A tele-oncology model replacing face-to-face specialist cancer care: perspectives of patients in North Queensland

Abstract

We explored the experiences of patients using the Townsville Tele-oncology clinic, where most patients are no longer seen face-to-face. All medical oncology patients who received services via telehealth at the Townsville Cancer Centre in 2012 were invited to participate in an interview. None refused. Thirty two patients were interviewed by telephone and three via videoconference at their local health service facility. Data analysis identified five major themes (quality of the consultation; communication and relationships; familiarity with technology and initial fears; local services and support; and lack of coordination of services between the local rural hospital and the major regional hospital) and each major theme included a number of sub-themes. Most patients interviewed (69%) had not seen their oncology specialist face-to-face, but 86% of them found the video-consultation to be of high quality and were extremely satisfied with the interaction. The acceptance of teleconsultation appeared to be linked to the patients' trust with their local health system and staff. Overall, the tele-oncology model that replaced face-to-face care in North Queensland was accepted and welcomed by patients.

Introduction

Tele-oncology has been used in cancer care to provide services to rural, remote and underserved populations.^1–3 Questionnaire-based surveys and qualitative studies have reported high satisfaction rates.^4–8 The reasons for these high satisfaction rates include the ability to receive specialist services closer to home, reduced travel time and its economic consequences and positive technical aspects of telehealth, such as the clarity of audio and video.⁵ In these studies, most patients have been seen face-to-face at some time during their cancer care, where providers had the opportunity to establish a rapport and orient them to telehealth in person.

As providers have become more familiar with telehealth, they have provided more complex management locally. Face-to-face care has been replaced by telehealth in the Townsville Tele-oncology Network in North Queensland.⁹ In this model, many patients have never seen the specialist face-to-face. New, routine and urgent reviews are performed via videoconference with support from local doctors, nurses and allied health professionals. Patients who are fit for chemotherapy receive most solid tumour regimens locally with the help of suitably trained nurses. Earlier evaluation studies found positive patient satisfaction with telemedicine. However, these studies were limited to patients who were initially seen face-to-face.⁵ The aim of the present study was to examine the patient perspective of the Townsville tele-oncology clinic where the majority of the patients are no longer seen face-to-face.

Methods

We conducted an exploratory, descriptive, qualitative study.¹⁰ All medical oncology patients who received services via telehealth at the Townsville Cancer Centre in 2012 were invited to participate in an interview. Semi-structured interviewing was conducted using a flexible interview guide. The interview guide was pilot tested with five participants and then refined. Interviews took between 30–45 mins. An experienced nurse researcher conducted all of the interviews. With the participants’ permission the interviews were all audio-recorded, later transcribed in full and analysed for common themes.¹¹ Two researchers independently coded the data and themes were agreed by consensus. The study was approved by the appropriate ethics committees.

Results

Thirty-five patients were invited to participate; none refused. Thirty two patients were interviewed by telephone and three via videoconference at their local health service facility. Six interviews were not included in the final analysis due to recording failures. Demographic details of the participants are summarised in Table 1.

Table 1.

Demographic details of patients (n = 29).

Median age, years	58
Age range, years	25–83
Gender
Men (%)	12 (41)
Women (%)	17 (59)
Ethnicity
Indigenous (%)	3 (10)
Non-indigenous (%)	26 (90)
Seen via videoconference only (%)	20 (69)
Seen face-to-face prior to videoconference (%)	9 (31)
Cancer type
Breast	12
Carcinoid	1
Colon	6
Lung	6
Head and neck	1
Ovarian	1
Testicular	2

Data analysis identified five major themes, and each major theme included a number of sub-themes. The major themes were:

quality of the consultation

communication and relationships

familiarity with technology and initial fears

local services and support

coordination of care.

The results are summarised in Table 2 using the participant’s own words. Pseudonyms have been used to protect the patient’s anonymity.

Table 2.

Responses of participants.

