Cancer Topics - Can You Hear Me Now? Challenges and Benefits of Telemedicine

ASCO Education Podcast

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Cancer Topics - Can You Hear Me Now? Challenges and Benefits of Telemedicine

ASCO Education Podcast

Can you hear me now? In this episode of the ASCO Education Podcast, host Rami Manochakian (Medical Oncologist, Mayo Clinic Florida) discusses Telemedicine with medical oncologists Ana Maria Lopez (Sidney Kimmel Cancer Center), Estelamari Rodriguez (University of Miami) and Douglas Flora (Executive Medical Director or Oncology at Saint Elizabeth Healthcare).

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Air Date: 5/20/2021

TRANSCRIPT

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ANNOUNCER: The purpose of this podcast is to educate and inform. This is not a substitute for 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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RAMI MANOCHAKIAN: Hello, and welcome to the ASCO Education Podcast. Today, we will be discussing the challenges and benefits of telemedicine in oncology, something that has become especially important over the last year in the wake of COVID-19 pandemic. My name is Dr. Rami Manochakian. I'm a thoracic medical oncologist and a vice chair for education at the heme/onc division at the Mayo Clinic, Florida. As the host of today's podcast, I am very excited to be joined by our three distinguished guest speakers. And I'll let them introduce themselves.

ANA MARIA LOPEZ: Hi, my name is Dr. Ana Maria Lopez, and I'm a medical oncologist and an integrative oncologist. And I am professor and vice chair of medical oncology and chief of the New Jersey Division of Cancer Services at the Sydney Kimmel Cancer Center in Philadelphia, Pennsylvania.

RAMI MANOCHAKIAN: Welcome.

ESTELAMARI RODRIGUEZ: Hi, I'm Dr. Estelamari Rodriguez. I am an associate director of community outreach and co-lead of the Thoracic Sciences Group at the Sylvester Comprehensive Cancer Center at the University of Miami.

DOUG FLORA: Hi. I'm Doug Flora. I'm a treating medical oncologist. I'm also the executive medical director for oncology here at Saint Elizabeth Health Care just out of Cincinnati, Ohio.

RAMI MANOCHAKIAN: Great to have you all here. Without further ado, we'll go ahead and start with our first questions. We all agree, this has been a very, very hot topic lately. And it's probably, for quite some time, it's going to continue to be. When we talk about telemedicine, specifically in oncology, what are some of the main advantages of telemedicine and oncology for patients and for providers, respectively?

DOUG FLORA: So obviously, this year, we dealt with a lot being handed at us. And I'm glad that we're coming from three different sections of the country because I think our perspectives will be unique. I'm coming from a community aspect here. We have about four or five hospitals in our system. And I practice in a place that's partially Cincinnati-based, and partially some patients from deep and rural Appalachia. And so obviously, there's some access issues that I think we'll talk about a little bit later.

I will say, in our system, it was interesting. We've been trying desperately to get our doctors to embrace telehealth before coronavirus landed on our shores. And it was a struggle as you guys know, and I think we'll talk about. There were some reimbursement issues, and the way that we approached this as a system was not finding traction with the providers.

So we went from about 250 patients on virtual visits or telehealth visits the year prior to COVID, to almost 250,000 in our large physician group the year after. And so I wondered if you guys had a similar experience where you were sort of pushed off that burning platform and all of a sudden, had to adapt to technologies that were maybe used in regular world but not yet in medical world yet. So how are things in Miami, Dr. Rodriguez?

ESTELAMARI RODRIGUEZ: So at the beginning of the pandemic, as a system, we turned all our visits from in-person to, overnight, telemedicine. And we had a system where you could connect in our electronic medical record via Zoom. But our patients didn't have that system. So there was a large kind of growing pain in terms of getting the patients adapted to the technology. And still, a year later, patients have a tough time with the technology.

But I think one of the great advantages of telemedicine, and we have learned, is that it really brings the medical visit to the patient in a different way that we were not doing before, so that I can share with you, we had patients during the pandemic where our doors where close to families and we were able to continue communications with patients and their families.

I had one visit where the children joined conversations from, like, Los Angeles, New York, and Miami. We were all in the same virtual world really talking to the patient about a new diagnosis of lung cancer. And that was, I think, where it was a different-- it was a discussion that we couldn't have had for many reasons, because it would have required travel. It would have required a lot of expense from the children having to take time off work. And I think our patients, especially in the community, really embraced the idea of being able to be at the doctor's office without having to take time off.

We know that it's a lot of financial toxicity to our treatments and driving into the city to get into the cancer center. So that's one thing that I think telemedicine will be here and continue because patients wanted that. They wanted that access to the patients when they needed. And they wanted to have more family members in the visit.

And then, one thing that we also have done, we have some diagnosis that we have to coordinate care with different specialists. So we started a multidisciplinary clinic in thoracic oncology during this time. And in one disease that it has really helped us has been in mesothelioma. So these are very rare cases that require complex surgeries from rehab doctors, pain management, thoracic surgeons. Sometimes, we need surgical oncologists for the abdomen. So that's a lot of medical visits. And we've been able to have all of those visits at once for the patient.

So I think, really, it's allowed us to provide care for patients in an expedited way, in a more kind of effective cost-saving way for the patients. And also, to have these conversations between specialists in the same virtual space with the patient makes the patient feel like they're at the center of this discussion. And it's more transparent.

So I think that we have learned that telemedicine can be used for really, making care more comprehensive. And I think we have more challenges. And Dr. Lopez, I wanted to hear about your practice, how you have integrated telemedicine and the challenges of trauma medicine.

ANA MARIA LOPEZ: Thanks. Thanks. The multi-D clinics sounds fabulous that you've been doing. You know, one of the things, of course, for all of us, has been that telemedicine has allowed people to stay safe, clinicians to be safe, patients to be safe, families to be safe. And I think of myself as an old-time doc because one of the things that I really love about it is because it's brought back the house call.

So we get to be at the bedside with our patients, be where they are. Some people call it getting back to the website, which I think is a great term. But really, we're where the patients are. We learn so much more by seeing them in their home environment. And also, seeing who's living with them, who's close with them in a much more intimate way. So I think those are factors that are really tremendous advantages from the perspective of helping to take care of people.

RAMI MANOCHAKIAN: Yeah, I love all these ideas and thoughts. I mean, we clearly all have felt it was maybe hard at the beginning. And I know we'll talk about this throughout, but then, it came with a lot of advantages. And I would add, probably, a couple of things as well. I think patients, when they are being considered for clinical trials or being referred to another center, or for a second opinion, of course, we know we're missing the medical exam part. We're missing certain things.

But sometimes, we ended up saving many patients that trip, and get them into the multi-D clinic after knowing exactly what we want. Certain things that we used to do by reviewing the chart and maybe on the phone, and now we have an official introductory visit save them. The other thing where it helped me a lot, and I'm a thoracic oncologist, is after the first visit when I sent a bunch of testing, genomic testing scans and others, and I want to schedule a follow-up to go over the results and set a treatment plan and the patient lives a few hours away, and we want to make the next visit maybe the treatment visit. So this is where, actually, it helped a lot.

