Telehealth in Oncology: Standards and Practice Recommendations

An interview with Dr. Robin Zon from Michiana Hematology Oncology in Mishawaka, IN, co-chair on "Telehealth in Oncology: ASCO Standards and Practice Recommendations." The standards address telehealth implementation, doctor-patient relationships, roles of advanced practice providers & allied health professionals, multidisciplinary cancer conferences, and teletrials. Read the standards at www.asco.org/standards. Suggest a topic for standards development at www.surveymonkey.com/r/standardssurvey.

TRANSCRIPT

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SPEAKER: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

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BRITTANY HARVEY: Hello and welcome to the ASCO Guidelines Podcast Series, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content, and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at podcasts.asco.org. My name is Brittany Harvey, and today I'm interviewing Dr. Robin Zon from Michiana Hematology Oncology in Mishawaka, Indiana, co-chair on the "Telehealth in Oncology: ASCO Standards and Practice Recommendations." Thank you for being here Dr. Zon.

ROBIN ZON: Thank you so very much for having me here with you, to discuss this very important topic and work, which was undertaken by an expert panel of ASCO incredible volunteers and ASCO staff lead, Erin Kennedy.

BRITTANY HARVEY: Great. Then first I'd like to note that ASCO takes great care in the development of its standards and ensuring that the ASCO conflict of interest policy is followed. The full conflict of interest information for the expert panel is available online with the publication of the standards in the JCO Oncology Practice. Dr. Zon, do you have any relevant disclosures that are directly related to these standards?

DR. ROBIN ZON: No. I do not have any relationships to disclose related to the subject.

BRITTANY HARVEY: Thank you. Then let's get into the content of these telehealth standards. So first, can you give us a general overview of the purpose and scope of these standards for telehealth in oncology?

DR. ROBIN ZON: Well, absolutely. The service background, pre-pandemic, telehealth was utilized less than 1% of the time for oncology ambulatory visits. With, of course, a subsequent rapid adoption of digital health, in response to the public health emergency. This uptake of technology intervention was then further facilitated by the Centers for Medicare and Medicaid Services increased flexibility and reimbursement for these services.

In response to the COVID-19 pandemic, ASCO published an interim policy statement on telemedicine. The signal is positions on emerging policy issues, as well as the road to recovery report, which presented ASCO's recommendations for modifying pre-pandemic policies and practices to improve high-quality patient care, wherein ASCO membership identified a need for more detailed oncology-based telemedicine. So these standards were created in response to this need. It is important to note that these standards include an endorsement of existing general guidelines as published by the American Medical Association Telehealth Implementation Playbook and the American Telemedicine Association's Quickstart Guide.

BRITTANY HARVEY: That background and context is helpful for our listeners. So, then these standards, reading through them, they address six questions. I'd like to review the key points in each section for our listeners. So the first section, which patients should be seen via telehealth versus in-person? And what are the important implementation considerations for oncology telehealth visits?

DR. ROBIN ZON: Those are great questions, Brittany. Generally speaking, patients should always have the option for in-person visits when feasible. But when appropriate infrastructure and personnel are available, telehealth visits are suitable for treatment or long term management visits, in addition to family conferences, genetic counseling, second opinion evaluations, consent form discussions for pre-research trial participation, or when care access issues exist. I would refer the audience to the bottom line box which highlights the 18 described visits, as well as the preferred in-person consultation recommendations.

So from an operations standpoint, the standards include recommendations for practices to develop their own policies and procedures for these types of visits, frequency of visits, and documentation requirements for all clinical visits. Additionally, patients need to be oriented to the technology being utilized and have real time access to troubleshoot and support, if there are technology issues. The panel strongly advocated the quality of care should be equivalent to in-person visits. Thus to support this concept, the standards include, key performance indicators evaluation, policies for interventions delivered asynchronously, automated reminders, and inclusion of patients and caregivers involvement, if new technologic interventions are developed.

BRITTANY HARVEY: Great. I think those specifics you outlined will be helpful both for clinicians and practices, as they implement telehealth. So then, how should the establishment of the physician-patient relationship occur within the context of telehealth in oncology.

DR. ROBIN ZON: Well, both state and federal policies permitting telemedicine to cross state lines, should include a provision requiring that the doctor-patient relationship be established, prior to provision of any telemedicine services. As a reminder to the listener, the ASCO position statement, Telemedicine Cross-State Licensure, was recently approved by the Board of Directors and references a valid doctor-patient relationship as outlined by the American Medical Association.

This includes establishment of relationship by face-to-face examination or consultation with another physician, who has an ongoing doctor-patient relationship with the patient, or meets the standards of establishing a doctor-patient relationship, if included, in clinical practice guidelines developed by a major medical specialty society. I would refer the audience then to this ASCO position statement, for a much more detailed discussion regarding this topic. Importantly, the doctor-patient relationship should include the usual follow-up and care responsibilities and include opportunity for in-person visits at the physical location of the physician practice.

BRITTANY HARVEY: Then following those recommendations for the physician-patient relationship, what is the guidance for when patients may see an advanced practice provider?

