Measuring Telehealth Quality in Cancer Care: We Don’t Know What We Don’t Know

J Clin Pathways. 2022;8(7):43-49. doi:10.25270/jcp.2022.10.02

Received: May 2022; Accepted: July 2022

Telehealth services in the United States exploded during the COVID-19 pandemic, with a 2,980% increase in telehealth claims lines between September 2019 and September 2020.¹ A study of in-person and telemedicine outpatient care trends in 2020 found that while fewer than 2% of clinicians delivered any outpatient care via telemedicine prior to the pandemic, nearly 20% of oncology visits were delivered via telemedicine following the public health emergency.²

Telehealth has been successfully used for years for cancer symptom management, survivorship care, and palliative care. However, during the COVID-19 pandemic, telehealth has fundamentally altered routine delivery of cancer services, including patient triage and screening before appointments, treatment of COVID-19–positive patients or patients being monitored for COVID-19, and remote monitoring of patients receiving treatment.^3-5 Though many services delivered virtually during the pandemic will likely return to in-person settings, telehealth is expected to continue to play a prominent role in cancer diagnosis, treatment, and survivorship care. This shift will alter the way patients, providers, payers, and policymakers view quality of care.

Quality measures assess performance against evidence-based standards of care to evaluate practice structures, care processes and utilization, clinical outcomes, and patient-reported outcomes and experiences. Cost or resource use measures assess spending or utilization against expected benchmark spending or use of services. Together, quality and cost measurement help elucidate the value of health care. As care delivery incorporates more telehealth services, there is an urgent need to examine how effectively these measures assess the use and impact of telehealth on cancer patient care and outcomes.

Recognizing the opportunity to enhance telehealth quality and cost measurement, the National Committee for Quality Assurance (NCQA) convened a Taskforce on Telehealth Policy (TTP) that issued recommendations in 2020⁶:

Measure stewards should carefully and thoughtfully review all measures to determine the need for telehealth adaptations. Review should consider how quality measurement could account for telehealth’s unique impact on quality, safety, cost effectiveness, access, and outcomes.

[Centers for Medicare & Medicaid Services] (CMS) should pilot a patient experience survey linked to telehealth encounters for all types of care, leveraging telehealth’s uniquely digital aspects to improve timeliness, targeting, and engagement. Lessons learned should help update patient experience measurement across settings to improve response rates and provide faster, more targeted feedback.

In late 2021, the National Quality Forum (NQF) released its Rural Telehealth and Healthcare System Readiness Measurement Framework report. The NQF report proposes a conceptual framework for telehealth quality and cost measurement, highlights which measures are available for use, encourages development of new measures that close gaps, and promotes the use of measures to assess the impact of telehealth on health care system readiness and outcomes in rural areas affected by emergency events. The report proposes five priority quality domains for telehealth⁷:

1. Access to care and technology: The ability of telehealth to increase rural patients’ access to certain types of health care during emergencies.
2. Costs, business models, and logistics: The costs of using telehealth, how it is supported financially, and delivery model implications.
3. Experience: How interactions of patients/caregivers and care team members through telehealth meet their needs and preferences.
4. Effectiveness: The desired outcomes, safety, and timeliness of care delivered via telehealth.
5. Equity: How telehealth can support equal opportunities for all.

In this article, we evaluate key quality considerations related to the use of telehealth in oncology in the context of NCQA and NQF’s recommendations and discuss strategies to enhance telehealth quality and cost measurement to support improvement and accountability.

Routine use of telehealth in cancer care has implications for several domains of care quality including access, health equity, patient experience, care coordination, clinical care and outcomes, and cost.

Access

Telehealth facilitates patient access to providers for care, particularly for those who would need to travel long distances for appointments or who would miss workdays. Telehealth also enables flexible communication (eg, the ability to rapidly report medication side effects or complications may help patients continue treatment and avoid an expensive emergency department [ED] visit or hospital stay).

During the COVID-19 pandemic, limitations to in-person visits led to sharp declines in cancer screening services that could not be replaced with telehealth, which will likely lead to long-term poorer patient outcomes, including diagnoses made at later stages, more complex and costly care, higher morbidity, and higher cancer mortality.⁸ Triaging care that requires an in-person visit and ensuring these visits are not replaced inappropriately with telehealth care are important access concerns. The NQF report emphasized specific clinical use cases where access concerns may arise (ie, disaster-specific care, time-sensitive clinical issues, and access to primary or specialty care).

