Article

State of eHealth in Cancer Care: Review of the Benefits and Limitations of eHealth Tools

Susan Doyle-Lindrud

eHealth, telemedicine, telehealth, teleconsult, technology, supportive care
CJON 2020, 24(3), 10-15. DOI: 10.1188/20.CJON.S1.10-15

Background: eHealth has the potential to improve patient access to care through the use of various tools.

Objectives: This article provides a review of some eHealth technologies, including a discussion of their benefits and limitations. An overview of studies using eHealth technologies are summarized, and future directions are explored.

Methods: A review of the eHealth literature was conducted, with a focus on outcomes of telehealth interventions in cancer care.

Findings: eHealth can transform health care by expanding the reach of clinical cancer care. Examples of this expansion of care include patients who live in remote areas with limited access to oncology providers, patients who find travel challenging, and patients who prefer the convenience of communicating with their provider from their home. Such telehealth interventions can increase patient satisfaction, but additional research is needed to further evaluate patient outcomes.

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    According to the World Health Organization (n.d.), eHealth is defined as the use of information and communication technologies for health, whereas telehealth, according to the Center for Connected Health Policy (n.d.), is defined as using digital technologies to deliver health care and health education by connecting multiple users from different locations. eHealth is an overarching term that includes a broader array of tools, such as telephones, smartphones, mobile wireless devices, electronic health records (EHRs), computerized provider order entry, prescribing mechanisms, and clinical decision support tools (Office of the Assistant Secretary for Planning and Evaluation, 2016). Important aims of eHealth are to improve patient access to care, safety, quality, and cost effectiveness (Office of the National Coordinator for Health Information Technology, 2017), with a potential benefit of delivering medical services to locations that have a scarcity of providers, such as rural areas and medically underserved urban communities. For patients with cancer living in rural locations, this vulnerability is exacerbated by having to travel long distances to access oncology services. For a patient with pain, fatigue, or financial issues, these become major obstacles to care. eHealth may be the answer to this problematic healthcare disparity.

    Background

    The visionary Institute of Medicine (2001) publication Crossing the Quality Chasm: A New Health System for the 21st Century states that “information technology must play a central role in the redesign of the health care system if a substantial improvement in quality is to be achieved” (p. 16). Important contributions to eHealth were made through the Mercury space program of the 1960s. The National Aeronautics and Space Administration (NASA) began monitoring physiologic and psychological effects on astronauts through telemetry and remote communications. Over time, NASA developed new smart medical systems that were designed to communicate and diagnose ill astronauts, including providing physicians on the ground with the capability to remotely provide treatment options (Institute of Medicine, 2012; Simpson, 2020). This was accomplished through the Integrated Medical and Behavioral Laboratory Measurement System Program.

    In the 1990s, the Internet brought about a global network that provided healthcare professionals with the ability to share information. In 1993, the American Telemedicine Association (ATA), a nonprofit organization, was developed to promote technology as a way of increasing patient access to care. ATA (n.d.) is made up of more than 400 organizations working to transform health and care via enhanced and efficient delivery. In addition, telehealth has been an important priority for the U.S. Department of Veterans Affairs. In 2016, about 12% of veterans received some of their care through a telehealth intervention. Telehealth has been implemented in more than 900 Veterans Affairs sites and is available in more than 50 specialties (U.S. Department of Veterans Affairs, 2019).

    With an aging population and a predicted shortage of oncologists in the United States, it is becoming more important for cancer centers and community health centers to incorporate eHealth into their practice settings. In 2012, the American Society of Clinical Oncology commissioned the Center for Workforce Studies of the Association of American Medical Colleges to develop a workforce information system with data on the number of practicing oncologists, the number of oncologists entering the workforce, and the incidence and prevalence of cancer in the United States (American Society of Clinical Oncology & Association for Clinical Oncology, 2013). Data have revealed that oncologists have a higher median age than the physician workforce in general, with a growing proportion aged 64 years or older (Kirkwood et al., 2013). This is concerning because the number of available providers will likely decrease as a result of retirement. In addition, there may be fewer incoming oncology-trained physicians to provide care; the proportion of international medical graduate trainees in oncology has increased, but many have visas allowing only temporary status in the United States. Consequently, these trainees may not add to the oncology workforce in the United States (Kirkwood et al., 2013). Because of the potential difficulty that patients may have when finding a local oncology provider, telehealth may be one solution; its fundamental aim is to increase access to healthcare providers.

