Evolving Remote Engagement in Oncology: Beyond the Telehealth Visit

In this episode of Breaking Down Health Care, John Hennessy and Dr Michael Kolodziej discuss the evolution of remote patient engagement in oncology—from the rapid expansion of telemedicine during COVID-19 to the growing role of tools like electronic patient-reported outcomes (ePROs) in enhancing care access, clinical efficiency, and personalized communication.

John Hennessy, MBA: Hi, my name is John Hennessy. I'm a consultant with Valuate Health Consultancy, and I'm joined by my good friend Mike Kolodziej, who is a practicing physician today and an advisor to a variety of companies in the oncology space. Today we want to talk about the opportunity that's presented itself to work with patients a little more remotely.

Mike, you've worked in upstate New York, and some patients are close to the office and some patients aren't that close to the office. Maybe start by talking about how, back when we were running practices, we didn't do a lot of remote work and it's pretty challenging for some patients who have to travel quite a distance to get to their oncologist.

Michael Kolodziej, MD: The story of remote engagement probably should start with the story of telemedicine, because telemedicine was a solution for the rural patient who had a hard time getting access to medical care. Medicare put it into place. The only problem was Medicare put so many restrictions on what you had to do in order to execute on a telehealth visit and get paid for it, it just was an impractical solution. So, what you say is true. Where I practiced, here in upstate New York, I was in a relative population center, but it didn't take very long to get out to—let’s call them the Boonies and the Adirondacks—where there's not much population and it'll take you several hours [to get there] in the summertime, and in the wintertime, forget about it.

Telemedicine was nowheresville until COVID-19. COVID-19 changed everything because people were scared to go to the doctor. Cancer patients were terrified of going to their doctor. Hospitals didn't really want patients to come in because they were afraid. Telemedicine went from nowheresville to prime time. Medicare and the commercial health plans facilitated that by paying physicians to execute on this telehealth engagement. We had real-life, real remote patient engagement.

I would say that although there were some technological challenges—you needed high-speed internet, it needed to be HIPAA compliant, all these things—it was really good. We went from less than 1% of visits in the oncology practices to more than 50% over the course of a few months.

We don't really know whether those visits were as good as face-to-face visits. We also know that we didn't really have a remote solution, at least not a good one, for giving people chemotherapy or radiation. They still had to come in. There was some talk about chemotherapy in the home. We can talk about that some other time. That's another story. But patients still came into the office for chemotherapy. In fact, the studies show that the chemotherapy patient volumes didn't really change all that much during the pandemic. But when the pandemic ended, people went back to face-to-face visits. Part of it, I think, was some concern that the payers wouldn't pay for telehealth visits anymore.

Many of the commercial payers did pare back their coverage policy. Medicare is still paying for it. Just recently, Congress passed another patch to allow a continued reimbursement of telemedicine, but I don't think we know how long that's going to go on. If I were a betting man, there just isn't the hue and cry for this anymore. But telemedicine is just the beginning of the story.

Hennessy: You mentioned that there are probably some things that telemedicine works great for, maybe long-term survivors, symptom-related visits, things like that. There are other things that maybe it doesn't work so well for. It maybe gives the opportunity for practices to engage different professionals within the practice in engaging with patients, getting the right person to talk to the patient at the right time.

Dr Kolodziej: Yes, I always think about genetic counseling, behavioral health, and palliative care as being perfect in the oncology space for remote patient engagement.

Hennessy: To go back a few years, the Association of Cancer Care Centers (ACCC) published something, I think it was with the Mountain States Institute up in Boise, showing that telemedicine for genetic counseling and live were basically exactly the same, they really didn't have a difference in terms of how patients saw them.

Talk about the interactivity that is involved here. It's one thing to have a phone going back and forth, but we've seen posters at the American Society of Clinical Oncology (ASCO) Quality Symposium talking about texting as a way of focusing on adherence and persistence. What other tools are there, other than what we're doing here face-to-face, that patients and practitioners can interact with?

Dr Kolodziej: Part of the problem with telehealth is, in many ways, it has the same shortcomings as face-to-face interactions because it requires you to have a scheduled visit and have a transactional process. You can't just Zoom your primary care provider and start chatting with them.

We've seen other solutions develop. The first that we should think about is portals. Portals came as part of meaningful use—or meaningless use, depending on how you want to phrase it. Portals were well intentioned. They were to move from transactional to patient-centric. The patient reaches out when they need help. To meet meaningful use, you have to have a portal, and portals exploded. A lot of patients use portals. I use the portal all the time with my primary care provider, but portals have turned out to be very good for certain things: administrative responsibilities, like asking about your bill or rescheduling a visit. They're good for looking at your medical records—that’s a whole complicated thing we won't get into—and then requesting refills.

What portals aren't good for is telling the doctor you're sick, because every practice manages their portal differently. A real-time response is often not available. My wife told me, for example, that in her practice, they used the portal to manage Coumadin (warfarin). They taught their patients to communicate with the practice about what their protime was and what the Coumadin dose ought to be. That worked out really well because they taught the patient. But let's say you're getting chemotherapy and you're vomiting, that is not the way to get your oncologist's attention. It's just not going to work.