Health Equity

Telehealth could exacerbate disparities in care for patients who do not have access to internet services or devices needed for telehealth engagements. Telehealth services require technologic accommodations for patients with impaired hearing, vision, or cognition. For patients who have access to technology, digital literacy is a concern, especially those who are older, have lower socioeconomic status, have limited health literacy, have limited English proficiency, and are racial and ethnic minorities.^9-11 Importantly, increased use of internet-enabled smartphones may improve access to telehealth; a Pew Research Center study found 85% of Americans own a smartphone. However, disparities persist among rural and socioeconomically disadvantaged populations; additionally, individuals who do have access to digital services may find telehealth services complex or inadequate for their needs.^12,13

In its framework, the NQF emphasizes the need for measures to consider geographic distance and travel, technology’s capacity for communication, broadband issues, patient and providers’ basic digital literacy, and the interoperability of technology. It recommends the development of measures to determine whether specific assessments or interventions related to social determinants were delivered during telehealth visits, as well as the development of measures that assess the presence of language translation services or whether care was delivered in a culturally competent manner. The NQF report further emphasized that identified measures can be stratified to assess disparities and equity of care based on specific factors (ie, age, race, gender identity, and language).⁷

Patient Experience

Oncology nurses have noted that telehealth can reduce patient burden by automating symptom monitoring and helping providers target follow-up to patients with poorly controlled symptoms. In turn, this can enable more individualized and meaningful symptom management.¹⁴ A 2017 systematic review found that telehealth interventions can support cancer survivors in safely managing their condition within their chosen environment, minimizing treatment burden and subsequent disruption to their lives.¹⁵

Conversely, some stakeholders fear that telehealth may lead to depersonalization of care, particularly in the absence of face-to-face visits that facilitate direct connection between patients and their oncology clinicians.¹⁶ This depersonalization could decrease emotional support and increase patient isolation. Studies of tele-oncology have observed feelings of emotional distance between patients and providers, with patients reporting nervousness, reluctance, or difficulty communicating with their providers.¹¹

Medical oncologist respondents to a telehealth research study also believed that patients may have trouble understanding complex treatment discussions and pointed to difficulty having discussions about serious or bad news. However, some physicians thought telehealth could improve patient experience through more frequent follow-ups, enhanced convenience, and additional educational sessions for family and caregivers.¹⁷

A July 2021 National Comprehensive Cancer Network (NCCN)-led provider survey found that a most providers reported video (88%) and telephone (80%) were the same as or better than office visits for reviewing benign follow-up data. However, relatively few providers indicated video (24%) and telephone (7%) were the same as or better than office visits for establishing a personal connection with patients.¹⁸ In a July 2021 study of medical oncology patient perceptions of telehealth, patients identified convenience, avoidance of anxiety, COVID-19, and provider preference as positive influences on the acceptability of video visits, and limitations in provider connections, physical examinations, and visit length as disadvantages.¹⁹

The NQF report describes a range of patient experience considerations for measuring telehealth, including trust in technology, patients’ choice for modality of services, and experience using technology.⁷

Care Coordination

Cancer diagnosis and treatment typically require a comprehensive care team including medical, surgical, and radiation oncologists; nurses; financial advocates; social workers; and schedulers.²⁰ Telehealth enables more rapid communication among care team members, fostering more effective multidisciplinary care. During 2020, cancer centers implemented virtual cancer multidisciplinary team meetings, allowing specialized clinicians and teams to remotely access meetings they may not have previously joined.²¹ When advising on complex or rare cancer cases, providers may host a single multidisciplinary call with various specialists and the patient, cutting down on the number of appointments.

