Summary of recommendations

From Clinical Guidelines Wiki


Models of care

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

Recommendation Grade
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
Practice point(s)
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.

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.

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

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.

What models of care for teleoncology are available to nursing services?

Recommendation Grade
Various chemotherapy regimens can be administered in rural towns using either medical teleoncology models or multidisciplinary models incorporating telenursing and telepharmacy. C
Practice point(s)
Nursing staff undertaking training and the delivery of chemotherapy by teleoncology need to receive basic training in the technology to ensure the learning and treatment experience is equitable to face-to-face delivery.

An audit of the environment where chemotherapy is to be administered should be performed to identify risks and hazards and formally document what a facility has or needs to have to meet legislative requirements and best practice standards. The audit should also ascertain if control measures are in place to enable protection of workers, patients, visitors and the environment from undue exposure to hazardous chemicals.

In addition to training related to the safe administration of chemotherapy, nursing staff in rural and remote areas who will be administering chemotherapy must have completed their annual mandatory training (such as basic life support) and education at an appropriate level.

Members of the multidisciplinary team at the provider and recipient sites should be included during all phases of development and implementation of local chemotherapy models to ensure quality and safety.

What models of care for teleoncology are available to allied health services?

Recommendation Grade
Telephone-based support systems are feasible and can help facilitate changed behaviours (eg. diet, exercise), improved function (eg., fitness, health related function), and improved psychological/psychosocial states. B
Computerised screening/assessment is feasible and can be used as a model of care to collect information on patient status and assist referral to allied health oncology services. C
Hybrid telepractice systems can offer alternative models of care for the provision of allied health education and support to oncology patients. C
Videoconferencing services can be used to deliver allied health assessment and treatment services for oncology patients. C
Practice point(s)
Equivalency to standard/usual care has been reported for some allied health telepractice models. Clinicians should refer to individual studies to determine the similarity in outcomes with their chosen model of care.

The care pathway

Is teleoncology as effective as standard oncology care for the screening of cancer?

Recommendation Grade
Telephone counselling to increase participation in colorectal screening should be considered for patients in lower socioeconomic groups and relatives of patients with polyps or colorectal cancer. C
It is recommended that physicians refer patients for telephone counselling or directly for colorectal screening. C
Telephone counselling should be considered to improve the uptake of mammographic screening or the intention for genetic screening. C
General Practitioners should support provide letters of support to accompany invitations for mammographic screening to increase the uptake. C
Telephone contact should be considered for women eligible for screening or re-screening for cervical cancer. C

Is teleoncology as effective as standard oncology care for the diagnosis of cancer?

Recommendation Grade
In patients with suspected dermatological malignancies the use of asynchronous transmission of skin images to remote dermatologists produces acceptable diagnostic accuracy. In resource scarce health settings more timely diagnoses can be reached using teleoncology. C
In patients with suspected non-dermatological malignancies the use of teleoncology should not replace the standard diagnostic work up algorithm, except in supervised and externally scrutinised trial situations. D

Is teleoncology as effective as standard oncology care for the treatment of cancer?

Recommendation Grade
Multidisciplinary care can be provided through teleoncology models in a manner acceptable to health professionals and patients. Use of teleoncology for multidisciplinary team care could result in management decisions similar to face to face assessments. C
Teleoncology models may help reduce waiting lists and inter-hospital transfers for rural patients. C
Practice point(s)
The nature of teleoncology services are determined by the service capability and resources of the providing and receiving centres. Centres wishing to embark on these models need to ensure that adequate resources, governance and quality control mechanisms are in place.

Is teleoncology as effective as standard oncology care for the palliative care of cancer patients?

Recommendation Grade
Regular nurse-led telephone or web-based multi-component coaching sessions (focused on problem solving, symptom management, self-care, identification and coordination of care resources, decision making, advance care planning and a life-review component), provided shortly after diagnosis may lead to some improvements in the symptom distress of advanced cancer patients. C
If rural, remote or isolated patients with advance cancer have unmet palliative care needs and do not have access to a specialist palliative care team, it is feasible to provide a specialist palliative care video-consultation involving the patient, their family and members of their treatment team. C

Safety, privacy and legal issues

How is the privacy of cancer patients protected when using teleoncology?

Practice point(s)
It is advisable that organisations ensure that electronic transfer of patient information occurs only by secure encrypted networks, and that policies and procedures are in place to protect data stored on mobile devices.

It is advisable that organisations identify and implement steps in addition to current policies and procedures to ensure patient privacy during video-consultations. This could include:

  • Having a system to ensure that there are no interruptions at the specialist and patient ends of the consultation.
  • Requesting that patients participating in a telehealth consultation from home do so in a quiet room where they will not be disturbed.
  • Introducing and acknowledging everyone present in the room during the consultation.
  • Alerting other staff that a telehealth consultation is about to occur and asking not to be disturbed.
  • Informing the patient and receiving their consent if there is a clinically appropriate reason for the recording of a consultation.
  • Storing any recording made during the consultation securely to ensure privacy and confidentiality is maintained.
  • Choosing videoconferencing hardware and software that has security features to ensure privacy and confidentiality.

Are there any legal issues for health professionals to consider when using teleoncology?

Practice point(s)
It is important for clinicians to be familiar with the principles of good clinical practice along with specific guidelines from various jurisdictions on technology based consultations.

Asking for consent, communication with patients and members of the multidisciplinary team, documentation and plans for continuity of care will avoid most medico-legal problems.

It is beneficial to clarify the indemnity arrangements when service is provided across jurisdictions.

Is teleoncology safe for cancer patients and health professionals compared with standard oncology care?

Recommendation Grade
It may be safe to administer chemotherapy in rural towns under the supervision of medical oncologists from larger centres by teleoncology, provided that rural resources and governance arrangements are adequate. C
Practice point(s)
The nature of chemotherapy regimens administered at rural and regional centres is determined by the rural service capabilities. Rural centres that have high dependency or intensive care units may be able to administer most chemotherapy regimens locally under remote supervision by medical oncologists using teleoncology. Centres that lack high dependency units may only be able to provide selected low and moderate risk chemotherapy regimens. In the latter case, it is advisable that first dose of chemotherapy is administered at the supervising center.

New centres embarking on remote chemotherapy supervision models could adopt a staged approach to the selection of medications administered at rural sites based on experience,confidence and service capabilities.

Satisfaction and cost

Are cancer patients and health professionals satisfied with teleoncology compared with standard oncology care?

Recommendation Grade
Teleoncology models of care are acceptable to patients from rural and remote areas including Aboriginal and Torres Strait Islanders. C
Practice point(s)
In line with contemporary research teleoncology and telehealth must be considered as an important adjunct when developing new oncology models of care to deliver care closer to home in rural and remote Australia.

Appropriate resources, both human and material should be allocated for the implementation of this form of care provision. Additionally, adequate training and support on the use of this technology must be provided prior to commencement of a teleoncology service.

How cost-effective is it for health services to use teleoncology compared with standard oncology care?

Recommendation Grade
Cost savings to the health systems can be achieved through teleoncology models when large travel distances and high patient numbers are involved. B