Published on April 17, 2020
- Patients who are on active chemotherapy, have a progressive disease or are having complications still need to be seen in-person.
- For a virtual visit, patients should have a computer or smartphone and a webcam. Test your webcam beforehand to make sure the audio and video are working well.
- Family members who want to be included but are geographically distant can be invited to a video consultation.
As we’re adapting to a temporary new reality with coronavirus, the role of technology in cancer care is expanding with the increasing use of telemedicine, or remote visits.
Who is a good candidate for telemedicine? Expert Dr. Mike Thompson, from the Vince Lombardi Cancer Clinic, breaks down different categories of patients by which cases require an in-person visit and which ones can be managed remotely.
Dr. Thompson also discusses the benefits and challenges that come with telemedicine, and ways to prepare and optimize your virtual visit. Watch now to learn more.
[Due to extreme load on our website and Zoom platform, viewers may experience a time delay between the audio and video of the interview - please note the transcript can be read below.]
Transcript | How Can Telemedicine Help You Now?
Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.
Recorded on April 15, 2020
Hello there, this is Esther Schorr with Patient Power. It's April 15th, and, of course, we are all in the midst of the coronavirus pandemic. I know all of you are probably in the same situation that I am, and that our staff is. We're kind of sheltering in place, but we're continuing to bring you as much good information as we can, as it relates to cancer patients during this crisis. We have a wonderful guest this morning. Dr. Mike Thompson is the medical director for the Early Phase Cancer Research Program, as well as the Oncology Precision Medicine Program at the Vince Lombardi Clinic, which is part of Aurora Health Care in Milwaukee. Welcome, Dr. Thompson. We're glad to have you.
Thanks for having me.
Absolutely. And we have, I think, a very timely topic today about telemedicine. I'm pretty sure that not all of the folks who will be watching this have heard of telemedicine, but it's on the rise as far as use during this pandemic. And what we'd like to try to do today is talk about what telemedicine really is, how it's being used during this crisis, what to expect when you have a telemedicine consult, and when it's appropriate to seek it out and where you can seek it out.
So before we get started, I just want to let anybody who's listening, if they have a question, at the bottom of your screen, there's a little Q&A button. And if you have a question while I'm talking with Dr. Thompson, put your question in there, and my trusty associate Andrew Schorr, who is my co-producer, will get those questions to me, so we can talk to Dr. Thompson. So let's get started, Dr. Thompson, and talk a little bit about what telemedicine is, especially in the context of talking with cancer patients. So can you explain what it is and why it's so important now during this pandemic?
So tele, of course, can refer to telephone or now, increasingly, video use for communicating with patients. And this has been used before COVID-19, and in some large cities this actually was a health insurance benefit through the employer. If you're a programmer working in a high rise in New York City and you have a sore throat, you might be able to contact someone and get some information without leaving your job and spending half a day at urgent care or something like that. So a lot of this was already in the works, and a lot of companies were working on it. There were some prohibitions of going across state lines and licensure and other things which have largely been relaxed, thankfully, during this so anyone can help any patient without some of those things. And that may change how we go forward, and actually how we do medicine, and how we interact with people, and how billing works and insurance and all that.
But obviously, everyone knows about social distancing and staying at home, and telemedicine can really help with that. And we were discussing earlier that there are many ways to do things, and part of it is keeping people out of the clinic, out of the hospitals. And so, my clinic is actually in a hospital, and it's, for the state of Wisconsin, one of the hot spots. So we're trying to keep people out of there. There are some people that have to come in if they need chemotherapy that's IV- or subcutaneously-based. And sometimes we're changing chemotherapy to oral regimens, sometimes we're having chemo holidays, et cetera, et cetera. But for a lot of people, we want to keep contact with them, so people can use either the telephone or video to help with those relationships and to help understand what's going on with patients.
Okay. So I understand for a lot of cancer patients, some of the things you have to do, not even just the treatment, but check-ins, you need blood work, you have to, in some cases, feel lymph nodes, the high touch part of an exam. So how does making those things happen when they're critical to continuing treatment, how does that work? Does it work in combination with telemedicine? I'm trying to get my head around that.
