Use of Asynchronous Interprofessional e-Consults in Cancer Patients During the COVID-19 Pandemic: Current and Future Role

Background

The COVID-19 pandemic created a unique challenge to health care systems worldwide. Decreasing transmission of a novel virus and preserving resource allocation to those at highest risk required the rapid implementation of telemedicine to provide continued medical care. ^1,2 Telemedicine includes both provider-to-patient and provider-to-provider communications, which can occur synchronously (through live audiovisual interaction) or asynchronously (portal messages or interprofessional e-consults [IPeCs]). ³ IPeCs are defined as an asynchronous clinician-to-clinician communication based on the consulting provider's review of a patient's electronic medical record. ³

IPeCs are billable encounters that permit rapid and documented recommendations for a patient. ⁴ Whereas synchronous traditional provider-to-patient telemedicine requires operational equipment, hardware, internet connectivity, and temporal coordination between both the patient and provider, IPeCs circumvent many of these logistical obstacles. ⁵ As such, telemedicine, including IPeCs, is well suited for disaster response as it overcomes physical barriers allowing for continued access to care. ^3,6 Thus, IPeCs are sometimes preferred by patients and referring providers alike as they permit cost-effective, timely, and convenient access to subspecialty care. ^3,7,8

Memorial Sloan Kettering Cancer Center (MSK) is an urban health care system in New York City that provides care to patients living with cancer. As New York City was an early epicenter of this pandemic, we at MSK, similar to other health care institutions worldwide, rapidly replaced most in-person encounters with both synchronous and asynchronous telemedicine visits. This permitted us to maintain health care delivery while enforcing social distancing, decreasing exposure to and transmission of disease, and preserving personal protective equipment (PPE). Cancer patients are a uniquely vulnerable patient population. Recently published reports show worse outcomes in their cancer after a COVID-19 infection. ^9,10

Thus, MSK clinicians strove to significantly limit our patients' in-person visits to those that could not be virtual such as chemotherapy administration encounters as well as radiation and surgical care visits. This rapid implementation of telemedicine in response to COVID-19 brought with it an onslaught of technological and logistical challenges. However, with the successful delivery of telemedicine services, the majority of oncology patients in one study felt that their concerns were met, had a sense of secured privacy, and wished to continue telemedicine services in the future. ¹¹

In this descriptive report, we highlight utilization of IPeCs as one form of telemedicine at MSKCC leveraged during the pandemic to continue high-quality oncological care to patients, safeguard PPE, minimize exposure to COVID-19 while preserving traditional in-person visits only for select individuals. We also posit the benefits of IPeCs and reasons for their continued use in a post-COVID era.

Methods

Use of IPeCs at MSK had already begun in 2019 but increased in frequency during the pandemic. For the purposes of this article, we identified and analyzed all IPeCs placed within our institution from January to December 2020 according to referring service, consulting service, frequency of consults by referring service, and volume by date. During the time of the study, use of IPeCs at MSK were limited to physician consults (“consultant”) within the Division of Subspecialty Medicine (Dermatology, Renal, Infectious Disease, Pulmonary, and Endocrine) and Benign Hematology. Conversely any clinician (MD, Advanced Practice Provider) at MSK can refer (“referring provider”) a patient for an IPeC.

At MSK IPeC referrals are fully integrated into our electronic ordering system. When a provider places a referral there is a drop-down menu with the following consultation options: in-person, telemedicine, and IPeC. If IPeC is chosen, the consent language appears and must be verified to proceed (Fig. 1). Once selected, the consent is embedded in the consultation note. If no consent is performed, then the consult cannot be entered. In addition, consultants are required to document recommendations within 72 h of the referral. At MSK, Benign Hematology was the only service that limited which diagnoses (anemia, thrombocytopenia, leukopenia, leukocytosis, thrombocytosis, and erythrocytosis) could be evaluated by an IPeC. These diagnoses were selected based on previously published data showing high-quality consultations for these hematologic abnormalities. ¹²

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Fig. 1.

IPeC order entry. IPeC, interprofessional e-consult.

Results

A total of 373 IPeCs were placed from January to December 2020 accounting for a small portion of the telemedicine visits performed during the same time period. For example, the Benign Hematology service was 100% virtual during the study time frame and IPeCs represented ∼10% of consultations.

Adult bone marrow transplant (BMT) and leukemia were the most frequent referring services, whereas the symptomatic care clinics (SCCs) and urgent care clinic (UCC) were the most common referring patient care centers. The SCC/UCC are acute care facilities for MSK patients in need of immediate medical attention. Figure 2 illustrates the number of IPeCs completed (“visit count”) according to referring and responding services. Infectious Disease, Pediatric BMT, and the regional network sites referred fewer patients for IPeCs than other services such as Adult BMT and Gastrointestinal Oncology (“referring service”). Dermatology, Benign Hematology, and Infectious Disease were the services that completed or responded to IPeCs most frequently (“responding service”).

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Fig. 2.

The number of IPeCs according to referring and responding services. ICU, intensive care unit.

