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Telemedicine: Transporting Cancer Expertise to All Corners of the World
Telemedicine has the capability to bring state-of-the-art healthcare to isolated areas, enabling the delivery of medical services to sites that are at a distance from the provider. Technologies used in telemedicine include videoconferencing, the Internet, streaming media, satellite, telephone landline, and wireless communications. Telemedicine also has the potential to facilitate better communication between patients and their providers, help patients take better care of themselves, help their caregivers keep better track of their health condition and their self-care, alert doctors to medical emergencies, and provide reminders when patients are due for cancer screening tests and other appropriate medical services.
Approximately one-fourth of the U.S. population lives in isolated or rural areas and many confront formidable barriers to quality cancer care. The lack of health care personnel and resources in rural areas and the cost and inconvenience of transportation can create obstacles for patients who don’t live in cities. Sometimes patients may end up choosing treatment options based on convenience rather than the best medical practice because some services or equipment are not available in their area. In addition, many managed care enrollees and Veterans Administration beneficiaries are required to obtain services from contracted providers that can be distant from the patient’s home, sometimes in another state. In most patients, even those in urban and other areas with many health providers, the norm is relatively infrequent face-to-face contact with their health care providers. Telemedicine offers a convenient means to increase the number of these contacts and thus improve patient monitoring and self care, resulting in improved health outcomes.
To evaluate the promise of telemedicine and determine the most effective ways to employ the technology, the National Cancer Institute is funding an array of research projects in a wide variety of settings. Here are a few examples:
Radiation Oncology
Hospitals and cancer centers that provide radiation oncology services to a large number of medically underserved, low-income, ethnic or minority populations are not often linked to the nation’s cancer research effort and sometimes struggle to maintain state-of-the-art cancer care. Qualified radiation oncologists practicing in these institutions, who may have a strong interest in conducting clinical science, have difficulty starting and sustaining research programs due to the lack of available resources and expert support.
To encourage increased involvement of these institutions in research, NCI recently developed the Cancer Disparities Research Partnerships (CDRP). The program supports mentoring partnerships between community hospitals that care for a disproportionate number of medically underserved, low-income, ethnic and minority populations and experienced institutions actively involved in NCI-sponsored cancer research. The mentor institutions will offer assistance in initiating radiation oncology research programs and help mentee institutions with protocol development, monitoring of trials, and data analysis. An integral part of this program is a telemedicine system that will enable experts at the mentor sites to perform consultations with patients at the mentee sites, as well as remote viewing of biopsy specimens, magnetic resonance imaging (MRIs), digital mammography, and other scans, with the ability to examine and discuss a case simultaneously. (see main BenchMarks article)
Two partnership projects are currently in progress: The San Antonio Cancer Institute in San Antonio, Texas, and the University of Texas M. D. Anderson Cancer Center, in Houston, are serving as mentor partners for the Mercy Health Center in Laredo, Texas. The University of Wisconsin Comprehensive Cancer Center, in Madison, and the Mayo Clinic Comprehensive Cancer Center, in Rochester, Minnesota, are serving as mentor partners for the Rapid City Regional Hospital in South Dakota. Four additional partnerships are just getting underway.
Symptom Management
A collaborative pilot project between NCI and the Department of Veterans Affairs (VA) enables cancer patients who are undergoing chemotherapy or coping with end-of-life issues to have their symptoms monitored by an electronic “Health Buddy” device connected to their telephone. The premise of the program is that many health problems can be handled in a more timely and effective way and that visits to the hospital or clinic could be averted through regular telephone contact with a care coordinator assigned to the patient.
Each day, patients are asked a number of questions about how they feel, and they respond by selecting answers on an electronic box attached to a telephone line. The information is fed into a central terminal monitored by health professionals. If a cancer patient reports pain, nausea, shortness of breath, depression, or any other distressing symptoms, a nurse calls back and consults with the patient to determine whether he or she needs to be seen in person, or whether a change in prescription, dosage, or other intervention could help. The investigators believe that tracking and responding to the needs of cancer patients is an important issue, because studies have shown that symptom management during cancer treatment, and especially at the end of life, is often poor.
The University of Utah and Boston University (Boston Medical Center) is testing the efficacy of a computer-based telecommunication system for cancer patients who are receiving chemotherapy. Telephone-Linked Care for Chemotherapy (TLC-Chemo-Alert) monitors and records the at-home symptom experiences of patients, focusing on the common side-effects of chemotherapy. The goal of the program, led by Kathleen H. Mooney, is to detect side-effects symptoms early and alert the responsible providers, so that there is better control of symptoms and better quality of life for the cancer patient. The program aims to accomplish this by enhancing communication between patients and their health care providers, and assisting providers in taking a more active role in symptom management. Patients are asked to call every day and an automated voice asks questions about their symptom experience during the previous 24 hours for 11 different symptoms such as their level of pain, nausea, fever, or fatigue, and prompts them to rank the severity of those symptoms by keying numbers into a telephone keypad. The patient’s oncology provider team (medical oncologist and oncology nurse) is alerted by fax or e-mail if the patient is experiencing symptoms that have exceeded a preset threshold for severity. Additionally, each group of patients is studied over two treatment cycles, and the information gathered from the patient during the first cycle can frequently be used to improve a patient’s symptoms during the second cycle of chemotherapy.
On-line help for parents of children with cancer
Pediatric Cancer CareLink, an Internet-based system is designed to help parents of children with leukemia. It gives caregivers needed information through a direct link to their oncology team and personalized on-line educational materials. Because treatment of childhood leukemia often entails a complex regimen of medications and chemotherapy, parents often struggle with keeping track of medication schedules and may be reluctant to call doctors in the evenings and on weekends when they have questions about side effects and safety issues. This program, led by Charles Safran of Clinician Support Technology, Inc., allows parents to create an electronic medication schedule and alerts them to the warning signs of dangerous symptoms and side effects.
Telemedicine for Cancer Screening
Telemedicine is also being utilized to promote cancer screening. In a project led by Robert H. Friedman, M.D., Boston Medical Center is currently testing the effectiveness of a telephone voice response system to increase the use of mammography among women ages 50 to 74 by identifying the barriers to getting regular mammograms and encouraging women to make mammography a consistent habit. After an initial reminder letter, study participants receive a phone call that uses a recorded voice to ask questions about the concerns and problems they might have that may influence whether they get their mammogram. By using the touch tone keypad on their telephones, women can respond to the questions and may either be asked follow-up questions or may be offered encouragement about the value of getting an annual mammogram.
The same system has previously been shown to be successful in changing people’s behavior in improving medication compliance, diet and exercise. Future systems will replace the telephone keypad with voice-recognition software.
Other resources for information on telemedicine and health disparities
CRISP is a searchable database of federally funded biomedical research projects conducted at universities, hospitals, and other research institutes. Use the search terms “telemedicine”, or “telehealth”. To find just what NCI is funding, narrow the search by selecting NCI under the “Institutes and Centers” category: http://crisp.cit.nih.gov/
Fact sheet on telemedicine from the National Library of Medicine: http://www.nlm.nih.gov/research/telemedinit.html
NCI’s Plans & Priorities – Reducing Health Disparities: http://plan.cancer.gov/public/disparities.htm
NCI’s Center to Reduce Health Disparities: http://crchd.nci.nih.gov/
Health Resources and Services Administration (Office for the Advancement of Telehealth: http://telehealth.hrsa.gov/index.htm.