So we set this video visit, reviewed all the results, set a treatment plan, discussed. And every patient essentially loved it. So I'm glad we all share the same feelings. Speaking of which, of course, any new things come up. I don't know if we could call it new things, but when telemedicine kicked in, as Dr. Flora mentioned, at the beginning, everyone was nervous.

And once it started rolling, even though it rolled very smoothly nationwide, but it still came up and will continue to come with some challenges, some drawbacks, maybe some limitation, whether it is a technology, infrastructure, communication. So I would love to hear your thoughts about what kind of challenges you've experienced or you continue to experience, or maybe you think may happen down the road with telemedicine and oncology.

ESTELAMARI RODRIGUEZ: So I will share with you, in our community, we have a very large Hispanic population of different educational backgrounds. So I think one thing that became very clear to us is that we do have a digital divide in this country. And all our patients can't adapt to this technology. And a lot of the technology was not developed for telemedicine, was not developed for older patients that have difficulty in hearing, that may need interpreters. So there's a lot of things that were not thought out because we didn't know we would be in this position. But I hope that the technology will evolve to be more user-friendly.

We try to kind of make it work. So we had a system that is HIPAA compliant, we assume. But there were patients that we would have to connect with them by WhatsApp out of emergency, which is something that a lot of our older patients are used to using with their families in South America and to stay in contact with family members.

So we tried to adopt what they knew, what they were comfortable with, with what we had. But ultimately, we hope that we come out of this with a better system that can reach different patients that have different needs. So, Dr. Lopez, I wanted to hear from you, from your experience in your community, how you've been able to reach this digital divide.

ANA MARIA LOPEZ: Yeah, I think that's such a great point. And certainly, the whole COVID/telemedicine experience has exposed so many gaps in where telemedicine, which is intended to increase access, really, there are clear barriers. And that's one of them. So there are folks, as you were saying, with WhatsApp or even just with audio, that we've been able to manage, and whether it's elders. And we really need more research in those areas to see what are the areas where this could be effective, and what does sustainability look like when there's this variability in digital knowledge and digital access?

Are there ways to get technology to people? So we were fortunate in that we were able to get technology to patients. But having technology and being able to use the technology is not the exact same thing. So really, having to ask, as part of our clinical history, do you have stable internet? If you have stable internet, do you have a device? If you have a device, can you access the portal? And if you can access the portal, can you access a telemedicine visit?

And only after all of those questions, to then be able to say, OK, let's do a test visit and see how that works. So we really had to change our thinking a little bit. And then, some of the comments that have been made around the physical exam and. Dr. Flora, I'm sure that that's something that you've experienced. And maybe, what's your sense of the limitations of assessing people at a distance?

DOUG FLORA: I love the webside visit. And it really is a house call for us. I would say that initially, the barriers were steep. We would log on, and you're used to an every 20 or 30 minute schedule in my office. And you'd spend 15 minutes trying to figure out how to turn their mics on. And as you guys have suggested, this digital divide is still pretty deep where we live and practice. The majority of our cancer patients are over 60 or over 65.

A lot of the ones that we're taking care of live in rural areas that may not have access to broadband or good cellphone access, or at least shoddy cell phone access on occasion. And computers are largely non-existent in a lot of my older patient population. So we've had to meet them where they live.

I would say also, we're dealing with a lot of social determinants of health and health literacy. And while there might be an advantage reaching some of these rural populations, on the other receiving end, they've got to have the technology and the ability to log on to talk to us. So like Dr. Rodriguez, we did pivot a little bit from our beautiful HIPAA compliant, EPPA built-in software to FaceTime or just telephone calls. And it was what we had at the time. And I think everyone adapted as we needed to.

But as we move forward to sustain this, I think you're correct exactly, that we need to look at the research to understand that when we adopt this permanently, which seems like it's going to be the case, that it's with methods that improve patient care outcomes, and that we're careful to abandon elements that harm patients or widen these disparities that we've just identified.

RAMI MANOCHAKIAN: Great points, I think, by all of you. The one thing I would add also and I know was brought up, is there are certain times or certain scenarios where maybe from a communication standpoint, that I felt maybe a video visit, telehealth visit wasn't ideal, especially with breaking bad news or sharing scans.

Fortunately, most of the time, when there is a scan, right, we order a lot of scans to assess response. And the patients are here anyway. So these happened to have it be as an in-person visit. I've had patients where their scan was a few days before, so ended up the result was a telehealth visit. And I felt that probably, even though there was an eye contact, I could argue. I had a fellow with me who said, well, the patient was surrounded by multiple family members at home. So even though we breaked not a good news, per se, they were able to take it.

But I still felt it was a little awkward moment. And I would say, usually, like a major visit, scan assessment, change in treatment plan, I would prefer for them to be in-person. But to your point, maybe we need some research, more understanding, as it could go either way depending on what patients favor. But great. I think we can move on to another question.

ESTELAMARI RODRIGUEZ: I was actually going to add something. So one thing that I have realized and I have kind of told my patients is that this is still a visit to the doctor's office. So I have seen that over time, people have very busy lives and they think they can do the telemedicine consultations while they're driving or they're watching TV. So there's a lot of distractions. And to your point, some of these discussions that we have with patients require preparation. You don't know who's in the room with the patient. Maybe these are news that they don't want to share with the whole group.

So I try to make it very serious to our patients and our nurses ahead of time, get information from them to tell them, your doctor will be coming to the room, the virtual room. And this is a visit. You can't be in the car. I mean, these are really serious conversations. So I think we have all seen that telemedicine can be used in different settings when people are busy.

RAMI MANOCHAKIAN: Yeah, Great point, absolutely. Absolutely. And one quick thing I would add also, I think it was brought up that video and audio, to me, when it's an only audio, that's almost like a phone call that we all do all the time, supporting our patient and calling them. So we've had patients that the video didn't work out so we switched it to audio. But for me, I'm always trying to avoid just an audio visit on the phone.

I know now the new system would let you make it as an actual visit and bill for it. But I think to me, the real telehealth is an audio/video, actually seeing the patient face, some eye contact. I would consider a lack of video in some instances is a major barrier. But hopefully, we're kind of overcoming that.

ANA MARIA LOPEZ: But again, really, such an opportunity for research. You know, let's answer the question prospectively. And at least, to me, something that was always so shocking was that telepsychiatry is so well-documented. And some of that is in audio only. So I think the questions are wonderful because it's really allowed us to raise the questions. And now we can really think, how do we answer these questions?

RAMI MANOCHAKIAN: I think this would be a very good segue to our third question. From your experience, what are some of the best practices for conducting, I guess, a well-designed or productive telemedicine visit with the patients? What are the keys for a good successful visit in your opinion? And I'll start with you, Dr. Flora.

DOUG FLORA: This is another adjustment for us, wasn't it, guys? I can't tell you the number of patients who don't know where the lens is on their computer or on their camera. And people are looking all over the place. And I found that maybe taking a moment to reintroduce the concept of the visit. Can you see and hear me OK? Because not all the time is the audio getting across as clearly as I think it is.

