By Megan Garlapow, PhD
Telemedicine becomes a reality for delivering rural oncology care with the advent of virtual infusion centers. At the 35th National Oncology Conference by the Association of Community Cancer Centers (ACCC), Susan Halbritter, a certified nurse practitioner (CNP) with Sanford Health, highlighted the Sanford Cancer Center’s recent efforts in South Dakota using telemedicine to bring oncology treatments to rural patients by way of virtual infusion centers.1
Delivering oncology care to rural patients has long been challenging as people in rural areas tend to age more rapidly than urban centers, and the demand for oncology services is projected to grow at twice the supply of available oncologists.2
One solution to the challenge of rural oncology care has been visiting consultant clinics, usually within hospitals, to which medical oncologists travel to provide diagnostics, treatment, and related services. While research on success metrics for these types of clinics is limited, a system in operation in Iowa showed that in 2011 a total of 2,100 clinic days was seen in 66 clinics by oncologists; 95% of these were in rural locations. Among participating physicians, this amounted to approximately 21,000 driving miles overall per month.2
Halbritter noted that in South Dakota cancer is the second leading cause of death and is increasing in prevalence. Many patients in and around the tri-state area that includes the city of Sioux Falls, SD, and Minnesota and Iowa live in rural communities. These patients have limited access to oncology care and limited transportation options. Some may travel over 100 miles for treatment, in a region where winter driving is often perilous.
Halbritter explained that oncologists are generally in the tertiary care centers and since many trials require receiving treatment at a tertiary care center, patients in rural areas have limited access to them.
An alternative to driving long distances for both patients and physicians alike in poor weather conditions is telemedicine, which is fundamental to the Sanford Cancer Center’s Virtual Infusion Project. The project provides chemotherapy infusion treatments to rural patients with oversight provided by a CNP, based remotely at the Sanford Cancer Center in Sioux Falls. A goal of this program is to transition rural patients who are receiving complex anti-cancer treatments to rural infusion sites.
An incentive for tertiary care centers associated with the satellite chemotherapy infusion center model is development of connections in broader communities for those needs that cannot be met in the rural setting.3
The main Sanford Infusion Center is a 20-chair, 4-bed center with a dedicated infusion CNP and nine infusion nurses on staff, of whom six are OCN-certified. There is also an adjacent pharmacy with board certified oncology pharmacists and a list of available medications allowed at facilities outside of the tertiary care center, but available medications are limited at these outside pharmacies.
The Sanford Virtual Infusion Project maintains three rural virtual infusion centers located in two states: South Dakota and Minnesota.4 The Sanford Vermillion Medical Center is located in Vermillion, SD, the Douglas County Memorial Hospital is in Armour, SD, and the Sanford Worthington Medical Center is in Worthington, MN. The program has developed expertise in multi-state issues, including appropriate certifications, since licensure applies to the state where the patient is located.
A key question behind the development of the Sanford Virtual Infusion Project has been whether a CNP located at a tertiary care infusion center can adequately provide oversight to RNs providing cancer treatments at rural infusion centers via telemedicine, an electronic medical record, and a dedicated telephone.
While telemedicine is not new to intensive care units and some other areas of medicine, Halbritter stated that models for using telemedicine to provide oncology care at rural infusion centers seem lacking.
To establish a successful telemedicine program, the Sanford Virtual Infusion Project focused on standardized and evidence-based policies, procedures, and workflows. They standardized their use of electronic medical record software, as well as telemedicine equipment. Staff training emphasized standardized workflows, equipment use, and oncology-specific education.
Considerations for success include safety, adherence to oncology standards, prompt problem resolution, minimized interruptions in treatment, and care provided close to home with reduced driving and costs to patients and their families.
Challenges identified were inconsistencies and hesitation. Inconsistencies related to variations in access to treatment plans in electronic medical records as well as differing pharmacy practices.