Yeah. So there's optimal care, which ideally, you're seeing your doctor, you're seeing them on time, you're in on time, he or she is working on time, and they can spend as much time with you as they want. But even before this, that often didn't work, there would be interruptions with that. But when you're seeing someone, what very often happens, I'm leaving, I grab the door, I'm going out the door, and someone's like, "Oh, by the way," and they add something else on. And it's again, "Can you just look at this or feel this?" And we can't do that. In some cases, what we're doing as inpatients is we're having the doctors that are already seeing the patients work on their exams, and the exam skills can differ between people, or people can say they felt for a spleen but didn't really feel too hard.
So there are some ways we can get around that by having other people do it. Or it could be like a patient that's being seen by me on video, I could ask one of my colleagues if they're at the hospital to examine them if it's critical. But a lot of the times, especially in hematology, we're not assessing deeply the response each time. We're looking at counts and things like that. And so we might miss out on some things that are really moving rapidly. But even then, we know for later, after at least two years for imaging for instance, we tend not to find that on imaging as much, and we can count on the patients that tell us, "Well, I've got this lymph node that's growing," or, "Oh, that thing I had is smaller now." If it's inside the body, we can't do that.
So I think it's a couple of categories. One are people that really still need to be seen, and we have people in our clinics to see those people. Those are people on active chemotherapy, people that may have progressive disease, or are having complications that don't involve the fever, which we triage off to get COVID screening. We're trying to keep our clinics and chemo areas as clean and COVID-free as possible. And then there are patients that need laboratory checks before chemotherapy but don't necessarily have to be seen by a doctor each time. So there are a lot of therapies where we might've seen them every time, but we probably don't have to. And some of the drug companies are actually helping with this. Celgene is giving two months of lenalidomide (Revlimid) or IMiD therapy for myeloma patients or other patients, so they don't have to check in once a month. It's a little bit easier to get over this peak window in the United States.
And I think in Wisconsin, we're probably hitting our peak about now, or maybe next week we'll be at our peak. So if we can get over this, it doesn't mean people are free and clear, but we can get over the worst part of it where you really, really don't want to be in the hospital because of resources. So I think those are a couple of categories of patients, and there are some people that, especially if they're a new consult and really need to be seen, we're still going to see those patients, we're just trying to limit it to people that—I have some people I see once a year for something, and we can push that out. And then there are other people that had a scan, and they want to talk to me who don't want to just talk to the nurse. And a lot of that stuff can be done by phone or by video.
Okay. So let me just run a scenario by you, and you're probably familiar with this living in Wisconsin. I live on a farm a hundred miles from where you are in Milwaukee. With the scenarios you were just talking about, if I'm supposed to go and see you in Milwaukee, will I generally be able to have one of these telemedicine consults with you or with one of your associates? Is that the bridge, so that I don't have to get in my car and go anywhere when I'm being told to stay where I am?
Yeah. So it depends on the individual situation. But in general, and this might be what changes actually in the future, is in my health system, we are the largest health system in the state, so we have a lot of clinics. So it's easier for people to go to a lab, and they can get laboratory testing. And we're increasingly trying to make this asynchronous. So I'm used to people come in, they get labs, I see them right away. But even then, sometimes they're slow or whatever. So that person would come and get their labs locally and probably minimize their exposure by planning. They can just space out the patients at the lab. And then I can see the results, because it's all integrated into an electronic medical record. And then there is an app we have, and a lot of health systems have, that integrates with Epic, that's our electronic medical record and one of the most common ones. And the patient sets that up to be able to do video.
So, there are other ways of doing this. There's a Doximity dialer and Doximity video that's HIPAA-compliant recently, there's of course FaceTime, there are all sorts of things. And what the government has said is for this interim period, even things that were not HIPAA-compliant are allowable, because we have to build up the capacity to do this. So there are a lot of different ways of doing things, and if it's a meeting set up in advance, actually my staff will go in, they'll set the video thing up, the person will have the app. If they're in the clinic, someone will actually help them if they need help getting it up and running. I do have some patients that don't want to do that and just want to talk on the telephone.
