1. Accessibility
1.1. Positive Effects
1.1.1. Patient Benefits
1.1.1.1. Target Populations
1.1.1.1.1. Geographically isolated populations
1.1.1.1.2. Prisoners/Correctional Institute residents
1.1.1.1.3. Nursing Home Residents
1.1.1.1.4. Patients confined to home
1.1.1.1.5. Community Oncology Clinics
1.1.1.2. Access to quality cancer care
1.1.1.2.1. Enables a link with expert surgeons, radiation oncologists and other specialists
1.1.1.2.2. Provides access to extensive knowledge regarding a variety of treatments (i.e. Proton Beam Therapy or Immunotherapy)
1.1.1.3. Convenience
1.1.1.4. Access to clinical trials and experimental therapies
1.1.1.5. Eliminates physical travel
1.1.1.5.1. "Pain from symptoms, discomfort caused by treatment, and the emotional toll associated with having cancer make it particularly challenging, both mentally and physically, to travel long distances to access treatment" (Doolittle & Spaulding, 2006, p. 228).
1.1.1.6. Eliminates time barriers
1.1.1.6.1. "Delays are pervasive in systems, and they are strong determinants of behavior. Changing the length of a delay may make a large change in the behavior of the system" (Meadows, 2008).
1.1.1.7. Reduces re-admissions and unnecessary emergency room visits
1.1.2. Provider Benefits
1.1.2.1. Ability to collaborate with a team of professionals
1.1.2.2. Alleviates off-hours work load
1.1.2.2.1. Video evaluations done when physicians are on-call
1.1.2.3. Ability to collaborate with non-physician providers
1.1.2.3.1. Multidisciplinary team environment provides a more comprehensive assessment
1.1.2.4. Reduces physical travel
1.1.2.5. Convenience
1.1.2.6. Expedited transmission of records between providers
1.1.2.7. Eliminates the potential for infectious disease transmission between patient and provider.
1.1.2.8. Increased oversight
1.1.2.8.1. Oral medicine supervision
1.1.2.8.2. Supervision of chemotherapy administration
1.2. Negative Effects
1.2.1. Increase in demand for care
1.2.2. Expectations more difficult to fulfill
1.2.3. Availability of appropriate technology
1.2.4. Inadequate assessments
1.2.5. Decreases human interaction and potentially negatively effects the patient-provider relationship
1.3. Challenges of Implementing
1.3.1. Provider resistance
1.3.2. Executive and Administration resistance
1.3.3. Ensuring access to reliable technology
1.3.3.1. Secure internet connection
1.3.3.2. Secure document and image transfer
1.3.3.3. Adequate workstations
1.3.4. Ensuring compliance with practice regulations
2. Cost
2.1. Positive Effects
2.1.1. Savings for Patients
2.1.1.1. Eliminates travel costs
2.1.1.2. Decreases missed days of work
2.1.1.3. Telemedicine consults less expensive than in-person consults
2.1.2. Savings for Physicans
2.1.2.1. Decreases office overhead costs
2.1.2.2. Lowers liability by improving documentation
2.1.2.2.1. Video record of patient consultations
2.1.2.3. Optimizes time
2.1.2.3.1. Video consults can be scheduled during downtime
2.1.3. Expanding reimbursement and payment opportunities
2.1.3.1. Both private and government payers will continue to expand telemedicine coverage as consumers gain experience with the technology and increasingly demand access to telemedicine-based services.
2.1.3.2. Laws supporting telemedicine reimbursement
2.1.3.2.1. Balanced Budget Act of 1997
2.1.3.2.2. TELE-MED Act of 2013
2.1.3.2.3. 21st Century Cure Act
2.1.3.3. Supports diversification
2.1.4. Collaborative healthcare can more economically delivered
2.1.4.1. Complicated oncology cases require physician collaboration
2.2. Negative Effects
2.2.1. Appropriate technology can be costly
2.2.1.1. The patient must have a smartphone or computer with webcam to access the service.
2.2.2. Reimbursement
2.2.2.1. Physicians receive lower rates from managed care companies for telemedicine than for in-person care.
2.3. Challenges of Implementing
2.3.1. Infrastructure
2.3.1.1. Unstable Internet Connection
2.3.1.2. Unsecured Internet Connection
2.3.2. Liability/Malpractice Lawsuits
2.3.2.1. Disconnected virtual consults can lead a patient to follow the wrong treatment regimen
2.3.3. Sustainability
2.3.3.1. Can the hospital maintain the service?
2.3.3.2. Will it be reimbursed by payors?
3. Provider Availability and Engagement
3.1. Positive effects on system
3.1.1. Early Detection for underserved areas: Provides expert care to patients that often go undiagnosed until later stages of cancer
3.1.2. Pre-familiarity for specialists for new patients
3.1.2.1. Specialists can have initial appointments before making patients travel to see them in person
3.1.3. simplifies logistics for waiting rooms
3.1.3.1. prevents the need to go to Provider's office
3.1.3.2. less chance for provider to be late b/c of backed up face to face visits
3.1.3.3. less chance of patient being late which leaves more time for consultation care
3.1.4. improves communication between provider and patient
3.1.4.1. sharing of vital information or test results can be done elxctronically, which is faster and cheaper; plus sharing results like MRIs and XRays with other providers is a lot more efficient.
3.2. Negative effects on system
3.2.1. technology glitches - creates a whole new area of healthcare that can experience technological complications in the delivery of care
3.2.2. provider assessment accuracy
3.3. Associated challenges
3.3.1. Patient/Provider Trust
3.3.1.1. Patients sometimes feel uncomfortable if attending specialist that is working real time with oncologist from afar is not a doctor;
3.3.1.2. sometimes patients don't trust an Rx from a doctor that is not with them in person (RN, Nurse Practitioner, etc) (Doolittle & Spaulding, 2006).
