Medical Oncology Professionals’ Perceptions of Telehealth Video Visits

Key Points Question How do medical oncologists perceive telehealth video visits for cancer care? Findings In this qualitative study, in which 29 medical oncology health professionals were interviewed prior to the coronavirus disease 2019 (COVID-19) pandemic, the barriers to and benefits of telehealth video visits were elucidated. Although oncologists disagreed on the scope of a virtual physical examination and the financial impact of video visits, most recognized the benefit of eliminating travel and the challenge of delivering serious or bad news. Meaning Differing opinions of medical oncology health professionals regarding the barriers to and benefits of telehealth video visits provide insight into the challenges that limit telehealth quality as well as its expansion potential.


Introduction
Telehealth is an emerging mode of care delivery that can improve access to care, reduce cost, and enhance patient and health professional experience while providing effective care. 1 One central component of telehealth is the video visit, in which audiovisual technology is used to connect patients and health professionals in lieu of an in-person encounter. 2 The video visit allows physicians to evaluate patients and provide treatment recommendations regardless of geographical distance.
While physicians' ability to perform a physical examination during the video visit is somewhat limited, many examination techniques are still feasible, and telehealth encounters and traditional in-person visits have similar performance characteristics. [3][4][5] Telehealth has promise for patients with cancer, where concerns regarding access, cost, and experience are common. [6][7][8][9] A randomized controlled trial of video vs in-person visits for follow-up after radical prostatectomy demonstrated equivalent efficiency, similar satisfaction, and significantly lower cost for the video visits. 10 In addition, multiple studies have demonstrated that telehealth can improve access to cancer care for patients in rural settings while achieving equal or better patient satisfaction and generating cost savings when compared with in-person visits. [11][12][13] Despite its many advantages, the use of telehealth in oncology is highly variable, and its uptake (until a recent surge due to the coronavirus disease 2019  pandemic) has been limited nationally. 14 Various factors likely contribute to slow adoption, including liability concerns, licensure challenges, reimbursement inconsistencies, and workflow ambiguity. 15 We hypothesize that the perceptions health professionals have of this care delivery model are also a critical component of adoption, as the presence of perceived barriers to a service is associated with low utilization. 16 However, to date, the perceptions of health professionals about the utility of telehealth for cancer care are not well understood.
The goal of this study is to report the results of a qualitative interview study focused on eliciting medical oncology health professional perceptions regarding the use of telehealth for patient care prior to the COVID-19 pandemic.

Study Setting
This study was conducted at Thomas Jefferson University, an urban academic health system in Philadelphia, Pennsylvania, with a cancer center that serves over 8000 patients each year. The practice is composed of 55 medical oncologists and 39 advanced practice professionals (APPs). In 2015, Jefferson launched JeffConnect, an enterprise-wide telehealth program that facilitates video visits for patients across a variety of use cases, including both scheduled visits and on-demand visits.
Health professionals received training in the use of JeffConnect with both personalized guidance and online training modules. All Jefferson health professionals, including those in medical oncology, were incentivized (with relative value unit equivalents and an end-of-year bonus for high usage) to utilize video visits. This study was designed and conducted by a team consisting of an emergency medicine physician researcher with expertise in qualitative methods (K.R.), 2 medical oncology physician researchers (A.B. and N.H.), a research coordinator with expertise in qualitative methods (A.G.), and 2 MD/MPH candidate research assistants (A.H. and R.G.).

Study Participants
All medical oncology health professionals (physicians and APPs) at Thomas Jefferson University were eligible to participate. The aim of our volunteer and convenience sample selection was to include health professionals with various levels of experience with telehealth video visits, as the objective of the study was to obtain medical oncologists' perceptions regardless of their frequency of offering or engaging in video visits. Potential participants were recruited first in a faculty meeting led by N.H. and A.B., who then emailed all health professionals instructing those interested to respond directly to nonclinical team members (A.G., R.G., and A.H.) to maintain anonymity among medical oncology colleagues. Health professionals who did not respond to the initial email were recruited directly via email and phone by R.G. and A.H. The study was approved by the Thomas Jefferson University institutional review board, and verbal consent was obtained from each participant. Interview quotations were scrubbed to remove identifying information.