Telemedicine uses telecommunications technology to evaluate, diagnose, and treat patients remotely and involves extra consideration of licensing, credentialing, and billing practices. At the operational level, Halbritter explained that telemedicine is easy to use and that the patient and provider can talk to and see each other, using headphones for patient privacy and an interpreter if needed.
Physicians, particularly those less experienced with the relevant technologies, showed initial hesitancy toward the telemedicine approach; this was replaced with enthusiasm as they witnessed positive results for patients. “In the end they were our biggest champions,” Halbritter said, even though many physicians initially feared they could not provide adequate care by telemedicine.
Patients, too, often show reluctance initially, as they sometimes fear they will receive lower-quality care than they would at a tertiary care center. Education issues and clinical trial regulatory requirements were also hurdles the program faced.
A drawback to the telemedicine approach is that it is not possible to remotely palpate, for instance, an abdomen. However, Halbritter emphasized the importance of the stethoscope and a high-resolution camera in making observations of a patient. Though there is a learning curve in adapting to the telemedicine system, signals from these instruments tend to transmit well over the telemedicine medium, and equipment costs are reasonable, according to Halbritter.
Because telemedicine does not currently allow tactile observations, depending on diagnosis, physicians in the Sanford Virtual Infusion Project have decided the frequency at which patients might need to split visits between the virtual infusion and tertiary care center.
During the two years leading up to April 30, 2018, utilization of the Sanford Virtual Infusion Centers amounted to 1,062 visits from 127 patients, with Worthington, MN, serving the most patients (852 visits from 93 patients).
In the first year, 16 patients, from eight counties, were served between two sites, while in the second year, 111 patients from 26 counties were served among all three sites. During the second year, payers included Medicare (for 59 patients), third-party (for 49 patients), and Medicaid (for 3 patients). By the end of year three, telemedicine visits totaled 225.
Use of the virtual infusion centers resulted in tremendous cost savings, for an estimated total of $65,791 saved based on mileage, shared among 127 patients in the first two years. Additionally, an estimated 1,757 hours were saved in total. Cost savings did not account for savings in hotel expenses that would likely have been encountered if patients had traveled for care.
The Sanford Virtual Infusion Centers reported no sentinel events, interruptions in treatment, or hospitalizations among patients that were attributed to the infusion process. There were seven infusion reactions reported that were adequately brought back to baseline with patients able to continue treatment. There were five occasions of medication variances that were discovered, but “nothing reached the patient,” according to Halbritter.
Halbritter explained that patient worries of lower-quality care become alleviated with the realization of how connected the facilities are. Outreach efforts to link to patients who may benefit from a rural infusion center include newspaper and radio advertising, as well as direct mailers and a social media presence.
“Patient satisfaction scores are high,” Halbritter said, and physician and nurse approval are also high. According to Halbritter, clinical trials have even broadened to two rural sites, and a market shift has occurred in which patients are increasingly attracted to the rural infusion centers. Additionally, all the nurses at the rural sites have since become oncology-certified.
A new horizon for the maturing program is a subscription-based model for monitoring or providing oversight over infusion centers. Overall, the Sanford Virtual Infusion Project has attained high levels of satisfaction, and “everyone wants in,” said Halbritter.
- Halbritter, S. Virtual infusion enhances patient care & expands a rural workforce. Oral presentation at: ACCC 35th National Oncology Conference; October 18, 2018; Phoenix, AZ.
- Gruca TS, Nam I, Tracy R. Trends in medical oncology outreach clinics in rural areas. J Oncol Pract. 2014;10:e313-320.
- Curtis ML, Eschiti VS. Geographic health disparities: satellite clinics for cancer care in rural communities. Clin J Oncol Nurs. 2018;22:500-506.
- Sanford Health. Traveling for cancer treatment? https://www.sanfordhealth.org/sioux-falls/cancer-center/cancer-services/virtual-infusion. Accessed October 24, 2018.