Although there have been many important advances in healthcare over the past couple decades, the introduction of new technologies into clinical practice may have had the most far-reaching impact on the healthcare system.
What is telemedicine?
Telemedicine is defi ned as the use of telecommunication technologies to provide health services over a distance.1 Teleoncology employs such technologies to connect patients with cancer at a distant site with an oncologist at a hub site. Telemedicine clinics utilize interactive televideo (ITV) technology to diagnose, treat, and manage patients, transmitting data over the Internet to conduct real-time clinical consultations. Because the equipment requirements for telemedicine are minimal—a typical ITV system includes a video monitor, a video camera, speakers, and a microphone—systems can be easily deployed in a clinic setting. Healthcare providers’ offi ces can also be equipped with the technology.
The teleoncology consult
The process by which a teleoncology consultation is conducted typically mirrors a face-to-face visit. Th e patient provides consent for treatment and is then given a brief overview of the telemedicine technology and process during the fi rst telemedicine encounter. Once the patient is familiar with the system, his or her history is obtained, a physical examination is performed, and diagnosis and potential treatments are discussed. With assistance from healthcare professionals at the distant site, the consulting physician is able to listen to heart and lung sounds using an electronic stethoscope. Other peripheral devices connected to the telemedicine system may also be used to visualize the ear, nose, and throat areas. Using a document stand allows for online review, in realtime, of CAT scans and MRIs. Dependent upon the radiology services at the distant site, X-rays may be reviewed online by accessing picture archiving and communications systems (PACS) at rural sites.
Role of the oncology nurse in telemedicine clinics
Although peripheral devices, such as an electronic otoscope or a document stand, may provide essential information during a telemedicine consultation and augment a physician’s understanding of a patient’s condition, this equipment certainly cannot replace the multifaceted, multilayered, and absolutely essential role an oncology nurse performs in a teleoncology setting.
Given the physical distance between the physician and the patient that necessitates a telemedicine consultation, the oncology nurse must literally become the “hands” of the physician performing the physical assessment. Consequently, with direction and guidance from the oncologist, the oncology nurse conducts all aspects of the physical examination, including auscultation and palpation.
In addition to their role during the physical assessment, teleoncology nurses undertake a variety of other responsibilities related to patient care. They become advocates for their patients, ensuring that each patient and his or her family members are comfortable with the telemedicine system and its operation. They coordinate the telemedicine consultations and often facilitate family members’ attendance at the visits by encouraging patients to bring family members to the distant site and/or by arranging for family members to be present at the hub site, where the physician is located.
Nurses also act as the primary liaison between the oncologist and the patients, remaining present throughout each telemedicine
consultation—in contrast to face-to-face visits, when oncology nurses may or may not be present for discussions between the physician and the patient. Being present throughout the consultation allows the teleoncology nurse to actively participate in the communication process and ensure the patient understands everything the physician communicates. For example, having heard the dialog between physician and patient, the teleoncology nurse is able to reiterate treatment plans, explain the physician’s instructions, and elaborate upon the information provided by the physician. Shawn Mulkey, RN, BSN, an oncology nurse at HMC with nine years of telemedicine experience, agrees that the nurse’s presence during the entire consultation is an advantage of telemedicine technology. She states that this unique dynamic allows her to “better answer questions the patient may have… and to facilitate and implement a treatment plan for the patient.”
Teleoncology nurses must also often add “technician” to their list of responsibilities. After initial training and instruction on how to utilize the telemedicine system, the teleoncology nurse is essentially the one who operates the equipment at the distant site during each consultation. As such, he or she must have a solid understanding of how the system operates and how the peripheral devices associated with telemedicine can diff er from similar devices used in a face-to-face clinic setting. Although the systems have become quite user-friendly and technical problems with them have decreased signifi cantly since they fi rst emerged on the healthcare scene, the teleoncology nurse must still possess the knowledge and ability to troubleshoot if a problem arises with the equipment.
