An Inside Look into the New World of Virtual Visits for Cancer Patients

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals exploring the latest innovative research in clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic overseeing our Taussig Phase I and Sarcoma programs. Today I'm happy to be joined by Dr. James Stevenson, Vice-Chair of the Department of Hematology and Medical Oncology at the Taussig Cancer Institute. He's talking to me today about virtual visits. So welcome James.

James Stevenson, MD: Thank you, Dale. Happy to participate today and thanks for inviting me.

Dale Shepard, MD, PhD: Sure, absolutely. So maybe just to start, maybe you could just give us a little background on your role here at Cleveland Clinic.

James Stevenson, MD: Yeah. So besides being a thoracic medical oncologist, administratively, I'm the vice chairman of the hematology and medical oncology department. So involved in a lot of the operational aspects of the department and also as part of that role, I've recently been named the distance health champion for the Institute so that's why I'm really happy to talk about virtual visits here today, since I'll really be involved in the Cleveland Clinic strategy moving ahead. So looking forward to that.

Dale Shepard, MD, PhD: And that certainly has become front and center, right? So we certainly were doing something in virtual visits, but then the pandemic hit. So tell me a little bit about how that all rolled out and how we've started to grow our presence in virtual visits.

James Stevenson, MD: It's really incredible the way the discussions changed from January and February to where we are now. At the beginning of the year within Taussig, within the department, we had talked about, well, how are we going to get docs to do more virtual visits? Maybe one or two a month just to get them used to the technology and see if they like it. We were sort of slow rolling it into this year and hopefully get people used to it, and then the public health emergency gets declared. Patients don't want to come to the hospital or doctor's offices, and CMS and other providers recognize that telehealth is going to be critical in managing medical issues for our patients and for patients all over the country. So a lot of the restrictions were lifted in terms of reimbursement starting with Medicare, as well as the types of patients and patient situations that we could use for virtual visits. So by basically creating this wide open virtual space, it gave us docs and other practitioners the freedom to really get moving on this and get some experience and understand how best it can work. As you know, it's been a little bit challenging but really exciting at the same time.

Dale Shepard, MD, PhD: What do you think are some of the greatest benefits from the patient side? So how are patients benefiting most?

James Stevenson, MD: Well, I think number one, logistically, being able to participate in their healthcare from their home where people are going to be most comfortable, of course. So that takes away all the stress of the travel, of parking, of check-in, getting to the right spot in the hospital or the office, all those things that lead up to the actual visit. And then sitting in a waiting room, wondering how long you're going to have to wait, wondering what you should do in the meantime. Just the atmosphere leading up to the visit and then the visit itself is so much more conducive to, I think, from a patient standpoint, for it to being a comfortable visit mentally and physically.

Dale Shepard, MD, PhD: How about the provider's side? What do you see as the biggest advantage as a provider?

James Stevenson, MD: I think that from my standpoint, knowing that the patient is comfortable, and I just think I can expect that we're going to have a lot of time just to have even a more meaningful visit, maybe even more productive and that some of the discussion will be a lot more efficient. So that I think helps me to really feel comfortable and starts that visit from a more advantageous kind of beginning.

Dale Shepard, MD, PhD: So have you found that there are specific types of patients that you think this works best? You know, new patients, follow-up for therapy or surveillance or where do you think this has worked best?

James Stevenson, MD: Well, first I would say, of course the patients having an internet connection and camera that they can use to allow this to happen is the most important aspect of it. We do some phone visits as you know. They're probably not the same I think as having the visual connection that's face-to-face, although phone visits are okay. But I think ultimately being able to do these where we can see each other and take cues, I think is the best way.

Dale Shepard, MD, PhD: Are there thoughts about how to maybe help older patients with this technology? They're used to, for 70 years, going to a doctor's office and now we're like, "Well, no, you're going to sit in your living room and talk to Dr. Stevenson."