Pharmacists faced complexity with tracking which clinicians were seeing which patients, particularly when electronic health records did not provide details specifying virtual or in-person visits and who was responsible for follow-up. Practices also facilitated more remote communication through secure chat among providers delivering virtual and in-person care to improve efficiency. Oncology teams determined proactive pharmacist outreach was best in coordinating patient follow-up calls and counseling.²²

NQF’s telehealth measurement report highlights the need for measures that consider “system-wide care coordination, including interoperable technology and local resources,” which may inform communication among care providers treating patients virtually and in-person.⁷

Clinical Care and Outcomes

While the effect of telehealth on oncology clinical outcomes is not well understood, some research has evaluated its impact. A June 2021 single-institution study comparing virtual care to in-person care did not identify significant differences in time to staging imaging, time to therapy initiation, treatment delays, or 3-month all-cause or cancer-specific ED presentations and hospitalizations.²³ A July 2021 NCCN-led survey found that 93% of providers reported adverse outcomes attributable to telemedicine visits never or rarely occurred, while 6% of providers reported they occasionally occurred.¹⁸ More research is needed to understand the impact of telehealth on priority cancer outcomes, including disease progression, survival, mortality, and quality of life. During the COVID-19 pandemic, telehealth played an important safety role by reducing risk for cancer patients who were too sick or whose treatment reduced their ability to fight infection by obviating face-to-face visits that were not clinically necessary, an important strategy to lower the spread of COVID-19 infection.¹¹

Overreliance on telehealth visits could lead to missed or delayed diagnoses and poor clinical outcomes, making appropriate triage critical. For example, in-person physical examinations may identify issues—such as soft tissue masses—that could be overlooked during a telehealth visit.²⁴ Face-to-face interactions also allow clinicians to better assess body language important for diagnosis and to build rapport, including through physical touch during exams.²⁵ In contrast to these concerns, one study found video telemedicine visits yielded a high degree of diagnostic concordance compared with in-person visits (96.8% for neoplasms).²⁶ Physicians surveyed about perceptions of the clinical effectiveness of telehealth in cancer care raised concerns about the capabilities of virtual physical examinations and recognized practical limitations of providing only written information to patients to explain complex treatments and follow-up. Other respondents cited clinical benefits for virtual care, including the possibility of more frequent interactions and the ability to anticipate potential ED visits or hospital admissions for high-risk patients.¹⁷

In a September 2021 report by the Society to Improve Diagnosis in Medicine (SIDM), researchers surveyed available literature and interviewed stakeholders to identify research questions about how to maximize the potential and avoid the pitfalls of telediagnosis. Priority research questions focus on issues related to urgency (symptoms are clearly urgent or urgency is unclear), patient health (patient is otherwise healthy or patient has underlying disease/risks), symptoms (symptoms are familiar to the patient or are new to the patient), patient/provider relationship (relationship is new or established), and telehealth quality (quality of telehealth is good or poor). Exploring these research questions can establish evidence-based clinical recommendations and best practices for the future use of telehealth.²⁷

The NQF report highlights telehealth measurement opportunities in discussing the effectiveness domain of its framework, including quality of care for clinical issues that are addressable through telehealth, those that are not addressable through telehealth, and timing of care delivery and whether patients received specific necessary care through the chosen modality.⁷

Cost

There is limited evidence demonstrating the cost impact of telehealth on oncology care. Physicians surveyed about their perceptions differed in their views, with some highlighting cost benefits for patients, such as avoiding parking fees, gas, tolls, and lost work time. Other respondents noted the ambiguity of insurance coverage status for telehealth and the inability to accurately estimate copayment costs, which may lead to patient uncertainty, particularly when patients might not view virtual care as equivalent to in-person care.¹⁷ The National Institutes of Health has encouraged research on the cost effectiveness of telehealth in cancer-related care, among other topics.²⁸

NQF’s telehealth framework highlights priorities for cost measurement, including costs to patients, caregivers, and insurers; technology costs; and the wider financial impacts on the community (eg, jobs, absenteeism). The report further discusses adaptability and system readiness costs for telehealth, business sustainability, and spillover effects of implementing telehealth, such as facilitating patient transfers and staffing costs.⁷

Quality measures aid in understanding performance gaps and improvement opportunities. Measures can be used to compare the patient experience and outcomes of care provided by telehealth vs in-person care. They can also assess performance related to the use of telehealth services for value-based payment and public reporting.

The Figure depicts opportunities to measure quality of telehealth in cancer care delivery using the NQF cancer measurement care model. Telehealth-related measurement opportunities focused on care coordination and clinical care domains are overlaid across the three major phases of cancer care. Outcomes relevant to access, patient experience, clinical care, and cost are described to the right of the figure.