    Review of the Technology

    Mobile Heath

    Also known as mHealth, mobile health includes the use of tablets and smartphones with mobile applications, or apps, designed for health and well-being (Center for Connected Health Policy, n.d.). These technologies can send targeted text messages that may include reminders to take medication at specific times or to get moving (an activity tracker alert). There also are apps that provide calorie-counting diaries and nutrition information. In addition, smartphone cameras, microphones, or sensors can be used to capture patients’ vital signs for input into apps that can act as a bridge to providers through remote patient monitoring.

    Videoconferencing

    Videoconferencing involves a live, or synchronous, audio/video connection to assess, treat, and provide care to a patient remotely (Center for Connected Health Policy, n.d.). A patient can be at one location, with the physician, nurse practitioner, and/or nurse at another location. The patient connects with the healthcare provider using a video device and telephone or computer audio. Videoconferencing may be initiated when a patient is at a healthcare facility with an established provider and reaches out to a specialist, or when the patient is at home and wants to connect with a nurse to discuss new symptoms or ask questions.

    Remote Patient Monitoring

    Remote patient monitoring is a means of monitoring patient health and clinical information from a distance (Center for Connected Health Policy, n.d.). The physician and/or nurse practitioner can monitor the data and alter treatments as needed. To capture data, remote patient monitoring uses devices such as blood pressure cuffs, glucometers, pulse oximeters, and electrocardiogram apps. Patient-generated data are stored on a secure server and are easily accessible by the patient’s healthcare provider.

    Store-and-Forward Technologies

    With store-and-forward technologies, clinical information is transmitted electronically from one clinical site to another for evaluation (Center for Connected Health Policy, n.d.). Information sent may include medical information, laboratory results, and imaging. Use of store-and-forward technologies includes the following:

    • Computed tomography scans, x-rays, or other imaging taken at a remote location and reviewed by a radiologist at another location

    • Images of a skin lesion transmitted for evaluation by a dermatologist

    • Pathology images presented during an interprofessional meeting

    • Images of a wound transmitted for evaluation by a wound care nurse

    Review of the Literature

    Many studies have evaluated the benefits of various eHealth interventions. A systematic review and meta-analysis by Larson et al. (2019) examined the overall effect of telehealth technology to support cancer survivors in the management of their symptoms. Larson et al. (2019) aimed to determine whether quality of life improved with telehealth interventions compared to usual care delivered via face-to-face interactions. Studies reviewed by Larson et al. (2019) included those evaluating adult cancer survivors and various telehealth interventions (e.g., Internet, telephone, videoconference). Eleven studies representing 1,349 patients were reviewed; a statistically significant effect of telehealth interventions was found in regard to increasing survivors’ overall quality of life compared to usual care (mean effect size = 0.14–0.144, p < 0.05) (Larson et al., 2019).

    Palliative care, an integral component of clinical cancer care, has incorporated telehealth interventions to expand patients’ access to care. A systematic review by Jess et al. (2019) examined whether the outcomes of video consultations in palliative care were advantageous. Of the 39 articles reviewed by Jess et al. (2019), 37 discussed how video interactions between the healthcare provider and the patient and/or their family member had transformed care, allowing for communication despite the patient and the provider being in different locations. Several of the reviewed studies noted how the visual component made a limited physical assessment possible. Another advantage mentioned was the ability of the patient to avoid travel to a hospital or clinic, as well as unnecessary emergency department visits. Sixteen of the studies reviewed by Jess et al. (2019) looked at the impact of communication in palliative care, with several noting the advantage of having verbal and nonverbal communication because of the visual component; this allowed the healthcare provider to respond appropriately to cues from the patient’s body language and facial expressions. Frequent challenges associated with these encounters were attributed to technical issues with audio, video, or the Internet connection, which caused some users to experience frustration (Jess et al., 2019).

    A number of telehealth interventions have been designed specifically for adolescents and young adults with cancer. The objective of a systematic review by McCann et al. (2019) was to assess the quality, feasibility, and efficacy of digital interventions for individuals with cancer aged 13–39 years who were in treatment or in the survivorship phase. Thirty-eight studies were included in this review, with focuses on symptom management, medication adherence, self-care, anxiety, and depression. Digital health interventions used were websites, mobile apps, video games, wearables (e.g., wrist-worn activity tracker, smartwatch, electrocardiogram monitor), social media, and virtual reality. Many of these interventions included automated responses and access to peer support. Studies reviewed by McCann et al. (2019) reported that participants had positive experiences using technology. Very few of these studies asked the participants for feedback on areas of improvement, but in those that did, participants noted technical difficulties, website designs that were too simple, and concern that the digital platforms providing them with the ability to talk with other study participants (peer support) were not equivalent to face-to-face interactions (McCann et al., 2019).