Data Collection
We developed a semistructured interview guide designed to elicit health professionals' perceptions regarding the utility of and barriers to delivery of telehealth services in cancer care (eAppendix in the Supplement). The initial interview guide was drafted by 1 member of the research team (N.H.) and based on previous literature on perceptions of telehealth. All other team members then contributed to and revised the draft until it reached its final form. Interviews were structured to be 1-on-1 to limit bias and influence that could result from larger interview groups with multiple participants. We targeted completion of 30 overall interviews, with a goal of 20 physician interviews and 10 APP interviews, with interviews continued until thematic saturation was reached. The interviews were conducted from October 30, 2019, to March 5, 2020, by 2 trained interviewers (R.G. and A.H.) via telephone or in person and were approximately 20 minutes in length. Health professionals were also asked to complete a demographic survey following the interview with questions regarding age, gender, race, number of years in practice, previous experience with telehealth, and specialty within oncology.

Data Analysis
Interviews were audio recorded and transcribed. Transcripts were verified for accuracy, identifying information was removed, and results were imported into NVivo 12 version 12 (QSR International) for coding and analysis. Given the exploratory nature of this study, the codebook was developed using a conventional content analysis approach, a common method of analysis when coding categories are derived directly from data. 17 All members of the research team read the first 3 transcripts and identified concepts that captured health professionals' perceptions. Team members discussed the identified concepts to create an initial code structure. This was applied to subsequent interviews by 2 coders (R.G. and A.H.) and refined to include new themes as they emerged. This process was iterative and continued until coders and at least 1 other team member (A.G.) agreed upon a final coding structure, with discrepancies resolved through consensus. The 2 coders applied the final structure to all transcripts. Coders double coded 43% of the transcripts. We calculated intercoder reliability in NVivo 12 by using the κ coefficient. 18 We organized themes and quotes into the 4 National Quality Forum (NQF) domains of clinical effectiveness, patient experience, access to care, and financial cost or impact on patients. 1 Each table corresponds to 1 domain, and reveals positive and negative themes with accompanying participant quotes. We used descriptive statistics to characterize the study population based on information collected from the demographic survey. This qualitative study is reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guideline.

Results
Analysis of intercoder reliability in this study showed a near perfect agreement (mean κ = 0.86).
Supporting this result is the percentage of agreement analysis, which revealed a mean of 98.7% (spread, 86%-100%) agreement of all codes.
We enrolled a total of 29 health professionals, including 20 physicians and 9 APPs (

Perceptions of Clinical Effectiveness
Respondents had divergent thoughts on the clinical effectiveness of telehealth for oncologic care (Table 2). Specifically, health professionals had opposing opinions on the capabilities of a virtual physical examination. Some reported they could not examine a sore throat, graft vs host disease, or shortness of breath via telehealth; others stated that they could assess the mouth and skin, as well as respiratory distress. Health professionals who noted the limitations of physical examinations on telehealth cited the dependency on patient knowledge, and raised concerns that the discordance between the physical examination and patient history could cause potentially important missed findings. Respondents noted that the lack of effective physical examinations made telehealth inappropriate for a number of visit types, including first appointments, patients who are seen only every 6 months to 1 year, multiple successive encounters, and patients who are symptomatic or sick.
Another practical limitation recognized by 1 respondent was the inability to provide written information explaining complex treatments, referrals, and labs slips.
Other respondents found merits in the clinical effectiveness of telehealth. Some believed telehealth would allow for increased frequency of patient interactions, noting that for particularly high-risk patients, telehealth could be utilized to anticipate potential emergency department visits or hospital admissions. One respondent noted the potential use of telehealth for patients with communicable diseases, such as shingles, which may pose a risk to other patients in the office setting. Another respondent noted the utility of telehealth because laboratory tests were typically performed the day prior to the video visit, which allowed for results to be discussed at the time of the visit. This is in contrast to in-person encounters, where tests were often obtained by a phlebotomist immediately prior to examination.

Perceptions of Patient Experience
Many respondents were concerned with the patient experience of telehealth, often noting the relationship between health professionals and patients as uniquely important in oncology ( Table 3).
Respondents frequently shared concern that a decreased ability to bond with and support a patient through telehealth is a disservice. Another concern was that patients may experience difficulty comprehending complex treatment discussions that may be better facilitated through an in-person interaction. Several respondents noted that it was not feasible to have discussions regarding serious or bad news through telehealth. A few respondents attributed this to potential technology glitches that made these conversations inappropriate. Respondents also reported that patients had expectations of a physical examination that may not be met when conducted via telehealth, potentially leaving the patient feeling unsatisfied.
Conversely, some respondents found telehealth to augment the patient experience as it provided more frequent follow-up and enhanced convenience, particularly regarding transportation difficulties or when follow-up questions arose after an in-person encounter. Several respondents also viewed telehealth as having the potential to improve the family's experience of care by providing additional educational sessions to supplement in-person encounters and involving family members in video visit conversations who otherwise would be unable to attend.