I tried to make sure that I was really looking into the camera so that there was that sense of intimacy that you'd mentioned that a doctor and a patient share when they're at the bedside together. So actually, I start my virtual visits. I did one yesterday and we start by a tech question. Are you able to see me? Are you able to hear me? Thanks for allowing me into your home.

And then, I do take a moment to sort of reflect on the place that the patient is living. And this is a unique opportunity to go into their cave and see how they live. Are they disheveled? Is it messy? Are they hoarders? Is it a safe place? Does it look like somebody who's keeping up with their life?

And I did think also, part of the visit that was unique for this is we see them without makeup on. We see them without earrings and lipstick and the things that you put on before you go out in public. So a lot of times, I would find them in their night clothes or their pajamas. And so the visit would proceed. We're doing a physical examination while they're talking. And you could see them showing you around their living room. And you can see their eyes moving in four directions.

And I think for us, the adaptation is, is you actually can do a pretty decent physical examination if you're careful to ask the patient to participate. And we got pretty adept at it. And so now, I think most of us probably have figured out how to do things like patient's not having any retractions. There's not any obvious accessory muscle use. The breathing is non-labored. There's no grunting. It's a pretty good assessment that the lung cancer patient is OK, not as good as we'd like to see if we can use our stethoscope on the back. But it's also not as bad as it sounds when you looked at it at first glance. So what other adaptations did you guys make?

ESTELAMARI RODRIGUEZ: I think Dr. Lopez mentioned something that we have done as a system, where we have, at the moment of making that appointment, we're trying to identify which are the patients that will have issues with the technology. So we make that as part of our screen. So we spend more time prepping that phone call.

And I also take the point that one thing that has helped and made the patient part of the team, we have asked patients to take their own weight. And some of my patients with lung cancer, they have purchased a pulse oximeter. So they are able to give us part of their vitals. And we have learned, and they have learned, that that makes the visit more useful and get more information from them.

So the patients can participate in a way that they were not before. But I think it's important to really understand what the barriers will be upfront. Because you really have a 15-minute visit, and it's not the time to learn how to get an interpreter or learn how to set up the computer. I mean, it's a lot if you want to keep the day going.

RAMI MANOCHAKIAN: Yeah, I like those thoughts. It's prepping. Obviously, we're sharing all that we need to prep well and set good expectations. I have a lot of good questions that I think our audience would be interested. So I'm going to, for the interest of time, I'm going to keep moving. A probably related question, and I'll start with Dr. Lopez, considering all that we've discussed, can you tell us how telemedicine-- we've been doing it for a year at least now-- have impacted your existing relationship with patients and family, and affected building maybe future relationships with that?

ANA MARIA LOPEZ: Thanks. I do think that one can create good relationships, even if it's online. And I know that was something we all had a lot of hesitancy about, especially at the outset. And certainly, some of the initial thinking around telemedicine was that this would only be for follow-up visits. And again, sort of being an old-time doc, I think I had some trepidations around that.

But I really think you can. And part of it, I think, is training for us. So we've talked about the education for the patient and setting the stage what to expect, but also for us. How do you look at the camera so that the patient feels that you are engaging? Pausing, speaking more slowly, intentionally giving patients space to communicate. I think all of these are factors that we can do, and probably would help us in our in-person communication as well, but that really helps us to stay connected.

I think the point that Dr. Rodriguez made of, you want to know who all is in that virtual room. So who's at home with you? Let's bring them into the conversation if the patient would like. Or, if the patient really seeks privacy, is there a way that we could have this encounter be more private? So I think all of these things that we normally kind of do to help patients be at ease, we just need to translate to the tele space.

But I think that there's a lot that can be done. I think there's a lot that can be done from an educational perspective. And then, when we finally meet in person, even though we're masked and all of that, I think people can really feel connected to us. I wanted to share just very early in doing telemedicine. And this was-- I was accompanying an infectious disease colleague. And he was talking with a patient.

And at the end, it was the patient's first telemedicine visit. And so at the end, you know, well, how was this for you? How different? What did you think? And at the end, all the patient said was this was great. The only thing I miss, and the patient went up and hugged the monitor. And I do think it is something that we miss. But there's a lot that we can do.

RAMI MANOCHAKIAN: Absolutely. Absolutely. Great thought. And Dr. Flora, I loved when you mentioned earlier, you thanked the patient for welcoming us in their home. I think that was a great way to start things. What kind of feedback you heard, Dr. Flora, from patients? You've been doing telemedicine for a while, and as far as the relationship and their thoughts on this?

DOUG FLORA: I'll tell you, I was surprised it's a delighter. We think they want to be with us because we're doctors. And who wouldn't want to come see these minds? And that's not the reality at all. And you know, I would say almost exclusively, the patients have benefited from it and have told me so. They prefer getting that hour back. Ours is a place there is a good travel burden for the majority of patients that we treat. And you know, obviously, it's very challenging.

I'll say as a hematologist, sometimes, I'll check a patient's platelet count. And it literally is a 5-minute lab draw. And we can tell with really good certainty that that patient is in good shape and didn't need to make a 45-minute drive and a 30-minute wait and a 45-minute drive. So I would say they've been appreciative that we're now able to care for them in a compassionate fashion that's thorough and that answers the questions that they have. And if we're fortunate enough that that patient's care didn't require a breast examination that day or tapping out a pleural effusion, then I think everybody wins.

And I'm not discounting the utility of a physical examination, but in oncology, the honest answer is, is sometimes, it is discussing a formal whole body PET/CT. And I'm going to get an awful lot from that right before I make my call. And it's probably not as important that day specifically that I put my stethoscope on the patient as it was maybe three weeks prior before the scan.

RAMI MANOCHAKIAN: True. True. Great points, great point. And on a kind of related note, my next question I'll ask Dr. Rodriguez. At your institution, how have you or other providers adjusted to telemedicine during the pandemic? We've be doing it for a year. We learned through it. What approaches or maybe protocols or certain training or things that you've asked for from IT, or your own division or support staff, so you can accommodate patients in telehealth visits?

ESTELAMARI RODRIGUEZ: So I think that we had a video, like a tutorial. But really, you learn by doing this over time, what works for your practice. One of the things that besides doing the prep work of really getting the technology in line and moving the visit alone and having our nurses speak to the patients before you go online, we have also learned that patients can take their own vitals. So I think that's one thing that we have incorporated.

We have learned that we can talk about clinical trials and have some of those conversations that would have required a different visit at that point. And I think overall, the providers have appreciated that they can, once they get the system running, we can see more patients. And we can access them when we need to. And like you mentioned, some of these conversations are quick conversations, but they need to be had.

And sometimes, you see a patient that had chemotherapy, and you would have liked to see the patient the week after just to check on, and really, to have them drive for an hour and wait for just a quick checkup, where you could do online. And that really has changed my practice and has allowed me to keep in contact with the patient more often, especially basic practices that don't have enough clinic space. Like some of our practices don't have enough parking. They don't have enough clinic space. So we really have adapted well to the telemedicine option to provide care for patients.

But again, we still have to incorporate other things that we don't have, like the interpreters, the hearing, patients that cannot hear well. So there's things that we need to work on to make it more user-friendly.

RAMI MANOCHAKIAN: Absolutely. Dr. Lopez, anything else you've done differently, or your team has done differently to adjust?

