Almost as soon as the COVID-19 pandemic began, telehealth-based care delivery became a necessity across multiple medical specialties. After decades of innovation and advocacy, telemedicine was elevated from a modality that was often seen as unnecessary or optional for all but the most remote or underserved areas to a critical link to essential medical care for many patients while minimizing virus exposure.
Previously, this mode of delivery may not have seemed as feasible for hematology consults compared to other specialties such as psychiatry or dermatology. The benefits of telemedicine quickly became more evident in the context of the current crisis, especially given the elevated risk of COVID-19 infection and severe symptoms among the patients served by hematology and oncology practices.1,2
In a paper published in September 2020 in CA: A Cancer Journal for Clinicians, clinicians from the division of hematology and medical oncology at Weill Cornell Medicine in New York described how they adapted their hematology and oncology services to “continue providing safe and essential cancer care while protecting our patients and personnel, minimizing resource utilization, and redeploying members of our team to inpatient COVID‐19 units.”3
In another recent article on the topic, physicians at the Sidney Kimmel Cancer Center at Thomas Jefferson University Hospital in Philadelphia stated that care models such as “telehealth, home-based chemotherapy, and remote patient monitoring . . . provide the right treatment, to the right patient, at the right time, in the right place.”3
Results of a study by researchers at the Houston Methodist Cancer Center indicate overall patient and physician satisfaction (92.6% and 65.2%, respectively) with video-based oncology/hematology services provided during the pandemic. However, opportunities remain to improve telemedicine access for vulnerable patients including those who are older, underinsured, and with lower incomes.4
We interviewed Steven Fein, MD, MPH, founder and medical director of the nationwide telemedicine practice Heme Onc Call, to discuss how this technology is being applied in hematology and oncology.
What was the state of telemedicine for hematology and oncology prior to the pandemic, and how has it changed due to the pandemic?
Prior to the pandemic, hematology telemedicine was limited to peer-to-peer advice. This was accelerated during the past 10 years as internet connectivity and electronic medical records became more universal. Remote physician-to-patient televisits, as we know them now, did not occur for hematology/oncology.
For other specialties there has been a gradual acceptance of the need to provide both inpatient and outpatient live televisits. For inpatients, stroke-focused teleneurology and telepsychiatry have become widely accepted for hospital ERs in both rural and nonrural settings. This was mostly because of the shortage of stroke-focused neurologists available to go in person to all hospitals, as well as the need for emergency coverage to plan tPA infusions for stroke patients.
The biggest obstacles to providing outpatient care by telemedicine were lack of widespread access to good A/V communication technology and Wi-Fi or internet connectivity, as well as lack of satisfactory “HIPAA-compliant” software. In fact, there was widespread fear among providers that televisits would violate HIPAA. There was also resistance among health plans, doubting the value of televisits and using the pre-2021 CMS CPT coding requirements that required comprehensive physical exams to justify payments.
During 2019, CMS approved coverage for other specialties in rural and critical access hospitals, including both inpatient and outpatient access. Uptake was slow, but there was some movement in rural and small nonrural hospitals to expand subspecialty inpatient telemedicine coverage, particularly infectious disease and pulmonary specialties. Then, in March 2020, new coverage rules brought about by the COVID-19 pandemic opened the door to all specialties in all hospitals.
Through all of this, hematology inpatient coverage has been limited because hematology/oncology providers prefer outpatient practices and their time is usually dominated by oncology. Thus, the possibility of practicing both rural and nonrural inpatient telemedicine hematology did not lead many to do it.
On the outpatient side, hematology/oncology providers were resistant to utilizing televisits, probably because many of their patients receive in-person treatments in the doctors’ offices. Among patients who really did not need to be seen in-person, there was widespread resistance to telehealth, likely over concerns about HIPAA and payments for visits.
With COVID-19 changes, all hematology/oncology practices transitioned to telehealth, now with better technology, no concern about HIPAA, and more confidence about payment for services. Over the past year, however, most hematology/oncology providers have reverted to as much in-person as possible, some providers citing that televisits are not easy nor enjoyable for them.
What have been the most notable benefits and drawbacks of inpatient telemedicine, especially those specific to this specialty?
In addition to the general benefits of inpatient telemedicine, including access to specialists and more efficient handling of patient transfers while avoiding potential virus exposure, the specific benefits of telemedicine for hematologists include the ability to identify and properly manage life-threatening hematologic problems; better utilization of hospital-based hematology expertise by enabling hematologists to participate in the care of more inpatients with blood concerns; earlier involvement in the care of inpatients who may need hospital transfer; and more efficient use of time by seeing inpatients online instead of going to hospitals.
For hematology/oncology providers, in-person inpatient coverage is time-consuming, limits their outpatient practice capabilities, and possibly causes physician burnout. This could be avoided by replacing in-person hospital coverage with televisits, or by having televisit hematology/oncology specialists cover their hospitals.