Perceptions of Access to Care
Respondents reported several ways in which they felt telehealth improved access to care ( Table 4).
One noted that for patients living far from large, comprehensive cancer centers, telehealth allowed them to receive treatment locally while remaining under the care of experts who specialize in their type of cancer. Furthermore, for patients with responsibilities at home, such as caring for children or elderly parents, telehealth increased their ability to see their oncologist. One respondent felt that telehealth allowed for concerns to be addressed in real time and increased availability of in-person

JAMA Network Open | Oncology
appointments for critically ill patients. However, another respondent felt that addressing acute issues via telehealth, rather than an office visit, could lead to delays in important interventions, such as hospital admission.
Finally, respondents felt as though telehealth visits, and specifically the technology required to perform them, were restrictive for older patients, patients who did not speak English, and for those with limited socioeconomic resources.

Perceptions of Financial Impact or Cost
Respondents had starkly different opinions regarding the financial impact of care ( Table 5). Some reported that the copayment for a telehealth visit was unacceptable to patients who did not view video visits as "real" or equal to in-person appointments. Others felt as though the costs eliminated by telehealth visits, such as parking, gas, tolls, and lost work time made them cost-beneficial for patients. Overall, the ambiguity of insurance coverage status for telehealth and the inability to accurately estimate the copayment cost were negative aspects of video visits identified by several respondents.

Discussion
In this single-center, qualitative study we examined medical oncologists' perception of the benefits of and barriers to telehealth video visits for patients. We found that respondents often had

Positive
Physical examination capabilities b "You can certainly still assess somebody's level of distress. You can assess their skin. There are things where talking to people that are really the telehealth pros where you can manage holding the camera and the right way to look in their eyes and their mouth." (D07-higher utilizer) More frequent patient interactions "I think that you could have more frequent visits with your patient. … Instead of saying, 'I know it's hard for you to get here, come back in two weeks instead of one,' it's, 'I'll talk to you by video next week and I'll see you the week after,' and a lot of providers do that." (A05-higher utilizer) "It would allow you to likely have frequent touch. … So I think that the frequency-high-risk patients, for example, so-called-try to anticipate the potential admissions, visits to the emergency room and so on." (D01-lower utilizer) Availability of laboratory tests "So the other big convenience I think for the patient is when you have a video visit, the patient necessarily has to get their labs the day before so you'll have them for the visit. So that … they're typically all resulted by the time you speak with them. So the patient can hear about their labs and all of the results at the time of the visit." (A05-higher utilizer) Communicable disease "The other thing that I think would be a benefit would be people that have acute illness that we don't want in our office. Like if somebody thinks they have shingles, I would much rather have them as a video visit, because it's a danger to the other patients in the office." (D04-lower utilizer)

Negative
Physical examination limitations b "I think if you need to see … listen to someone's lungs because they're complaining of a cough or they have a sore mouth or something, you can probably get a pretty good picture, but it's hard to look at a TV monitor and see a mouth, and you can't listen to lungs and do that." (A01-lower utilizer) Physical examination and history discordant "You can be doing a physical exam and they tell you, 'Oh, no, I'm not in any pain or discomfort.' You go to palpate the abdomen and then they flinch. a A higher utilizer was defined as a health professional who, at the time of the interview, had conducted more than 10 video visits. A lower utilizer was defined as a health professional who, at the time of the interview, had conducted 1-10 video visits. The participant ID has a 2-digit number, and either an "A" denoting an advanced practice professional, or a "D" denoting a physician. b A subtheme and associated quote that was identified as both a positive and negative feature of telehealth in oncology. While recognizing the convenience of telehealth, many respondents emphasized the importance of the health professional-patient relationship in oncology and voiced concerns that patients would feel unsupported, particularly regarding serious or bad news delivery. While our study demonstrated that many respondents felt there was a reduced health professional-patient bond that resulted in a worse patient experience compared with in-person visits, this perception is not universal. Previously, telehealth has been suggested as a means to facilitate a patient-centered care