ANA MARIA LOPEZ: So we had sort of a series of modules. But I completely agree that you sort of learn by doing. And I think that there are opportunities to bring in. So we're experimenting with this virtual waiting room, so that the MA comes in, sees the patient. The nurse then does what they normally have done, and then the clinician. And then similarly, at checkout, so that it's like including all of the pieces that would have taken place during an in-person visit and involving the whole team that normally engages with the patient. So I think, again, this is definitely evolving. And we're, I think, making it more like the regular in-person visit.

RAMI MANOCHAKIAN: One thing I would add also, as a fellowship program director, we were at the beginning wondering, how do we include the trainees, the fellows, the residents? There are some providers who would say, I would just have the fellows or the trainees see them in-person and not do the video. But the longer we've gone through this, we realize this is actually an important training experience, and not necessarily, but here we go where we are we and the trainees have zero experience in this. So we kind of learned from each other and support each other.

But there are also, I think having the trainee, the fellows in the room. Sometimes, we had logged in from two different computers. I think it helped and it also showed the patient that the team hasn't changed. We've had pharmacists sometimes join if there was some education needed. But I, again, needed some adjustment, needed some IT help and so forth. And we continued to learn through the process.

Dr. Flora, I think there is a very important question that has been always posing itself during this year is, when it comes to billing and documentation, how has the use of telemedicine affected that? Many of you know actually maybe participated ASCO advocacy at the Congress, one of the major bills that we've been advocating for is future keeping of telemedicine.

Because ultimately, as far as being able to build and generate the proper income since we continue to invest. And we're doing the same care we do for our patients but in a telemedicine mode. So how was it different for you, Dr. Flora? Any challenges there?

DOUG FLORA: Well, you know, I participated in some of that lobbying. And I do it at the state level. And we just did it at the federal level as well. And I think it's great that the oncology community is coming together as our patient advocacy groups. Our first question, we established that it's time-saving. There's cost-saving advantages both for patients and payers. Helps with child care, helps with people being away from work. So it's actually a good thing for society in addition to the good thing to keep us afloat during COVID when they can't come to our office.

The CARES Act was voted on and enacted March 6. And since then, we've kind of had the trust of the federal government to say, do what you can to take good care of patients. And for that to be sustainable, I think we've discussed that it has to be in an evidence-based fashion to say that we're not just accepting these things because it's easier care, but that we're actually making sure that we provide the same level of care that existed prior to the pandemic.

And so some of the sustainability stuff that is in the proposed laws, we'll touch on that, making sure that we're still documenting well, making sure that as we build, we really are providing the service that we said that we were, which I think the majority of physicians take very seriously, to say that we did the work that we've claimed.

And so we've all adapted with virtual physical examination. We've adapted with having the patient take their own heart rate or weigh themselves, as we've discussed earlier. I love the idea of a home oximeter. My wife bought one at the beginning of COVID, but most of my patients probably didn't. So as we move forward, we're seeing this move into research infrastructure for checkups on patients who are on trials at remote sites.

And I think that the train has left the station, according to everything that we've seen from Medicare and our consultants who we've engaged in. Now we have to figure out how to make it work and make it sustainable. But it's not going to go away.

RAMI MANOCHAKIAN: Absolutely. Dr. Lopez, any comments on the billing or the documentation portion?

ANA MARIA LOPEZ: You know, I actually really love to do telemedicine from the documenting perspective. I have a lot of difficulty using the computer during the patient visit. I just don't feel right. So like right now, I could be typing and you might not see me typing.

[LAUGHS]

RAMI MANOCHAKIAN: We all do that sometimes.

ANA MARIA LOPEZ: So, anyway, I do think, as Dr. Flora was mentioning, there are lessons to be learned. And we like working with our legislative colleagues to be able to have the sustainability. But yes, very important to keep the documentation in sync with the billing aspects.

RAMI MANOCHAKIAN: Absolutely. Absolutely. And we're kind of coming close to our last question, which again, a good segue from what you just mentioned, lessons learned. You know, I think we all believe clearly that telemedicine in general and in oncology specifically is here to stay. What lessons, what kind of last notes if you want to mention? And I'd like to hear every one of you saying what lessons you've learned, what lessons you want to take moving forward so we can keep telemedicine and oncology, and continue and strive to provide our oncology patient with the best possible care? And I'll start with Dr. Rodriguez.

ESTELAMARI RODRIGUEZ: So I think it's upon us to make sure that telemedicine breaks barriers, doesn't create more barriers to our current care. So I do worry about our older patients who already feel like they have been left behind by the whole technology divide. So I think we really have to work hard in understanding what's the best way to communicate with patients that have difficulty hearing, may not understand the technology. We have to develop better systems for them.

But overall, I think it's a great addition. It does break barriers for patients that you cannot reach physically, or they may spend a lot of money coming in and driving and taking time from work. But again, we have to keep in mind that we don't want to leave parts of the population behind who are not easy to get into technology.

RAMI MANOCHAKIAN: Great. Dr. Flora?

DOUG FLORA: Well, as I mentioned when I said the train has left the station, the future is now. And so we can either have this thrown at us, or we can do it ourselves. And I would say that in our center, we're really looking to expand upon this. And we're looking more into more home care, and how can we deliver chemotherapy safely in the home? I think we would all be remiss if we didn't start to really look at the landscape of these devices that are available at home. You know, anybody who's ever worn an iWatch now knows that you can send them your own EKG to your own phone in a matter of two or three minutes.

Why can't we get a pulse of a patient with an appropriate device? And these things are here and the economies of scale are driving these down. So eventually, in the next three to five years, I think a lot of these technologies will be democratized and in every patient's home, even the 65-year-olds, because it's a watch that their daughter buys them.

And I think when we start to plan for things like that, we're going to find ourselves meeting the patients where they are, which is where they want to be in their living room, effectively and safely.

RAMI MANOCHAKIAN: Couldn't agree more. Dr. Lopez?

ANA MARIA LOPEZ: I feel like telemedicine is a new translational science. We're beaming people in wherever we can and seeing how it works and seeing the outcomes. And we've talked a lot about bridging the distance between patients and physicians, patients and clinical care teams. But there's also the opportunity to bridge the distance between clinical teams. So that's another potential benefit.

And I think it's really made us better clinicians, because we're doing these exams now that are primarily observational. So I feel a little bit like Sherlock Holmes. Your observational skills, I think, are really sharpened with this opportunity. So I think there's a lot of benefit. There's a lot that we've learned, and there's a lot that we still have to learn.

RAMI MANOCHAKIAN: Absolutely. Absolutely. Unfortunately, that's all the time that we have for today. Otherwise, really, the conversations have been so good that I could have taken this for hours to come. I'd like to thank every one of you for your participation in this episode of ASCO Education podcast. It was, I think, a very productive and insightful conversation.

I think we all agreed that we're helping patients with telemedicine. And I think many of you, or all of you said it best, is that we learn from the lessons. We've built up on the strength that we've already come across, and then looked for rooms for improvement. And it's an area of research, as Dr. Lopez mentioned. And keep looking for how could we enhance this further, because I think we're going to keep doing it for a very long time. Thank you again, very much. I appreciate your time.

