Over the past few decades, economic and political factors have reshaped oncology, especially in the community setting. To defray risk, we’ve seen a trend toward oncology practices partnering with hospitals or aggregating into larger networks. Moreover, the Internet and the advent of telemedicine have profoundly changed the way physicians and patients access clinical information and interact. To gain insight into how oncologists are addressing this Brave New World of technology, The ASCO Post spoke with H. Jack West, MD, a medical oncologist and Director of the Thoracic Oncology Program at Swedish Cancer Institute, Seattle.
Telemedicine Issues
Why haven’t we seen more use of telemedicine in oncology?
Telemedicine has two major limitations. First, the reimbursement for telemedicine compared, for instance, with a conventional brick-and-mortar oncology consultation is not only much less, in some cases it doesn’t exist. And second, there are still arcane jurisdictional rules for doctor-patient relationships that extend across state lines.
If a patient from Alaska wants a consult with me via a telemedicine portal, because it would take him 9 hours of travel to see me in person, I need to have an Alaskan medical license to legally participate in the telemedicine conference. I can practice telemedicine in the outer reaches of Washington, but not across the border into Oregon. In part, this jurisdictional issue is just a way for the states to protect their medical revenue stream. But stifling telemedicine is certainly not in keeping with delivering the best medical care possible.
Proactive telemedicine has been shown to reduce costs, for example, in preventing unnecessary ER visits for patients with cancer who need advice on how to manage treatment-related side effects. Any thoughts on this issue?
Telemedicine offers huge cost- and time-saving opportunities, but unfortunately they are being missed. For instance, there are large employers like Boeing, which is now contracting all its cardiac care with the Cleveland Clinic. It would be beneficial for Boeing to facilitate telemedicine conferences for routine cancer care and follow-up visits that don’t need an intervention.
When you tally up the costs of employees traveling to the doctor’s office, the waiting time, and the visit itself, it really adds up. Any large employer who could substantially reduce the time of a 30-minute appointment to 30 minutes via telemedicine instead of half a day due to driving and wait times should be eager to improve “presenteeism” by facilitating telemedicine opportunities when possible.
Now, just imagine how much Boeing would save by having an onsite telemedicine terminal. This would hold true for any large company like Amazon or Microsoft. The advantages of using telemedicine in the proper settings are substantial.
Keeping Up
The Internet has changed the way doctors gather information, but there are still more than 200 print journals focused on cancer. Do you have a sense of which way all this digital and paper-based information is trending?
I don’t believe there are data that truly capture the extent of usage or the breakdown between where doctors harvest their information. However, even the most motivated physicians—oncologists in particular—spend more and more time trying to stay up to date with the latest therapy, ending up buried in the avalanche of new clinical information.
The volume of new material becoming available has been escalating rapidly, more than doubling over the past 20 years. It’s reached the point where it is infeasible to expect any single physician to remain updated on the emerging treatment options and clinical research opportunities across anything other than the most subspecialized patient population.
In this era of information overload, we need to create a relationship with our patients and acknowledge on both sides that it is impossible, especially for the general oncologist, to know all the information on one given subject. It’s better if patients and their caregivers partner in the information-gathering process. This way we can come together in the exam room and have a truly informed discussion, and ferret out all the clinical possibilities. This type of bidirectional exchange removes the unrealistic expectation that a single busy practitioner is the sole source of information in a field that is producing new markers and new agents every few months.
Impact of Online Information
Sharing information is a good thing, but how does unfettered access to online medical information affect the doctor-patient relationship?
It affects the relationship dramatically, cutting across many directions. Online medical information undermines any pretense toward paternalism that there might have been. It’s very easy now for patients to go to “Dr. Google” and learn about the latest study or new agents and markers that might not have been discussed by their doctor.
That said, the great challenge we face from patients seeking information online is that patients are not experts in culling through the vast amount of information, and, as we know, there’s a lot of misinformation available. So, it can create false expectations as they walk into the exam room.
Also, there’s the overblown expectancy that the doctor should be up to date on every new data point on the Internet. Doctors should not self-flagellate about not knowing the newest 1% marker that’s just come out in a press release. A patient might have a Google search set up to automatically return to specific sites that give them the latest cancer news, and much of this information will have no relevance to their particular clinical issue. The access to unlimited medical information is a double-edged sword that we need to learn to live with.
Role of Chat Rooms
The Internet is also full of online medical chat rooms. Do they play a role in the changing doctor-patient relationship?
Absolutely. Cancer patients on these chats sometimes urge other patients to demand this particular clinical trial or new drug, whether it’s appropriate or not. However, there are online chat communities that are very constructive, giving patients and caregivers support and instructing patients on how to have a constructive bidirectional conversation with their doctors about clinical approaches. I think that’s a good thing.
That’s why websites like ASCO’s Cancer.Net are important, because they give patients timely and credible information. We can’t stand on the sidelines; we need to ensure that we are providing online venues that deliver the best information possible for patients.
Future of Telemedicine
What do you see as the future of telemedicine?
There are several models that could work well. For instance, many leading academic centers, ranging from Harvard to Johns Hopkins to the Cleveland Clinic, are now offering remote second opinions and report information or an actual interactive clinical discussion via video. This is something that’s likely to increase. Hopefully, payers will see the value of doing remote clinical work in situations that don’t need interventions.
I also think we’ll see large networks like Kaiser Permanente moving toward having a major specialist available to do remote consults with the patient and his or her doctor within the same network to help shape the big picture clinical plan. It would be a very efficient way to ensure that patients enrolled in a broad network are getting the same care they would in a big tertiary center in the middle of a major city. This model also melds with the direction in which health care is moving—having a handful of major networks across the country. ■
Disclosure: Dr. West reported no potential conflicts of interest.