James Stevenson, MD: Well, I think that most people do have the ability to complete a virtual visit. Maybe they just don't know it. But again, the majority of folks that we see at least have phones with cameras on them even if they don't have computers that have cameras attached to them. But the phone works, it's just a matter of education, which for established patients starts with their visits here and making sure that they've signed up for things like MyChart. So really being able to connect through the EMR platform is important. And then a lot of reaching out and education before the visits which we also have, and those efforts are just going to grow within our Institute, within the enterprise, reaching out to people and making sure that they have the knowledge, that they have the capacity to really participate in these visits fully.

Dale Shepard, MD, PhD: It seems like that's an important step to making this work most effectively.

James Stevenson, MD: Yeah. Again, like I said, even if somebody doesn't have dedicated internet line in their home, they still have the phones with access through a phone. So it's really very few patients that we shouldn't be able to reach in this way.

Dale Shepard, MD, PhD: Yeah, makes sense. So I guess the other thought in terms of patients and who this works best, what your experience has been with either new patients or consult patients, maybe patients who are sort of mid treatment or surveillance patients, what do you think has been the sweet spot or have you had good success with each of them or what does the world look like at this point?

James Stevenson, MD: Of course, our patients getting treatment need to come here for their treatments, but there's a lot of business that lend themselves to be tapped in virtually. I think, starting off with the surveillance visits for patients off of therapy or say postsurgical patients where we're doing imaging surveillance or even say patients who have anemia and are just getting blood work, we can take advantage of all the regional sites around us to have a patient go get a cat scan a day or two before the visit, make that a quick trip and then do the visit from their house. We can review the results with them. I think what a lot of my current visits are entailing, those are really simple. And again, that allows us to really leverage all of our network and regional sites where we can have folks get imaging done closer to home, and we can order those tests easily and see the images online.

So I think those are accounting for a lot of our visits and then when you come to new visits, to new consults, second opinions, I think, are going to be increasing, again, especially for folks geographically who aren't nearby. These should be great to be done virtually. It's just a matter of, again, getting the records and imaging in front of us. We found a lot of our systems were able to get images actually pushed out from another system into ours so that we can view images without having the radiology discs sent to us. So that's being made a lot easier, which will facilitate new patient visits and second opinions. So definitely eliminating any geographic barriers to a patient being seen by one of us for a new consult, second opinion, opinion about clinical trials as well.

Dale Shepard, MD, PhD: This has certainly grown out of necessity, but it really does have the potential to change things in a positive way, providing specialty care to rural areas that may not have had it readily available otherwise. And when you think about it, the surveillance visits, if someone's an hour and a half away, to make that three hour trip back and forth to know that their scans are fine, when you take a step back, seems silly that that was happening.

James Stevenson, MD: That's a great point thinking about geographically, rural underserved areas, folks that don't have access to a lot of specialty care like we provide where we can really be involved in their care I think in a much more connected way.

Dale Shepard, MD, PhD: So, certainly people who are listening in on the podcast, this has become a reality. So a lot of people are certainly getting heavily invested in virtual visits, but thoughts about how we picked a platform to use for this or things with our current system we'd like to maybe optimize, do you have some thoughts about that?

James Stevenson, MD: The natural lean was to find a system that would work in a connected way with our EMR. So once that was accomplished and that that was found to be functional, that was kind of a no brainer, so that we were consistent with the platform that we would use and that we could use it within an EMR visit and document at the same time. So it did take us a little while to get there. I mean, relatively, it took us a couple of months in the pandemic to get that started. But now that it has started, it looks like that's going to be the way to go. And then still having telephone visits as a fallback for those patients that can't manage the visits within our EMR platform that's connected to video.

Moving ahead, certainly optimizing it, I think it's a little bit of clunkiness at the start as I'm sure you would echo, in terms of that initial connection where sometimes it takes a while either from the provider end or from the patient end to get it fully connected. But I think we're having less dropouts than we had initially. So things are only going to get smoother and better as we move along. And if you think about it, we're really only into our fourth full month of doing these and we've learned so much. So the progress has been nearly exponential in terms of how things have moved along.

Dale Shepard, MD, PhD: Yeah. Speaking of that, what does that growth look like in terms of you think beginning of the year, how many virtual visits actually happened and what is that volume now?