I think it does take away from it, because it's nice to see someone. And as experienced doctors, a lot of what we get is just by eyeballing someone. We can see a lot just by, do they look listless, do they look happy. You can see something's going on. So the video is great, but that's the ideal format. And then, if that doesn't work, there are some other ways of contacting people and doing that. And then sometimes we just use the telephone, especially if it's delivering lab results. I have patients with anemia for instance, like, "Oh your numbers all look great, let's wait to have you see me for three or six months or something." So that's fairly easy. It's for the chemotherapy patients where it's not quite as easy.
But then we also do rely on labs look good, the nurse or nurse practitioner will assess you when you're going to come in to get your chemotherapy or something. But for the people that are at a distance, we've been doing this for a while for something called telegenetics, or genetic counseling. And people really liked it. If they're in Northern Wisconsin and they're told, "Hey, you may have this condition." And they're like, "I don't have to drive down to Milwaukee and park? And I can just do this all from home?" And a lot of times they can also conference in their family members from other states, and it's a nice way that, as people get more sophisticated with this, and people are doing this for family members and virtual happy hours and all sorts of things to stay in touch, I think as we get more sophisticated, you could actually bring in your family members who want to be on the visit but are geographically distant.
And so those are some of the cool features that are actually better than what we were doing before. Still, one of my problems is, if I'm supposed to talk to someone at, let's say, 1:00 PM, and their phone is busy or they're not on and then it takes me 20 minutes to get ahold of them, and then talk and then document it, it's hard to stay in line and to be as adjustable with people. So it's not perfect, but I think we're doing fairly good for a complex situation.
No, for sure. And it is complex, and you make the point that, I think, one of the areas that's going to have to get adjusted is that we have some number of people in the cancer population that are not technically-savvy. And so, it sounds like your staff, and probably staffs at other medical centers and clinics, are trying to bridge that gap, that if somebody is going to use telemedicine with you, that somebody can ask to say, "I don't know how to set this up. Is there somebody at your end who can help me do that?" Am I hearing that correctly?
Yeah. And that's why, as we're offloading the staff workload in the clinic, the staff are now doing a different job, and everyone's doing different jobs. So they will help set that up and give them the instructions for the video chatting. And we're using Zoom, but I'm on lots of webinars, and sometimes it's WebEx, sometimes it's Zoom or Google. There are all sorts of different programs. And that's one of the complexities of trying to figure out for each individual patient. Am I seeing them in-person? Am I seeing them on the phone? Am I seeing them through Zoom on the EMR? And then, even in the EMR, we have messaging and chatting and all sorts of stuff. So I think everyone has to realize that they have to be flexible, both on the patient side and the physician side, and try to work everything out.
But it's not like it's something that's been running this way for years and it's the same old, same old, where you just go into a room, you wait for someone to arrive. And it's a lot easier, because it's more of what we're used to. And so, some of the things I think will stay, but I think a lot of times, we like seeing people in-person. People like seeing us. They like seeing the other staff members. And that's why I think conferences aren't going to go away, and seeing your doctors in real life is not going to go away.
But there will be scenarios where I think we will loosen up on things where like, "Look, maybe you don't need to actually have me touch you every three months. We can do that virtually, because you're far away, and you can't get a ride." There are all sorts of scenarios like that. Some people, I had a patient who doesn't have a smartphone, so they said they couldn't do it, they could only do it from a telephone. And I think he may have only had a home phone, like a land-based phone.
There are people like that still. For sure.
Yeah. So in those scenarios, each person you have to adjust. And the hard part is if I know and they say that someone's in a room, I go in a room, when I'm done, I'm done. And then someone can holler if something's happening, or things change, or someone's running late, we can adjust. But in this scenario, you might have dialed in and then someone doesn't pick up, someone needed something earlier. It's not perfect, but I think we're adapting fairly well.