    Concerning eHealth applications in dermatology, a systematic review by Finnane et al. (2017) investigated whether teledermatology was as accurate for the diagnosis of skin cancer as a face-to-face evaluation. The 21 studies reviewed focused on the use of teledermatology interventions for diagnosing or managing melanoma or nonmelanoma skin cancers. Of these, eight studies reported the diagnostic accuracy of teledermatology consultations. The diagnostic accuracy (defined as obtaining the same result from the histopathology of an excised lesion or the clinical diagnosis of a nonexcised lesion) of a face-to-face dermatology visit was higher (67%–85% agreement with reference standard) when compared to teledermatology (51%–85% agreement with reference standard) for the diagnosis of skin cancer. One reviewed study reported Breslow thickness of melanoma as an indicator of an earlier diagnosis and reported a lower Breslow thickness in the teledermatology group compared to usual care (1.06 mm versus 1.64 mm, p = 0.03). Four reviewed studies evaluated waiting times and reported a reduction in waiting times for the teledermatology groups. One reviewed study reported higher overall satisfaction with the teledermatology visit as compared to a face-to-face visit. Finnane et al. (2017) noted that, in general, face-to-face dermatology consultation has a higher accuracy rate than teledermatology, and they recommended that teledermatology be used for patients who cannot meet face-to-face with a provider or as a triage tool to reduce waiting times to assessment.

    eHealth Limitations

    Concerns exist that the quality of the patient–provider relationship will be affected without the in-person visit. This is, in part, because it is difficult to develop a trusting relationship through remote communication and because these telehealth encounters could happen prior to the establishment of a relationship. Telehealth encounters occurring prior to an established relationship can lead to fragmented care and disconnected healthcare providers (Dorsey & Topol, 2016). Initially, videoconference encounters were arranged in circumstances where a physical examination was less important, such as teleradiology and mental health (Dorsey & Topol, 2016). In recent years, videoconference encounters have expanded to many different types of providers, but the inability to perform a hands-on physical examination can be problematic, such as when the provider is not able to perform an abdominal examination on a patient with abdominal pain or is not able to perform a lung examination on someone with symptoms of shortness of breath (Dorsey & Topol, 2016).

    Another concern is that individuals living in rural locations and/or with lower incomes may not have access to the Internet (Office of the Assistant Secretary for Planning and Evaluation, 2016). Older individuals may not be as familiar with this technology and may struggle with connectivity issues, have difficulty setting up a video feed, or lack the ability to participate in social media chat groups. Another concern is that in a situation where a patient with cancer becomes sicker and needs to be seen more frequently, a telehealth intervention will not be a sufficient substitute for this face-to-face evaluation and not having a local provider may become problematic (Worster & Swartz, 2017).

    Reimbursement

    In the United States, telehealth reimbursement laws and regulations vary by state; regulations may be a barrier to telehealth implementation. Some states are expanding their telehealth reimbursement, whereas others continue to restrict telehealth reimbursable services. Medicaid has generally had broader coverage for telehealth services than Medicare. The Centers for Medicare and Medicaid Services has proposed expanding patient access and coverage to telehealth in the Medicare Advantage plan by 2020. With the Bipartisan Budget Act of 2018, enrollees have greater access to telehealth (Centers for Medicare and Medicaid Services, 2019).

    A key finding of the Center for Connected Health Policy’s fall 2019 State Telehealth Laws and Reimbursement Policies is that no two states are alike in their definitions and regulations of telehealth. All 50 states and the District of Columbia have some form of Medicaid reimbursement. The most widely reimbursed telehealth intervention is live videoconferencing, with every state including some form of reimbursement in its Medicaid program, although services reimbursed vary (Center for Connected Health Policy, 2019). Store-and-forward technologies tend to have various reimbursement criteria because telehealth may be defined as a service that occurs in real time. Twenty-two states have some reimbursement for remote patient monitoring in their Medicaid programs (Center for Connected Health Policy, 2019). Restrictions include the type of monitoring system used to collect data and allowed medical conditions for remote monitoring of symptoms. A few states permit the prescribing of medication after a live video interaction (Center for Connected Health Policy, 2019). As of 2019, 40 states and the District of Columbia have laws that govern private payer telehealth reimbursement. Most of the laws require parity in service, but only a few laws require reimbursement equal to in-person coverage (Center for Connected Health Policy, 2019).

