2 European Summer School in Telemedicine Teleimaging in Medicine Udine, 2428 September 1997

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2 European Summer School in TelemedicineTeleimag
ing in MedicineUdine, 24-28 September 1997

• Teleoncology
• Fabio Puglisi
• University of Udine, Italy

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Teleoncology

• The use of telecommunications technologies to
  provide oncological services

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Lipsedge M et al. Digitised video and the care
of outpatients with cancer. Eur J Cancer
1990261025-6
Teleoncology historical perspectives
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AIMS Clinical expectations

• Improvement of access to specialty care
  (underserved/rural areas, incapacitated patients)
• Teleconsultation
• diagnosis
• second opinion
• treatment planning process

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Teleoncology devices

• Dynamic (one-way/two-way interaction, real time)
• Static (store-and-forward technology,
  asynchronous)

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TELEONCOLOGY The Kansas experience

• 82/105 counties lt 1 physician/1,000 people
• (U.S. average 2.37/1,000)
• telemedicine vs "fly-in" clinic
• telemedicine sites 16 rural and 2 urban areas
• equipment leased lines at 384 kbits/s, high
  resolution CCD colour cameras, colour monitors,
  electronic stethoscopes)
• Since 1992, over 300 teleoncology/haematology
  consultations have been conducted

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TELEONCOLOGY The Kansas experience

• Pertinent patients data are sent to the remote
  oncologist before consultation
• On arrival, patients are briefed by a local
  physician or nurse on how the system works
• Informed consent
• Patient sits in front of a monitor
• A camera is remotely controlled by the oncologist
• Usual medical interview

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TELEONCOLOGY The Kansas experience

• Physical examination by a local nurse or
  physician used as a proxy
• Remote control of a stethoscope and transmission
  of breath and cardiac sounds
• Zoom in and zoom back to assess areas of interest
• Transmission of radiographs
• Two-way discussion at all times

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Teleoncologythe value of on-site services

• Nurses and physicians from the referring centre
• Specialized nursing for chemotherapy and
  management of side-effects
• Psychological support during telemedicine
  consultation

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TeleoncologyHow to deliver bad news?

• Professional detachment accentuated by
• Telemedicine
• On-site support
• Ample time allowed for the patient to ask
  questions
• Ample time allowed for the tele-oncologist to
  check the patients understanding

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Teleoncologymain fields of research

• Patient perception
• Physician satisfaction
• Efficacy
• Cost analysis

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TeleoncologyPatient satisfaction

• Comparison between interactive-video mediated and
  on-site consultation
• (by a 12-item, 2 stage questionnaire)
• Modest difference on level of satisfaction with
  the two consultation modes
• No age- or gender-related differences in
  satisfaction
• Correlation with the particular oncologist seen
  (physician attitude towards telemedicine approach
  ?)

Allen and Hayes. Telemed J 1995
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TeleoncologyPhysician satisfaction

• Comparison between interactive-video mediated and
  on-site consultation
• (by a 9-item, 2 stage questionnaire)
• High level of satisfaction (perception of
  efficacy)
• No difference between specific elements of
  satisfaction (technical aspects of consultation,
  communication aspects etc)

Allen A et al. J Telemed and Telecare 1995
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Concerns about teleoncology perception studies

• Small sample size (need for multicentre studies)
• Bias associated with researchers evaluating their
  own programs
• Questionnaire based on stereotyped fashion
  (unability to catch finer distinctions)

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Teleoncologycost-effectiveness

• Establishing and mantaining a teleoncology
  programm
• Comparative studies between a tele- and
  conventional practice
• Locally available resources
• Comparative studies between tele- and other
  methods improving access to health care
• Is the system used to maximum capacity?

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Teleoncologycost-effectivenessThe Kansas
example

• Cost per patient visit
• Teleoncology 812
• Traditional practice (in person) 149
• Fly-in outreach clinic 897

Doolittle GC et al. J Telemed
Telecare 1997
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Teleoncology questions to solve

• What subsets of cancer patients are best served
  by telemedicine?
• Efficacy studies
• gold standard
• hard copy of radiographs vs teleradiogy
• examination by proxy vs actual examination
• etc.
• Multicentre studies

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Distant communication with patientsTelephone
Follow-up and Counseling

• Mammography Use
• Physician telephone or volunteer-initiated
• telephone contact to encourage women to have
• mammography and to offer counseling
• N of mamm increased
• Mohler et al, 1995 25(plt.05)
• King et al, 1994 14(plt.001)
• Calle et al, 1994 14(plt.001)

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TEAM WORK
Radiologists
Pathologists
CLINICAL ONCOLOGY
Surgeons
Radiotherapists
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Case-oriented multispecialty tumour conference
Tele-tumour board
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TeleoncologyAccessing Cancer Data/Knowledge
Bases

• International Cancer Information Centre
• (ICIC) of the National Cancer Institute (NCI)
• CANCERLIT data base
• PDQ
• Clinical Trials
• Cancer Information though e-mail
• The Internet and WWW

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PDQPhysician Data Query

• Peer-reviewed syntheses of state-of-art clinical
  information on cancer
• treatment
• supportive care
• prevention
• screening
• Summaries of clinical trials
• Directories of physicians and organizations

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DATA SHARING

• ICIC WWW site
• NCIs Cooperative Breast Cancer Tissue Registry
• tissue sections and clinical and outcome data
• AIDS Malignancy Bank
• tissue sections, fresh frozen tissues,
  malignant cell suspensions, fine needle
  aspirates, cell lines
• GenBank
• (http//www.ncbi.nlm.nih.gov/)
• molecular biology data base

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NCI Information Services

• CANCERLIT
• Comprehensive source of
• bibliographic citations on
• published cancer research

• CANCERFAX
• CANCERNET
• via e-mail
• through the Internet

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Computers are not converting medical care in a
commodity uncontrolled market forces are. Our
task is to make sure that the best of medicine is
preserved during any technological transformation
in the delivering of medical care. We can do so
only by staying involved.

• Jerome P. Kassirer, 1995