Theme	Quotations
Quality of consultation	‘I thought it was a very good thing because of the travel, particularly with people who aren’t well and I was willing to give it a try and see how it went’ (John, lung cancer). ‘I found it fantastic because having a doctor in the same room – it’s absolutely fantastic!’ (Mary, breast cancer) ‘It’s just like sitting in the doctor’s surgery, only you couldn’t shake hands with him.’ (Sam, colon cancer) I thought it was pretty good, surprising actually. The conversation I had I thought was pretty good.’ (Mike, testicular cancer)
Communication and relationships	‘He was quite friendly and had things to say to me as a person, not just as a patient so that sort of gives you a bit of a relationship with the person as well, because they are a person as well and not just your doctor.’ (Bert, colon cancer) ‘I prefer face-to-face, but obviously the telelink is there because there is 900 kilometres between Mt Isa and Townsville – not everyone can be in Townsville.’ (Barry, colon cancer) ‘I’m better off with the doctor talking in front of me because of my hearing. I can’t hear that well. It’s hard to talk to a TV.’ (Bert, colon cancer) ‘The first one [teleconsultation] was difficult to understand my doctor because he does have an accent but there is always someone else there like a nurse or another doctor that understands him.’ (Sue, breast cancer) ‘I haven’t met him [the specialist] in person… It is a relationship, basically it’s not an intimate relationship like I have with my partner but it’s a different relationship.’ (Larry, testicular cancer)
Familiarity with technology	‘It was strange the first time but last time it was alright because I was used to it by then. I know there is an old couple that got cancer not long after myself and they have no experience with computers and they were quite frightened about it. They came to see me and I was able to put their fears to rest, then they sat in on one of my sessions and then they were fine.’ (Sally, colon cancer)
Local services and support	‘I felt that the way the doctor had a nurse assigned to us was a plus. Her being in the room made me feel more comfortable. I knew that I could ask her anything afterwards if you had sort of skipped over something that the doctor brought up. It just made you feel more comfortable to know that someone in your town, when you are so far away from the specialist, knows your history right through because at first you are scared about any little thing and having someone in your local area that knows your history makes you feel a lot more comfortable.’ (Pippa, colon cancer) ‘It is very convenient [with telelink being treated locally]. I feel happy and the staff are very good. They look after me here and it is all on a personal basis you know. I walk in and it’s ‘hello [name] how’s it going? It’s not like a number in bigger places.’ (Bill, colon cancer) ‘As far as the treatment at the hospital here and the two girls in the Oncology section, I don’t think I would have got better treatment if I’d gone to Townsville or Brisbane.’ (Mary, breast cancer) ‘The team here fill that [distance] gap for you, because if anything is a problem, they encourage you to ring them or come down to see them. Nothing is too much of a bother for them. If you are in Townsville you wouldn’t be able to just ring the specialist at the drop of a hat, you would have to go through his surgery or office to be in touch with him anyway to make an appointment to see him.’ (Andrew, lung cancer) ‘I don’t mind going to Townsville, because it is a major thing [cancer treatment] and you want to get the best care and you want to understand what is happening to yourself, than do it by a TV script. Well in [local town] I am not confident with the doctors here.’ (Helene, breast cancer)
Coordination of care	‘If you are in Townsville you can make one phone call and get those results straight away. Whereas it’s not easy when you are in a remote hospital and they haven’t got all the gear ready.’ (Barry, colon cancer) ‘About two weeks later I would go to the local doctor as Dr [the specialist] would ask me to and get him to do a total once over [thorough examination]. I don’t think the local doctor took it seriously enough and more or less said, ‘you’ll be right.’ A letter needs to be sent to the doctors explaining the situation.’ (Sally, colon cancer) ‘I have to wait for the chemo to arrive and last time, because they don’t realise that we have limited services out here [600 kilometres away] it took five days to get here.’ (Susan, breast cancer)

1. Quality of the consultation The majority of patients interviewed (69%) had not seen their oncology specialist face-to-face. Despite not having received the conventional model of care, 17 of these patients (85%) found the video-consultation to be of high quality and were extremely satisfied with the interaction. When participants were asked about the quality of the consultation with the specialist on the video link, they commented on the broader aspects of the interaction rather than merely the technical components. One patient who had received initial face-to-face consultations at the regional hospital and was now receiving follow up consultations via videoconference found the teleconsultations helpful.

Another patient, who lived approximately 600 km from the hospital and had seen the specialist face-to-face previously, was extremely enthusiastic about teleconsultation. For six patients interviewed, their initial fears appeared to subside once they were greeted warmly by the specialist via the video link. Three patients who had not been seen face-to-face were surprised by the quality and ease of communication via videoconference.