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Can you hear me now? In this episode of the ASCO Education Podcast, host Rami Manochakian (Medical Oncologist, Mayo Clinic Florida) discusses Telemedicine with medical oncologists Ana Maria Lopez (Sidney Kimmel Cancer Center), Estelamari Rodriguez (University of Miami) and Douglas Flora (Executive Medical Director or Oncology at Saint Elizabeth Healthcare).

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Air Date: 5/20/2021

TRANSCRIPT

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ANNOUNCER: The purpose of this podcast is to educate and inform. This is not a substitute for 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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RAMI MANOCHAKIAN: Hello, and welcome to the ASCO Education Podcast. Today, we will be discussing the challenges and benefits of telemedicine in oncology, something that has become especially important over the last year in the wake of COVID-19 pandemic. My name is Dr. Rami Manochakian. I'm a thoracic medical oncologist and a vice chair for education at the heme/onc division at the Mayo Clinic, Florida. As the host of today's podcast, I am very excited to be joined by our three distinguished guest speakers. And I'll let them introduce themselves.

ANA MARIA LOPEZ: Hi, my name is Dr. Ana Maria Lopez, and I'm a medical oncologist and an integrative oncologist. And I am professor and vice chair of medical oncology and chief of the New Jersey Division of Cancer Services at the Sydney Kimmel Cancer Center in Philadelphia, Pennsylvania.

RAMI MANOCHAKIAN: Welcome.

ESTELAMARI RODRIGUEZ: Hi, I'm Dr. Estelamari Rodriguez. I am an associate director of community outreach and co-lead of the Thoracic Sciences Group at the Sylvester Comprehensive Cancer Center at the University of Miami.

DOUG FLORA: Hi. I'm Doug Flora. I'm a treating medical oncologist. I'm also the executive medical director for oncology here at Saint Elizabeth Health Care just out of Cincinnati, Ohio.

RAMI MANOCHAKIAN: Great to have you all here. Without further ado, we'll go ahead and start with our first questions. We all agree, this has been a very, very hot topic lately. And it's probably, for quite some time, it's going to continue to be. When we talk about telemedicine, specifically in oncology, what are some of the main advantages of telemedicine and oncology for patients and for providers, respectively?

DOUG FLORA: So obviously, this year, we dealt with a lot being handed at us. And I'm glad that we're coming from three different sections of the country because I think our perspectives will be unique. I'm coming from a community aspect here. We have about four or five hospitals in our system. And I practice in a place that's partially Cincinnati-based, and partially some patients from deep and rural Appalachia. And so obviously, there's some access issues that I think we'll talk about a little bit later.

I will say, in our system, it was interesting. We've been trying desperately to get our doctors to embrace telehealth before coronavirus landed on our shores. And it was a struggle as you guys know, and I think we'll talk about. There were some reimbursement issues, and the way that we approached this as a system was not finding traction with the providers.

So we went from about 250 patients on virtual visits or telehealth visits the year prior to COVID, to almost 250,000 in our large physician group the year after. And so I wondered if you guys had a similar experience where you were sort of pushed off that burning platform and all of a sudden, had to adapt to technologies that were maybe used in regular world but not yet in medical world yet. So how are things in Miami, Dr. Rodriguez?

ESTELAMARI RODRIGUEZ: So at the beginning of the pandemic, as a system, we turned all our visits from in-person to, overnight, telemedicine. And we had a system where you could connect in our electronic medical record via Zoom. But our patients didn't have that system. So there was a large kind of growing pain in terms of getting the patients adapted to the technology. And still, a year later, patients have a tough time with the technology.

But I think one of the great advantages of telemedicine, and we have learned, is that it really brings the medical visit to the patient in a different way that we were not doing before, so that I can share with you, we had patients during the pandemic where our doors where close to families and we were able to continue communications with patients and their families.

I had one visit where the children joined conversations from, like, Los Angeles, New York, and Miami. We were all in the same virtual world really talking to the patient about a new diagnosis of lung cancer. And that was, I think, where it was a different-- it was a discussion that we couldn't have had for many reasons, because it would have required travel. It would have required a lot of expense from the children having to take time off work. And I think our patients, especially in the community, really embraced the idea of being able to be at the doctor's office without having to take time off.

We know that it's a lot of financial toxicity to our treatments and driving into the city to get into the cancer center. So that's one thing that I think telemedicine will be here and continue because patients wanted that. They wanted that access to the patients when they needed. And they wanted to have more family members in the visit.

And then, one thing that we also have done, we have some diagnosis that we have to coordinate care with different specialists. So we started a multidisciplinary clinic in thoracic oncology during this time. And in one disease that it has really helped us has been in mesothelioma. So these are very rare cases that require complex surgeries from rehab doctors, pain management, thoracic surgeons. Sometimes, we need surgical oncologists for the abdomen. So that's a lot of medical visits. And we've been able to have all of those visits at once for the patient.

So I think, really, it's allowed us to provide care for patients in an expedited way, in a more kind of effective cost-saving way for the patients. And also, to have these conversations between specialists in the same virtual space with the patient makes the patient feel like they're at the center of this discussion. And it's more transparent.

So I think that we have learned that telemedicine can be used for really, making care more comprehensive. And I think we have more challenges. And Dr. Lopez, I wanted to hear about your practice, how you have integrated telemedicine and the challenges of trauma medicine.

ANA MARIA LOPEZ: Thanks. Thanks. The multi-D clinics sounds fabulous that you've been doing. You know, one of the things, of course, for all of us, has been that telemedicine has allowed people to stay safe, clinicians to be safe, patients to be safe, families to be safe. And I think of myself as an old-time doc because one of the things that I really love about it is because it's brought back the house call.

So we get to be at the bedside with our patients, be where they are. Some people call it getting back to the website, which I think is a great term. But really, we're where the patients are. We learn so much more by seeing them in their home environment. And also, seeing who's living with them, who's close with them in a much more intimate way. So I think those are factors that are really tremendous advantages from the perspective of helping to take care of people.

RAMI MANOCHAKIAN: Yeah, I love all these ideas and thoughts. I mean, we clearly all have felt it was maybe hard at the beginning. And I know we'll talk about this throughout, but then, it came with a lot of advantages. And I would add, probably, a couple of things as well. I think patients, when they are being considered for clinical trials or being referred to another center, or for a second opinion, of course, we know we're missing the medical exam part. We're missing certain things.

But sometimes, we ended up saving many patients that trip, and get them into the multi-D clinic after knowing exactly what we want. Certain things that we used to do by reviewing the chart and maybe on the phone, and now we have an official introductory visit save them. The other thing where it helped me a lot, and I'm a thoracic oncologist, is after the first visit when I sent a bunch of testing, genomic testing scans and others, and I want to schedule a follow-up to go over the results and set a treatment plan and the patient lives a few hours away, and we want to make the next visit maybe the treatment visit. So this is where, actually, it helped a lot.

So we set this video visit, reviewed all the results, set a treatment plan, discussed. And every patient essentially loved it. So I'm glad we all share the same feelings. Speaking of which, of course, any new things come up. I don't know if we could call it new things, but when telemedicine kicked in, as Dr. Flora mentioned, at the beginning, everyone was nervous.

