What teleoncology models of care are available to health services in Australia and overseas?

From Cancer Guidelines Wiki

Introduction

Many oncology centres around the world provide their services to patients living in rural and remote areas through teleoncology in the fields of allied health, nursing, radiation and medical oncology, palliative care and haematology. Teleoncology models are also used in other aspects of cancer care including care coordination and multidisciplinary meetings.

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Medical models of teleoncology

A number of models exist to provide medical services by teleoncology:

  1. Videoconferencing for consultations and monitoring of patient symptoms
  2. Videoconferencing for consultations and supervision of oral chemotherapy
  3. Videoconferencing for remote planning in radiation oncology
  4. Videoconferencing for consultations and supervision of administration of intravenous chemotherapy

Many oncology centres adopt the first three models to complement their face to face outreach services. In these models, patients usually attend major centres for the first medical consultation and at least the first dose of oral chemotherapy. Subsequent care is provided by videoconferencing.

Examples of the fourth model where the majority of specialist supervision is provided by videoconferencing include the Townsville Teleoncology Network (Queensland, Australia)[1] and the University of Kansas Center for Telemedicine & Telehealth (Kansas, United States).

The Queensland remote chemotherapy supervision model involves telemedicine, telenursing and telepharmacy and direct supervision of chemotherapy administration by professionals from larger centres.[1]


Evidence summary Level References
Several cancer centres have implemented teleoncology models of care to provide cancer care closer to home for patients living in rural and remote areas. Services included initial and review consultations, review of admitted patients, monitoring of toxicity, supervision of chemotherapy administration and survivorship care. IV [1], [2], [3]
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Teleoncology models can be used to provide medical services including initial and review consultations, review of admitted patients, monitoring of toxicity, supervision of chemotherapy administration and survivorship care. This is dependent on service capabilities, scope of practice and experience of both the providing urban sites and the receiving rural sites.
C


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Radiation Oncology

Some of the content of this section is extracted from the Tripartite National Strategic plan for Radiation Oncology 2012-2022, The Royal Australian and New Zealand College of Radiologist, Sydney, Australia 2012.

Teleoncology, enabled by the National Broadband Network, provides significant opportunity to improve professional support to regional radiation oncology services, outreach services and patient follow up. Teleoncology is vital to extending the benefits of multidisciplinary care to regional and rural patients and reducing the associated cost of care. Although teleoncology is already established in Australia, the use of telemedicine in radiation oncology is well behind other countries such as Canada and other medical disciplines in Australia.

There are existing initiatives in radiation oncology capitalising on the potential of telemedicine, for example:

  • The North Coast Cancer Institute in NSW runs nurse-led phone follow-up appointments, doctor-led phone follow-up clinics, and videoconference clinics with patients.
  • Radiation Oncology Queensland are enabling nurses to follow-up patients about skin conditions two weeks after treatment using tablet computers, so patients do not have to travel once their treatment is complete.
  • The radiation oncology department of the Townsville Cancer Centre uses teleoncology for review of new patients, family meetings and follow-up.
  • Many centers around the world use telemedicine for remote planning for radiotherapy.[4][5]

Lessons learnt from successful telemedicine projects in other health disciplines suggest that teleoncology has the potential to:

  • Improve access to specialist health services;
  • Reduce patient travel;
  • Encourage local case management;
  • Improve staff training and support;
  • Improve recruitment and retention of staff.

Cancer care is increasingly multimodal and multidisciplinary team (MDT) care is the gold standard of treatment. It is not always possible for regional and rural health services to support every discipline that makes up an MDT. In this context, teleoncology can also alleviate some of the pressures that specialist shortages in rural areas create. The use of videoconferencing or web-conferencing technology can enable access to tumour-specific MDTs.[6] Patient access to these teleoncology innovations are further supported by Medicare Benefits Schedule item numbers, making it a feasible and practical direction for regional health planning.

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Clinic set up

The basic requirements of teleoncology clinics are similar for all cancer centres. However, staffing requirements at rural sites, governance for the type of consultation provided, technology used and the nature of coordination between sites is dependent on the resources available at each site.

Staffing requirements at the providing and receiving sites are determined by the complexity of the services provided. For example, while a simple review may only require a patient and their families at the receiving site, supervision of complex medical therapies such as chemotherapy administration would require doctors and nurses at the receiving site. While many centres require a medical officer at the receiving site, the Kansas model allows nurses as proxy for physical examinations.

Scheduling depends on the complexity and volume of services provided under teleoncology models of care. While an ad-hoc consultation for one patient can be performed anytime, providing a clinic service to larger number of patients requires dedicated clinic time slots. Some centres incorporate teleoncology into their routine face to face clinics and most centres will have internal mechanisms to coordinate clinics between urban and rural centres. Centres in Ontario, Canada rely on the Ontario Telehealth Network, an entity external to the Ontario health department for coordination and booking of sessions.

Choice of technology is also determined by the nature of services provided. A review of symptoms or toxicity monitoring can be performed through web-based systems. However, remote supervision of chemotherapy, provision of comprehensive oncology services and teleoncology models that replace face to face care require high-quality videoconferencing equipment. It is also important to have effective coordination between sites, back up plans for technical failures, systems for documentation and communication between health professionals and capturing of financial incentives and remuneration.


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Staffing requirements for the rural site depends on the complexity of clinical problems. For example, a doctor may not be necessary for review of side effects or monitoring of symptoms.


