Benefits of Virtual Second Opinions

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 One and Sarcoma programs. Today I'm happy to be joined by Dr. Peter Rasmussen, a cerebral vascular surgeon here at Cleveland Clinic and Chief Clinical Officer of Virtual Second Opinions by Cleveland Clinic. He's here today to talk to us about the benefits of Virtual Second Opinions. So, welcome Peter.

Peter Rasmussen, MD: Oh, thanks for having me, Dale. It's my pleasure.

Dale Shepard, MD, PhD: Well, maybe start off, give us a little bit about your role here at Cleveland Clinic and then also with the Virtual Second Opinion service.

Peter Rasmussen, MD: I'm probably one of the more lucky physicians here at Cleveland Clinic. I've been here 23 years now, and I always seem to have exactly the perfect job for myself, and I don't know how that's happened. But as you mentioned, I've been practicing cerebral vascular neurosurgery here for 23 years, which has really been quite a pleasure to help a great number of patients. And over the years, starting back probably about 10, 12 years ago, Toby Cosgrove, our former CEO, asked me to work on telemedicine. And I did that for six years for the enterprise. We made some great progress getting the organization prepared for COVID, and then two and a half years ago, our current CEO, Tomislav Mihaljevic, asked me to move over and work on this joint venture spin out we have called The Clinic by Cleveland Clinic, which is really like an incubator for digital health products for the enterprise, working in partnership with Amwell. And our first product that we've gone to the market with is Virtual Second Opinions, as you mentioned.

Dale Shepard, MD, PhD: How has it grown since it became an idea to move to a virtual second opinion? What did that look like? You kind of started from scratch and this has developed into a pretty big program.

Peter Rasmussen, MD: It sort of started at scratch. The Cleveland Clinic has been doing remote second opinions for probably the last 20 years. It was very much, I guess I would characterize it as an analog program up until the last two to three years. And then we really revamped it, tried to make it more digital. As I mentioned, we moved it out of the Cleveland Clinic proper to give us a little bit more nimbleness, made a little bit of an investment into it. And we've tried to change our focus and strategy of how we've gone to the market. Obviously, there are a large number of patients who are referred to us by their local physicians or perhaps they find us independently through our webpages. We've also focused heavily on going to the payers for virtual second opinions. There's a strong desire amongst the payer and the self-insured employer market to really offer this as a benefit to their members or their employees, that they have access to best in class care. Obviously that includes cancer care as part of this.

Peter Rasmussen, MD: Since we've made these changes, improved user experience on the website, going to the payers and the self-insured employers, we've seen a dramatic growth in patients requesting second opinions. And it's an entirely virtual program, as you've mentioned, so there's no barriers for patients to access expertise of Cleveland Clinic physicians. We've tried to make the process the equivalent of hitting the easy button. So as you know very well, those patients who are faced with diagnoses of complex conditions like cancer, they frequently can have a plethora of medical records, pathology, specimens, and imaging. That could be a daunting task for a patient to gather up those records themselves or have their family do that in the midst of a difficult diagnosis like cancer. We have a very skilled team that gets all the medical records for the patient, gathers up the imaging, get the pathology for the patient, and then bundle that up into a packet of information to pass on to experts like yourself. Since we've brought this sort of premium level service to bear, as I mentioned, the volume has grown dramatically. Historically we had been doing about 45 consults a month. Last month, we went over 200 now.

Dale Shepard, MD, PhD: Wow, it's impressive. I think you can't underestimate that whole process of everything's gathered up for the patient, everything sort of takes place, and then when they have that interaction with the provider, we've already reviewed it. The path's been reviewed, everything. So too often people come in in person and we still may not have gotten the records or we may not have gotten path and things like that. So just that is immensely helpful.

