GROWING USE OF EHEALTH IN PATIENT CARE
Over the past several decades, there has been a growing interest in how to capitalize on advances in information technology to provide remote quality and patient-centered care to cancer patients and survivors. eHealth or telehealth are broad terms used to refer to the use of health information and communication technologies. Telehealth tools such as web-based programs, patient portals provided by the health system or mobile device applications housed in smart phones and tablets all facilitate patient engagement, education and care. More specifically to patient care, telemedicine involves interactive patient care, remote patient monitoring and storage of patient health information to facilitate communication and continuity of care. With the widespread use of computers, tablets and smartphones, delivery of cancer care via these eHealth platforms continues to expand. The internet also continues to serve as a key source of health information for many patients. The importance of the internet and web-based information during the pandemic was highlighted in a PEW Research Center article that reported that up to 87% of Americans characterized the internet as an “essential” or “important” source of information during the COVID-19 outbreak. The trend for remote healthcare and patient monitoring accelerated dramatically last spring as the COVID-19 pandemic essentially changed the landscape of clinical care in the U.S. and around the world. Therefore, eHealth is now more of a necessity than an option to foster patient engagement, promote communication and facilitate ongoing patient care during the COVID-19 pandemic and beyond. One unexpected benefit 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 healthcare professionals alike. Whether comprehensive cancer care is 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, growing evidence supports that eHealth has the potential to effectively deliver and even enhance patient care.
EHEALTH PROGRAMS IN ONCOLOGY PATIENTS
It has been estimated that up to 70% of cancer patients and survivors seek medical information via the web, while over 30% seek support programs to help them cope with the unique and complex challenges of cancer. A significant amount of effort has focused on the development and evaluation of eHealth-based education and support for oncology patients. This work suggests that eHealth applications can be effectively implemented to monitor and manage symptoms and deliver psychosocial and supportive care. Numerous studies have documented the feasibility and acceptability of the use of eHealth programs during and after active cancer treatment. However, a continuing limitation is that most eHealth programs have been deployed in the context of controlled trials. These studies typically target psychosocial challenges and/or assessment and management of symptom burden to improve health-related quality of life. Work in these areas is promising and supports that programs delivered via eHealth can favorably and significantly impact fatigue, depression, anxiety and health-related quality of life. Recent work also shows positive results of eHealth interventions in managing pain, psychosocial distress and other symptoms. Preliminary efficacy of eHealth programs has also been established in managing various other specific outcomes including reduced lymphedema-related chronic pain, improved sexual function in female survivors, and improved health-related quality of life. However, there are several limitations in this work. For example, the structure of these programs is highly variable across studies. 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 healthcare providers. Most studies have not assessed which tools are more effective or whether a combination of such tools (e.g., social connectivity with therapist-led sessions) are more effective. Furthermore, there is a need to evaluate the efficacy of these programs in “real world” settings via dissemination and implementation approaches that evaluate the efficacy of eHealth tools in clinic and community based programs.
BENEFITS AND CHALLENGES OF EHEALTH-BASED CARE
Telemedicine-based patient care provides healthcare teams and patient with 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, services can be accessed remotely by utilizing voice conferencing tools. Some of these tools have now been fully integrated into patient portal interfaces, thus seamlessly providing the eHealth connectivity in a familiar technological environment for patients. Patient benefits also extend to reduced waiting times and no time spent traveling to and from appointments. For patients with caregiving responsibilities, telemedicine appointments can occur from the comfort of their homes without worrying about abandoning these responsibilities. An additional benefit of eHealth-based care is its potential to improve patient-provider communications, symptom monitoring and management, and enhance patient engagement as greater care continuity (e.g., greater adherence to visits). As capabilities of mobile devices and apps continue to expand, valuable information including toxicities, emotional well-being, 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 are not limited to clinical care. Supportive programs such as yoga, exercise, meditation, music, eBeauty, art and other topics are now offered via a videoconferencing applications. 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.
Despite these benefits, there are qualities and benefits 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. Limitations in computer literacy, connectivity and communication skills can all also adversely impact the quality of the telemedicine visit. Consequently, 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.
Technological advances in eHealth do not necessarily reach those patients who may benefit the most. Most work evaluating the efficacy of eHealth programs lack substantial inclusion of racial and ethnic minorities, rural and financially disenfranchised communities, and older patients. While these communities may have the most to gain from eHealth services, they also face considerable barriers to effectively accessing eHealth programs. Patients of low socioeconomic status are likely to have limited access to high-speed networks or be geographically located in communities with limited high-speed connectivity. Similarly, rural communities that have limited access to optimal cancer care also face inadequate broadband connectivity, thus limiting the reach and potential benefits of telemedicine. A significant technological gap also exists for many seniors in the U.S. who continue to lag behind in technology adoption, particularly in access to broadband high-speed services, cell phone ownership and use of the internet. However, about 70% of the elderly population goes online every day or almost every day, with 82% accessing the web three to five times per week. Therefore, the technological gap in this subgroup of cancer patients and survivors is decreasing. One should also consider the impact of eHealth on the provider experience. At the provider end, multiple challenges are also experienced including poor or disrupted video imaging and sound quality, real-time information processing via video conferencing, connectivity issues and poor integration into existing clinical workflows. Privacy remains a major concern as well, and secure and Health Insurance Portability and Accountability Act compliant services needed to be employed. These services included platforms such as Facetime (Apple Inc. – Cupertino, CA), Zoom (Zoom Video Communications – San Jose, CA), or other similar tools allowing audio and video communication between providers and patients.
Advances in eHealth offer the opportunity to optimize remote delivery of cancer care and address the multiple challenges faced by patients, their families, and care partners during the COVID-19 pandemic. Today, eHealth applications support the delivery of remote clinical routine care, 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 has become the primary mechanism of care delivery for patients 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, but only as a complement to routine in-person care.