    Future Directions

    Use of various eHealth technologies as part of data collection in clinical trials can support study recruitment and improve diversity (Cox et al., 2018). During clinic visits, patients’ clinical trial data can be captured in the EHR, with nurses ensuring that their telehealth-based intervention data are accurately captured and retrieved and that they follow regulatory requirements. The U.S. Food and Drug Administration (2020) has published guidance on the clinical use of digital health devices; however, this guidance does not focus on device use in clinical trials.

    Technology can increase public awareness of clinical trials. SWOG (formerly the Southwest Oncology Group) has taken a leadership role in this by developing a digital engagement committee, which has compiled recommendations concerning the use of digital tools to advance research, engage group members, and inform the public. Results from a SWOG survey of 1,340 cancer survivors representing different cancer diagnoses and stages showed that 72% of respondents use the Internet as their primary source of information, 70% were interested in obtaining facts about their cancer, and 54% wanted to learn more about clinical trials (Dizon et al., 2018).

    Communication via the Internet has facilitated online communities of patients and providers. These types of online communities can affect patient behaviors. A study by Attai et al. (2015) aimed to determine the effectiveness of social media for patient education on breast cancer using the Breast Cancer Social Media Twitter support community (#BCSM), which provided evidence-based information and support via weekly tweet chats to those affected by breast cancer. A participant survey was provided to chat participants, and 206 responded, noting increased knowledge about breast cancer, including survivorship, cancer types and biology, clinical trials and research, treatment options, genetic testing, and risk assessment. Participation in the chats led 31% of respondents to seek a second opinion or bring additional information to the attention of their treatment team, and 72% of respondents reported plans to increase their outreach and advocacy efforts (Attai et al., 2015).

    Another technology affecting how patients and providers interact is the Apple Health app, which allows data (e.g., heart rate, blood pressure, blood glucose levels) to be pulled from sensors on wearables to the app itself. Apple Health can also take data from a patient’s EHR if the hospital or healthcare provider uses a compatible EHR system. (An Android app with similar capabilities is in the works.) Once data have been collected by the app, these data can then move to other apps on the individual’s smartphone or can be sent to the cloud for storage. Through the Apple Health app and EHR integration, clinicians will be able to obtain select health information when reviewing the patient’s EHR. This integration is expensive, but the federal government’s call for increased interoperability may push this capability forward faster. With expanded ability to connect such health apps with a patient’s EHR, these apps may become even more useful tools for patients and providers (Apple Inc., n.d.; Sim, 2019).

    Implications for Nursing

    eHealth has enabled nurses to communicate with patients remotely, which has provided opportunities for patients to stay in their homes, avoiding unnecessary travel and emergency department visits. Nurses can use telehealth interventions to monitor patients for side effects related to their cancer treatment or to provide management to patients for symptoms of their disease. In addition, nurses should be aware of different types of mobile health options, such as apps that monitor medication adherence, track pain, map glucose trends, or, if indicated, provide listings of clinical trial opportunities. With this information, nurses can then educate their patients about such technologies. Those working in telehealth must be aware of state laws and regulations that govern eHealth practice, as well as that laws, regulations, and reimbursement policies vary by state.

    Conclusion

    eHealth use in clinical oncology has had a significant impact on the delivery of cancer care. With concerns that certain populations have difficulty accessing cancer care because of their remote location or inability to travel, the potential for telehealth to increase access to physicians and nurses and improve outcomes is promising. Advances in telecommunications, which include improvements in high-resolution imaging and greater access to broadband Internet, have expanded access to cancer care. eHealth tools have changed the way that health care is delivered, providing patients with cancer access to a highly specialized healthcare team via remote communication.

    About the Author(s)

    Susan Doyle-Lindrud, DNP, APN, is the assistant dean of academic affairs in the School of Nursing at Columbia University in New York, NY. The author takes full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. The article has been reviewed by independent peer reviewers to ensure that it is objective and free from bias. Doyle-Lindrud can be reached at smd9@cumc.columbia.edu, with copy to CJONEditor@ons.org. (Submitted December 2019. Accepted February 19, 2020.)

     

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