publication date: May. 8, 2020
Embracing the increasing value of eHealth in patient-centered cancer care during the COVID-19 pandemic and beyond
Frank J. Penedo, PhD
Associate director, Cancer Survivorship and Translational Behavioral Sciences,
Professor, Departments of Psychology and Medicine, Sylvester Comprehensive Cancer Center,
University of Miami Miller School of Medicine
Joshua Kronenfeld, MD
Post-doctoral fellow, Surgical oncology,
Resident, General surgery, Sylvester Comprehensive Cancer Center,
University of Miami Miller School of Medicine
This story is part of The Cancer Letter’s ongoing coverage of COVID-19’s impact on oncology. A full list of our coverage, as well as the latest meeting cancellations, is available here.
In the past decade, there has been a growing interest in capitalizing on advances in information technology to provide quality and patient-centered care to cancer patients and survivors outside a hospital or clinic setting.
Telehealth is not a recent innovation, but it continues to evolve with advances in communication and information technologies. eHealth involves the broad use of health information and communication technologies also referred to as telehealth, telemedicine or mHealth delivered via internet-based platforms or mobile applications.
eHealth during the COVID-19 pandemic
With the widespread use of computers, tablets and smartphones, delivery of cancer care via eHealth platforms continues to expand. This trend has accelerated dramatically this spring, as the COVID-19 pandemic has changed the landscape of clinical care in the U.S. and around the world.
The importance of the internet and web-based information during this pandemic was recently highlighted in a PEW Research Center article that reported that up to 87% of Americans report that the internet has been an “essential” or “important” source of information during the COVID-19 outbreak.
eHealth applications provide opportunities to deliver healthcare via mobile health, web-based portals and other telehealth and telemedicine platforms. Although initially conceptualized as a tool to connect health care providers and patients who are not in physical proximity, eHealth is now more of a necessity than an option to foster patient engagement, promote communication and facilitate ongoing patient care.
A silver lining in the challenges we face today in cancer care due to COVID-19 is that advances in eHealth have provided an unimaginable yet necessary route to maintain continuity of care while promoting the safety of patients and health care professionals alike.
As the pandemic has presented health systems with major and extraordinary challenges regarding patient and employee safety due to the risk of COVID-19 infection, many routine cancer care and follow-up appointments have been moved to telehealth sessions.
Whether comprehensive cancer care be effectively delivered via telehealth platforms during this pandemic is a key concern for the oncology community. Drawing from programs that have evaluated the utility of eHealth in assessing and managing patient symptoms and toxicities and improving psychosocial functioning and health-related quality of life, eHealth has the potential to effectively deliver and even enhance patient care.
eHealth programs in oncology patients
Studies suggests that up to 70% of cancer patients seek medical information via the web, while over 30% seek support programs to help them address the unique and complex challenges of a cancer diagnosis and treatment.
As access and use of the internet to obtain health information and support has become vastly widespread, much effort has been devoted to the development and evaluation of eHealth-based educational and support programs specifically targeting oncology patients.
Research conducted over the past decade suggests that eHealth applications can be effectively implemented to monitor and manage symptoms and deliver psychosocial and supportive care to cancer patients and survivors. Numerous studies have documented the feasibility and acceptability of the use of eHealth programs during and after active cancer treatment.
Most programs are self-directed, asynchronous and provide self-management and psychoeducational tools with a growing trend to embed these tools and patient experiences into electronic health records. Although most eHealth programs have been deployed in the context of controlled trials targeting psychosocial challenges and assessment and management of symptom burden with efforts to improve health-related quality of life, work to date is promising and supports the feasibility and acceptability of eHealth in oncology care.
Generally, eHealth programs have been shown to favorably and significantly impact fatigue, depression, anxiety and health-related quality of life. Recent studies also show positive results of eHealth interventions designed to help cancer patients and survivors manage pain, psychosocial distress and other symptoms, with good retention and engagement rates.
eHealth programs have also shown preliminary efficacy in various other specific outcomes, including reduced lymphedema-related chronic pain, improved sexual function in female survivors, and improved health-related quality of life. The eHealth programs involved a mix of tools that included texting support, chat functionality with peer support, therapist led structured online groups, and/or tailored feedback on PROs by health care providers.
Benefits of implementation of eHealth-based care
The implementation and expansion of eHealth to routine patient care affords a cancer center, and its patients, many potential benefits.
For patients who live far from a healthcare facility, such as those in rural areas or patients who wish to see a physician at a distant location, physicians can be accessed by utilizing voice or video communications. The ability to provide care to patients at a distance greatly extends the geographic footprint of a healthcare system.
Patients also enjoy benefits of telemedicine encounters as waiting time in the office is often reduced and time spent traveling to and from appointments is eliminated. For patients caring for children or other persons, they can be evaluated by a provider from the comfort of their homes without worrying about abandoning these responsibilities or endangering others by bringing them to the provider visits.
eHealth also has the potential to improve patient-provider communications, improve symptom monitoring and management, and enhance patient engagement across the cancer care continuum. More and more, tools available via eHealth can be integrated into the patient record thus facilitating information exchange across providers regarding symptoms, toxicities, and other clinically relevant information.
Also, as capabilities of mobile devices and apps continue to expand, valuable lifestyle and clinical information, such as physical activity, body temperature and other data can be easily obtained and integrated to promote patient care.
The benefits of eHealth approaches surpass clinical care. With the onset of the COVID-19 pandemic, the eHealth delivery of cancer support services has increased dramatically. Many cancer centers now offer supportive programs, such as yoga, exercise, meditation, music, eBeauty, art, and other topics via a videoconferencing application.
