What Oncology Nurses Need to Know About Telehealth
Thrust into the mainstream in 2020 (https://www.usnews.com/news/healthiest-communities/articles/2020-06-02/covid-19-and-the-transformation-of-telehealth), telehealth has transformed how patients with cancer receive some of their care, substituting certain traditional in-person office or clinic visits for phones, videos, and apps and devices that monitor patients’ health. It’s improved access to care in areas previously considered at risk for disparities: for example, patients in remote locations can be managed (https://telehealth.va.gov/) in an acute-care setting using television monitors, cameras, and call buttons to contact specialists.
Telehealth expanded over the past decade with the proliferation of smartphones and apps, but the concept has been followed for more than two centuries (https://blog.evisit.com/virtual-care-blog/history-telemedicine-infographic). And it’s not slowing down anytime soon: in late 2020, the Centers for Medicare and Medicaid Services made the additional telehealth coverage it introduced as temporary pandemic measures a permanent (https://www.cms.gov/newsroom/press-releases/trump-administration-finalizes-permanent-expansion-medicare-telehealth-services-and-improved-payment) part of the Physician Fee Schedule.
It Improves Access and Outcomes
In 2016 and 2019, the Agency for Healthcare Research and Quality completed two systematic reviews (https://telehealth.hhs.gov/providers/telehealth-for-emergency-departments/tele-triage) of the evidence for general telehealth as well as its use in acute and chronic conditions; in 2020, it released a white paper that extrapolated the findings to telehealth’s current expansion:
In specific uses and patient populations (e.g., remote, home monitoring and communication for patients with chronic conditions; providing psychotherapy as part of behavioral health), clinical outcomes with telehealth are as good as or better than usual care and telehealth improves intermediate patient outcomes and satisfaction.
Remote intensive care units report lower, statistically significant mortality rates and small, nonsignificant reductions in length of stay.
Emergency telehealth consultations improve triage by decreasing the time to decisions about transport and treatment and ultimately receipt of care.
It Still Has Challenges to Overcome
Even though telehealth can remove physical barriers to care, access can still be a challenge if patients lack the technology tools and know-how to engage in virtual appointments and treatment. Patients may not own computers or mobile devices, have insufficient data or internet service, or simply be fearful of technology. Some institutions are employing innovative strategies (https://hbr.org/2020/11/4-strategies-to-make-telehealth-work-for-elderly-patients) to mitigate those barriers:
- Delivering tablets and mobile hot spots to patients in need
- Conducting practice appointments one to two days before the actual appointment
- Deploying the tablet delivery drivers, medical assistants, or healthcare ambassadors to log patients in (sometimes even completing the intake) and connect them with the remote care team
It Requires Telehealth Competencies and a ‘Webside’ Manner
Training is essential for providers who practice telehealth. The American Medical Association identified three critical competencies (https://www.managedhealthcareexecutive.com/view/prepare-providers-telemedicine-3-critical-training-areas):
- Virtual data capture
- Patient safety
- Patient education
Other considerations for telehealth are a practitioner’s ability to read body language or other subtle signals that necessitate further inquiry or an in-person visit. Visits should be shifted to in-person (https://www.managedhealthcareexecutive.com/view/prepare-providers-telemedicine-3-critical-training-areas) if providers have any concerns about patient safety or challenges with patients reporting or accessing the system.
When conducting a video visit, position yourself in a well-lit area with your face at the center of the screen and as few background distractions as possible. Putting yourself at the focus of the camera makes patients feel that they are the focus and facilitates trust. Don’t hesitate (https://www.ama-assn.org/practice-management/digital/succeed-telehealth-know-your-webside-manner) to ask the patient to move or reposition as needed to make sure you are able to conduct a thorough assessment.
Providers also need to think about their webside manner (https://www.ama-assn.org/practice-management/digital/succeed-telehealth-know-your-webside-manner) and use the same empathy and understanding they employ at the bedside, chairside, and exam room on the video screen. If patients don’t use video chat often, give them a bit more time to feel comfortable; practitioners can use that time to assess nonverbal cues.
Nurses Can Use It in Cancer Care
As the first point of contact when patients need to report a problem, nurses can use telehealth triage technology to supplement or replace (https://telehealth.hhs.gov/providers/telehealth-for-emergency-departments/tele-triage) aspects of the patient interaction. Patients can use web- or app-based tools to take vital signs or record symptoms either manually or automatically, which triggers an alert to healthcare providers and becomes part of the medical record. Those technologies are especially useful (https://telehealth.hhs.gov/providers/telehealth-for-emergency-departments/tele-triage) with home care, long-term residential care facilities, and homeless shelters.
Telehealth triage continues when patients arrive at the healthcare institution through kiosks or video interactions that help prioritize and manage cases and reduce wait times. HRSA has a guide for telehealth (https://telehealth.hhs.gov/providers/telehealth-for-emergency-departments/tele-triage) triage, and more telehealth resources can be found at the National Consortium of Telehealth Resource Centers (http://telehealthresourcecenter.org/).
Other applications of telehealth in oncology include providing chemotherapy education, genetic counseling, telepathology, certain elements of clinical trials, and survivorship care. Cancer care teams (https://doi.org/10.1200/EDBK_200141) can even use it to connect with each other outside of direct patient interactions, conducting tumor boards and other collaborative meetings virtually from any location.