Most urgently, researchers should build the evidence base for telehealth to improve our understanding of its impact on patient outcomes and guide recommendations for its appropriate use. As these efforts are undertaken, we have proposed recommendations for public (eg, CMS, state Medicaid agency) and private (eg, commercial health plan) payers, quality measure developers and stewards, and health care researchers to prepare for telehealth quality and cost measurement that can build knowledge about gaps in oncology care and inform best practices.

Refine and Develop Telehealth-Focused Oncology Quality Measures

NCQA and other measure stewards are modifying measure specifications to recognize the use of telehealth services. These modifications would place telehealth patients in measure denominators and specify when telehealth services meet the criteria for measure numerators.²⁹ Public and private payers, along with measure stewards, should ensure that measures in their oncology quality measurement and payment programs are updated to reflect appropriate use of telehealth services. For Medicare, these programs include the Enhancing Oncology Model (EOM), Merit-based Incentive Payment System (MIPS), and Prospective Payment System (PPS)-Exempt Cancer Hospital (PCH) Quality Reporting (PCHQR) Program. For example, measure specifications for NQF 0384 (Quality Payment Program #143 and EOM-4): Oncology: Medical and Radiation – Pain Intensity Quantified have expanded beyond face-to-face encounter codes to include telehealth visit codes.³⁰ As CMS develops new quality measures for use in value-based models, it should consider how telehealth visits can be appropriately reflected in specifications.

In response to the COVID-19 pandemic and increased use of telehealth, the Agency for Healthcare Research and Quality (AHRQ) released a beta version of its Clinician & Group Visit Consumer Assessment of Healthcare Providers and Services (CG-CAHPS) patient experience survey that is designed to apply to phone, video, or in-person visits. AHRQ suggests that users may wish to adapt CAHPS supplemental items, such as those focused on health information technology and access, to assess how patients are interacting with technology services.^31,32 Efforts to incorporate telehealth considerations into patient experience assessments should include refinements to cancer surveys and measures that reflect priorities in the patient experience domain, including AHRQ’s Cancer CAHPS and the CMS’ Patient-Reported Experience of Care measure, used in both the Oncology Care Model and EOM.^33,34

Oncologists’ prioritization of efficient care coordination for telehealth encounters suggests that new quality measures in this domain may be needed. Structural care coordination measures could assess a practice’s resources and readiness to prepare patients for virtual visits and follow-up, as well as assess use of patient navigators to coordinate follow-up care. This aligns with recommendations from NQF that “telehealth measures should be developed that assess team-based care delivery and access to specialist care. Telehealth can … improve multidisciplinary coordination required during longer-term public health emergencies.”⁷ Effectiveness of telehealth care coordination may also be a suitable survey domain for updated patient-reported experience of care measures. Prioritization of research questions to optimize triage—such as defining criteria related to urgency, patient health, symptoms, provider-patient relationship, and quality of telehealth discussed in SIDM’s “Improving TeleDiagnosis: A Call to Action” report—is important for establishing evidence-based clinical guidance.²⁷

Implement Telehealth Measures in Cancer Value-Based Payment Programs

Public and private payers and program implementers (eg, NCQA) should continue to update existing measures with specifications that account for the use of telehealth services in quality measurement and payment programs. CMS should ensure that measures incorporating telehealth for specific programs, such as MIPS,³⁵ are aligned with overlapping measures used in cancer quality programs such as the EOM and PCHQR. CMS should further consider how other oncology measure sets, such as the proposed “Advancing Cancer Care” MIPS Value Pathway,³⁶ incorporate measures that assess appropriate use of telehealth services.

Patient experience survey measures that account for virtual and in-person visits should be embedded into quality measurement and payment programs. There is a heightened need to understand patient experience as care transitions to virtual settings.³⁷ CMS should evaluate the adequacy of AHRQ’s telehealth expanded CG-CAHPS survey for use in future performance years of MIPS and the Medicare Shared Savings Program (MSSP) for Accountable Care Organizations. As mentioned, the Patient-Reported Experience of Care measure presents a key opportunity for CMS to account for patients’ experiences with virtual cancer visits under the EOM and future value-based payment models for cancer care. Measure domains specifically focused on the threat of depersonalized care, patient/caregiver and physician bonding, and the ability to understand and use technology may be priorities for patient experience surveys.