An alluvial plot (Fig. 3) illustrates the referral pattern of IPeCs according to service in relationship to the frequency of reason for consult. The adult BMT service requested the highest number of IPeCs, and the most likely reason for consult was rash, specifically graft-versus-host disease of the skin. In fact, our data also show that “rash” was the most common diagnosis for IPeC referral overall, followed by infection, “other” and hematologic abnormality. Similarly, the SCC/UCC were also frequent referrers and almost exclusively placed consults for rash, specifically skin eruption due to antineoplastic agents. Interestingly, the most common reason for consult from the GI oncology service was a hematologic abnormality (bleeding), whereas the most common reason for an IPeC referral from a surgical service was a question regarding an infection.

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Fig. 3.

Frequency of referring service placing an IPeC in relation to reason for consult. Other interpretations can be garnered from a deeper study of this graphic, where the width of each alluvium corresponds to its frequency of use. BMT, bone marrow transplant; DVT, deep venous thrombosis; GYN, gynecology; GU, genitourinary; H&N, head and neck; MSKCC, Memorial Sloan Kettering Cancer Center; PE, pulmonary embolism; SCCs, symptomatic care clinics; UCC, urgent care clinic.

IPeCs were utilized most frequently in February and March of 2020 (Fig. 4), in concordance with the sharp increase in incidence of COVID-19 cases in New York City. After a decline in utilization in the spring, IPeCs again increased in incidence over the summer months; and finally decreased in frequency in the final month of 2020.

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Fig. 4.

Total number of IPeCs by month.

Discussion

Telemedicine including IPeCs were utilized at our center during the height of the COVID-19 pandemic. Dermatology was the service most frequently consulted. The reasons for this may be twofold: the high rate of cutaneous adverse events seen from antineoplastic treatments but also the ease with which certain dermatologic conditions not requiring a biopsy can be managed remotely. ^13,14 For example, at MSK Dermatologic IPeCs utilize Vectra 3D imaging when available or rely on referrers to e-mail high-resolution photographs. Use of IPeCs along with Vectra imaging allowed some of our most vulnerable patients (BMT recipients) to avoid an in-person dermatology visit. Similarly, patients with cancer unfortunately are likely to suffer from concomitant hematologic complications, many of which can be managed successfully virtually. ¹⁵

We also noted that the majority of IPeCs were referred by clinicians in the UCC and their regional counterparts, the SCCs. Such increased utilization by UCCs presents an opportunity to expand and improve upon use of IPeCs in these settings. For instance, IPeC referral from an UCC to a dermatologist or hematologist facilitated the delivery of subspecialty care with rapid turnaround in a safe and efficient manner. Thus, the UCC/SCCs would serve as good pilot sites for future expansion of IPeCs for complications related to cancer care.

As with synchronous telemedicine services, IPeCs are beneficial during a public health emergency, as limited patient contact preserves PPE and decreases community and nosocomial disease transmission. ⁴ However, IPeCs serve an important role in the absence of a pandemic, and we argue for their continued utility in a noncrisis era. IPeCs formalize traditional “curbside” consults that are fraught with many potential problems, including lack of formal documentation, liability, and loss of revenue. ⁸ By implementing IPeCs into standard patient care, we intend to replace the traditional “curbside” consult. In doing so, documentation of clinical recommendations avoids medicolegal liability issues and captures revenue that would otherwise be lost.

Furthermore, IPeCs can circumvent interstate licensing restrictions that limit the utilization of live telemedicine visits across state lines. ¹⁶ There are limits to the IPeC process to discourage and avoid overbilling and overutilization. For example, patients must consent and acknowledge they will be billed for the IPeC. Importantly though, an IPeC cannot be billed for a service within 14 days of a standard doctors visit nor can there be direct transfer of care immediately after the IPeC. Another benefit to continued expansion of IPeC usage is increased access to specialized consultations without having to miss days and time off from work and incur the financial toxicity that so many cancer patients suffer from. ^17,18

IPeCs are additionally valuable because they provide subspecialty care access to patients who cannot actively participate in traditional telemedicine due to barriers, including lack of reliable internet access, poorly functioning or lack of equipment required for the visit, and language barriers. ¹⁹ Indeed, the higher reliance on technology to provide health care has been shown to exacerbate inequities that are already experienced in certain vulnerable patient populations, including females, elderly, poor, and non-English speaking patients. ^20,21 IPeCs obviate the need for a patient's participation, except for their consent, but maintain access to care, and thereby potentially overcoming some of the inequities created by traditional telemedicine models.

The COVID-19 global pandemic has highlighted the many benefits of telemedicine transforming health care delivery at a rapid speed. ² Telemedicine will likely continue to complement standard health care delivery models in the post-COVID era. Therefore, we must be mindful of best practices, new opportunities, improved delivery, and awareness of health care inequities exacerbated by telemedicine implementation. In the setting of COVID-19, despite the rapidity of implementation, the majority of physicians responded favorably to utilization of telemedicine. ²²

IPeCs are one of several types of telemedicine used during the public health emergency to maintain patient care. In this study, we present the first report of IPeC usage during a pandemic in an urban cancer hospital. We expect that once the pandemic has ended the use of telemedicine including IPeCs will continue to be a tool for clinicians to provide access care for both existing and new patients alike. More research is required to better understand the potential role that IPeCs can play in health care delivery overall and in cancer care specifically.