We have had further evolution—now we've got this thing called electronic patient-reported outcomes (ePROs). Those came into the spotlight about 5 or 6 years ago when Ethan Basch, who, at the time, was with Memorial Sloan Kettering, now is the boss at North Carolina, published a report that showed that if you emailed a patient once a week and got a response from them and then responded to the response, it was good for patients. That was close to real-time reporting of symptoms. The reason it was good was because you didn't have to wait until the next office visit to bring it up. You didn't have to manage the physician office phone tree; anybody who's called their doctor know that knows that's a nightmare.

The idea was to learn about the symptoms fast and intervene, and he showed better quality of life, longer time on treatment, fewer inpatient [visits], and, surprisingly, in their very first study, longer survival. That was the birth of ePROs, and that has now taken off.

Hennessy: The ePRO allows communication that's not part of the scheduled patient day. But the scheduled patient day, for most doctors, hasn't shortened. When do these ePRO conversations take place? A challenge for those of us managing practices is I've added a whole bunch of work and not much more time to the day.

Dr Kolodziej: The way I think that this is playing out—and, in full disclosure, I'm a consultant to an ePRO company and I work on this—the idea is that it replaces phone triage. This is a nursing tool. We've developed pathways for managing common symptoms and ways to identify patients who are in trouble, who ought to be brought into the office urgently. The idea is to get the nurses off the telephone, have them seeing these ePRO reports, and then reaching out to the patients to intervene, either remotely or by bringing them into the office after an appropriate triage. It is not a doctor's solution; it's a practice and a nursing solution.

Hennessy: Interesting. I recall back from our practice days that one of the most inefficient processes we had was the nurse on the phone. There were too many people calling at the same time, waiting on hold, things like that. The ePRO seemed to solve at least some of that. It may involve more back and forth, but at least it's a manageable queue of events as opposed to sitting in front of a phone with all the lights blinking.

Dr Kolodziej: There are rules that are built in for prioritization of high-risk ePROs vs lower-risk ePROs. We're using artificial intelligence (AI) to manage patient advice for the lower=risk ePROs so that they don't even have to talk to the nurse.

For the higher-risk ePROs, what we're trying to do is remote messaging so that we can get as much done before we have to pick up the phone and try to reach out to that patient. The idea is to use technology to facilitate the patient engagement. Of course, this is the ultimate in real-time symptom management. This is not going to make phone calls go away, but it should expedite patient engagement, symptom management, and then ultimately to lead to better health outcomes.

Hennessy: What is the experience of patients using these tools? It obviously makes sense for us from the practice operations side, but there's this myth that patients on Medicare don't know how to use a smartphone or aren't familiar with apps. It sounds like there is pretty broad engagement across the patient populations at some of these practices.

Dr Kolodziej: First of all, patients generally love it, as a broad general statement. The second thing is, there has been some work done looking at age, sex, etc. Old people can do this. Just take my word for it. If you don't have a smartphone, we've built an audio interactive device that allows you to submit a report via the same system. However, more than 90% of people use the app on the phone or computer. It's pretty straightforward.

This is going to continue to evolve. What I think is going to happen is how we electronically engage patients will depend on the patient. What is the patient's sociodemographic status, education level, disease treatment, comorbidities? All that stuff is going to determine the best way to talk to that patient remotely. Then we'll have truly personalized medicine for that patient that's very patient-centric.

Hennessy: That makes a lot of sense. It's challenging, as we start thinking about equity initiatives, you can only do so much. The patient brings with them a lifetime of experiences within the health care system and outside the health care system that determine what the right tool is.

It feels, as a practice, that you almost have to have a pretty flexible approach to meeting the patients where they are, as opposed to having a universal solution and expecting the patients to just broadly adapt to any of those sorts of things.

Dr Kolodziej: The other thing is, if you think about how this could be expanded, this could be a very interesting way to facilitate clinical trials, for example.

I've always thought that this is the best way to execute on palliative care. If you have a bad day, you can engage your provider, and they can tell you what to do with your pain medicine. The idea of texting your doctor, phoning your doctor with that kind of immediacy is unfathomable. If you have this line of communication open that the patient is comfortable with, and it's very important that the nurse feels empowered to manage that patient, this is going to be the way we do things going forward.

Hennessy: It brings in some of the elements that you hear of in concierge care where you're talking in a live situation. The idea of empowering clinicians to act at top of license is particularly important as we're looking to have people stay in the profession longer. We avoid some of the workforce shortages.

This may, in fact, help us sort through what's really going on much more quickly. I'm sure you've been in the exam room more than once where you spend 10 minutes just trying to figure out what the problem is. This may help get us to the right answer a lot more quickly than we might otherwise do.

Dr Kolodziej: Concierge sounds great. It's just a little too elitist for me, and I think that's a problem. You have to be able to afford it. But everybody I know who's used the concierge system loves it.

Hennessy: The element of timely service is something that, particularly in an era where it takes several months sometimes to get an appointment with a doctor, the fact that you can use other tools to solve for the problems you have, is particularly fascinating.

That's all we have today. We're going to have more conversations about this, so we encourage you to keep an eye on Breaking Down Health Care, and we'll see you next time.