Teleoncology models of care require adequate governance and resources for implementation into clinical practice.

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Patient selection

Most patients can be managed under teleoncology models of care at some stage of their cancer journey. Several cancer centres use teleoncology models of care to manage patients at initial consultations, inpatient and ward consultations, chemotherapy supervision, follow-up care and palliative care.[7] [1] Patient selection depends on many factors including the experience of the providing site physicians and the receiving site health professionals, individual circumstances, patient preferences, service capabilities and the complexity of cases.[1]


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Physicians should consider teleoncology as an option for patients who have to travel long distances for consultations.


When commencing teleoncology consultations, it is recommended to start with simple cases with a view to managing more complex cases in the future. This will allow the practitioner to become more familiar and comfortable with using videoconferencing for clinical consultations.

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Doctor patient communication

Studies show that patients can experience effective doctor patient communication during technology based consultations and that they are able to establish close relationships with specialists regardless of patient ethnicity.[8] [9] [3] Patients on teleoncology consultations have the same issues during face to face consultations. Therefore, most communication skills that are applicable to face to face consultations are useful for teleoncology.

Suggestion for improving the quality of communication during teleoncology consultations include:

  • Before starting the consultation, check that the audio and video are working and make sure your picture is in the middle of the screen and zoomed in.
  • Introduce and greet everyone at both receiving and providing sites.
  • Explain that whatever is covered in face to face consultations is covered by teleoncology consultations and that the service will be the same.


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It is useful to have a mental framework or physical checklist to ensure every teleoncology consultation is successful.

Establish rapport by:

  • Spending time discussing family and home life as in face to face consultations.
  • Using eye contact and zooming in and out to pick up nonverbal cues.
  • Using visual aids such as imaging studies and the use of white boards to relay information about a topic.
  • Summarising key points and checking that everyone understands them.
  • Encouraging support from local health professionals and family, especially if the discussion at the consultation is sensitive.
  • Offering opportunities for discussion outside of consultations including local and specialist contact numbers.


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Screens can be barriers to a good doctor-patient relationship. Connecting with the patient at a human level is important for an effective therapeutic relationship.


Most communication techniques used in face to face consultations are applicable to teleoncology.

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Physical examination

One of the concerns many people have about teleoncology models of care is the inability of providers to physically examine patients. This concern was overcome in the Townsville teleoncology model by explaining to patients why a physical examination is not always required.[8] Once an adequate explanation was given, the patients accepted this rationale. If a physical examination is required, rural-based doctors perform the necessary procedure during the teleconsultation.

In a study in British Columbia, of the 76 patients who had video conference consultations, 53% had a physical examination within 60 days. Importantly, there were no changes in clinical management due to the lack of physical examination by specialists. In the same study, 60% of the specialists felt it was unnecessary to perform a physical examination.[10]


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When a physical examination is required, it can be performed by local health professionals during the teleconsultation. Alternatively, examination findings can be summarised in referral letters to the specialist prior to the appointment.

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References

  1. 1.0 1.1 1.2 1.3 1.4 Sabesan S, Larkins S, Evans R, Varma S, Andrews A, Beuttner P, et al. Telemedicine for rural cancer care in North Queensland: bringing cancer care home. Aust J Rural Health 2012 Oct;20(5):259-64 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22998200.
  2. Doolittle GC, Spaulding AO. Providing Access to Oncology Care for Rural Patients via Telemedicine. J Oncol Pract 2006 Sep;2(5):228-30 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20859340.
  3. 3.0 3.1 Weinerman B, den Duyf J, Hughes A, Robertson S. Can subspecialty cancer consultations be delivered to communities using modern technology?--A pilot study. Telemed J E Health 2005 Oct;11(5):608-15 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16250826.
  4. Olsen DR, Bruland S, Davis BJ. Telemedicine in radiotherapy treatment planning: requirements and applications. Radiother Oncol 2000 Mar;54(3):255-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10738084.
  5. Muellera BA, Obcemeaa C, Leea J, Sim S. Pilot Study of a Radiation Oncology Telemedicine Platform. JROI 2010;2:1:20-30 Abstract available at http://jroi.org/index.php/jroi/article/view/10.
  6. Olver IN, Selva-Nayagam S. Evaluation of a telemedicine link between Darwin and Adelaide to facilitate cancer management. Telemed J 2000;6(2):213-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10957733.
  7. Sabesan S. Medical models of teleoncology: current status and future directions. Asia Pac J Clin Oncol 2014 Sep;10(3):200-4 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24934093.
  8. 8.0 8.1 Sabesan S, Simcox K, Marr I. Medical oncology clinics through videoconferencing: an acceptable telehealth model for rural patients and health workers. Intern Med J 2012 Jul;42(7):780-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21627743.
  9. Mooi JK, Whop LJ, Valery PC, Sabesan SS. Teleoncology for indigenous patients: the responses of patients and health workers. Aust J Rural Health 2012 Oct;20(5):265-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22998201.
  10. Taylor M, Khoo K, Saltman D, Bouttell E and Porter M. The use of telemedicine to care for cancer patients at remote sites. Journal of Clinical Oncology, 2007 ASCO Annual Meeting Proceedings 2007;Vol 25, No 18S (June 20 Supplement), 2007: 6538 Abstract available at http://meeting.ascopubs.org/cgi/content/short/25/18_suppl/6538.

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Appendices