Peter Rasmussen, MD: The team is quite skilled at it, too. On average, we're able to get the full packet of medical records within about seven days. Obviously there's some variability about that. As you know, many hospital medical record departments and film libraries have been short staffed because of COVID. We work very hard despite those barriers at other hospitals to get the information for our physicians. We have a wonderful relationship with Cleveland Clinic pathology. If we can get the tissue blocks, which what we at least strive for is to get the actual tissue blocks, about a third of the time, our pathologists will do additional stains in addition to what's been done locally, and they'll turn around that interpretation of those tissue blocks or slides within less than 24 hours. So they've really done a great job in confirming, or in many times, changing the diagnoses of patients, which obviously can be very dramatic in a patient who has a cancer diagnosis.

Dale Shepard, MD, PhD: And particularly things like rare tumors. So I find that frequently in sarcomas, somebody might say, it's an angiosarcoma. But well, maybe it's an angiosarcoma. So I think this has been really helpful for getting outreach to places where they may not have expertise in rare tumors.

Peter Rasmussen, MD: And one of the strengths or values of our program is the way we've structured it. It allows for global access to experts like yourself. Frequently, licensure barriers may come into play. But as I mentioned, as the way we've structured this, patients from around the globe can access our experts like yourself. As you mentioned, sarcoma, our pathologists are world-leading experts in sarcoma pathology interpretation. Like you said, it's not uncommon that a diagnosis will be changed based on your or another expert's review. And patients don't need to travel, which is important. We get a number of requests out of Europe for pediatric tumors. You can imagine how distraught those parents may be, and to be able to get their child in front of a world-leading expert without having to travel or the expense of that, the time away from work, disruption to the family routine. How do you put a price on that? That's really an amazing service.

Dale Shepard, MD, PhD: But I guess another component of that is once they've had that initial consultation, they may know that we have something else to offer. Talk about conversion to visits here to Cleveland Clinic.

Peter Rasmussen, MD: Yeah, what we're seeing across the spectrum of second opinions, and we're willing to offer a second opinion on virtually any diagnosis, about a third of the time, our physicians are changing the diagnosis, which I think is pretty surprising. And up to 80% of the time, we're seeing different treatment recommendations. So it could be something as dramatic as perhaps no surgery versus surgery or perhaps delayed surgery and further evaluation may be needed. Or in the cancer realm, it's not uncommon that additional chemotherapeutic regimens are being recommended or future plans for chemotherapeutic regimens as there may be inevitable disease progression. And then of course, there's the offering of clinical trials that are available at Cleveland Clinic or you may know of at other sites around the country. And I read many of these opinions as they come through. As a neurosurgeon, I find the hope that is offered by additional options really is gratifying and has got to be immensely valuable to the patients.

Dale Shepard, MD, PhD: An important part of cancer care is multidisciplinary involvement, surgery or radiation in addition to things like chemotherapy. How have you been able to work multidisciplinary opinions into this program?

Peter Rasmussen, MD: We've done it several different ways. Our program is really structured and designed to answer key questions for the patients. Many times that might be additional chemotherapeutic options. It might be is surgery an option for me? It might be is there a different type of radiation or is radiation a good treatment option for myself? So we'll try to get those patients to those particular experts. It's not uncommon though that experts like yourself might say, "We really should have a surgeon weigh in on this patient's case," or "We should have the radiation therapists weigh in," or perhaps our experts may take the patient's case to the disease-specific tumor board for a group evaluation around what would be the best treatment options for the patient. And that's also been a service that we've gone to self-insured employers and payers with is the idea of out of the box, really a multidisciplinary approach to the patients and their concern. So there's a variety of different avenues that we can offer that multidisciplinary opinion for patients.

Dale Shepard, MD, PhD: I'm going to take a step back here, just so everyone's kind of on the same page, payers, certainly. Self-insured employers, define sort of an example of that and groups that we might be working with.