3.3.2. Provider Availability
3.3.2.1. Scheduled appointments - old model of telemedicine
3.3.2.1.1. Doctors would have to block time on their schedule and rotate blocks
3.3.2.1.2. Hard to schedule around face to face appointments
3.3.2.2. Real time scheduling because of mobility
3.3.2.2.1. video consultation and even peripherals for examination of patients available through
3.3.2.2.2. point to point technology allows patient, regional clinic and specialist from afar to 3-way conference if necessary
3.3.3. Limited Usability with Existing Patients
3.3.3.1. Can telemedicine providers cater to their "in person" patients for followups, or are they always busy with other one-time patients
3.3.3.1.1. Oncologists can exclusively offer telemedicine to their patients that have to travel long distance for normal followups
3.3.4. Telemedicine primarily is for urgent care
3.3.4.1. Assume routine conditions are only situations
3.3.4.2. Telemedicine doesn't allow for deeper relationship with providers
3.3.5. Regulatory Acceptance
3.4. General Availability Statistics
3.4.1. 200+Telemedicine networks in the United States (ATA Website, 2016)
3.4.2. 3500+ Locations providing Telemedicine services (ATA Website, 2016)
3.4.3. Teleoncology is vital for an even more dire divide between rural patients and oncologists
3.4.3.1. According to the American Society of Clinical Oncology’s (ASCO) recent workforce analysis, only 3% of medical oncologists practice in rural areas, whereas 20% of the US population resides in rural areas, and over 70% of counties in the United States do not have medical oncologists (Charlton, M. et al, 2015, p.1)
4. Patient Experience
4.1. Positive Effects
4.1.1. timeliness of care
4.1.1.1. social presence of clinician
4.1.1.1.1. "right care at the right time" (Principi, 2015, p.1)
4.1.1.2. interactive education
4.1.1.2.1. consultation for patient
4.1.1.2.2. medication regimen (Sabesan & Kelly, 2014)
4.1.1.3. continuity of care (Zilliacus et al., 2009)
4.1.1.3.1. access to more specialists
4.1.1.3.2. referrals through primary care physician
4.1.2. cheaper out-of-pocket costs
4.1.2.1. save on gas money and possible hotel stays to see specialists
4.1.2.2. fee-for-service
4.1.2.3. insurance reimbursement
4.1.3. shorter appointment commutes to see specialists
4.1.4. increased patient engagement
4.1.4.1. reduces no-shows
4.1.4.2. patients more inclined to see a physician over their smartphone
4.1.4.2.1. "64% of Americans used a smartphone compared to just 35% in 2011" (Principi, 2015, p. 1)
4.1.4.3. self-organization (Meadows, 2008)
4.2. Negative Effects
4.2.1. lack of psychosocial support
4.2.1.1. easier to be distracted with telephone consultations (Zilliacus et al., 2009)
4.2.1.2. sensory and nonverbal limitations
4.2.1.2.1. may hinder clinicians' ability to make diagnoses (Miller, 2003)
4.2.2. overuse of care
4.2.2.1. over referring patient for teleoncology consultations because it is easily accessible
4.2.2.2. address appropriate care (Field, 1996)
4.3. Challenges of Implementing
4.3.1. technical difficulties within system
4.3.1.1. delay of care
4.3.2. patient has limited access to internet or a reliable phone
4.3.3. need EMR that is accessible and robust
5. References
6. Key
6.1. cost for provider
6.2. cost for patient
6.3. provider engagement connections
6.4. government support for telemedicine
7. Chaos/Complexity within Teleoncology
7.1. Chaotic Dissipative Structure (Fonseca, 2002)
7.1.1. Dissipation of redundant diversity
7.1.1.1. Telemedicine/Teleoncology can allow for more robust communication between patient and provider, more commonality because there's so many options for how to connect and share information; but with this new diversification comes uncertainty and chaos with unexpected challenges.
7.1.2. Dissipation of misunderstanding
7.1.3. New meaning and understanding
7.1.3.1. Patients are more enlightened with more information faster
7.1.3.2. Providers can have multiple touchpoints and deeper understanding of issues and conditions with more connectivity to patient
7.2. Key Complexity Considerations
7.2.1. functionality, communication, security, technology management, reliability/assurance, reliance on software, usability
7.3. Telemedicine is EXPLODING in popularity
7.3.1. 2000% growth from 2015-2017
7.3.2. With 7M patients using Telemedicine projected by 2017, that would equate to approximately 19,000 patients a day, 319 every hour of every day, or 5 per second of every hour of every day...and that's not rational because there's bound to be downtime in the system.(Watson, R. 2015, p.1)
7.4. BEEP, TWEET, DING, DING, BEEP...Remote areas still use DIAL-UP INTERNET?
7.4.1. As much as 70% of all internet users in remote areas of the United States still use dial-up internet service, because of lack of broadband availability...which is limiting and makes it more difficult and unreliable to get a connection when necessary. (Pagliery, J., 2015, p.1)
7.5. Handheld Cancer Care? There's an App For That!
7.5.1. A Norwegian scientist has invented an app that can diagnose skin cancer
7.5.1.1. The space Börve is in, like the exposed skin of people splayed out on the park lawn that Saturday, is getting hotter and hotter. Buoyed by growing interest in digital health from governments, health care institutions and investors, telemedicine is on a march toward the mainstream. During the first half of 2014, digital health funding rose to $2.3 billion, more than the entire previous year. Helped by the Affordable Care Act’s embrace of technology standards, the adoption of smartphones and the rising burden of noncommunicable diseases, telemedicine is an area that startups and major corporations alike are clamoring to get a piece of. (Sanders, 2015, p. 1)