And once it started rolling, even though it rolled very smoothly nationwide, but it still came up and will continue to come with some challenges, some drawbacks, maybe some limitation, whether it is a technology, infrastructure, communication. So I would love to hear your thoughts about what kind of challenges you've experienced or you continue to experience, or maybe you think may happen down the road with telemedicine and oncology.

ESTELAMARI RODRIGUEZ: So I will share with you, in our community, we have a very large Hispanic population of different educational backgrounds. So I think one thing that became very clear to us is that we do have a digital divide in this country. And all our patients can't adapt to this technology. And a lot of the technology was not developed for telemedicine, was not developed for older patients that have difficulty in hearing, that may need interpreters. So there's a lot of things that were not thought out because we didn't know we would be in this position. But I hope that the technology will evolve to be more user-friendly.

We try to kind of make it work. So we had a system that is HIPAA compliant, we assume. But there were patients that we would have to connect with them by WhatsApp out of emergency, which is something that a lot of our older patients are used to using with their families in South America and to stay in contact with family members.

So we tried to adopt what they knew, what they were comfortable with, with what we had. But ultimately, we hope that we come out of this with a better system that can reach different patients that have different needs. So, Dr. Lopez, I wanted to hear from you, from your experience in your community, how you've been able to reach this digital divide.

ANA MARIA LOPEZ: Yeah, I think that's such a great point. And certainly, the whole COVID/telemedicine experience has exposed so many gaps in where telemedicine, which is intended to increase access, really, there are clear barriers. And that's one of them. So there are folks, as you were saying, with WhatsApp or even just with audio, that we've been able to manage, and whether it's elders. And we really need more research in those areas to see what are the areas where this could be effective, and what does sustainability look like when there's this variability in digital knowledge and digital access?

Are there ways to get technology to people? So we were fortunate in that we were able to get technology to patients. But having technology and being able to use the technology is not the exact same thing. So really, having to ask, as part of our clinical history, do you have stable internet? If you have stable internet, do you have a device? If you have a device, can you access the portal? And if you can access the portal, can you access a telemedicine visit?

And only after all of those questions, to then be able to say, OK, let's do a test visit and see how that works. So we really had to change our thinking a little bit. And then, some of the comments that have been made around the physical exam and. Dr. Flora, I'm sure that that's something that you've experienced. And maybe, what's your sense of the limitations of assessing people at a distance?

DOUG FLORA: I love the webside visit. And it really is a house call for us. I would say that initially, the barriers were steep. We would log on, and you're used to an every 20 or 30 minute schedule in my office. And you'd spend 15 minutes trying to figure out how to turn their mics on. And as you guys have suggested, this digital divide is still pretty deep where we live and practice. The majority of our cancer patients are over 60 or over 65.

A lot of the ones that we're taking care of live in rural areas that may not have access to broadband or good cellphone access, or at least shoddy cell phone access on occasion. And computers are largely non-existent in a lot of my older patient population. So we've had to meet them where they live.

I would say also, we're dealing with a lot of social determinants of health and health literacy. And while there might be an advantage reaching some of these rural populations, on the other receiving end, they've got to have the technology and the ability to log on to talk to us. So like Dr. Rodriguez, we did pivot a little bit from our beautiful HIPAA compliant, EPPA built-in software to FaceTime or just telephone calls. And it was what we had at the time. And I think everyone adapted as we needed to.

But as we move forward to sustain this, I think you're correct exactly, that we need to look at the research to understand that when we adopt this permanently, which seems like it's going to be the case, that it's with methods that improve patient care outcomes, and that we're careful to abandon elements that harm patients or widen these disparities that we've just identified.

RAMI MANOCHAKIAN: Great points, I think, by all of you. The one thing I would add also and I know was brought up, is there are certain times or certain scenarios where maybe from a communication standpoint, that I felt maybe a video visit, telehealth visit wasn't ideal, especially with breaking bad news or sharing scans.

Fortunately, most of the time, when there is a scan, right, we order a lot of scans to assess response. And the patients are here anyway. So these happened to have it be as an in-person visit. I've had patients where their scan was a few days before, so ended up the result was a telehealth visit. And I felt that probably, even though there was an eye contact, I could argue. I had a fellow with me who said, well, the patient was surrounded by multiple family members at home. So even though we breaked not a good news, per se, they were able to take it.

But I still felt it was a little awkward moment. And I would say, usually, like a major visit, scan assessment, change in treatment plan, I would prefer for them to be in-person. But to your point, maybe we need some research, more understanding, as it could go either way depending on what patients favor. But great. I think we can move on to another question.

ESTELAMARI RODRIGUEZ: I was actually going to add something. So one thing that I have realized and I have kind of told my patients is that this is still a visit to the doctor's office. So I have seen that over time, people have very busy lives and they think they can do the telemedicine consultations while they're driving or they're watching TV. So there's a lot of distractions. And to your point, some of these discussions that we have with patients require preparation. You don't know who's in the room with the patient. Maybe these are news that they don't want to share with the whole group.

So I try to make it very serious to our patients and our nurses ahead of time, get information from them to tell them, your doctor will be coming to the room, the virtual room. And this is a visit. You can't be in the car. I mean, these are really serious conversations. So I think we have all seen that telemedicine can be used in different settings when people are busy.

RAMI MANOCHAKIAN: Yeah, Great point, absolutely. Absolutely. And one quick thing I would add also, I think it was brought up that video and audio, to me, when it's an only audio, that's almost like a phone call that we all do all the time, supporting our patient and calling them. So we've had patients that the video didn't work out so we switched it to audio. But for me, I'm always trying to avoid just an audio visit on the phone.

I know now the new system would let you make it as an actual visit and bill for it. But I think to me, the real telehealth is an audio/video, actually seeing the patient face, some eye contact. I would consider a lack of video in some instances is a major barrier. But hopefully, we're kind of overcoming that.

ANA MARIA LOPEZ: But again, really, such an opportunity for research. You know, let's answer the question prospectively. And at least, to me, something that was always so shocking was that telepsychiatry is so well-documented. And some of that is in audio only. So I think the questions are wonderful because it's really allowed us to raise the questions. And now we can really think, how do we answer these questions?

RAMI MANOCHAKIAN: I think this would be a very good segue to our third question. From your experience, what are some of the best practices for conducting, I guess, a well-designed or productive telemedicine visit with the patients? What are the keys for a good successful visit in your opinion? And I'll start with you, Dr. Flora.

DOUG FLORA: This is another adjustment for us, wasn't it, guys? I can't tell you the number of patients who don't know where the lens is on their computer or on their camera. And people are looking all over the place. And I found that maybe taking a moment to reintroduce the concept of the visit. Can you see and hear me OK? Because not all the time is the audio getting across as clearly as I think it is.

I tried to make sure that I was really looking into the camera so that there was that sense of intimacy that you'd mentioned that a doctor and a patient share when they're at the bedside together. So actually, I start my virtual visits. I did one yesterday and we start by a tech question. Are you able to see me? Are you able to hear me? Thanks for allowing me into your home.