Among the many roles and responsibilities a teleoncology nurse is asked to fulfi ll, perhaps the most essential role is that of collaborator. Teleoncology nurses must have a team-player mentality and be willing and able to interact with physicians, patients, and family members alike. Th ey must understand the needs of each person involved in a telemedicine consultation, and they must possess the ability to translate that understanding into action in order to meet those needs. At the heart of it all, they must have a desire to collaborate with everyone involved to establish the most eff ective care plan possible for the patient.
Advantages of telemedicine technology
The use of telemedicine technology to care for oncology patients eliminates the need for patients to leave their communities to receive much-needed specialty healthcare in a timely manner. Responding to a need for specialty healthcare services in rural areas of Kansas, the University of Kansas Medical Center (KUMC) began off ering telemedicine services to patients with cancer in rural areas of the state more than 10 years ago.2 Th e KUMC practice initially connected a university-based oncologist with Hays Medical Center (HMC), a rural medical facility located in central Kansas. After the initial teleoncology practice was established in Hays, another practice connected KUMC oncologists with the Northeast Kansas Center for Health and Wellness in Horton, Kansas two years later. Establishing both practices allowed patients with cancer in rural areas of the state to receive the care they needed in the comfort and familiarity of their own communities. Cancer is a substantial public health issue for all population groups. Certain subgroups, however, including individuals living in rural communities, have more risk factors for cancer than others. Consequently, being able to receive care without traveling a great distance is particularly advantageous.
Travel—particularly by car —can often lead to undue stress and discomfort for the patient, especially if the patient is undergoing treatment at the time that travel is necessary. Additionally, many patients rely on a family member or friend to travel with them to clinic appointments, which can lead to lost wages for the travel companions from having to take time off work to travel outside their communities. Stress, discomfort and/or pain, lost wages, and general travel expenses combined can render traveling to receive specialty healthcare a highly unattractive or potentially unfeasible option for many patients living in rural areas. Therefore, the ability to readily access specialty healthcare can significantly impact treatment outcomes of people living with cancer.
Although it is definitely beneficial to the patients to receive specialty care without leaving their communities, providing care via teleoncology must also be financially feasible. Analyzing costs from the KUMC-HMC practice over several fiscal years, researchers have found that the cost of providing services via telemedicine steadily declined since the inception of the practice, making it an attainable and attractive modality of specialty healthcare delivery.
Disadvantages of telemedicine technology
Given that telemedicine systems rely on technology, one drawback to utilizing telemedicine with oncology patients is the potential for the system to malfunction. However, telemedicine systems have undergone many improvements over the years to make them more user-friendly, and system malfunctions today occur with relative infrequency. Problems that do occur tend to be simple and quickly remedied.
Shannon Karst, RN, BSN, IT oncology module coordinator at HMC, has nearly three years of telemedicine experience and notes that one disadvantage telemedicine has when compared with face-to-face consultations is that “patients who receive bad news… don’t receive the personal physical touch from the physician.” Karst is quick to point out that the oncologist she works with in a telemedicine clinic “provides the best of care even if it is over the ITV system.” Additionally, the active role a teleoncology nurse assumes in a telemedicine setting can be advantageous during times when patients receive bad news, as the bond between patient and nurse may be a source of great comfort to the patient.
New tools, new challenges: What does the oncology nurse need to know?
As two experienced teleoncology nurses advise, it is wise to make the most out of the technology when learning how to incorporate telemedicine into daily practice. Karst recommends that other teleoncology nurses “use the system to [their] advantage.” She did so by taking notes during each visit so that she could refer back to communication on a particular date when a patient called her with follow-up questions.
And as Mulkey so aptly states, “teleoncology nurses [should] not be afraid of the technology or of messing up!”
Ashley O. Spaulding, MA, TeleOncology Project Manager at KUMC, has served in various capacities on telemedicine projects over the past eight years.Gary C. Doolittle, MD, professor of clinical oncology and medical liaison to the Center for Telemedicine and Telehealth at KUMC, has conducted over 1,200 telemedical visits evaluating and managing patients with a wide variety of hematological and oncology disorders. He has authored publications concerning telemedicine delivery, cost-tracking, and patient satisfaction, and has been instrumental in the expansion of the Kansas telemedicine project.