Telehealth Standards for Cancer Care: Better Safe Than Sorry

After the onset of the COVID-19 public health emergency, ensuring access to care through telehealth became a primary objective. The need to maintain safety and quality of care delivered to patients virtually has accelerated during the pandemic.

By shifting care from physician offices to patient homes, telehealth has been the most practical solution for safeguarding patients against the threat of the COVID-19 virus. At the same time, providers have needed to address safety risks inherent in the use of telehealth.

While some studies have demonstrated that telehealth generally does not lead to worse efficiency or outcomes, medical errors stemming from virtual care remain a concern. One pre-pandemic study found that poor documentation and faulty triage in telephonic care resulted in failed diagnoses, injuries including death, and costly settlements.  

In 2020, the NCQA Taskforce on Telehealth Policy released a report that examined the impact of telehealth on patient safety. The report made several recommendations to guide patient safety, including identifying and recommending minimum standards for maintaining patient safety via telehealth and efficiently integrating these standards across health policy by adapting and supplementing existing standards, rather than layering new policies on top of existing in-person regulations.

Why Use Standards?

Standards can play an important role in driving high-quality care and differentiating users based on their ability to meet requirements. For example, publicly reporting accreditation status can aid patients in selecting which provider or services they prefer to use. As another example, payers may recognize providers who meet quality standards by offering enhanced payment. Standards can also serve as a foundation for practice redesign activities and structural measures in quality performance programs.

For telehealth, standards offer a mechanism to certify both the technology manufacturers and providers of virtual healthcare on key elements of quality, including safety. From a manufacturer standpoint, standards can certify that their products are secure (ie, protects the privacy of patient information) and have necessary infrastructure requirements (eg, technical support to rapidly resolve problems). From a provider perspective, standards can certify providers’ proficiency with technology, equipment safety and maintenance, and use of appropriate technology in accordance with national and state regulations (eg, obtaining required licenses, using non-public facing live video services, meeting informed consent requirements).

Standardizing telehealth delivery is particularly important for cancer care. For patients receiving treatment and monitoring remotely, patient and caregiver education and training for appropriate drug storage, medication administration, and identification of side effects of therapy are essential for mitigating adverse events. From a population health standpoint, there is a threat that inappropriately shifting patients from in-person to virtual visits may lead to care delays, contributing to late-stage diagnoses or progression of disease. In addition, standards can inform triaging of visits to determine whether in-person care and a physical exam are necessary.

Several organizations have recommended steps to better understand the impact of telehealth on patient safety and improve clinical quality:

• The American Society of Clinical Oncology (ASCO) published standards and guidance for telehealth in oncology, focusing on which patients should be seen via telehealth, establishment of the doctor-physician relationship, role of allied health professional and advanced practice providers, multidisciplinary cancer conferences, and cancer teletrials.
• The Joint Commission called for more research to answer key questions about telehealth, including whether observed patient self-exams are accurate and safe and if clinicians are being trained adequately to conduct virtual visits, as well as improving the healthcare community’s understanding of optimal telehealth practice.
• NCQA recommended that the Agency for Healthcare Research and Quality develop best practices for telehealth as it does for other care sites, clarify how to aggregate and analyze patient safety data and publish research on telehealth encounter safety, and incorporate telehealth into existing adverse patient safety events, including data collection and patient safety event reporting structures such as the Patient Safety Organizations (PSOs).

What Are the Current Telehealth Standards?

Current standards for telehealth include URAC’s Telehealth Accreditation Program. URAC’s standards address best practices in five key areas, including patient safety protocols and clinical triage. Achieving accreditation demonstrates that patient care delivered through telehealth meets the same standards as in-person visits and could help providers meet future payer requirements for telehealth reimbursement or differentiate from competitors for value-based contracting.

NCQA has proposed a telehealth distinction for patient-centered medical home (PCMH) and patient-centered specialty practice (PCSP) recognized entities. One goal of the distinction is to improve operational and clinical processes for coordinated, effective virtual care delivery. As stated by NCQA, an objective of achieving the distinction is to demonstrate “to payers that you are a trusted partner to contract with.” As with the PCMH and PCSP recognition programs, achieving a telehealth distinction may lead to differential payment.

How Can Standards Be Applied to Improve Cancer Care Quality?

Use of standards, including those that address patient safety, is frequently driven by public and private payer accreditation requirements and provider interest in promoting their ability to deliver high-quality care. Today’s telehealth standards can serve as a starting point to enhance cancer quality programs, build cancer-focused best practices, and improve understanding and monitoring of safety concerns. 

Revamping Quality Program Structural Requirements to Address Telehealth: As CMS/CMMI contemplates the future of its value-based payment (VBP) portfolio and cancer models, such as the Oncology Care First (OCF) Model, it could enhance existing structural requirements for participants to integrate standards for telehealth. The original Oncology Care Model (OCM) practice redesign activities built on the clinical infrastructure required by patient-centered oncology medical home models. Anticipating an ongoing role for telehealth in future oncology VBP, CMS should look to the current telehealth standards and recognition models for structural measures that can incentivize participating practices to provide higher-quality, safer patient care to cancer patients.

Building Telehealth Safety Best Practices in Oncology: Existing telehealth safety standards can serve as a starting point for improving consistency in care delivery. Oncology providers, including those who participate in value-based models that also serve as incubators for identifying and sharing best practices, can help expand on cancer-specific best practices for improving patient safety. Identified best practices for implementing virtual care can be used to update current standards, or develop oncology-specific safety initiatives.  

Monitoring and Evaluating Telehealth Safety: CMS and other payers should require providers to adopt agreed upon telehealth safety standards and monitor for compliance and improved patient safety. Such monitoring should include short-term assessment of avoidance of telehealth medical errors, and long-term evaluation of the impact of virtual care on complications, disease progression, and survival compared to in-person care.

For the readers: How do you think standards for telehealth patient safety should be integrated into value-based models?

About the Quality Outlook Commentary Series

Breakthrough treatments in cancer care, including precision therapies tailored to specific patient factors, are driving rapid changes in the definitions of oncology quality and value. Efforts to implement value-based care models in oncology must meet the demands of evolving science, new best care practices, and shifting patient priorities. Quality measures must be up-to-date and relevant. Payment models must recognize the challenges and costs of managing complex patient populations with diverse needs. In this JCP blog series, Quality Outlook, Discern Health, part of Real Chemistry, will explore key issues in oncology quality and value through posts focused on measurement, value-based payment, and quality improvement.

About Tom Valuck, MD, JD

Tom Valuck is a Partner at Discern Health, part of Real Chemistry. He is a thought leader on health care system transformation and helps lead the firm’s focus on achieving better health and health care outcomes at a lower cost. Tom’s work at Discern includes facilitating the exploration of next-generation measurement and accountability models for health care delivery systems. He also helps clients develop strategies to achieve success within the value-based marketplace.

About David Blaisdell

David Blaisdell, a Director at Discern Health, part of Real Chemistry, leads and manages client projects, providing insight and subject matter expertise, particularly on quality landscape analyses and measure gap identification. David has led and contributed to projects focused on oncology quality measurement to identify key gaps in measures used in accountability programs and opportunities for measure development. Through this experience, David helps clients navigate measurement and value-based payments and define strategies for success.