IO Institute Roundtable Focuses on Telemedicine Solutions

The Association of Community Cancer Centers (ACCC) Immuno-Oncology Institute (the Institute) recently brought together experts from relevant healthcare sectors and Institute leadership for a one-day meeting focused on the application of telemedicine in oncology and, specifically, in delivery of immunotherapy for cancers.

The Telemedicine Roundtable, held in December, is one piece of a larger ACCC educational program that is exploring the current use of telemedicine by cancer programs and practices and how technology can be better leveraged going forward. Opportunities for telemedicine to improve access to quality cancer care, while also improving the patient and provider experience, include:

• facilitating provider-to-provider consults
• increasing access to certain oncology services
• delivering patient education
• improving clinical trials access
• disseminating expert knowledge
• mentoring members of the multidisciplinary care team

ACCC Immuno-Oncology Institute outgoing Executive Committee Chair Lee Schwartzberg, MD, FACP, Executive Director, The West Cancer Center, welcomed participants and opened the discussion by sharing his views on why oncology must better leverage telehealth for quality care delivery.  Dr. 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  by-invitation Telemedicine Roundtable engaged ACCC IO Institute 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; front-line providers utilizing telemedicine for patient monitoring; and cancer program leaders.

To level-set the conversation, 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 day's discussion started with a review of common problems healthcare organizations face in integrating telemedicine solutions along with proven approaches for success. By the end of the day, participants aimed to reach consensus on some practical next steps for understanding and advancing potential telemedicine approaches for the care of patients treated with immunotherapies for cancer.

Participants agreed that telemedicine is a path forward for addressing 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 how aspects of telemedicine are 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 telehealth has the potential to improve both the patient and provider experience. However, the Roundtable conversation touched on a number of common pitfalls that often lead to failure of 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.
  

Discussion on the potential of telemedicine for delivery of immunotherapy for cancers focused heavily on identifying and managing irAEs—an on-going concern for providers and patients. Patient-reported outcomes and real-time symptom monitoring, especially of high-risk patients, could aid in triaging symptoms which, in turn, could help to reduce emergency department visits and hospital admissions.

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.

Participants learned about existing research on leveraging telemedicine approaches to improve the patient experience, including patient-reported outcomes, 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 EHRs and/or patient portals. 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,¹ as well as research by Kathi Mooney, PhD, RN, FAAN, et al. utilizing the automated Symptom Care at Home (SCH) system.²

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 explored 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.

View video from the Roundtable discussion. Access new resources from the ACCC IO Institute. Stay tuned for more in the coming months.

______________________________________________
References

1. Basch E, et al. Symptom monitoring with patient-reported outcomes during routine cancer treatment: a randomized controlled trial. J Clin Oncol. 2016;34(6):557-65.
2. Mooney KH, et al. Automated home monitoring and management of patient reported symptoms during chemotherapy: results of the symptom care at home RCT. Cancer Med. 2017;6(3):537-546.