And then, I do take a moment to sort of reflect on the place that the patient is living. And this is a unique opportunity to go into their cave and see how they live. Are they disheveled? Is it messy? Are they hoarders? Is it a safe place? Does it look like somebody who's keeping up with their life?

And I did think also, part of the visit that was unique for this is we see them without makeup on. We see them without earrings and lipstick and the things that you put on before you go out in public. So a lot of times, I would find them in their night clothes or their pajamas. And so the visit would proceed. We're doing a physical examination while they're talking. And you could see them showing you around their living room. And you can see their eyes moving in four directions.

And I think for us, the adaptation is, is you actually can do a pretty decent physical examination if you're careful to ask the patient to participate. And we got pretty adept at it. And so now, I think most of us probably have figured out how to do things like patient's not having any retractions. There's not any obvious accessory muscle use. The breathing is non-labored. There's no grunting. It's a pretty good assessment that the lung cancer patient is OK, not as good as we'd like to see if we can use our stethoscope on the back. But it's also not as bad as it sounds when you looked at it at first glance. So what other adaptations did you guys make?

ESTELAMARI RODRIGUEZ: I think Dr. Lopez mentioned something that we have done as a system, where we have, at the moment of making that appointment, we're trying to identify which are the patients that will have issues with the technology. So we make that as part of our screen. So we spend more time prepping that phone call.

And I also take the point that one thing that has helped and made the patient part of the team, we have asked patients to take their own weight. And some of my patients with lung cancer, they have purchased a pulse oximeter. So they are able to give us part of their vitals. And we have learned, and they have learned, that that makes the visit more useful and get more information from them.

So the patients can participate in a way that they were not before. But I think it's important to really understand what the barriers will be upfront. Because you really have a 15-minute visit, and it's not the time to learn how to get an interpreter or learn how to set up the computer. I mean, it's a lot if you want to keep the day going.

RAMI MANOCHAKIAN: Yeah, I like those thoughts. It's prepping. Obviously, we're sharing all that we need to prep well and set good expectations. I have a lot of good questions that I think our audience would be interested. So I'm going to, for the interest of time, I'm going to keep moving. A probably related question, and I'll start with Dr. Lopez, considering all that we've discussed, can you tell us how telemedicine-- we've been doing it for a year at least now-- have impacted your existing relationship with patients and family, and affected building maybe future relationships with that?

ANA MARIA LOPEZ: Thanks. I do think that one can create good relationships, even if it's online. And I know that was something we all had a lot of hesitancy about, especially at the outset. And certainly, some of the initial thinking around telemedicine was that this would only be for follow-up visits. And again, sort of being an old-time doc, I think I had some trepidations around that.

But I really think you can. And part of it, I think, is training for us. So we've talked about the education for the patient and setting the stage what to expect, but also for us. How do you look at the camera so that the patient feels that you are engaging? Pausing, speaking more slowly, intentionally giving patients space to communicate. I think all of these are factors that we can do, and probably would help us in our in-person communication as well, but that really helps us to stay connected.

I think the point that Dr. Rodriguez made of, you want to know who all is in that virtual room. So who's at home with you? Let's bring them into the conversation if the patient would like. Or, if the patient really seeks privacy, is there a way that we could have this encounter be more private? So I think all of these things that we normally kind of do to help patients be at ease, we just need to translate to the tele space.

But I think that there's a lot that can be done. I think there's a lot that can be done from an educational perspective. And then, when we finally meet in person, even though we're masked and all of that, I think people can really feel connected to us. I wanted to share just very early in doing telemedicine. And this was-- I was accompanying an infectious disease colleague. And he was talking with a patient.

And at the end, it was the patient's first telemedicine visit. And so at the end, you know, well, how was this for you? How different? What did you think? And at the end, all the patient said was this was great. The only thing I miss, and the patient went up and hugged the monitor. And I do think it is something that we miss. But there's a lot that we can do.

RAMI MANOCHAKIAN: Absolutely. Absolutely. Great thought. And Dr. Flora, I loved when you mentioned earlier, you thanked the patient for welcoming us in their home. I think that was a great way to start things. What kind of feedback you heard, Dr. Flora, from patients? You've been doing telemedicine for a while, and as far as the relationship and their thoughts on this?

DOUG FLORA: I'll tell you, I was surprised it's a delighter. We think they want to be with us because we're doctors. And who wouldn't want to come see these minds? And that's not the reality at all. And you know, I would say almost exclusively, the patients have benefited from it and have told me so. They prefer getting that hour back. Ours is a place there is a good travel burden for the majority of patients that we treat. And you know, obviously, it's very challenging.

I'll say as a hematologist, sometimes, I'll check a patient's platelet count. And it literally is a 5-minute lab draw. And we can tell with really good certainty that that patient is in good shape and didn't need to make a 45-minute drive and a 30-minute wait and a 45-minute drive. So I would say they've been appreciative that we're now able to care for them in a compassionate fashion that's thorough and that answers the questions that they have. And if we're fortunate enough that that patient's care didn't require a breast examination that day or tapping out a pleural effusion, then I think everybody wins.

And I'm not discounting the utility of a physical examination, but in oncology, the honest answer is, is sometimes, it is discussing a formal whole body PET/CT. And I'm going to get an awful lot from that right before I make my call. And it's probably not as important that day specifically that I put my stethoscope on the patient as it was maybe three weeks prior before the scan.

RAMI MANOCHAKIAN: True. True. Great points, great point. And on a kind of related note, my next question I'll ask Dr. Rodriguez. At your institution, how have you or other providers adjusted to telemedicine during the pandemic? We've be doing it for a year. We learned through it. What approaches or maybe protocols or certain training or things that you've asked for from IT, or your own division or support staff, so you can accommodate patients in telehealth visits?

ESTELAMARI RODRIGUEZ: So I think that we had a video, like a tutorial. But really, you learn by doing this over time, what works for your practice. One of the things that besides doing the prep work of really getting the technology in line and moving the visit alone and having our nurses speak to the patients before you go online, we have also learned that patients can take their own vitals. So I think that's one thing that we have incorporated.

We have learned that we can talk about clinical trials and have some of those conversations that would have required a different visit at that point. And I think overall, the providers have appreciated that they can, once they get the system running, we can see more patients. And we can access them when we need to. And like you mentioned, some of these conversations are quick conversations, but they need to be had.

And sometimes, you see a patient that had chemotherapy, and you would have liked to see the patient the week after just to check on, and really, to have them drive for an hour and wait for just a quick checkup, where you could do online. And that really has changed my practice and has allowed me to keep in contact with the patient more often, especially basic practices that don't have enough clinic space. Like some of our practices don't have enough parking. They don't have enough clinic space. So we really have adapted well to the telemedicine option to provide care for patients.

But again, we still have to incorporate other things that we don't have, like the interpreters, the hearing, patients that cannot hear well. So there's things that we need to work on to make it more user-friendly.

RAMI MANOCHAKIAN: Absolutely. Dr. Lopez, anything else you've done differently, or your team has done differently to adjust?