Peter Rasmussen, MD: So as an example, we have contracted to provide virtual second opinions to a union here in the Midwest, and a fair number of patients have sought second opinions through that process. Historically what we're seeing is about 0.5% of members who are eligible for the benefit use the virtual second opinion on an annual basis. I guess it's good and bad. That may reflect the fact that complex disease is relatively rare. It also may reflect the fact that the service is underutilized and may be more valuable more frequently than it's actually being sought.

Dale Shepard, MD, PhD: So we've sort of focused on cancer, but what other areas with the second opinion service have been particularly popular within medicine?

Peter Rasmussen, MD: Yeah, we do offer second opinions really for any diagnosis. So what we've seen here is about 50% of the requests have been for cardiac issues. Cancer would be the second most frequently requested second opinion. And then after that, it would be a tie probably between neurologic disease and GI diseases.

Dale Shepard, MD, PhD: And I guess from a very, very practical standpoint, how do people go about getting a second opinion?

Peter Rasmussen, MD: So patients can initiate them directly themselves through the Cleveland Clinic website. Just look for Virtual Second Opinions on the landing page. It's a simple registration process of essentially name and telephone number and email address. And then they can schedule a time with an intake nurse who's very skilled at working with patients or they can, at that moment, if it's during usual working hours, they can initiate a process with one of our nurses, as well. As I mentioned, within five to seven days, we'll usually have the medical records together and our physicians have been fantastic in turning these opinions around. Usually within about 48 hours of receiving the records, they'll be chatting either by telephone or video with the patient directly. And the patients obviously have an opportunity to ask their additional questions at that time. And then we do give a summary document back to the patient that they can share with their local physicians.

I think the other thing that's important to remember for some of the listeners is that as you and I both know, we're employed physicians of the Cleveland Clinic. We have no financial incentive in trying to lure patients to Cleveland for further follow-up care. Really our goal is to give patients the best opinion on what they can do now and in the future. And it's not uncommon that our physicians recommend continuing care locally with their physicians, or if there's other experts nearby that they may need to get additional subspecialty care from, that recommendation happens quite frequently, too.

Dale Shepard, MD, PhD: Yeah, no, you're absolutely right. Even patients that come by traditional means to my clinic, most of my consults end up going back to their local communities for their actual care. This is just a way to provide that same level of consultation, but without them leaving their living room. It's a nice feature.

Peter Rasmussen, MD: Exactly. It's very convenient for patients. We have very high patient satisfaction scores through this program. I think a reflection of the high quality physicians and the great work they do with their opinions, our nurse care team in terms of helping the patients through their journey of the second opinion, which can be an important component of their overall cancer journey. And we really pride ourselves on delivering a premium high quality service for patients.

Dale Shepard, MD, PhD: The opinions I've given in the past, some have been written, some by phone, some by video, and clearly the best interactions are by phone or video, because you have that ability to have patients ask questions in real time.

Peter Rasmussen, MD: And that's what we hear from patients as well. They really enjoy having the opportunity to talk directly to our experts. There are other second opinion programs that are available from other academic health centers or from commercial vendors of second opinions. Our program really stands head and shoulders above them in the sense that patients have an opportunity to talk to experts like yourself directly, which is pretty rare amongst the other programs.

Dale Shepard, MD, PhD: Do you find that most are coming through patients that are seeking out those second opinions? How often is it the physicians that are looking for some extra help? What does that split look like?

Peter Rasmussen, MD: Yeah, I would say most of the requests are coming directly from the patients. There are some physicians who will recommend their patient, perhaps things like sarcoma, as you mentioned, "You should seek a second opinion from Cleveland Clinic." A second opinion can be initiated really by anyone. It can be the patient, and our relationships with the payers, frequently their care managers will assist the patient with initiating the second opinion. Overseas with our relationships we have there, a lot of physicians are initiating the second opinions on behalf of their patients. We're really open for any way of just being able to help patients.

Dale Shepard, MD, PhD: And it seems like that's one of the bigger areas of growth is more international coverage of various disease, which is great. Because particularly rare diseases, there oftentimes aren't local experts. So are there particular areas that we have a strong footprint or that we're looking to expand into?

