Now, it is possible to bring health care to the patient instead of bringing the patient to health care. I cannot envision the future of health care without connected health.
—Richard J. Boxer, MD, FACS
The term “telemedicine,” which is sometimes used interchangeably with “telehealth” and “m-health” (for mobile health) and is now collectively called “connected health,” involves the use of information and communications technology to connect patients with their providers through a variety of electronic devices, including interactive videoconferencing, e-mail, smart phones, handheld wireless tools such as tablets, and other types of telecommunications technology. Another term gaining traction is “teleoncology”—the application of telemedicine in the advancement of cancer care, including diagnostics, treatment, and supportive care.
Telemedicine can offer oncologists a way to consult remotely with specialists in other disciplines in other parts of the country or the world to help in their assessments and diagnoses. For patients with cancer, telemedicine can expand access to care, facilitate their reporting of treatment side effects and outcomes, and even improve their quality-of-life.
Results from the Indiana Cancer Pain and Depression study,1 which evaluated the use of telephone-based care management and automated symptom monitoring to reduce depression and pain in patients with cancer, show that these symptoms were significantly improved.
“The technology that is available today is helping bring about a fundamental change in U.S. health care,” said Richard J. Boxer, MD, FACS, Visiting Professor of Urology, David Geffen School of Medicine at University of California, Los Angeles, and Visiting Scholar, the Business of Science Center, UCLA. “The current system of bringing patients to health care is changing because of technology. With innovations such as videoconferencing, telephone-based care management, and automated symptom monitoring, high-quality health care is becoming much more convenient and much more affordable, and providing greater access to care. Now, it is possible to bring health care to the patient instead of bringing the patient to health care. I cannot envision the future of health care without connected health.”
The ASCO Post talked with Dr. Boxer, who was Chief Medical Officer at Teladoc, a telemedicine company, from 2006 to 2013, and is currently a consultant for several technology-enabled health-care services companies, including Pager (www.getpager.com) and 2nd.MD (www.2nd.md.com), about how telemedicine may impact cancer care in the future.
Better Access to Care
How can telemedicine provide better quality health care to patients?
Interactive videoconferencing and Internet-based technologies are allowing physicians from a variety of specialties, including oncology, cardiology, dermatology, and neurology, to provide access to medical care to larger segments of the population, regardless of where patients are located. Currently, while a large number of people in the U.S. receive outstanding health care, it is often very expensive and inconvenient to access. And there are still tens of millions more Americans who don’t have access to the best oncologists. Telemedicine will provide patients with cancer greater access to better care.
For example, there is substantial evidence that cancer outcomes are worse in rural or remote areas of the country. Telemedicine or teleoncology can decrease the travel burden on these patients.
In addition, Internet-based technologies, such as patient Web portals, will enable patients to learn more about their cancer and treatment and how to manage their care, connect with providers, and receive social support through online support groups.
Please explain how cancers might be diagnosed or monitored remotely.
If a person is worried about a possible skin cancer, for example, and can’t get to her dermatologist for a diagnosis, she can upload a photo of the skin lesion to her doctor’s office, and the physician and consulting dermatologist may make a decision about whether the patient needs to come to the office for an in-person skin check.
For patients with cancer who need to be monitored by their oncology team, but either live long distances from their medical center or don’t need or cannot be physically in the oncologist’s office for a checkup, the oncology team would be able to virtually visit the patient in the patient’s home.
Alleviating the Workforce Shortage
In March, ASCO published its report The State of Cancer Care in America: 2014,2 which detailed a potential workforce shortage of oncologists over the next decade just as the demand for oncology services will be surging. Can telemedicine or teleoncology help mitigate the problem of a physician workforce shortage?
Yes. This will be especially true for primary care physicians, where the workforce shortage is even greater than it is in oncology. Currently, there is a disconnect between where the physician is and where the patient is. That disconnect can be reversed through telemedicine, or teleoncology, through videoconferencing or telephone-based care management.
The technology of connected health increases the number of available time slots a doctor may use to care for patients. One of the great inefficiencies in medicine is that the doctor and the patient are disconnected through time or physical distance. Each appointment slot in a doctor’s office calendar that is not filled due to cancellations or incomplete scheduling results in another patient not receiving medical care. If these empty appointment slots can be filled with a virtual office visit, the doctor’s time is efficiently used and the patient receives care.
In addition, the technology allows other populations of physicians, such as retired, disabled, or stay-at-home moms and dads, to continue to use their medical expertise by practicing medicine as virtual consultants as long as they maintain their board certification and keep current through CME courses.
How prevalent is telemedicine in the practice of oncology?
The application is just beginning in oncology. In primary care practice, there are about 50,000 telemedicine consultations a month in the U.S. vs 80 million in-person medical consultations each month, so the sky is the limit in terms of telemedicine growth potential.
In oncology, the use of communications technology can facilitate second opinions for patients seeking confirmation of their diagnosis or proposed treatment plan. There are companies specializing in obtaining remote second opinions. Patients upload their medical data to the company’s server, the company contacts and pays a world-class consulting oncologist, and then the patients have a videoconferencing or telephonic interaction within a couple of days of their request.
The opportunities for any oncologist to offer first or second opinions are nearly endless. I predict that every medical office, especially medical specialists’ offices, will have a dedicated room for virtual consults.
Are patients likely to use virtual technology to supplement the physical interaction they receive from their oncologist and other members of their medical team?
Teleoncology or telemedicine is not meant to replace the physical interaction between the patient and doctor. The first interaction between a patient and the doctor is always in-person. The use of telecommunications technologies is reserved for follow-up, second opinion, and supportive care.
Oncologists commonly have nurse practitioners, physician assistants, nutritionists, various therapists, social workers, and other professionals on their oncology team. Any of these professionals could perform virtual patient care.
Can telemedicine reduce health-care expenses?
Yes. Bringing virtual health care to the patient reduces brick-and-mortar overhead and increases efficiencies for improved access to care. Everyone wins in the connected health scenario. Patients receive rapid access to appropriate care, more doctors are immediately introduced into the
system, potentially reversing the dire predictions of workforce shortages, and physicians are better compensated for improved efficiencies. ■
Disclosure: Dr. Boxer was Chief Medical Officer at Teladoc, a telemedicine company, from 2006-2013. He is currently a consultant for several technology-enabled health care services companies.
1. Kroenke K, Theobald D, Wu J, et al: Effect of telecare management on pain and depression in patients with cancer: A randomized trial. JAMA 304:163-171, 2010.
2. The State of Cancer Care in America, 2014: A report by the American Society of Clinical Oncology. J Oncol Pract 10:119-142, 2014.