By Luis E. Raez, MD, FACP, FCCP
Posted: August 21, 2020
Our current electronic medical records (EMR) are equipped with telehealth capability. Some of us have spent the last 2 to 3 years working on the implementation of this field in our cancer practices. However, during that time, the enthusiasm from doctors and patients was very low. With the COVID-19 pandemic, the situation had changed dramatically; telehealth has become one of the most efficient and safest ways to provide healthcare during the crisis.
Telemedicine—another term commonly used for telehealth—means “healing at a distance,” and signifies the use of information and communication technologies (ICTs) to improve patient outcomes by increasing remote access to care and medical information.1 There is no consensus for the definition of “telemedicine”—a 2007 study found 104 peer-reviewed definitions of the word.2 The World Health Organization has adopted the following broad description:
“The delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities.”3
Although the IASLC’s preferred term is “telehealth,” the meaning does not change. In general, we can say that are four elements that are essential to telehealth: 1) providing clinical support; 2) overcoming geographical barriers, connecting users who are not in the same physical location; 3) utilization of various types of ICT; and 4) maintaining a goal of improving health outcomes.
Recent Shifts in Implementation
Before the COVID-19 pandemic, we used telehealth in a limited fashion. It was mainly used for radiology reading across facilities and sometimes used for post-surgical follow-ups, triage of patient calls in the cancer center, and weekly tumors boards to connect different facilities. When the crisis started in North America at the beginning of March, for large healthcare systems like ours—Memorial Health Care System in Broward County, Florida with 6 hospitals and close to 1,500 doctors—it was a challenge to keep not only fighting the COVID-19 pandemic but also to keep running the fifth-largest cancer center in the state of Florida. As of May 13, 2020, we had almost 6,000 COVID-19 cases diagnosed in the county and 1,100 hospital admissions. Fortunately, there are more hospitals in the county, and our hospitals census peaked at 180 patients with COVID-19 admitted in the middle of April. Cancer operations were scaled down: survivors were kept away from the offices, elective cancer surgeries were cancelled, physician schedules were trimmed, and working shifts were established for the doctors to minimize risk of exposure, among other precautionary measures taken. Certainly most of the patients with lung cancer had to continue their maintenance therapies (e.g., immunotherapy, chemotherapy, or targeted therapy).
Telehealth played a very important role for our patients with lung cancer. It enabled us to conduct follow-ups with our survivors who were in remission, as well as with patients receiving oral therapy (i.e., tyrosine kinase inhibitors). We were also able to see new patients and order workups to confirm lung cancer. Oncology support services, including social workers, nutritionists, psychologists, integrative medicine consultants, and patient navigators largely made use of telehealth services as well, making calls to our patients with lung cancer.
There were also some other advantages to the use of telehealth. Among them, we started to give second opinions to people living in other counties and countries, which is something that we normally preferred to do in person in the past. We were also able to follow patients on clinical trials even in other countries. For example, we had two patients with NSCLC and RET fusions on LOXO 292 who live in Peru and Brazil. They used to fly once a month for their follow-ups in Miami, but they were unable to do that due to the COVID-19 pandemic. We got waivers from the sponsor to conduct the follow-ups by telehealth, and we were able to ship the oral agents to their countries.
What does the future look like? Telehealth is here to stay. It may never replace our live meetings, conversations, and visits with our patients with lung cancer. But from now on, a significant number of our visits will be conducted through telehealth. We hope that we can derive further advantages from telehealth, for example, in the area of clinical research, with remote telehealth consenting in trials that are feasible, in order to improve the experience for patients. Like everything in medicine, nothing is perfect. There are down sides to telehealth, such as the fact that implementation of a network wide system may be expensive. Many providers are also wondering about the reimbursements and whether telehealth is cost effective. Now due to the pandemic, Centers for Medicare and Medicaid Services has clarified some concerns and are paying for telehealth visits, as Medicaid and most payers are doing. We also have the challenge of protecting patients’ private information. Federal regulations only allow EMR platforms that have previously been approved for telehealth and not commercial platforms such as Skype, WhatsApp, or Doximity. However, for now, all of the rules have been relaxed because not all patients feel comfortable with EMR, and they prefer the other ways of communication. In conclusion, the COVID-19 pandemic has moved telehealth to the front lines, and it is here to stay and benefit our patients with lung cancer. It is now our job to discover and implement more effective ways to use this tool.
About the Author: Dr. Raez is the chair of the IASLC Latin American Group (LATAM) and is past chair of the IASLC Membership Committee. He is also the president of the Florida Society of Clinical Oncology (FLASCO). He works as chief scientific officer and medical director of Memorial Cancer Institute at the Memorial Health Care System. He is also clinical professor of Medicine at Florida International University.
1. Strehle EM, Shabde N. One hundred years of telemedicine: does this new technology have a place in paediatrics? Arch Dis Child. 2006;91(12):956-959.
2. Sood SP, Negash S, Mbarika VWA, Kifle M, Prakash N. Differences in public and private sector adoption of telemedicine: Indian case study for sectoral adoption. Stud Health Technol Inform. 2007;130:257-268.
3. WHO Group Consultation on Health Telematics. A health telematics policy in support of WHO’s Health-For-All strategy for global health development: report of the WHO group consultation on health telematics. Presented at: World Health Organization; December 11-16, 1997; Geneva, Switzerland.
Telehealth Successes and Challenges
By Luis E. Raez, MD, FACP, FCCP