Positive
Patient follow-up "A follow-up visit, the patient in the office today may come up with two or three questions, but then as they drive home all of a sudden they realize they have actually ten more questions and now they have to wait. So I think that that gives you … again, it's more frequent touching, more frequent conversations, more frequent discussions. I think that patients … I'm sure they will love that part." (D01-lower utilizer) Eliminates complications associated with transportation "They would prefer to have a video visit and not have to travel. Whether it be distance, or it may have been difficult for them to get out, maybe they're more homebound and transportation issues may be in place for them. Or having that social support available for someone to bring them, whatever. It just … it works good for them and it works for us." (A04-lower utilizer) Multiple family members included "Maybe accessibility to other family members. Sometimes they can't always make it in with their loved ones due to work schedules or if they're at home watching their children or whatnot, so if we had this planned out ahead of time on this day [or] at this time, maybe they could make it a point to be with the patient and then this way any other questions or concerns on their behalf can all be attended to and talked about at that one very moment instead of doing the call with the patient and then an hour later a phone call comes in from the daughter … because they misunderstood this and we get a chain of events." (A08-no telehealth experience) Family education and counseling "Certainly educational things that could be done over video instead of, again, face-to-face or as an adjunct where the patients and their families-for example, stem cell transplant [recipients] have had the opportunity to educate themselves a little bit more and then come see me in person, because then it'll be a much more valuable session. And it could be a telemedicine visit, because we could have a nurse or a nurse practitioner or a physician's assistant triaging the visit or participating in the visit to answer questions too. So it might also turn out to be a more efficient way to use our physician extenders also." (D14-higher utilizer)

Negative
Comprehension difficulties "It's not helpful when someone really doesn't understand their treatment or has questions and they just can't get it through talking. They need to be physically in front of you. Because that sometimes that seems to help more in understanding things." (A03-lower utilizer) Patient-health professional lose connection "Cancer care, particularly a new diagnosis of cancer, is not something that most patients are gonna wanna handle through a video visit. They want to get to know you. They want to see you. They want to see your body language. They want to be able to get a relationship with their doctor. And you generally speaking can't forge a good relationship with a patient just on video visits." (D13-higher utilizer) "I think you lose a little bit of the personal connection you get with people when you sit in the same room and you talk to them and you lay your hands on them and you do an exam. The person who was in [City in PA 1], even though we saw her in the video visits and we did all that, she said that she didn't get the services she needed, she didn't feel like we were connected to her, she felt like she was alone." (A01-lower utilizer) "You can't do a physical exam, that's a huge one. And that's such an important part of a doctor visit. The patients kind of feel cheated, they don't feel like it's a real visit if I don't put my hands on them. Sometimes I will do an exam that I don't really have to, I'll listen to their heart and lungs because that's the ritual, patients expect that as part of a medical visit." (D04-lower utilizer) a A higher utilizer was defined as a health professional who, at the time of the interview, had conducted more than 10 video visits. A lower utilizer was defined as a health professional who, at the time of the interview, had conducted 1-10 video visits. The participant ID has a 2-digit number, and either an "A" denoting an advanced practice professional, or a "D" denoting a physician.
approach that decreases the anxiety associated with an in-person consultation regarding bad news in oncologic care. 21 This perspective is supported by a study of 351 patients with cancer that found the most important elements for patients receiving information about their cancer were factors related to content, including the physician's knowledge or competence. Elements related to support-including factors such as being comforted or showing concern; and facilitation, which included being told in a private setting or in person-were rated lower, but still regarded as important by patients. 22 Notably, this study, among others, recognized the individual preferences of patients and found that these preferences have been associated with certain demographic factors such as Positive Patient responsibilities limiting ability to go to in-person visits "I have a couple of patients who are the primary caregiver for other people in their family, so a parent with dementia, or have small children. And so, for those patients, too, I think getting away from the house is challenging and also really costly, because they have to find other caregivers for those people during that time. So, allowing them to be at home for their visit is … helps them with both of those things." (D03-higher utilizer) Access to large cancer centers "We have patients that come from two hours away, three hours away to get comprehensive care here in a large cancer center. And they get the expertise of people that are highly experienced in their specialty, but they don't physically have to come here all of the time." (A06-no telehealth experience) Allows concerns to be addressed in real-time, may open up health professional schedules to see acutely ill patients in person b "I mean, I guess maybe if scheduling was tight. Not to say that one patient is more important than the other, but say you have this sickly, acute patient that can only come in at this time and you already have a patient scheduled and they're not willing to come in any earlier or any later. In that case you can maybe offer … would you want to maybe do a video visit here. … But at least any issues or concerns could at least be discussed in real time at that moment and then that obviously sicker patient could then get slotted." (A08-no telehealth experience)

