Specialist Cancer Care Through Telehealth Models
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Special Issue – Rural Cancer Original Research Specialist cancer care through Telehealth models Sabe Sabesan, BMBS(Flinders), FRACP Tropical Centre for Telehealth Practice and Research, Townsville Cancer Centre, Townsville Hospital, and School of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia Abstract Objective: Disparities in outcomes are experienced between people who live in rural and remote areas and those who live in larger cities. This paper explores the ability to deliver specialist cancer care through the use of telehealth models. Design: Review of telehealth models for cancer care. Setting, participants and intervention: Cancer patients in rural, remote and Indigenous communities who receive their care through telehealth. Outcome measures and results: Telehealth models seem to be applicable to all fields of oncology and all health professionals. These models not only facilitate the pro- vision of specialist services closer to home in an accept- able, safe and cost-effective manner, but also help expand the rural scope of practice and enhance service capabilities at rural centres. Conclusion: New models of telehealth are another avenue to help further decrease the disparity of access and survival outcomes between rural and urban patients. Implementation of these models requires health system wide approach for development key per- formance indicators and allocation of resources. KEY WORDS: cancer, rural, telehealth, telemedicine. Introduction Limited and/or lack of access to specialist cancer ser- vices is a well-known health and societal problem faced by patients from rural and remote areas in Aus- tralia and other countries with large travel distances. 1–3 These access problems are partly due to lack of spe- cialist visits or availability of specialists locally, narrow scope of practice for rural health professionals and overall work force shortages. These three factors create and perpetuate a vicious cycle (Fig. 1), with the end result of lack of availability of specialist services closer to home and the need for often costly long dis- tance travel. In this vicious cycle, lack of availability of specialists or specialist visits may be due to true shortage of specialist workforce, or low patient numbers, which does not justify the time and cost of specialist travel to many rural centres. 3 Telehealth is an example of one solution to break this vicious cycle by increasing the rural access to specialists from tertiary or larger regional centres. It appears that there is a role for teleoncology (telehealth in oncology) models in almost all the subspecialties in cancer care including medical and radiation oncology, haematology and bone marrow transplantation, palliative care, nursing and allied health. Table 1 summarises the nature of services provided by various subspecialties. In addition, teleoncology models are increasingly used for providing clinicians from smaller centres access to multidisci- plinary team meetings at larger cancer centres. 13 Outcomes of teleoncology models Several evaluation studies have reported positive find- ings with telehealth and teleoncology. These findings include: • High rates of satisfaction of telehealth models among patients and rural health professionals, 14–16 • Safety of chemotherapy supervision remotely, 17 • Cost savings to the health systems. 18,19 However, literature on true savings to the patients and their carers and survival outcomes is limited. These out- comes are summarised in Table 2. Requirements for teleoncology services Various colleges and professional associations have developed guidelines to assist with the effective Correspondence: A/Prof Sabe Sabesan, Tropical Centre for Telehealth Practice and Research, Townsville Cancer Centre, Townsville Hospital, 100 Angus Smith Drive, Townsville, Queensland, 4814, Australia. Email: sabe.sabesan@health .qld.gov.au Accepted for publication 4 December 2014. Aust. J. Rural Health (2015) 23, 19–23 © 2015 National Rural Health Alliance Inc. doi: 10.1111/ajr.12170
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Specialist Cancer Care Through Telehealth Models
Transcript of Specialist Cancer Care Through Telehealth Models
Special Issue – Rural CancerOriginal Research
Specialist cancer care through Telehealth modelsSabe Sabesan, BMBS(Flinders), FRACP
Tropical Centre for Telehealth Practice and Research, Townsville Cancer Centre, Townsville Hospital,and School of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
AbstractObjective: Disparities in outcomes are experiencedbetween people who live in rural and remote areas andthose who live in larger cities. This paper explores theability to deliver specialist cancer care through the use oftelehealth models.Design: Review of telehealth models for cancer care.Setting, participants and intervention: Cancer patientsin rural, remote and Indigenous communities whoreceive their care through telehealth.Outcome measures and results: Telehealth models seemto be applicable to all fields of oncology and all healthprofessionals. These models not only facilitate the pro-vision of specialist services closer to home in an accept-able, safe and cost-effective manner, but also helpexpand the rural scope of practice and enhance servicecapabilities at rural centres.Conclusion: New models of telehealth are anotheravenue to help further decrease the disparity of accessand survival outcomes between rural and urbanpatients. Implementation of these models requireshealth system wide approach for development key per-formance indicators and allocation of resources.
