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Telemedicine

Remote Cancer Care Improves Communication

Boxer, Richard J. MD, FACS

doi: 10.1097/01.COT.0000512175.80464.3f
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telemedicine

telemedicine

Telemedicine has become the fastest growing segment of the healthcare economy, with estimates of 50 percent growth annually over the next 5 years.

“Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient, and professional health-related education, public health, and health administration,” as defined by the Health Resources and Services Administration.

The American Telemedicine Association defines telemedicine as “the use of medical information exchanged from one site to another via electronic communications to improve a patient's clinical health status. Telemedicine includes a growing variety of applications and services using two-way video, email, smart phones, wireless tools, and other forms of telecommunications technology (Model policy for the appropriate use of telemedicine technologies in the practice of medicine. 2014).”

Finally, the Federation of State Medical Boards defines telemedicine as “the practice of medicine using electronic communication, information technology, or other means of interaction between a licensee in one location and a patient in another location with or without an intervening healthcare provider.”

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Medicare & Medicaid

Medicare Part B covers visits and consultations that are provided using an interactive two-way telecommunications system (with real-time audio and video) by a doctor or certain other health care provider who isn't at your location. However, there are restrictions. Services in rural areas are covered under certain conditions and only if located at one of these places: doctor's office; hospital; critical access hospital; rural health clinic; federally qualified health center; hospital-based or critical access hospital-based dialysis facility; skilled nursing facility; and community mental health center (Telehealth, https://www.medicare.gov/coverage/telehealth.html).

Medicaid recognizes the benefits of utilizing telemedicine as a means to promote efficiency, economy, and quality of care to its beneficiaries. Modeled after Medicare's definition of telehealth services, Medicaid defines telemedicine as the “two-way, real-time interactive communication between the patient, and the physician or practitioner at the distant site.”

Telehealth is not considered part of Medicaid's entitlement definition, but is often reimbursed by states under the umbrella of telemedicine services (Telemedicine. www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/DeliverySystems/Telemedicine.html). Currently, 48 state Medicaid programs have some type of coverage for telemedicine (American Telemedicine Association. www.americantelemed.org/policy/state-policy-resource-center\l.Vo0sX_krLVY).

An excellent resource for all issues regarding telemedicine reimbursement is the American Telemedicine Association 50 state analysis (http://americantelemed.site-ym.com/page/RegulatoryTracker), and the Robert J Waters Center for Telehealth (Reimbursement. http://ctel.org/expertise/reimbursement/).

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Tele-Oncology

The technology that is available today is helping bring about a fundamental change in U.S. health care. The current system of bringing patients to health care is changing because of such 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.

Telemedicine is being used for the care of patients in nearly every medical discipline. The reason for the incredible increase in utilization across all areas of healthcare is the need to provide convenient access to affordable, quality care. The fundamental change that must occur in the care of patients is bringing healthcare to the patient and not the patient to healthcare. Because there are too few oncologists to care for the increasing burden of cancer, efficiencies without sacrificing quality must be brought to bear to link specialists to patients in need. Telemedicine is one of the prime efficiencies.

ASCO published its report The State of Cancer Care in America: 2016, which detailed a potential workforce shortage of oncologists over the next decade just as the demand for oncology services will be surging.

Telemedicine or tele-oncology will definitely help mitigate the problem of a physician workforce shortage. Although it is especially true for primary care physicians, where the workforce shortage is even greater than it is in oncology, there is a maldistribution between the locations of physician and the patients. That disconnect can be reversed through telemedicine, or tele-oncology, 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 (ASCO Post 2014; http://www.ascopost.com/issues/august-15-2014/how-technology-is-helping-bring-health-care-to-patients.aspx).

Two studies in 2014 reported in Journal of Clinical Oncology indicate that telephone-based education or counseling initiatives can be successful in educating individuals at familial or genetic risk of cancer and in inducing these at-risk individuals to undergo recommended screening (J Clin Oncol 2014; DOI: 10.1200/JCO.2013.51.6765, J Clin Oncol 2014; DOI:10.1200/JCO.2013.51.3226).

Telemedicine can also bring clinical trials directly to the patient. Numerous cancer centers offer this to patients, such as the University of Maryland. Patients receiving care at affiliated community hospitals have the same access to clinical trials and novel treatments as those at academic medical centers (Oncology Times 2016;38(5):35).

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Benefits for Rural Patients

Although urban patients profit enormously from tele-oncology, rural patients may see even greater benefits (Oncology Times 2016;38(5):35).

A 2012 report by the Institute of Medicine for the National Academies, entitled The Role of Telehealth in an Evolving Health Care Environment (DOI: 10.17226/13466), found that telehealth drives volume, increases quality of care, and reduces costs by reducing readmissions and unnecessary emergency department visits for rural communities. Through telemedicine, rural hospitals can serve rural patients at better costs and help cut down on the time it takes rural patients to receive care, particularly specialty care.

Rural hospitals are leveraging telemedicine through in-home monitoring. One example is decreased hospitalization rates for seniors enrolled in the FirstHealth Home Care Chronic Disease Model. FirstHealth is in North Carolina (Home Care. https://www.firsthealth.org/specialties/more-services/home-care). Patients previously diagnosed with heart failure, diabetes, or COPD and who experienced frequent hospitalizations are monitored by telehealth at home between periodic visits from nursing staff. Response and intervention times have improved substantially, according to the program.

Another benefit to struggling rural hospitals is outsourced diagnostic analysis and access to remote specialists. It is difficult for many rural communities to staff their own diagnosticians, but mobile imaging centers and lab specimen kiosks that can take X-rays and perform collections can work in conjunction with remote analysis labs in larger urban areas, thus bridging the gap.

One study that looked at 24 hospitals in four rural states in the Midwest including Kansas, Oklahoma, Arkansas, and Texas found that telemedicine brought an annual economic impact of at least $20,000 per year, with an impact of up to $1,300,000 (Agricultural and Resource Economics Review 2011;40(2):172-83). The majority of these savings came from increased lab and pharmacy revenues due to additional work performed locally.

In addition to outsourced diagnostics, telemedicine also enables consultation with remote specialists at larger, urban hospitals instead of the need for having these specialists on staff. This can be particularly good for attracting doctors to rural hospital settings.

“Telemedicine fosters a collaboration that reduces the feelings of isolation that physicians may experience when they go to practice in a small town,” noted Wilbur Hitt, MD, in a report, Telemedicine: Changing the Landscape of Rural Physician Practice (NEJM;http://www.nejmcareercenter.org/article/telemedicine-changing-the-landscape-of-rural-physician-practice). “With telemedicine, it's like having one foot in the city but being able to live and practice out in a rural area. It's also reassuring to know that you're on the right track with the treatment plan and are staying current.”

Tele-oncology has an extraordinary role in cancer care. At least as important as discoveries of new treatments, is the access to care of those treatments. It is in the public interest as well as the individual oncologist to immediately offer telemedicine to patients. Oncologists' livelihoods will likely depend upon it in the future, and certainly patients' lives will dependent upon it.

RICHARD J. BOXER, MD, FACS, is Clinical Professor of Urology, Visiting Scholar, Business of Science Center, David Geffen School of Medicine at UCLA.

Richard J. Boxer, MD, FACS

Richard J. Boxer, MD, FACS

Wolters Kluwer Health, Inc. All rights reserved.
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