2. Communication and relationships

Four patients interviewed spoke of the ways in which the specialist made them feel like a person, not just a patient. Six of those interviewed who had been seen face-to-face and then received treatment via video link regarded the first face-to-face visit with the specialist as advantageous, although they reported that even without this first visit, the videoconference would still have been acceptable and comfortable for them. Two other patients saw the usefulness of videoconferencing as it saved them from travelling long distances.

One patient, who had been treated for more than 12 years by the specialist, preferred face-to-face consultations. However, he acknowledged the benefits of videoconferencing for people who live in rural and remote areas. The long standing relationship with his treating specialist may have influenced his reaction to the use of video consultations. The other patients interviewed did not have such long standing relationships with their specialists.

Certain communication problems occurred during the teleconsultations. Hearing loss, experienced by an 84-year-old patient, posed a challenge to his experience of videoconferencing. He had been seen face-to-face at the regional hospital 200 km away from his home and was subsequently reviewed via video link. This patient expressed that initially he did not find it easy to ask questions. However, although he found it difficult to hear, he was satisfied with this mode of consultation. Three patients explained that they found the doctor’s accent hard to understand, although one 53-year-old patient who had not been seen face-to-face acknowledged that having other health professionals present in the room helped. A patient who had not seen the specialist face-to-face explained how the teleconsultation enabled a relationship to develop.

3. Familiarity with technology and initial fears

The patients interviewed had varied experiences with technology and their comfort with teleconsultations reflected these experiences. Despite at least five people not having used videoconferencing previously, once they became familiar with it their initial apprehension appeared to lessen. One of the patients explained how she was able to assist another patient to overcome her fear of the unfamiliar technology: she invited this new patient and her partner to attend one of her teleconsultations as a way of alleviating her fears.

4. Local services and support

Overall, patients were pleased with the teleconsultation and the follow up treatment and support provided by their local, rural hospital. The advantages of having local doctors and nurses in the teleconsultation were highlighted by 13 participants. For nine patients, the active participation of their local health professionals in the teleconsultation with the specialist gave them extra reassurance and was a source of comfort to them. One participant mentioned how the local medical staff acted as interpreters and explained test results to them. Participants who had confidence with the skills and abilities of the local health service staff were more likely to be in favour of teleconsultations than those who did not trust the local service. Two of the patients interviewed explained that they did not trust their local health service and as a result they would prefer to travel long distances to the regional hospital for their treatment, even though the treatment could be provided locally.

Coordination of care

Whilst the majority of patients interviewed (93%) spoke positively of the advantages of teleconsultations, some of the patients (15%) were critical of the lack of a coordinated approach to their cancer care and treatment. Not having blood tests and/or scan results available locally at the time of the teleconsultation created further stress for them. The time needed to chase up results was a source of frustration for many of the participants interviewed. One of these participants explained how her cancer care could be improved by improving the communication link between the specialist and the local treating doctor. Another spoke of the problems associated with not having her chemotherapy drugs available when it was time to begin her next round of chemotherapy. These points are illustrated in Table 2.

Discussion

Our study explored the perspectives of cancer patients from rural North Queensland who received most of their medical oncology treatment close to home in their rural towns. The majority of participants (69%) received specialist consultations via videoconferencing without seeing their specialist medical oncologists in person. Previous studies of tele-oncology from our centre⁶ and other centres, reported high rates of acceptance of tele-oncology by patients who were seen by their specialist in person sometime during their cancer journey.^3,7 The benefits of the present model were the same as those previously reported, including convenience and reduction in travel. With the exception of two patients, all participants interviewed in our study were satisfied with, and welcomed, the teleconsultation model of care.

Our study identified five major themes concerning tele-oncology. While these themes are similar to those reported in previous studies, our study identified additional aspects of telehealth: lack of coordination between the referral hospital and the local hospital, lack of perceived privacy, difficulty in understanding doctors with strong accents and mistrust of local hospital staff.

Most patients (93%) felt that the quality of the video consultations was as good as face-to-face consultations and similar to having the specialist present with them in the room. For three patients, other matters such as privacy, hearing loss and doctors with accents were initial barriers to successful consultation. However, the difficulties were mitigated by having rural health professionals with them in the consulting room to fill in the gaps.

