CHAPTER 4 Telemedicine in patient care of long‐term transplant survivors
Catherine J. Lee1, Mihkaila Wickline2, and Mary E.D. Flowers3
1 Utah Blood and Marrow Transplant Program, Huntsman Cancer Institute, Salt Lake City, UT, USA
2 Seattle Cancer Care Alliance, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
3 Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, Seattle, WA, USA
Introduction
Telemedicine is a quickly expanding mode of healthcare and is garnering great interest for its potential to improve access in a cost‐efficient manner to long‐term Hematopoietic Cell Transplant (HCT) survivorship care. Telemedicine, broadly defined as delivery of medicine from a distance, encompasses a range of technology spanning from the internet, telephones or smartphones, or other mobile wireless devices to provide a range of healthcare services and exchange of information [1].
One of the earliest reported uses for telemedicine was for acute conditions, such as ischemic stroke, as this life‐threatening condition required critical and time‐sensitive determination of fibrinolytic therapy from a remote neurologist [2]. Telemedicine has also been used to deliver care for those in the military, prisons, and rural locations and, more recently, it has been utilized for chronic medical conditions [3,4]. In the past few years, telemedicine has had an increasing presence in the delivery of oncology care. Beginning in the late 1990s, Doolittle and colleagues from the University of Kansas Medical Center pioneered teleoncology to improve access for rural patients to oncology care [5]. This approach resulted in high levels of patient satisfaction and cost‐effectiveness [6,7], which has been replicated by other oncology groups [8–10]. Since then, teleoncology has further expanded to include other services such as cancer telegenetics, teleradiology, telepathology, survivorship care and palliative care medicine [11].
Telemedicine is gaining increasing popularity in providing a cost‐effective means to deliver specialized medical care to patients who have difficulty accessing healthcare services due to limited resources, distance, or inconvenience. While its utility has been well‐documented for care of oncology and chronic illnesses, there is paucity of information for its use in the care of long‐term HCT survivors. We will discuss the current state of telemedicine in HCT long‐term follow‐up (LTFU) and future directions for a telehealth model of care in this setting.
Principles of telehealth
Components of Telehealth
Telehealth is an emerging care delivery modality with many nuances that can most simply be explained as a wide range of activities that aim to provide healthcare from a distance [12]. Telehealth makes it possible for people living in remote areas to connect across geographic distance which allows improved access to specialty health care [13]. Often, the terms telehealth and telemedicine are used interchangeably, but telemedicine has a narrower definition of the provision of clinical diagnosis and monitoring services whereas telehealth is broader and may include patient education, provider education, health promotion and remote monitoring [14].
While telehealth began with telephone calls between patients and providers, in recent years, telehealth has expanded to new modalities of communications as technology has become less expensive, more reliable and more widely available [15]. The four main modalities of telehealth are: synchronous (real‐time) communication via telephone or internet, asynchronous (store‐and‐forward) sharing of medical data with a later response from a healthcare provider, remote patient monitoring, and mobile health, sometimes called mHealth, which are typically wearable devices or smartphone apps that are directly marketed to the consumer [14]. Table 4.1 provides examples according to the four telehealth modalities that could be used for long term HCT survivors.
Practical applications for Telehealth
Telehealth has a wide array of applications for patients of all ages, with or without chronic health conditions, to improve access to needed healthcare. A recent review of patient satisfaction with telehealth identified 44 papers published since 2010 that describe wide‐ranging interventions for special populations using varied technology which highlights the diverse potential applications for telehealth [16]. In the National Quality Forum’s report entitled, “Creating a Framework to Support Measure Development for Telehealth,” a robust section delineates telehealth programs in both the United States (US) and abroad and describes the diversity of interventions and the potential opportunities for influencing health outcomes in ways that traditional in‐clinic medicine cannot [17].
Table 4.1 Telehealth modalities that can apply to Long Term Follow Up (LTFU) HCT survivors
| Modality | Example |
|---|---|
| Synchronous (real‐time) | A Skyped “clinic visit” between an LTFU patient in a rural community provider’s office and the HCT center specialist |
| Asynchronous (store‐and‐forward) | An LTFU patient sends photos of a skin rash which is later reviewed by an HCT center specialist to help with the diagnosis of cGVHD |
| Remote patient monitoring | Results of an LTFU patient’s home spirometry using a handheld smart device are transmitted automatically and securely for monitoring of lung GVHD by the HCT Pulmonologist |
| Mobile health | A Fitbit device that tracks fitness goals for an LTFU survivor increasing exercise tolerance that allows the patient to report objective health measures to providers |
HCT, hematopoietic cell transplantation; GVHD, graft‐versus‐host disease.
In the earlier days, telehealth was thought to be most effective for specialties that relied more on verbal interactions than physical contact, such as psychology or neurology [18], but improved technologies have led telehealth to benefit a broader range of sub‐specialties, including oncology [5]. A French review of “Cancer outside the Hospital Walls,” identified recent clinical trials that have demonstrated every level of care in oncology (education, prevention, diagnosis, treatment and monitoring) delivered via telehealth to have good results [19].
Twenty percent of the US population lives in a rural area, but only 3% of medical oncologists practice in rural areas and over 70% of US counties lack a practicing medical oncologist [20]. Additionally, the number of LTFU HCT survivors is growing annually with a predicted 500,000 HCT survivors living in the US by 2030 [21]. HCT recipients are usually discharged back to their primary communities within several months of transplant and oftentimes, they do not live in proximity to their transplant center. Usually, HCT survivors want to retain a connection to their transplant center and may prefer to have their LTFU in person. However, they are often unable to return to their transplant center and, therefore, a telehealth option is an attractive option for delivering care to HCT survivors [22]. Telehealth can help HCT survivors and their caregivers save time and money by offering access to specialty care remotely. Cox et. al. reported that the reassurance cancer survivors feel by having telehealth available to them, “I can always get in touch,” is a helpful connection that provides a sense of safety [23]. An identified key advantage to telehealth is the ability to deliver complex care remotely, which is particularly valuable to academic centers that consult on patients with