KEY WORDS: cancer, rural, telehealth, telemedicine.
IntroductionLimited and/or lack of access to specialist cancer ser-vices is a well-known health and societal problemfaced by patients from rural and remote areas in Aus-tralia and other countries with large travel distances.1–3
These access problems are partly due to lack of spe-cialist visits or availability of specialists locally, narrowscope of practice for rural health professionals and
overall work force shortages. These three factorscreate and perpetuate a vicious cycle (Fig. 1), with theend result of lack of availability of specialist servicescloser to home and the need for often costly long dis-tance travel.
In this vicious cycle, lack of availability of specialists orspecialist visits may be due to true shortage of specialistworkforce, or low patient numbers, which does notjustify the time and cost of specialist travel to many ruralcentres.3 Telehealth is an example of one solution tobreak this vicious cycle by increasing the rural access tospecialists from tertiary or larger regional centres.
It appears that there is a role for teleoncology(telehealth in oncology) models in almost all thesubspecialties in cancer care including medical andradiation oncology, haematology and bone marrowtransplantation, palliative care, nursing and alliedhealth. Table 1 summarises the nature of servicesprovided by various subspecialties. In addition,teleoncology models are increasingly used for providingclinicians from smaller centres access to multidisci-plinary team meetings at larger cancer centres.13
Outcomes of teleoncology modelsSeveral evaluation studies have reported positive find-ings with telehealth and teleoncology. These findingsinclude:
• High rates of satisfaction of telehealth modelsamong patients and rural health professionals,14–16
• Safety of chemotherapy supervision remotely,17
• Cost savings to the health systems.18,19
However, literature on true savings to the patients andtheir carers and survival outcomes is limited. These out-comes are summarised in Table 2.
Requirements forteleoncology servicesVarious colleges and professional associations havedeveloped guidelines to assist with the effective
Correspondence: A/Prof Sabe Sabesan, Tropical Centre forTelehealth Practice and Research, Townsville Cancer Centre,Townsville Hospital, 100 Angus Smith Drive, Townsville,Queensland, 4814, Australia. Email: [email protected]
Accepted for publication 4 December 2014.
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Aust. J. Rural Health (2015) 23, 19–23
© 2015 National Rural Health Alliance Inc. doi: 10.1111/ajr.12170
implementation of telehealth models. Although theseguidelines are not specific to oncology, the requirementsand principles of establishing such models are same forall specialities. One such example is the Royal Austral-asian College of Physicians (RACP) Guidelines and Prac-tical Tips for Telehealth accessible via http://www.racptelehealth.com.au/guidelines/. Another usefulresource is the practical aspects of Telehealth series ofarticles produced by the RACP Telehealth WorkingGroup.
Essentially, all these guidelines assist the cliniciansand health managers in several requirements oftelehealth including issues such as technology, fundingand resources, training, governance and other aspects ofhealth care. Specific to oncology, more guidance isneeded in relation to breaking bad news and discussingprognosis on technology-based consultations.
Enhancing rural capabilitiesthrough telehealthTelehealth models can improve the access to specialistscloser to home.6 Providing telehealth consultations will
FIGURE 1: The vicious cycle of issues related to rural specialist services.
TABLE 1: Examples of telehealth services provided byoncology sub-specialities
Subspecialty Examples of services
Radiationoncology4,5
Radiotherapy treatment planningPatient consultations
Medical oncology6,7 Patient consultationsRemote supervision of chemotherapyAcute care management
Palliative care8,9 Patient consultation and homemanagement
Haematology/Bone marrowTransplantation
Patient consultations
Nursing10 Patient educationSupervision of oral and intravenous
chemotherapy administrationAllied health11,12 Swallow assessment, lymphoedema
management psychosocialcounselling
What is already known on this subject:• There are disparities in outcomes between
people who live in metropolitan and rural/remote Australia. These disparities arecomplex and are not simply related to differ-entials in access.
