By Teresa Hagan Thomas
Telehealth is here to stay, and if used correctly can be a tool to promote patient-centered care. In July 2021, the American Society of Clinical Oncology(ASCO) issued its practice standards and recommendations for telehealth in oncology. This follows revisions made to the draft recommendations that ASCO made available for public comment in April 2021. In their final report, the ASCO Telehealth Expert Panel, led by Robin T. Zon, MD (Michiana Hematology Oncology, Mishawaka, IN) and Ray D. Page, DO, PhD (The Center for Cancer and Blood Disorders, Fort Worth, TX), lays out the basis for six practice recommendations with corresponding standards for general and specialty oncology practices, tailored for oncologists, nurses, advanced practice providers, allied health professionals, and administrators involved in the delivery of cancer care.
Telehealth refers to 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. The scope of telehealth is broader than that of telemedicine, which usually refers only to remote clinical services. Telehealth is also used for remote patient monitoring (including wireless wearable devices), patient and provider remote communication (texting, videoconferencing, telephone), and electronic patient records. The technology involved in telehealth includes cell phones and tablets (mHealth) using mobile applications (apps) and sensors, as well as desktop/laptop computers.
Conditions imposed during the COVID-19 pandemic increased the need for telehealth, and this was accelerated by action of the Centers for Medicare and Medicaid Services, which in 2020 loosened restrictions on reimbursement for telehealth and significantly expanded its list of covered telehealth services. An ASCO interim policy statement called for this expansion to be made permanent, and with healthcare providers and payers beginning to plan more permanent ways to integrate telehealth into oncology care, the need for detailed oncology-based standards was acknowledged.
To meet this call, the ASCO Expert Panel, which consists of health care providers, patient advocates, and a research methodologist, conducted a systematic review of the literature to evaluate the evidence supporting telehealth in oncology. Their analysis concluded that two guidelines published previously by the American Medical Association (AMA) and the American Telemedicine Association (ATA) were sufficient for general advice. They also identified 12 systematic reviews and six primary studies specific to oncology that were incorporated into their own recommendations.
The ASCO Expert Panel identified six areas specific to oncology that they felt needed additional guidance in addition to the general telehealth guidelines:.
- Patient selection and implementation of telehealth in oncology
- Establishment of the doctor-patient relationship
- Advanced practice providers
- Allied health professionals
- Virtual multidisciplinary cancer conferences
- Tele-trials and/or virtual participation in oncology clinical trials
Standards relevant to oncology nurses include:
- Standard 1.1: Where appropriate infrastructure and personnel are available, telehealth delivered by health professionals is a reasonable option for treatment, long-term management, and other oncology care.
- Standard 1.3: Practices should develop policies and procedures for the frequency of telehealth versus in-person visits while also considering patient preferences.
- Standard 1.4: All clinical visits conducted via telehealth should be documented including certain pieces of information (date, location, participants, etc.)
- Standard 1.5: Individualized orientation should be provided to patients and health care professionals for the specific type of technology that will be used to deliver the intervention (e.g., mobile phone, web-based, etc).
- Standard 1.7: Practices should evaluate key performance indicators for oncology telehealth initiatives and quality of care.
- Standard 1.8: Standard operating procedures for asynchronous interventions (e.g., online symptom reporting) should be created.
- Standard 1.9: Asynchronously delivered interventions (including automated reminders delivered via text message) should be tailored to the individual patient to optimize adherence to and minimize discontinuation of treatment regimens.
- Standard 3.1: Practices should develop policies that determine when patients see an advanced practice provider or a physician telehealth visit.
The standards suggest when telehealth visits by qualified individuals may be acceptable (e.g., prechemotherapy visits, supportive care visits, post-discharge coordination, routine follow-up, etc.) and when in-person oncology visits may be preferred (e.g., initial consultations, delivery of key information, patients with complex illnesses). They also stress the need for flexibility, based on patients’ needs, and suggest areas for future research to determine best practices.
The ASCO Expect Panel plans to update these standards as new evidence arises.
These standards should be encouraged by oncology nurses because they ultimately lead to improved patient-centered care. Based on this review and other literature, telehealth can:
- Allow for easy and effective patient reporting of symptoms, quality of life, adverse events, and satisfaction.
- Make patients more comfortable in sharing their opinions.
- Allow patients living in rural areas to more easily access oncology care (only if they have access to broadband or satellite).
- Reduce patient (and hospital) financial cost of attending routine clinic visits (e.g., parking, gas, hotel, childcare, lost wages, etc.).
- Encourage caregiver self-care and inclusion.
- Promote communication between oncologists and tertiary hospitals, primary care providers, and other providers.
Oncology nurses can use telehealth strategies to promote evidence-based oncology care, ranging from providing supportive interventions to addressing patients’ and caregivers’ unmet needs. This is especially true for oncology nurses providing care with limited access to healthcare services. However, for nurses to fully harness the power of telehealth solutions to oncology care during the COVID-19 pandemic and beyond, they need to become well-versed in the barriers and facilitators to promoting evidence-based telehealth that results in improved patient care.
The Oncology Nursing Society’s Voice recently published an article summarizing how oncology nurses can enhance their telehealth skills. Suggestions included assisting patients who do not have access to the necessary devices or adequate broadband service and providing “dry run” appointments. Resources are provided for three critical competencies identified by the AMA: 1) virtual data capture, 2) patient safety, and 3) patient education.
At a practical level, oncology nurses can learn e-etiquette, or how to act professionally via telehealth modalities that promote patient-provider relationship. This includes reminders to put oneself at the center of the screen during videoconferencing and ways to recognize nonverbal cues.
These standards also offer an opportunity for oncology nurses to shape the future of oncology care. The new forms of providing care need intense scrutiny to ensure they equitably deliver care equivalent or superior to traditional in-person care. Nurses can help design, implement, and evaluate telehealth strategies. By following these standards and contributing to the scholarship of telehealth oncology care, they can not only improve their practice, but also ensure the quality metrics and outcomes of telehealth improve patient care.