ANA MARIA LOPEZ: So we had sort of a series of modules. But I completely agree that you sort of learn by doing. And I think that there are opportunities to bring in. So we're experimenting with this virtual waiting room, so that the MA comes in, sees the patient. The nurse then does what they normally have done, and then the clinician. And then similarly, at checkout, so that it's like including all of the pieces that would have taken place during an in-person visit and involving the whole team that normally engages with the patient. So I think, again, this is definitely evolving. And we're, I think, making it more like the regular in-person visit.

RAMI MANOCHAKIAN: One thing I would add also, as a fellowship program director, we were at the beginning wondering, how do we include the trainees, the fellows, the residents? There are some providers who would say, I would just have the fellows or the trainees see them in-person and not do the video. But the longer we've gone through this, we realize this is actually an important training experience, and not necessarily, but here we go where we are we and the trainees have zero experience in this. So we kind of learned from each other and support each other.

But there are also, I think having the trainee, the fellows in the room. Sometimes, we had logged in from two different computers. I think it helped and it also showed the patient that the team hasn't changed. We've had pharmacists sometimes join if there was some education needed. But I, again, needed some adjustment, needed some IT help and so forth. And we continued to learn through the process.

Dr. Flora, I think there is a very important question that has been always posing itself during this year is, when it comes to billing and documentation, how has the use of telemedicine affected that? Many of you know actually maybe participated ASCO advocacy at the Congress, one of the major bills that we've been advocating for is future keeping of telemedicine.

Because ultimately, as far as being able to build and generate the proper income since we continue to invest. And we're doing the same care we do for our patients but in a telemedicine mode. So how was it different for you, Dr. Flora? Any challenges there?

DOUG FLORA: Well, you know, I participated in some of that lobbying. And I do it at the state level. And we just did it at the federal level as well. And I think it's great that the oncology community is coming together as our patient advocacy groups. Our first question, we established that it's time-saving. There's cost-saving advantages both for patients and payers. Helps with child care, helps with people being away from work. So it's actually a good thing for society in addition to the good thing to keep us afloat during COVID when they can't come to our office.

The CARES Act was voted on and enacted March 6. And since then, we've kind of had the trust of the federal government to say, do what you can to take good care of patients. And for that to be sustainable, I think we've discussed that it has to be in an evidence-based fashion to say that we're not just accepting these things because it's easier care, but that we're actually making sure that we provide the same level of care that existed prior to the pandemic.

And so some of the sustainability stuff that is in the proposed laws, we'll touch on that, making sure that we're still documenting well, making sure that as we build, we really are providing the service that we said that we were, which I think the majority of physicians take very seriously, to say that we did the work that we've claimed.

And so we've all adapted with virtual physical examination. We've adapted with having the patient take their own heart rate or weigh themselves, as we've discussed earlier. I love the idea of a home oximeter. My wife bought one at the beginning of COVID, but most of my patients probably didn't. So as we move forward, we're seeing this move into research infrastructure for checkups on patients who are on trials at remote sites.

And I think that the train has left the station, according to everything that we've seen from Medicare and our consultants who we've engaged in. Now we have to figure out how to make it work and make it sustainable. But it's not going to go away.

RAMI MANOCHAKIAN: Absolutely. Dr. Lopez, any comments on the billing or the documentation portion?

ANA MARIA LOPEZ: You know, I actually really love to do telemedicine from the documenting perspective. I have a lot of difficulty using the computer during the patient visit. I just don't feel right. So like right now, I could be typing and you might not see me typing.

[LAUGHS]

RAMI MANOCHAKIAN: We all do that sometimes.

ANA MARIA LOPEZ: So, anyway, I do think, as Dr. Flora was mentioning, there are lessons to be learned. And we like working with our legislative colleagues to be able to have the sustainability. But yes, very important to keep the documentation in sync with the billing aspects.

RAMI MANOCHAKIAN: Absolutely. Absolutely. And we're kind of coming close to our last question, which again, a good segue from what you just mentioned, lessons learned. You know, I think we all believe clearly that telemedicine in general and in oncology specifically is here to stay. What lessons, what kind of last notes if you want to mention? And I'd like to hear every one of you saying what lessons you've learned, what lessons you want to take moving forward so we can keep telemedicine and oncology, and continue and strive to provide our oncology patient with the best possible care? And I'll start with Dr. Rodriguez.

ESTELAMARI RODRIGUEZ: So I think it's upon us to make sure that telemedicine breaks barriers, doesn't create more barriers to our current care. So I do worry about our older patients who already feel like they have been left behind by the whole technology divide. So I think we really have to work hard in understanding what's the best way to communicate with patients that have difficulty hearing, may not understand the technology. We have to develop better systems for them.

But overall, I think it's a great addition. It does break barriers for patients that you cannot reach physically, or they may spend a lot of money coming in and driving and taking time from work. But again, we have to keep in mind that we don't want to leave parts of the population behind who are not easy to get into technology.

RAMI MANOCHAKIAN: Great. Dr. Flora?

DOUG FLORA: Well, as I mentioned when I said the train has left the station, the future is now. And so we can either have this thrown at us, or we can do it ourselves. And I would say that in our center, we're really looking to expand upon this. And we're looking more into more home care, and how can we deliver chemotherapy safely in the home? I think we would all be remiss if we didn't start to really look at the landscape of these devices that are available at home. You know, anybody who's ever worn an iWatch now knows that you can send them your own EKG to your own phone in a matter of two or three minutes.

Why can't we get a pulse of a patient with an appropriate device? And these things are here and the economies of scale are driving these down. So eventually, in the next three to five years, I think a lot of these technologies will be democratized and in every patient's home, even the 65-year-olds, because it's a watch that their daughter buys them.

And I think when we start to plan for things like that, we're going to find ourselves meeting the patients where they are, which is where they want to be in their living room, effectively and safely.

RAMI MANOCHAKIAN: Couldn't agree more. Dr. Lopez?

ANA MARIA LOPEZ: I feel like telemedicine is a new translational science. We're beaming people in wherever we can and seeing how it works and seeing the outcomes. And we've talked a lot about bridging the distance between patients and physicians, patients and clinical care teams. But there's also the opportunity to bridge the distance between clinical teams. So that's another potential benefit.

And I think it's really made us better clinicians, because we're doing these exams now that are primarily observational. So I feel a little bit like Sherlock Holmes. Your observational skills, I think, are really sharpened with this opportunity. So I think there's a lot of benefit. There's a lot that we've learned, and there's a lot that we still have to learn.

RAMI MANOCHAKIAN: Absolutely. Absolutely. Unfortunately, that's all the time that we have for today. Otherwise, really, the conversations have been so good that I could have taken this for hours to come. I'd like to thank every one of you for your participation in this episode of ASCO Education podcast. It was, I think, a very productive and insightful conversation.

I think we all agreed that we're helping patients with telemedicine. And I think many of you, or all of you said it best, is that we learn from the lessons. We've built up on the strength that we've already come across, and then looked for rooms for improvement. And it's an area of research, as Dr. Lopez mentioned. And keep looking for how could we enhance this further, because I think we're going to keep doing it for a very long time. Thank you again, very much. I appreciate your time.

[MUSIC PLAYING]

ANNOUNCER: Thank you for listening to this week's episode of the ASCO E-Learning weekly podcast. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive e-learning center at elearning.asco.org.

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