James Stevenson, MD: I can tell you where we're trying to get to. We're trying to get to about somewhere around 15 to 20% of total will be virtual visits by the end of this year. I'm just going to imagine that our baseline at the start of this year was way down in single digits, maybe it was 1% or not. So if you think about how that percentage jumped at a year from maybe 1% or so to 15 to 20% and will likely grow even a bit more over time. Do I think we're going to get to a day where half of our visits are going to be virtual? No, I don't think that'll be appropriate for our specialty, but maybe a third or so. Could it look like that someday? Yeah, I wouldn't be surprised.

Dale Shepard, MD, PhD: So maybe we'll end up being in a position where we have one day dedicated to virtual clinic.

James Stevenson, MD: Yep. Well, we'll turn our offices into studios.

Dale Shepard, MD, PhD: As I recall, that 15 to 20% goal was initially a goal for not the end of this year but the end of a couple of years from now. So it's been a pretty significant increase.

James Stevenson, MD: Yeah, I agree.

Dale Shepard, MD, PhD: So when we think about things that might be limitations to access you at the beginning, you talked about CMS and the approvals to do this, are most insurance companies covering costs of virtual visits now or how is that working at this point?

James Stevenson, MD: Yes. And that's basically kind of sprung from the CMS mandate that, during the public health emergency of the pandemic, that, again, all of these restrictions on types of visits have been lifted and reimbursements are now in line with standard E&M visits. We haven't gotten guidance outside of what's going to happen after the public health emergency has ended. But we expect that CMS will continue to reimburse at near in-person rates for telehealth and that private payers will follow as well. The change in that world, we think will also continue moving ahead. A lot of the details will remain to be seen, but I think it'll work out.

Dale Shepard, MD, PhD: One of the limitations initially, and you also mentioned this earlier, was about changes in our ability to reach out and have visits with patients out of state. There have been changes, just to clarify, changes in terms of our ability to provide medical advice to patients out of state at this point?

James Stevenson, MD: Yes, there were some restrictions, again, that were in place prior to the pandemic that have been lifted. So that's really expanded our ability to do consults, especially new consults with patients out of state. There's every reason to think that we'll be able to continue to do that in the future since with experience, it's clear how advantageous these types of visits can be. So other limitations on prescribing and things, there may be some more details that'll have to be worked out with that, but at least knowing that we can see patients outside of Ohio without restriction at this point, that's a big step.

Dale Shepard, MD, PhD: And a lot of shared electronic medical record across health systems that helps with that as well, so even if a patient's far away, we could still pretty much see everything going on with them. So that certainly helps. What do you think is next? What's the next big move in these virtual visits and telemedicine and what do we need to improve? What would you like to see better?

James Stevenson, MD: Well, I think that, as you know, we are working on patients having access to virtual visits outside of our normal working hours, so that'll just make it more convenient for patients where some of us will be working later or a little bit earlier. And patients don't have to take time out of work to do their visits with us. So that will be something that we'll expand and that we've already started. Also potentially having multiple providers involved in virtual visits, doing multidisciplinary care through virtual visit, how can we make those work? That's also going to be something that we'll see moving ahead. So really expanding the scope of who a patient interacts with during a visit.

Dale Shepard, MD, PhD: And it seems like if we could interact with more family as well, that could be helpful.

James Stevenson, MD: Yeah. And I think we've seen that, again, with more experience and with the platform that we're now using, the ability for patients to bring other family members in a video link at that same visit. So that's really cool.

Dale Shepard, MD, PhD: Well, Jamie, you've given us some great insight. Any additional thoughts, any additional comments?

James Stevenson, MD: No, it's a brave new world and it's great to be at the forefront of it. And these are obviously challenging times right now, but as we've seen in other aspects of medicine in the world, there are really going to be some positive things that will come out of it.

Dale Shepard, MD, PhD: Well, thank you very much.

James Stevenson, MD: All right. Thank you, Dale.

Dale Shepard, MD, PhD: This concludes this episode of Cancer Advances. You will find additional podcast episodes on our website, Clevelandlinic.org/canceradvancespodcast. Subscribe to the podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you listen to podcasts. And don't forget you can access real time updates from Cleveland Clinics Cancer Center experts on our Consult QD website at consultqd.clevelandclinic.org/cancer. Thank you for listening. Please join us again soon.