Yeah. So let's say somebody is a candidate for telemedicine or listening to this and learning about it. Somebody says, "Well, maybe I don't need to go, but how do I find a telemedicine program for my area?" I mean, for example, I know our insurance, they reached out to me and said, "There's this thing called Teladoc, and you could use this for certain things." But if I'm a patient not familiar with this, how do they find out that they can do telemedicine with their doctor?
Right. So what we're doing for our cancer patients, and I don't even know in our own organization if this is through everything, but in cancer, we are reaching out proactively. Like, "You have an appointment in a week, and we are doing social distancing." And they'll do some screening, COVID things and say, "Would you like to meet by a WebEx, with this program, with this app? Or is there some other way you'd like to meet in?" There might be some people who we've suggested, you don't need to meet, or you don't need to come in, and they still want to come in or whatever. And so that'll be triaged on an individual basis. But if you have an established provider, they probably have a plan. This is high on the radar of every health system, and so they probably have a way to approach things.
If you may see multiple doctors in multiple places, it's probably going to be complicated, because they may all be doing different things, and you might have to talk to each of them individually. If you're looking for a new doctor, I think, as far as I can tell, everyplace is advertising on social media what their plans are, what they're doing. I did talk to someone who's on an advisory committee with me as a patient, and she said, "Well, I didn't get that. I'm pretty savvy, and I didn't get that." So I think it's not perfectly communicated.
And I can say I think I'm pretty tech-savvy, but when we were doing this, I was confused and many of my colleagues were confused, and we're pretty smart. So it's easy to see how people need some time at this, but I think, ideally if you have someone that can show you how to set it up, that's the optimal way. A lot of people are like, "Oh that's not that hard. I just click this and click this." But even writing it out like instructions, it's hard to instruct people how to do some of these things.
Well, there are some basics though. There are some basics. You need a computer, or that's ideal. I guess you could do it on a phone. You need that, and you need either a computer with a webcam, where, like you and I, can see each other, or there are ones you can order from Amazon or whatever that sit on top of your computer. So that's kind of minimum. And then if I'm hearing you right, it kind of depends on how it works based on what software is being used. And that's the point it sounds like a patient needs to be proactive with their provider and say, "Okay, I got the computer. I have a webcam. Now what do I do if we're going to do this?" Does that sound accurate?
Yeah. So one is the hardware, and we were discussing before we started this, that I don't have my good hardware here. It's back in my office. So I have my tiny little camera.
You get the closeup.
Yeah, it's not even optimized. But I looked on Amazon, and they're all sold out, just like cleaning supplies. So actually, I've no financial conflict of interest, but there's a place called Full Compass in Madison, Wisconsin that sells to churches and commercial stuff, and that's where mine is incoming, a new webcam. But having a nice webcam, especially if you're doing a lot of communication, can be very helpful and then trying it out ahead of time. So you want to see, is there a problem with your video, with the camera, with the mic. And I've seen people who, their video is not working well, or it's smudged up or something.
And ideally, I think that's—what I'm seeing is, in the initial few weeks of this, is patients aren't ready for it. So I'm calling, and it's taking 15 minutes for them to get up to speed. So ideally, as volume goes up, as the people we've pushed out from seeing, we're eventually going to have to see and talk to these people, and probably our efficiency will be lower initially, for both on the patient and the healthcare system and physician side, we're all figuring it out and doing new things, that everyone should try to make it as efficient as possible so that you can get to people.
Okay. So we actually did get a couple of questions. One is from a wonderful patient advocate who sometimes works with us but is very plugged into the myeloma community, Cindy Chmielewski. And she asked a really good question. She said, "How can a cancer patient who worries," which is a lot of them, a lot of us care partners too, "how can we be calmed by a telemedicine visit, rather than worry that something's being missed?" Where are the comfort factors around that?
Okay. And I know Cindy very well. She is very sophisticated and, as a teacher, knows that what we tell everyone is, when you're going in, have a list of questions you already want to address. And a lot of people do that when they go into their in-person visits. So I think if you think of it ahead of time, "What do I want to get out of this?" And it could be, "I really need to know this imaging study," or, "I really need to know if these labs changed, or is my chemo plan changed, or whatever." You probably have things in your head. And writing them down is a good way to address them and make sure they're not missed.