New structural measures, MIPS improvement activities, or other redesign activities under future value-based payment models for cancer care should also prioritize practice transformation to ensure appropriate access to telehealth and effective coordination of virtual visits. These structural measures can build on best practices identified and established by oncology providers during the COVID-19 pandemic.

Analyze Measure Data to Identify Quality Trends for Cancer Telehealth

Researchers, including Medicare program evaluators, can leverage quality measure data to study the impact and value of telehealth services compared to in-person care for cancer patients during and after the COVID-19 public health emergency. In its report, NQF recommends that existing and endorsed measures of general health outcomes, access to care, and care coordination can “potentially be used to assess the impact of rural telehealth indirectly,” including measures of hospital admissions and readmissions.⁷

Medicare oncology quality measurement and payment programs include claims-based utilization measures—such as PCH-30/PCH-31/EOM-1: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy and PCH-36: 30-Day Unplanned Readmissions for Cancer Patients—that can be used to compare clinical outcomes between patients whose treatment and side effects were primarily managed remotely and those that were managed in-person.^{33, 38} The NQF report specifically cites PCH-30/PCH-31/EOM-1: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy as a measure that is potentially useful for understanding aspects of telehealth quality. Cost measures can also put quality comparisons in context, examining trends in episode or total spending associated with in-person vs remote care.

Researchers should also leverage quality and cost data to evaluate how use of telehealth is affecting vulnerable populations. Stratifying performance results based on criteria associated with social determinants of health—such as race, age, or rural geography—may provide insights into whether at-risk patients have appropriate access to both telehealth and in-person care as well as the impact on outcomes. Research findings may inform development of novel telehealth measures that can directly assess equity, such as whether specific assessments or interventions related to social determinants of health were delivered during telehealth visits, in alignment with the recommendations in the NQF report.⁷

Pilot Test Routine Collection of Patient Experience Data and ePROs During Telehealth Encounters

As described in the NCQA TTP report, virtual care presents a unique opportunity to electronically capture patient-reported data before and after a telehealth visit.⁶ Inputting electronic patient-reported outcome (ePRO) information regarding treatment side effects or functional status before and during telehealth visits may provide as natural a process for surveying patients as providing a tablet in a waiting room prior to an in-person visit. Requesting feedback on patient experience with a virtual visit could happen immediately after the patient signs off with the provider, compared with collecting feedback via a mailed paper survey weeks or months later.

The CMS EOM requires a new practice redesign activity for participants to “gradually implement [ePROs].”³³ Given the expanded role of telehealth, this should include ePRO data collection during virtual visits, and use of the data to inform patient visits and continuous quality improvement. The CMS should also seek opportunities to pilot collecting experience of care information, based on required Patient-Reported Experience of Care survey measure domains, during EOM telehealth visits and for future value-based payment models for cancer care. Analysis of this data, in comparison to routinely sampled and surveyed patients, could help determine the reliability and validity of electronically collected patient experience information, and potentially facilitate more efficient patient surveying across quality measurement and payment programs.

The expanded use of telehealth services, expected to continue beyond the COVID-19 public health emergency, necessitates evolution in quality measures assessing cancer care processes, clinical outcomes, cost and utilization, and patient experience. Public and private payers and measure developers should prioritize refinement, development, and implementation of telehealth-focused measures for oncology quality measurement and payment programs.

Authors: David Blaisdell, Tom Valuck, MD, JD

Affiliations: Tom Valuck and David Blaisdell are employees of Real Chemistry, a global health innovation company providing consultative services to pharmaceutical and medical device manufacturers.

Address correspondence to: David Blaisdell

1120 N Charles St

Baltimore, MD 21201

Phone: (212) 301-7200

Email: dblaisdell@discernhealth.com

Acknowledgements: The authors would like to acknowledge Palak Patel, MHA, for her support in developing this manuscript.

Disclosures: Discern Health, a part of Real Chemistry, is a for-profit consulting firm that receives fees for serving numerous health care clients, including life sciences companies.