In December 2019, the Association of Community Cancer Centers (ACCC) Immuno-Oncology Institute (the Institute) convened a 1-day Telemedicine Roundtable bringing together Institute leadership and experts from relevant health care sectors to share perspectives on the application of telemedicine in oncology and, specifically, in delivery of immunotherapy for cancers.
The Telemedicine Roundtable is one component of a larger ACCC program that is exploring how telemedicine is currently being leveraged by cancer programs and practices for provider-to-provider consults, to increase access to certain oncology services, deliver patient education, improve clinical trials access, and disseminate expert knowledge and mentor members of the multidisciplinary care team-the goal is to improve quality care delivery, and the patient and provider experience.
ACCC IO Institute outgoing Executive Committee Chair Lee Schwartzberg, MD, FACP, Executive Director, The West Cancer Center, welcomed participants and opened the discussion by sharing his perspective on why oncology must better leverage telehealth for quality care delivery. Schwartzberg referenced the impending dilemma succinctly: more cancer patients and fewer providers. This imbalance is occurring as the therapeutic options for cancers are rapidly evolving and expanding. As more patients are treated with immune checkpoint inhibitors, alone or in combination, managing immune-related adverse events (irAEs) continues to be challenging-regardless of care setting. Toxicities from immune checkpoint inhibitors are variable and can occur weeks, months, or even years after treatment.
The Institute's by-invitation Telemedicine Roundtable discussion engaged ACCC IO Institute leadership, including Working Group members; providers with deep experience in treating patients with immune checkpoint inhibitors; telehealth implementation experts; professionals active in collecting and conducting research on utilization of patient-reported outcomes (PROs); oncology-specific information technology professionals; frontline providers utilizing telemedicine for patient monitoring; and cancer program leaders.
To level-set the discussion, the Roundtable participants agreed to the following definition of terms: Telehealth more commonly refers to the overall field, while telemedicine relates specifically to the delivery of medical care. The Roundtable conversation began with a review of common problems experienced by health care organizations in adoption of telemedicine solutions and proven approaches for success. By the end of the day, participants aimed to develop practical next steps for understanding and advancing the deployment of telemedicine solutions for the care of patients treated with immunotherapies for cancer.
Participants agreed that telemedicine is a way forward to address the shortage of providers, the closure of more and more rural hospitals, and the reality of care deserts in the U.S. Providers shared examples of components of telemedicine already in use at their programs, including technology that enables provider-to-provider consults, supports standardization of care across sites of service through virtual tumor boards and other programs, and-in very specific circumstances-allows providers to remotely monitor certain high-risk, high-acuity outpatients.
In general, participants agreed that, for oncology care delivery, telehealth has the potential to improve both the patient and provider experience. However, Telemedicine Roundtable participants were reminded of common pitfalls that often lead to failure in telehealth integration. Before adoption of telehealth solutions, cancer programs must:
* Know the clinical goal.
* Ensure the platform under consideration supports the goal.
* Capture the telehealth workflow correctly.
* Engage clinical, IT, and administrative staff in the project team.
Conversation on the potential for telemedicine in delivery of immunotherapy for cancers focused heavily on identifying and managing irAEs-an ongoing concern for providers and patients. PROs and real-time symptom monitoring, especially of high-risk patients, could aid in triaging symptoms that, in turn, could help to reduce emergency department visits and hospital admissions.
Participants learned about existing research on leveraging telemedicine approaches to improve the patient experience, including PROs, wearables, and health coaching. While PROs are still often captured on paper, a variety of technologies are currently in use to collect patient-reported symptoms including automated phone systems, the Internet, mobile apps, and connections to the EHR and/or patient portal. The discussion covered recent research by Ethan Basch, MD, MSc, and colleagues, on the clinical benefits associated with patient-reported symptoms communicated via tablet computers (J Clin Oncol 2016;34(6):557-65), as well as research by Kathi Mooney, PhD, RN, FAAN, et al utilizing the automated Symptom Care at Home system (Cancer Med 2017;6(3):537-546).
The application of PROs to immunotherapy is challenging, participants agreed, due to the variability of irAE development. Experience with immune-related toxicities is still evolving and data collection from patients in the community is underway. To implement PROs for symptom management in IO, providers need to know:
* What to measure. Currently there are no validated PROs specific to IO side effects.
* When to measure. Development of immune-related toxicities is variable.
* Who to measure. The most appropriate patient population for telehealth applications has yet to be determined.
To begin to answer these questions, real-world data sets on patients treated in the community are needed, participants agreed.
Beyond the promise of PROs for the management of irAEs in patients treated with immunotherapy, the roundtable discussion touched on case studies of technology integration to expand the provider knowledge base through virtual tumor boards, tele-mentoring initiatives such as Project ECHO, and the real-time monitoring of certain outpatients treated with CAR-T therapy.
In the coming months, the ACCC Immuno-Oncology Institute will be releasing a full report on the landscape of telehealth in oncology; current and potential applications of telehealth as a mechanism for care delivery, education, collaboration, and access to new and emerging therapies, and oncology clinical trials; and policy and reimbursement barriers to deployment of telehealth solutions. Learn more at accc-cancer.org/immunotherapy.
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