And like I said, you could have other people in the call or in the video, where they're there, and because they're inviting them in, they'll be like, "Mom you missed—but you said this." And just like they bring them in to the visit, they can be there and say, "You're missing something." And so, I think some of the same techniques we use for in-person can be used digitally, and sometimes even more effectively. You could just even have the phone listening to the conversation from someone else who's in a different part of the country.
Well, I have a list of questions I'm asking you. We're essentially on a telemedicine conference right now. So I'm going to make sure I don't miss any questions. I see the applicability for sure.
One of the things from my side, I kind of prep, I figure it, like, I got everything nailed down, so I can come in, and they can just hit me with questions, and I've got it. Now, especially if the tempo is different, I am sometimes looking stuff up as I'm communicating. In-person, I try to not use the computer in the room. I use it before and after. But now, it's getting much more like, if the screen is here and I have a second computer to try to do things, it may be somewhat distracting. And I think people can see that as not paying attention or being aloof or something. But you're really just managing a different way. But I think creating a list, and making sure all your stuff was addressed, and asking for help from others to help you navigate is good.
Okay. So couple of other sort of related questions. Someone is asking if they have a scheduled consultation, say with a specialist at the end of April, should the patient reach out about a telemedicine visit, or will they contact me? And so, there's kind of this overall question, will the clinics generally contact the patient for telemedicine if you're scheduled for a follow-up, or is the onus still kind of on the patient to say, "Hey, do I need to come in? Do you have telemedicine?" How is that working? Sounds like it's evolving, but maybe you have a comment on that.
Yeah. And it's probably even on a state or region-by-region basis. So there are some states that are not on lockdown, some that have been for a long time, and the places that have been on lockdown for a long time based on a regional or state mandate have had to address this. Places that haven't may not be as up to speed with having a plan. So if you're thinking about it, I would call and try to get ahold of them. Sometimes you see the stuff from the airlines or for banks and stuff like that. If you don't really need us now, you may be delayed for the people that need us right away.
So, some of what we're doing is just going to the next week, we're looking at the people that have next week. And four weeks ahead, we don't know exactly what's going to be happening. Are we going to be overwhelmed? We don't think it would be quite back to normal, but we're trying to, just based on what we have to do, to rearrange things and call people and reschedule, and all that can be some effort for the staff. But if you're thinking about it, and you haven't heard, it's reasonable to call. And the answer may be, "We don't have a plan yet," or, "Call us in a week." But you can just call them, and they should have something to tell you.
Okay. So we sort of touched on this earlier, but I want to just get clear. Is it always the doctor or specialists that would do the telemedicine exam? Where do nurse hotlines and triage lines come into this whole new equation for assessing whether a patient needs to come in and what treatment they need?
Yeah, ideally everyone's working in the best way they can to help the health system and the patients. And for COVID screening we have a dedicated hotline and people for doing that. And there are online tools to look at what your symptoms could be and things. So we are having some people in-person seeing the PAs or NPs, and we're having RN assessments for chemotherapy, which we have always done. As we all know, the chemo nurses are very, very good at assessing things, especially for someone that they've known for a long time getting chemo. They are very good at picking stuff up. So again, it probably depends on the resources of the individual health system or clinic and the patient population. But we're trying to have as much communication. Let's say it's simple stuff for scheduling, not having the doctor do all that, and kind of reserving them for the high-level discussions about things like, "Oh, the CT says this. What are we going to do with it?"
And so, just yesterday I was discussing some kind of very nuanced things, and we could do this, or we could do this. And that is hard to communicate with others. And that's where you would want someone to really be on board for not triaging a bunch of other calls about scheduling and stuff. So it is a team approach. And I think that's another thing we're seeing, is there's lots of stuff that other people could do, and one of the complaints of physicians, I think for at least a decade or two decades, has been doing more clerical work and more busy work that can be offloaded. And as we're really pushing what really, really needs to get done, we're, I think, increasingly doing some of the stuff that's really making those big decisions or having those discussions. I had the discussion with someone that I didn't know very well about, "If you don't do this, this is an end-of-life scenario. Has anyone ever addressed it with you?"