DR. ROBIN ZON: Well, the panel recommends that practices follow established standards, policies, and algorithms that govern when Advanced Practice Providers, also known as APPs, or physicians should conduct the televisit based on the disease, treatment, or decision inflection point. However, the panel advises that practices should also review and comply with state and local regulations, for advanced practice provider supervision, including on how the APPs and physicians form teams.

BRITTANY HARVEY: Understood. And then further, in addition to those, what is the role of allied health professionals in oncology-specific telehealth interventions?

DR. ROBIN ZON: And just to orient the audience, when we refer to allied health professionals, we are referring to health professionals who are valued oncology team members. But they're distinct from physicians and nurses. That said, the expert panel referred to the Clinical Oncology Society of Australia, also known as COSA, Tele-oncology Guidelines, which provides guidance for oncology telehealth in rural and remote Australia. This evidence base was the largest for allied health professionals supportive interventions, delivered by both telephone and video conferencing. So due to the strength of the COSA evidence base, the expert panel endorses these recommendations, and refers to the utilization of telephone-based support systems, computerized screening, hybrid tele-practice systems, and video conferencing, as instruments for allied services delivery.

BRITTANY HARVEY: Great. And then the standards went into specifics regarding multidisciplinary cancer conferences. So how should discussion occur at virtual multidisciplinary cancer conferences, compared to in-person MCC meetings?

DR. ROBIN ZON: Well, as many of you know, many practices, in both academia and community settings, consider cancer conferences, which we also refer to as tumor boards, as essential for high quality patient care. Therefore, virtual cancer conferences replace these face-to-face meetings. The expert panel endorses the recommendations by the University of Pittsburgh Medical Center, for implementation of a virtual cancer conference. These include finalization of the agenda, one day in advance, secure video conferencing software, prioritizing complicated cases, and documentation and evaluation guidance. The expert panel also suggests that practices follow institutional guidelines, allowing the discussion to be directed by the presenter. And that there be no recording of the conference taking place without prior legal review.

BRITTANY HARVEY: Once again I find those specifics will be very helpful and explicit for clinicians. So then the last question that was addressed in these standards, how can telehealth be incorporated into clinical trials in oncology?

DR. ROBIN ZON: Well, utilization of telehealth and clinical trials are recommended, as a method for increasing recruitment, while reducing patient burden. Importantly, I want to emphasize that the expert panel endorses these recommendations prevail, beyond COVID-19 pandemic restrictions. This includes consideration for a hub and spoke model for patient enlistment. As well as recommendations to facilitate the conduct of teletrials, which are modifications intended to reduce risk during the pandemic, but also results in increased accessibility, reduced costs, and are less time-consuming.

BRITTANY HARVEY: Thank you for reviewing all of those key statements that were highlighted in the standards. So then, in your view, Dr. Zon, what is the importance of these standards to clinicians, and how will their implementation impact clinical practice?

DR. ROBIN ZON: Well, as I mentioned earlier, telehealth was very uncommonly utilized in cancer care, prior to the pandemic. However, with the soaring use of this intervention, there was a noted gap specific to oncology standards beyond the general telehealth guidance. These standards, then, are designed to assist the cancer care team in delivering the highest quality patient care, similar to the face-to-face quality care the oncologists strive to provide on a daily basis.

Furthermore, what we have witnessed, from both the practice responses and the convening of many experts in the delivery of telecare, is the flexibility to swiftly change and harness innovation among our colleagues worldwide. Telehealth, then, has the potential to improve care beyond the pandemic. And these standards serve as a roadmap for telecare best practices to continue to develop and address the needs for rural communities, patients with poor access to care, increase overall clinical trial participation, support patient education, and become one strategy, in a toolbox of other strategies, to help narrow the gap in disparate care.

BRITTANY HARVEY: Great. And then you've started to touch on this already, and talking about access to telehealth and how that impacts patients. But finally, how will these standards affect patients?

DR. ROBIN ZON: With regards to patients, what we learned from this evidence review, is that patient satisfaction is high. And they appreciate the convenience, flexibilities, and time and cost savings, as a result of telehealth options. I can share from my own practice that my patients were very grateful that we were able to provide telecare during the pandemic, and even now, as restrictions lessen, they're very thankful to have that opportunity. Many oncology patients want this option to continue for the future, and do not believe their clinical care was compromised.

However, oncology patient-reported outcomes and ongoing patient satisfaction evaluations must continue, along with the assessment of how the continuing challenges of broadband access, lack of technologic devices, or even familiarity with some technology, may serve as barriers to this care model. These standards are meant to assure the same high quality care for patients who choose to use this intervention, as they would if it were in person.

BRITTANY HARVEY: Definitely. Well, thank you for your work on these evidence-based standards directed at delivering high quality and accessible oncology care. And thank you for taking the time to speak with me today Dr. Zon.

DR. ROBIN ZON: And thank you so very much for this opportunity.

BRITTANY HARVEY: And thank you to all of our listeners for tuning in to the ASCO Guidelines podcast series. To read the standards go to www.asco.org/standards. Additionally, our annual survey for standard topics is open for submissions suggest a topic for standard development at www.surveymonkey.com/r/standardssurvey. Our standards survey. The link is also available in the episode notes of this podcast. If you have enjoyed what you heard today, please rate and review the podcast, and be sure to subscribe, so you never miss an episode.

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