Peter Rasmussen, MD: Currently, we do have relationships in many, many different countries. Probably the most frequent international location for second opinion requests is coming from Canada, and we're working to grow our business in South America. We do have a relatively underutilized resource in Weston, where there are extremely high quality Cleveland Clinic experts in Weston that patients from South America can get to quite easily, as you know. We do have strong relationships in China and India and Indonesia. The challenges with China can be a little bit specific. There's fairly heavily regulated international access to care, if you will, through China. We have solved that with a particular technology and business partner that we work within China. I think it's still obviously tremendously underutilized. One of the things we hear very frequently out of China is the quality of the pathologic interpretation services. And I know Cleveland Clinic as a whole has a network of connections into many health systems in China to help them with their pathology interpretation as well.

Dale Shepard, MD, PhD: I think one of the things in other countries sometimes becomes availability of therapies that might be more common here, particularly if you start looking at managing metastatic recurrent disease. But certainly workable. What about coverage? You mentioned more payers are taking this on as a product that they cover, but in general, what does coverage look like?

Peter Rasmussen, MD: As it stands right now, for the most part, if this is not a specific benefit from the patient's insurance coverage, it's really a cash service. Fortunately commercial payers are recognizing that this is a cost-effective solution for their members. In addition to really being the right thing, a key value proposition is gaining access to Cleveland Clinic expertise without the need to travel. From a payer perspective, they're recognizing that paying for care for the wrong diagnosis or the wrong treatment plan is just money wasted. We've done a pretty careful analysis of this that was adjudicated by an independent third party that when we change diagnosis or we change treatment plan, on average the payers were saving $12,000. So not only are patients getting what we would deem to be the right diagnosis and the best treatment plan, which is usually guideline directed therapy, that everyone wins, right? The patients are getting the right diagnosis, the best treatment, and the payers are saving money as well.

So, that's really becoming recognized amongst the payer community. We have contracts with a number of payers and have ongoing negotiations with a number of payers right now. And you're also seeing this in the marketplace. Recently, Transcarent is a startup health company that's come to market with a cancer-specific program where they're selling a cancer longitudinal care journey for their members directly to the self-insured employers. And I think the employers are recognizing that accessing care through traditional means is a little bit challenging for their members, and they want to bring a little bit of higher level service to their employees and to their members.

Dale Shepard, MD, PhD: Well, this has certainly been growing in a big way and provides a great service. What do you see are the biggest gaps that need to be sort of overcome to make this even more accessible to patients and better for their care?

Peter Rasmussen, MD: Couple things. Obviously, offering a concierge-like experience for patients does come with a little bit of a cost. And many of the insurance companies are not willing to cover this unless it's a specific benefit, so that's somewhat of a barrier. But really from a technical standpoint, the biggest barrier is the old problems in digital healthcare, which is medical record interoperability. Those who work in EPIC as an electronic health record recognize that they've done a pretty good job at making those records portable amongst the EPIC health system community. But once you cross from EHR to EHR, there's really no good way of doing that. It becomes quite a challenge for patients and/or health systems to access those records. Images are a little bit more portable. There's a large number of cloud-based image sharing solutions that many health systems subscribe to. So through a little bit of connection work, the images generally will transmit through the cloud. But even in these regards and with the positive aspects of HIPAA, the portability aspect of medical records supported by HIPAA, the need to share releases for medical information really slows the process down.

Dale Shepard, MD, PhD: Well, you're making great progress to help our patients, and I appreciate your insights.

Peter Rasmussen, MD: Thanks for the time, Dale. Appreciate it.

Dale Shepard, MD, PhD: To make a direct online referral to our Taussig Cancer Institute, complete our online cancer patient referral form by visiting clevelandclinic.org/cancerpatientreferrals. You will receive confirmation once the appointment is scheduled.

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