Previous evaluations have reported high ratings by patients for closeness of relationship with specialists.^5,7 Similarly, the results of the present study reveal that many patients are able to relate to the specialists as people rather than as images on a TV screen, and can therefore establish effective relationships with them. Some patients were apprehensive about the new model of care before meeting the specialist for the first time through videoconferencing. However, most patients became comfortable after few minutes. Since the doctor-patient relationship is an important aspect of medicine, specialists need to spend time to establish a rapport, rather than discussing medical matters with the patient immediately.

The need for rural health professionals to be present during consultations has been emphasised by various telehealth guidelines, such as those of the Royal Australasian College of Physicians.¹² According to the participants in the present study, the benefits of local health professionals extended beyond their ability to conduct a physical examination when required and to implement the care plans devised by specialists. Other benefits included (1) filling in any gaps in communication between specialists and patients, (2) troubleshooting technical problems and (3) acting as the local contact person for day to day concerns and reassurance.

The acceptance of teleconsultation appeared to be linked to the patients' trust with their local health system and staff. The three patients who did not have trust in their local health system were less satisfied with the model, even though they received the same care as other patients from rural towns and patients in Townsville. In these three cases, the patients had previously had negative experiences with the hospitals before their oncology treatment and had unrealistic expectations of tele-oncology. Patients should be informed of the benefits of tele-oncology, the credentials of their local, rural health professionals, and their roles and limitations.

One of the lessons we learned from the study was about the importance of coordination of care at rural sites. We had not previously considered the consequences of high staff turnover and rural health workforce shortages on the coordination of care. It is important to have a comprehensive knowledge of the availability of medical, nursing and allied health services in rural towns so that providing sites can accept a major coordination role if there are workforce problems in rural areas.

Limitations of the study

A limitation of the study was that the study participants were from a single, mining and farming region of rural North Queensland. Another limitation was that the socioeconomic status and education status of the participants was not obtained. For these reasons, our findings may not be generalisable to urban and other settings.

Conclusion

The tele-oncology model that replaced face-to-face care in North Queensland was accepted and welcomed by patients. Effective communication and a satisfactory doctor-patient relationship are possible through this model of care. There are many benefits to the patients related to support from local health professionals during and after consultations. Part of the informed consent process needs to include explanations about the model and reassurances that the services provided through telehealth are secure, and of similar standard to regional services. Information on the credentials of the health professionals involved should be provided to patients receiving telehealth in order to foster their trust in teleconsulting and the local health care system. Providing centres may need to assist where there are workforce shortages in rural areas.

References

Doolittle

Spaulding

. Providing access to oncology care for rural patients via telemedicine. J Oncol Pract 2006; 2: 228–30.

Taylor

Khoo

Saltman

Bouttell

. The use of telemedicine to care for cancer patients at remote sites. J Clin Oncol 2007; 25(18S): 6538–6538.

Weinerman

den Duyf

Hughes

Robertson

. Can subspecialty cancer consultations be delivered to communities using modern technology? – A pilot study. Telemed J E Health 2005; 11: 608–15.

Hazin

Qaddoumi

. Teleoncology: current and future applications for improving cancer care globally. Lancet Oncol 2010; 11: 204–10.

Mair

Whitten

. Systematic review of studies of patient satisfaction with telemedicine. BMJ 2000; 320: 1517–20.

Sabesan

Simcox

Marr

. Medical oncology clinics through videoconferencing: an acceptable telehealth model for rural patients and health workers. Intern Med J 2012; 42: 780–5.

Mair

Whitten

May

Doolittle

. Patients' perceptions of a telemedicine specialty clinic. J Telemed Telecare 2000; 6: 36–40.

Mooi

Whop

Valery

Sabesan

. Teleoncology for indigenous patients: the responses of patients and health workers. Aust J Rural Health 2012; 20: 265–9.

Sabesan

Larkins

Evans

. Telemedicine for rural cancer care in North Queensland: bringing cancer care home. Aust J Rural Health 2012; 20: 259–64.

10.

Polit

Beck

. Nursing Research: principles and methods, 7th edn. Philadelphia: Lippincott Williams & Wilkins, 2004.

11.

Richards

. Handling Qualitative Data: a practical guide, London: Sage, 2005.

12.

Royal Australasian College of Physicians. Telehealth Guidelines and Practical Tips. See http://www.racptelehealth.com.au/wp-content/uploads/2013/02/Telehealth-Guidelines-and-Practical-Tips.pdf 2012 (last checked 3 January 2014).