Negative
Acute issues may need rapid admission, which can be done more easily if the patient is already in the office b "In stem cell transplant, if you think there's something acute going on, you need to see them in person, because you need to … you have to decide whether they need to be admitted or not. And if they need to be admitted, you'd rather have them there to be admitted than two hours away." (D14-higher utilizer) Language barrier "I also have a lot of patients that don't speak English. And that makes it impossible because we need … I need my phone to translate. And it's hard enough to have a conversation through the translator in the same room, let alone through video. So, it's just another added layer of difficulty." (D04-lower utilizer) Older patient population lacks comfort and skills setting up and troubleshooting technology "A lot of our patients have trouble using it because I work with a very older patient population. Also, I have a lot of people that are low income and have poor health literacy, so getting the software set up on their phone can be difficult." (D04-lower utilizer) Socioeconomic status restricting access to technology "The people with less SES [socioeconomic status], less financial resources, are gonna be the ones that probably could benefit the most but also have the least likelihood of having access to it. Unless the cancer center was gonna give out some form of a device for them to use at home." (D08-lower utilizer) Older patient population lacks devices necessary "A surprising number of our patients, particularly elderly patients, don't have access to an appropriate device to do [video visits]." (D19-lower utilizer) a A higher utilizer was defined as a health professional who, at the time of the interview, had conducted more than 10 video visits. A lower utilizer was defined as a health professional who, at the time of the interview, had conducted 1-10 video visits. The participant ID has a 2-digit number, and either an "A" denoting an advanced practice health professional, or a "D" denoting a physician. b A subtheme and associated quote that was identified as both a positive and negative feature of telehealth in oncology. "What I worry about so much is that it's never clear to me what the patient is getting charged for the video visit … it's not knowing what the upfront cost is for the patient that I absolutely hate." (D12-higher utilizer) a A higher utilizer was defined as a health professional who, at the time of the interview, had conducted more than 10 video visits. A lower utilizer was defined as a health professional who, at the time of the interview, had conducted 1-10 video visits. The participant ID has a 2-digit number, and either an "A" denoting an advanced practice health professional, or a "D" denoting a physician. b A subtheme and associated quote that was identified as both a positive and negative feature of telehealth in oncology.  24 Pennsylvania Medicaid announced that health professionals should bill the same for video visits and in-person visits. 25 Although Medicaid did not officially change its cost-sharing requirements for its beneficiaries, it did allow health professionals to reduce or waive cost-sharing for telehealth visits without the risk of facing administrative sanctions. 26 Furthermore, Medicare waived some prior restrictions to accessing telehealth to allow any beneficiary, not only those in rural areas, to receive telehealth services, to do so from their homes, and to use a smart-phone in lieu of other equipment such as computers or tablets. 27 While it remains unclear how long these changes will last, COVID-19 has ushered in a new era for telehealth services, and further research regarding the barriers to offering them due to perceived financial impact is necessary.

Limitations
This study had several limitations. All participants were health professionals at a single, urban, Though this study demonstrated health professionals' perceptions of the barriers to and benefits of telehealth for oncologic care, further research is necessary. Perceptions of telehealth acceptability, including specific benefits and disadvantages, may have changed given the rapid expansion of telehealth secondary to the COVID-19 pandemic and the establishment of the medical oncology telehealth taskforce at our institution. Furthermore, it is critical to directly examine patient JAMA Network Open | Oncology perceptions of telehealth and whether the patient experience of telehealth, as well as its potential limitations and benefits, align with those of health professionals.

Conclusions
This study demonstrated the conflicting opinions of medical oncology health professionals on telehealth and provides insight into potential barriers or limitations to its utilization, as well as the benefits of this health care delivery modality. More specifically, our results emphasize the need to address oncology patients' access to telehealth technology, especially for older populations, and the acceptability of delivering serious or bad news as telehealth continues to change the landscape of patient-health professional interactions. This is especially relevant during the COVID-19 pandemic, as many institutions worldwide have needed to create or expand telehealth programs.