And I thought that was the most important thing I could do. And there's a whole bunch of other stuff that might need to be done, but that was the most important thing that I had to do that day for that person. So I don't know. I think if a system has a process like, "You're going to talk to this scheduler." That's probably the best person. Or if it's the nurse, we sometimes call them team nurses, that work with the individual doctors, they're probably going to be the best person to figure out how to fit you in. And we have to realize that some people are being displaced. I moved my clinic to help cover a population of people, so I didn't know any of the patients, and I was in a different scenario. And with all of that, we're all trying to make the whole system work and load balance the resources with utilization.
So what I'm taking away from all of this is we're all adapting to a new reality that not only are patients trying to figure out the best way to get care, but also all practitioners and patients trying to figure out how technology can supplement to relieve some of the load that we now have, that's even more because of the pandemic. So how are you, as a provider and a leading hematology oncology expert, how are you adapting to this new reality? How's it impacting you?
So Wisconsin and the Midwest in general have not been as hard-hit as the coasts or some other areas. But I think no system or individuals have done things perfectly. But I think we've been pretty proactive in shutting things down, so elective surgeries, elective mammograms, a lot of stuff that can wait, a lot of biopsies, procedures. So eventually this is going to be now this other wave of stuff where there's issues. But one thing that I've been doing is I go to a clinic once a week, and I'm seeing a couple people that need to be seen. I'm handling phone calls and video conferencing from there, and covering the chemo area in case there's any reactions and stuff like that. There are still things that you can only deal with in-person. And then the other weeks, I'm working from home like today, and the load is a little bit lighter.
I think it'll pick up as people get more savvy with this and trying to fit things in between. And so we're all doing that. So one thing we've been doing is actually having some people for weekends not go in, and trying to expose some people more and have some people in reserve for if there's a second wave. And we do have some people that are out and on quarantine. And I forget how many it was from our health system, but a lot of people are on quarantine. Not all of them necessarily have been positive but could have been exposed and waiting. So as that happens, over time, we're going to lose more and more people to quarantine, and hopefully we'll get this antibody testing to figure out if you've developed antibodies, and we'll hopefully have some metric showing what antibody thresholds are protected. We don't really know a lot yet.
But I think I'm doing well, and I think our health system is doing well. Every patient I've talked to, no one has been upset. No one has been frustrated. Everyone gets it. I think we've done a good job of communicating that way. Everyone's a little bit anxious. Lots of people are not sleeping well, thinking through the night. But I think people are adapting fairly well, and I think we're over some of that initial fear, and there's ennui. Everyone needs to get out of the house, and everyone wishes they could go on vacation again, and all sorts of things. I know you guys have been disrupted with some of your trips. I canceled about five trips that I was supposed to go on. And sometimes we're going to be doing things harder, and some times are going to be quieter, and lots of jigsaw puzzles and lots of other things.
Lots of movies.
Well, we’ve got to tell you, Dr. Thompson, and I hope that your team and all the other providers who are dealing not only with the everyday wonderful work that you do with your patients, but this additional layer of, as you say, angst, anxiety, fear, that you guys are all angels. And I can speak for myself as a care partner, I know I'm speaking for my husband who's a two-time cancer survivor, and for all the patients who are listening or will be listening, that we just can't thank you and your staff and other people like you all over the world, who are working together to try to keep patients healthy, to try to figure out what's the vaccine, how are we going to go back to normal? And I think that keeping the faith that everybody's pulling together and that we're all in it together is really important.
So, I just want to thank you very much for being here, and we'll look forward to talking again. Hopefully not with everybody freaked out, maybe in a more subdued situation. But in the meantime, we want to thank you very much. And I want to thank those of you who are watching now. There will be a replay of this program in a few days posted on our website. So let other people know that if they're interested in this topic about telemedicine, that it'll be available. And from all of the Patient Power team here, we just want to remind you that knowledge can be the best medicine of all.
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