• New models of care allow a number of thera-pies to be provided safely closer to home andsome ongoing assessment that otherwisewould require travel.
What this study adds:• This paper is a worked example of telehealth
in the real world, delivering care in theAustralian context.
• It provides a framework for models that candeliver systems change.
• It is a successful demonstration project of theuse telehealth, significantly improving spe-cialist access over a large geographic regionwithin existing funding mechanisms.
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reduce the need for unnecessary travel to major centres.If specialist treatment is not provided as part of themodel, it is unlikely that the scope of practice and work-force will improve at rural centres. The following casestudy illustrates how rural service capability can beimproved by shifting specialist services closer to home.
Townsville-Mt Isa case studyPrior to the establishment of the Townsville teleoncologynetwork (TTN)6, all patients had to travel to Townsvillefor specialist consultations and most types of chemo-therapy regimens. Because the establishment of the TTN,by shifting specialist medical oncology services to Mt Isagradually over 6 years, the scope of practice hasexpanded and the number of health professionalsincreased to accommodate the new services and scope ofpractice. As a result, Mt Isa has become a stand-alonerural cancer care unit as depicted in Figure 2.
This case study illustrates how telehealth models havethe potential to break the rural viscous cycle depicted in
Figure 1 and to expand the scope of practice andenhance the rural workforce as illustrated in Figure 3.As a result of such models rural patients are able toreceive their specialist services closer to home withouttravelling long distances and suffering disruption towork and family routine.
More needs to be doneCurrent telehealth and outreach models serve patientsfrom larger rural centres and patients from smallercentres; however, many are unable to receive cancercare closer to home due to shortages of chemotherapynurses and oncology pharmacists. Therefore, newmodels of remote chemotherapy supervision incorporat-ing telenursing and telepharmacy are needed in additionto the specialist consultations via telehealth.
One such model is the Queensland Remote Chemo-therapy Supervision model; endorsed by the QueenslandHealth for state-wide implementation.
TABLE 2: Summary of reported outcomes on telehealth models
Outcome Results Comments
Patient satisfaction High levels of satisfaction among patientsincluding Indigenous patients
Benefits include reduction in travel, reduced cost oftravel, less disruption to family and work routine
Perspectives of healthprofessionals
High levels of acceptance of telehealth models Major benefits for continuity of care, ability tonetwork with tertiary colleagues and to receivesupport
Safety of chemotherapysupervision
Dose intensity and safety profile was similarto reports in the literature
This is based on a single centre study.
Cost Telehealth models can save money to the healthsystem
When the number of consultations increases, savingsalso increase.
Limited studies on cost savings to patients.
Mt Isa Cancer Care Unit
Staff
Allied health, local senior and junior medical officers, nursing
Services
Specialist clinics-new, routine and on demand, ward consults, urgent reviews, most cancer types, all chemotherapy regimens, in patient admissions
TownsvilleCancer CentreMedical oncology Staff specialists
Telemedicine
FIGURE 2: A Townsville teleon-cology network model of rural specialistservice.
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Another issue for rural centres is the limited access toclinical trials, which are important aspect of moderncancer care. Because one of the barriers to participationin clinical trials is distance and travel,20 pharmaceuticalcompanies and corporate trial groups need to accepttelehealth models as part of their protocols. Telehealthmodels can be used for consenting, monitoring of tox-icities, supervising oral medications and follow up aspart of clinical trials.
Because communication skills are paramount inoncology, health professionals, such as doctors, nurses,allied health professionals and cancer care coordinators,involved in cancer care of rural patients need to havesome training in telehealth consultations in order toprovide effective and culturally appropriate cancer care.
Finally, to increase the uptake of telehealth, hospitalsneed to incorporate telehealth as part of their core busi-ness and implement it through appropriate key perfor-mance indicators and allocation of necessary resources.
ConclusionTelehealth models are applicable to all fields of oncologyand all health professionals. These models not onlyfacilitate the provision of specialist services closer tohome but also help expand the rural scope of practiceand enhance service capabilities at rural centres. Newmodels of telehealth are needed to decrease the disparityof access and survival outcomes between rural andurban patients.
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FIGURE 3: Impact of telehealth on rural service capabilities.
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