Some of the drawbacks of inpatient telemedicine for hematologists are the lack of access to seeing patients’ blood smears and the inability to perform bone marrow biopsies, and for oncologists, there is the challenge of telling bad news without in-person hand-holding. Additionally, it is sometimes hard to coordinate the episode of live A/V televisit with nursing staff, and hospitals may be reluctant to pay for televisits without understanding the value added.
What have been the most notable benefits and drawbacks of outpatient telemedicine?
For hematology, many problems can be addressed without in-person physical exams. With outpatient telemedicine, patients can be seen more promptly because the doctor’s schedule is more efficient, and patients in rural or underserved areas have access to specialists without having to miss work or hire childcare to see their doctors.
Patients who are discharged from hospitals can be seen more quickly for follow-up, and they are less likely to miss appointments because televisit is more convenient. It is also easier to bring in patients’ family members during televisits, including times when telling bad news for oncology patients.
Regarding the drawbacks of outpatient telemedicine, it is sometimes difficult to do a thorough evaluation without an in-person physical exam, and the A/V connection is sometimes challenging. There is a “digital divide” among people who don’t have good hardware and a “digital desert” among people who don’t have good internet connection.
As with inpatient telemedicine, there are also issues pertaining to the lack of in-person hand-holding, health plans’ reluctance to pay for televisits, and the inability to perform bone marrow biopsies.
I was part of the original team that developed Georgia’s statewide telemedicine program, which later became the Global Partnership for Telehealth (GPT). I noticed that they hosted you for a recent webinar on telemedicine consults for life-threatening hematologic emergencies. Can you say a bit about this particular use of telemedicine?
Hospital-based hematology includes several life-threatening hematology conditions. These include but are not limited to: severe bleeding with coagulopathy, including bleeding disorders, anticoagulant-related bleeding, and post-partum bleeding; DVT/PE, clotting stroke, other site clotting, and heparin-induced thrombosis; low platelet counts caused by ITP or APL leukemia; new presentations of heme malignancy, including leukemia, lymphoma, and multiple myeloma; very high blood counts, with stroke or impending stroke; and special hematologic disorders including TTP, HUS, HLH, acute porphyria, and other conditions.
Hospital-based oncology also involves several life-threatening inpatient conditions, including, but not limited to, SVC syndrome, spinal cord compression, pleural and pericardial effusions, new brain tumor presentations, severe pain, obstructive nephropathy, and metastatic germ cell tumor.
The general benefit of telemedicine for these conditions is early recognition and intervention. We educate patients and their families about the conditions, and we start early intervention to stabilize very sick patients. Then we determine whether the patient needs to be transferred to a tertiary care hospital and we help facilitate the transfer.
In the GPT lecture, I discussed 3 examples of “life-threatening” hematology consults. In one case, a patient with APL leukemia, the patient would have likely died without telemedicine evaluation and intervention.
What are other important points regarding the use of telemedicine in hematology and oncology?
Inpatient hematology/oncology televisit consults should become universally accepted. From my perspective, there is no reason hematology/oncology physicians should be required to go to hospitals in person now that most of their activities can be performed by televisit. Now that hospital-based hematology has become more nuanced, time-consuming, and risk-bearing, it also makes sense for hospitals to have inpatient televisit coverage (instead of peer-to-peer advice) for life-threatening hematology and oncology emergencies.
Providers and their associated hospitals should decide whether the outpatient providers themselves can do inpatient televisits. If not, then they should utilize televisit-only hematology/oncology practices that specialize in inpatient televisits. This will likely expand in rural and small nonrural hospitals.
What are remaining needs in terms of research, technological advances, and patient or provider education?
The whole telemedicine explosion offers and demands research questions, including confirmation of the value provided by televisits. Outcomes research could establish that rural and small nonrural hospitals have fewer unnecessary hospital transfers or more efficient appropriate transfers. I’m most interested in seeing the number of APL leukemia patients who are saved by providing telemedicine.
My goal is to be present in every hospital ER to offer early hematology emergency consults.
Education and culture change is still needed for patients, providers, health plans, and hospitals to expand the broad acceptance of telemedicine hematology/oncology consults.
For technology, every patient’s hospital room should eventually have an A/V communication device “already installed” like they already have televisions.
- Binder AF, Handley NR, Wilde L, Palmisiano N, Lopez AM. Treating hematologic malignancies during a pandemic: utilizing telehealth and digital technology to optimize care. Front Oncol. 2020;10:1183. doi:10.3389/fonc.2020.01183
- Kumar P, Aggarwal M, Dhawan R, et al. Tele-Medicine services in hematological practice during Covid pandemic: Its feasibility and difficulties. Indian J Hematol Blood Transfus. Published online November 20, 2020. doi:10.1007/s12288-020-01385-7
- Shah MA, Emlen MF, Shore T, et al. Hematology and oncology clinical care during the coronavirus disease 2019 pandemic. CA Cancer J Clin. 2020;70(5):349-354. doi:10.3322/caac.21627
- Darcourt JG, Aparicio K, Dorsey PM, et al. Analysis of the implementation of telehealth visits for care of patients with cancer in Houston during the COVID-19 pandemic. JCO Oncol Pract. 2021;17(1):e36-e43. doi:10.1200/OP.20.00572