Although pre-pandemic eHealth-based supportive services have been in place for some time, the fact that these programs are now only available via eHealth options will not only foster greater use of eHealth platforms but perhaps also lead to greater acceptability of remote delivery of these services.
Furthermore, in many cases patients cannot physically access these programs due to multiple barriers, such as transportation, scheduling conflicts and caregiving commitments. Therefore, the forced remote delivery of supportive care services in the presence of COVID-19 may have the unintended benefit of extending the reach of these programs and helping patients at need who otherwise would not be able to attend these supportive oncology programs in person.
Arguably, despite these benefits, there is a quality to the in-person encounter that eHealth cannot replace. The proximity or closeness of being with a patient and a caregiver, behavioral cues and obviously, the physical exam are irreplaceable.
Not surprisingly, and rightfully so, eHealth has been promoted and accepted as an ancillary approach that can facilitate and enhance, but not replace, in-person care or reach patients that otherwise would not be able to physically attend a visit with a care provider.
Suddenly, with not much warning, eHealth-based care has become an only option for many. Although time will tell as research studies report on the quality of cancer care delivery via telehealth, we are likely witnessing a cultural shift among many in their appreciation of technological advances that have facilitated, albeit not without many challenges, the provision of routine oncology care due to COVID-19.
The technological divide
Technological advances in eHealth have great potential to expand and improve patient care. Ironically, these advances do not necessarily reach those patients who may benefit the most.
Most studies lack substantial inclusion of racial and ethnic minorities, rural and financially disenfranchised communities, and older patients.
These communities may have the most to gain from eHealth services, but also continue to face considerable barriers to adequately accessing eHealth programs. Patients who are financially disenfranchised are likely to have limited access to high-speed networks or be geographically located in communities with limited high-speed access.
Similarly, rural communities that face limited access to optimal cancer care can have limited broadband thus limiting the reach and potential benefits of eHealth programs. More eHealth research that includes larger and diverse samples, randomized trial designs, long-term follow-up, and evaluation of clinical outcomes are needed to establish the efficacy of these programs across promoting optimal outcome and providing patient care.
As most cancers occur in people 65 years of age or older, it cannot go unnoticed that a significant technological gap exists for many seniors in the U.S. Seniors continue to lag in technology adoption, particularly in access to broadband high-speed services, cell phone ownership and use of the internet relative to all American adults 18 years or older.
PEW estimates indicate that over 70% of the elderly population goes online every day or almost every day with 82% accessing the web three to five times per week. But this elderly population is also more likely to face functional limitations and greater symptom burden due to cancer treatments and comorbid conditions that add complexity to their care.
Another point to consider is that most of the available programs are self-administered and intended to provide self-management skills or psychoeducation. Therefore, while patient acceptability has been high, one must consider that these programs were not intended to provide or replace routine care as it has been necessary during this pandemic.
Whether patients will accept eHealth as a viable option during routine cancer care independent of a crisis such as we are facing remains to be determined.
One should also not lose sight of the impact eHealth on the provider experience. Human factors research that has evaluated clinician user interfaces for telemedicine services point to multiple challenges including, but not limited to, poor or disrupted video imaging and sound quality, real-time information processing via video conferencing, connectivity issues, and poor integration into existing clinical workflows.
Additionally, privacy remains a major concern, and secure and Health Insurance Portability and Accountability Act compliant services needed to be employed. These services included platforms such as Facetime, Zoom, or other similar tools allowing audio and video communication between providers and patients.
In addition to establishing an avenue for delivery of care, there needed to be the ability for providers to receive payment for these virtual encounters. The Centers for Medicare and Medicaid Services responded to this need by expanding reimbursement for telemedicine encounters to allow for adequate compensation for healthcare providers and healthcare systems.
Establishing the infrastructure for healthcare providers and systems, however, overcomes only some of the barriers to providing adequate healthcare remotely.
Advances in eHealth technology offer a timely opportunity to optimize research on cancer care delivery and address the multiple challenges faced by patients, their families, and care partners. Today, eHealth applications support the delivery of valuable psychosocial services and monitoring of symptoms and toxicities among patients and survivors.
As we face the COVID-19 pandemic, eHealth can present an opportunity to sustain valuable patient care under challenging circumstances. Telemedicine, although not a recent innovation, has become the primary mechanism of care delivery for patients during the COVID-19 crisis. While obstacles are present for hospitals and providers to establish these services, many barriers exist with patient access to these services.
Appropriate follow-up should be provided for those with chronic medical illnesses and malignancies, helping to prevent the deterioration of these conditions during the COVID-19 crisis.
We are now witnessing technological developments that will transform models of cancer care delivery. We are at a pivotal point in this transformation.
Deploying eHealth services can enable better management of both patients and cancer survivors. In addition to improving patient outcomes, implementation of eHealth programs and patient can also ultimately improve systems-level outcomes, such as a reduction in visits to emergency departments, hospital readmissions and other high-cost services.
We are amid a transformative experience that has necessitated the use of real-time, dynamic, and technology-assisted assessments, interventions and cancer care delivery via telehealth. eHealth has the potential to improve the delivery of cancer care through enhanced patient–provider communication, improved symptom and toxicity assessment and management, and optimized patient engagement across the cancer care continuum.
Finally, when considering eHealth programs, a critical consideration is to ensure equity for all patients seeking to access health services. Patients of lower socioeconomic status, racial/ethnic minorities, and older adults may require additional assistance in connecting with providers, and it is our duty to help solve these issues.
Telemedicine can connect patients and providers during this time of crisis, but hopefully, this will serve as a model for continued use after the global pandemic has abated.