/2020-04/ama-telehealth-playbook.pdf. 2020. Accessed November 30, 2020.
  4. Smith AC, Thomas E, Snoswell CL, et al. Telehealth for global emergencies: implications for coronavirus disease 2019 (COVID-19). J Telemed Telecare. 2020;26:309-313.
  5. Leach CR, Weaver KE, Aziz NM, et al. The complex health profile of long-term cancer survivors: prevalence and predictors of comorbid conditions. J Cancer Surviv. 2015;9:239-251.
  6. American Cancer Society Cancer Action Network. COVID-19 Pandemic Ongoing Impact on Cancer Patients and Survivors: Survey Findings Summary. www.fightcancer.org/sites/default/files/National%20Documents/COVID19-Ongoing-Impact-Polling-Memo.pdf. 2020. Accessed November 30, 2020.
  7. The Commonwealth Fund. The Impact of the COVID-19 Pandemic on Outpatient Visits: Changing Patterns of Care in the Newest COVID-19 Hot Spots. www.commonwealthfund.org/publications/2020/aug/impact- covid-19-pandemic-outpatient-visits-changing-patterns-care-newest. August 13, 2020. Accessed November 30, 2020.
  8. Young JD, Badowski ME. Telehealth: increasing access to high quality care by expanding the role of technology in correctional medicine. J Clin Med. 2017;6:20.
  9. US Department of Health & Human Services. Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency. www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html. 2020. Accessed November 30, 2020.
  10. US Department of Health & Human Services. Medicare Beneficiary Use of Telehealth Visits: Early Data from the Start of COVID-19 Pandemic. https://aspe.hhs.gov/pdf-report/medicare-beneficiary-use-telehealth. July 28, 2020. Accessed November 30, 2020.
  11. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020;323:1239-1242.
  12. AlGhatrif M, Cingolani O, Lakatta EG. The dilemma of coronavirus disease 2019, aging, and cardiovascular disease: insights from cardiovascular aging science. JAMA Cardiol. 2020;5:747-748.
  13. Zoom Video Communications. Zoom for Healthcare. https://zoom.us/healthcare. 2019. Accessed February 9, 2019.
  14. Centers for Medicare & Medicaid Services. Medicare Telemedicine Health Care Provider Fact Sheet. www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet. March 17, 2020. Accessed November 30, 2020.
  15. Orazem M, Oblak I, Spanic T, Ratosa I. Telemedicine in radiation oncology post-COVID-19 pandemic: there is no turning back. Int J Radiat Oncol Biol Phys. 2020;108:411-415.
  16. Ohannessian R, Duong TA, Odone A. Global telemedicine implementation and integration within health systems to fight the COVID-19 pandemic: a call to action. JMIR Public Health Surveill. 2020;6:e18810.
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