Barriers & Facilitators to Telemedicine: Lessons Learned from ASCO 2021

The COVID-19 pandemic spurred the widespread adoption of telemedicine, but were all patient populations able to enjoy the benefits of telemedicine equally? Seeking to address that exact question was the session titled, “Can You Hear Me Now: Barriers and Facilitators to Telemedicine,” at the 2021 American Society of Clinical Oncology (ASCO) Annual Meeting.

Featuring Drs. Ana Maria Lopez, Ramya Thota, Kenneth Lam, and Ateev Mehrotra, this session covered some of the key factors affecting a patient’s—and even a physician’s—ability to access and implement telemedicine, ranging from demographic factors to policies.

Here’s a recap of the key lessons learned from this session.

Assessment of Disparities in Digital Access & Implications for Telemedicine

Kicking off the session was Dr. Lopez, Professor and Vice-Chair of Medical Oncology at Sidney Kimmel Cancer Center at Thomas Jefferson University who looked at the use of telemedicine amid the COVID-19 pandemic.

According to recent data, 35 percent of healthcare professionals surveyed said that they were not planning on offering telemedicine in 2019. However, with the onset of the COVID-19 pandemic, telehealth went from being a curiosity to a necessity.

And while telemedicine was shown to be comparable to in-person care, it was discovered that those patients with limited access to telemedicine were in the same population who was experiencing poor health outcomes amid the pandemic, including those over the age of 65 as well as Black and Latinx patients. Dr. Lopez cited demographic factors, such as age, race, and ethnicity, and technology access factors, like broadband access and user capability, as key contributors to this disparity.

To conclude, she argued that to ensure the successful and equitable application of telemedicine, healthcare professionals need to address patient and physician barriers, maintain facilitators for telemedicine, and conduct research to identify best practices for integration into clinical practice.

Telehealth to Improve Oncology Care for Rural Communities

The next panelist was Dr. Ramya Thota from Intermountain Healthcare in Utah who zeroed in on the use of telemedicine in rural areas.

One in six Americans live in rural areas and often lack access to healthcare, especially high-quality cancer care. Because of this, rural residents with cancer have worse survival rates since they are typically diagnosed at later stages.

The good news, however, is that telehealth can help improve access to cancer care in rural areas by reducing barriers to care like travel and cost burdens. In fact, the tele-oncology program at Sevier Valley Hospital in Richfield, Utah found that by having over 2,000 telehealth visits, patients saved a total of $700,000 in travel fees.

Dr. Thota also argued that telemedicine can increase access to clinical trials. Rural patients typically have to travel long distances to participate, but with telemedicine, patient monitoring, follow-ups, and surveys can all be done digitally.

Despite all of these benefits, however, Dr. Thota outlined four key challenges in rural areas:

• Technology Challenges, including a lack of reliable high-speed internet, limited access to smartphones, and lack of EHR interoperability
• Patient Challenges, including low-digital literacy, mistrust in technology, and concerns for data protection
• Physician Challenges, including cross-state licensures, restrictive federal and state legislation, lack of connection with patients, and difficulty incorporating into workflows
• Organizational Challenges, including lack of sustainability, lack of reimbursement, and limited resources

Because of these challenges, Dr. Thota emphasized the importance of increasing digital literacy and universal physician licensing so that those patients living in rural areas can access high-quality cancer care.

Understanding Telemedicine Readiness Among Older Adults

Dr. Lam from the University of California, San Francisco focused on another patient group who didn’t always reap the benefits of telemedicine during the COVID-19 pandemic: older adults.

Throughout the pandemic, one in four older adult outpatient visits were done via telemedicine compared to one in three visits in the rest of the population. This is especially jarring since older adults comprise of over one-third of healthcare expenditure. In fact, the median age of cancer diagnosis is 66.

In addition, Dr. Lam’s recent research found that older adults had the greatest reduction in outpatient visits during the COVID-19 pandemic and the least uptake in telemedicine visits. And while Dr. Lam pointed out that some older adults did adopt telemedicine, a majority of them were left behind in the transition to telemedicine.

So what can be done to avoid these disparities moving forward? According to Dr. Lam, it’s important to separate unwilling versus unequipped older adults as this leads to different interventions.

For instance, if you ask a patient if they’re interested in telemedicine or if they own a device and they say no, that might mean the patient is unwilling to adopt telemedicine. If you have an unwilling patient, Dr. Lam recommends the following:

• Provide reassurance on why telehealth is recommended
• Provide an explanation for how an in-person visit can be arranged if needed
• Offer a phone visit and then ask to switch to video after rapport is achieved

Asking questions like “Do you have an internet connection? Do you have someone to help you? Do you have vision, hearing, or cognitive impairments?” can help you determine if the patient is unable to participate in telemedicine. In this case, Dr. Lam recommends the following:

• Consult social work to assist with finding local resources
• Consider using a virtual waiting room with someone to check patients in and answer questions
• Have support staff conduct a test visit
• Have a printed sign to communicate with patients in case their sound doesn’t work
• Simplify the login process
• If a patient suffers from any impairments, consider a hub and spoke model, advocate for phone visits, and use video conferencing services with live closed captioning

Evolving CMS Policies Towards Telehealth & How to Incentivize Best Practices Through Reimbursement

Any discussion of telemedicine wouldn’t be complete without acknowledging the role of policies, which is exactly what Dr. Mehrotra from Harvard Medical School discussed.

In response to the disruption in care brought on by the COVID-19 pandemic, policymakers implemented temporary policies to facilitate telemedicine, including visits no longer being limited to rural residents and waiving licensure requirements across state lines.

These policies increased the use of telemedicine, but they also brought several changes and questions regarding what telemedicine policy will look like post-pandemic.

In an effort to address that question, Dr. Mehrotra said that policymakers’ framework includes the idea that just like no patient is the same, there shouldn’t be just one telemedicine policy out there. Another component of the framework is the belief that policy should be formulated through the lens of value by looking at health outcomes achieved per dollar spent.

To encourage the high-value use of telemedicine, he provided examples of what some policies might include:

• Alternative payment models
• Out-of-pocket costs
• Limit coverage to certain patients, providers, or conditions
• Payment rate for telemedicine
• Requiring in-person visit before telemedicine

And while there are still some areas of debate that need to be sorted out, such as the licensure of physicians and fraud concerns, Dr. Mehrotra noted that amid the tremendous uncertainty on post-pandemic policies, the overarching goal is to encourage the high-value use of telemedicine.