S1E7 | Telehealth: Virtual visits transforming the delivery of cancer care
Dr. Pat Basu: Hi, I'm Dr. Pat Basu, the president and CEO of Cancer Treatment Centers of America and the host of Focus on Cancer. On today's show, I welcome a very special guest, Dr. Chevon Rariy. Not only is Dr. Rariy an expert in the field of endocrine oncology, she is the national director of telehealth at Cancer Treatment Centers of America. And our show today is primarily focused on the exciting world of telehealth and what it means for the future of medicine and what it means for our future patients. So, Dr. Rariy, welcome to the show. Thanks for being here.
Dr. Chevon Rariy: Thank you. Thank you so much, Pat. I'm thrilled to be here. Thanks for having me.
Dr. Pat Basu: I'm thrilled to have you here. You and I have a shared passion for telehealth and the real game- changer that it already has been. And frankly, we're just in the early innings of what telehealth will do in the years to come. But before we dive into that topic, tell me just a bit about your background, what got you into medicine and cancer care, and what you did before coming to CTCA?
Dr. Chevon Rariy: So I got into medicine, I can start there, as a child, I've always been very interested in science and how things work, and how to improve upon something that's there or improve upon or solve a problem. So for me, medicine was a natural fit. Ultimately, I was seeking a better understanding of the world around us. And through medical school, I went to Harvard Medical School there, and vividly remember a time when, in anatomy, so the first class that we as medical students get introduced to, where we are humbly introduced to the patient that we're going to be working with from an anatomical standpoint, and I was blown away by the awe that is the human body, the human being. And I think my love for medicine, my love for science and my quest for answers really took off. I then further went into endocrinology, which is study of hormones, and endocrine oncology specifically, which encompasses a number of rare cancers, including the more common thyroid cancer, mainly because I wanted to treat the entire patient. I was fascinated with the human body. And the study of hormones interact with each and every organ, so that was important for me to be able to have a holistic understanding of the patient who sits before me.
Dr. Pat Basu: That's terrific. You've got a fantastic background and I love that that introduction. It's similar to what drew me into the field, and some of our colleagues. I often tell medical students and residents that this is just the most fulfilling job because the humanity and the ability to take care of patients is so fulfilling. The science is always so interesting, and the privilege to do it in cancer care is, I know you and I share the feeling that it is the most fulfilling thing that we could be doing is to take care of patients in this tremendous battle against this horrible disease. And you've made tremendous strides and a huge impact in the field of cancer care and at CTCA as leader of the telemedicine program. Really excited to talk about the present, and frankly, the past, present and future of telehealth. Let's start with maybe a couple of just basic definition. So, Dr. Rariy, what exactly is telehealth?
Dr. Chevon Rariy: Telehealth in general is a broader concept. So for our patients, for our audience, we'll see the term telemedicine versus telehealth. And the idea is that when we dive deep, telemedicine is a subset of telehealth, telemedicine involves audio/ video communication between the provider and a patient, and telehealth is that broader concept where telehealth can involve telemedicine, the audio/ video, but it encompasses more. It can encompassed the communication that you have between your provider on your mobile phone, on your mobile app. The portal can encompass telehealth. So any type of tele communication between you and your care team is encompassed in the word telehealth.
Dr. Pat Basu: Absolutely. And I think as this becomes, well, it's already become mainstream, we'll talk about that in a moment, but before, maybe 10 years ago, this was such a new concept and a lot of the terms were confusing to people. But I agree, telehealth is that broader super set, and telemedicine, an aspect of that. This is a field actually that you and I share a huge belief in the impact that it is having on patient care delivery. And really, in the last year, especially given the pandemic of COVID- 19, that the use of telehealth and its impact has grown dramatically. That said, this is actually an area that has been around for a long time. In fact, when I sometimes speak about telehealth, I say that it's been around for decades. One of my favorite examples is to it's to use NASA and space with regards to taking care of astronauts and their health care, even when they were orbiting the earth or on their way to the moon. But really, the delivery of healthcare from a location where the patient and the physician or any member of the clinical care team is not right next to you is a powerful concept. It reduces time and distance. It allows tremendous specialty care to be delivered in far off reaches, as well as in a much more efficient and an effective manner. As you know, I used to lead an organization called vRad, which was the largest telehealth organization conducting telehealth visits in the radiology space, and then helped start a company called Doctor on Demand in 2013, where we delivered urgent care visits in telemedicine. And it's been really remarkable to see the progression of telehealth grow from that point until now. When we started Doctor on Demand, it was truly such a novel concept that you had to explain to people that you could deliver healthcare over a video visit. And we spent a lot of time just educating patients on that aspect. And a lot of funny stories, a lot of really smart questions from patients who would say," Wait a second, I'm used to getting this care in person. How do you do a physical exam? How do you take a history over video?" But we found that through the education of patients and through the adoption, but in particular, once patients had a visit, they loved it. There was no more of the waiting for a couple of hours in the waiting room in a crowded room. There was just so many advantages to the patient being cared for at home, to the point now, Dr. Rariy, where telehealth in the past year has almost become commonplace. Can you talk a little bit about the evolution that you've seen just in telemedicine over the last decade and in your career and where we are now?
Dr. Chevon Rariy: Absolutely. Absolutely, Pat. So you describe it very well. So I've been in this space for over a decade, as you have have alluded to, and like you, we have been paving the way, if you will, for something so revolutionary as now. So I'll start off by saying COVID has changed many things, if not everything that we do. The pandemic has impacted all aspects of our lives. It's impacted how we communicate, how we socialize, how interact with teachers, how we interact with healthcare providers. And it really has spurred the significant uptake of adoption of telehealth, where, in the past, like you had mentioned, telehealth has been in existence since the 1960s, and at that time, it was relegated mostly towards providing care to those patients in rural areas where access was an enormous issue. Then we moved into the urgent care space, but specialty care, short of radiology, was very slow to pick up. So cancer care within the telehealth space was very slow to pick up in, and particularly in the United States. Internationally, it was quite prominent in areas where the demand was there. So in Australia, in particular, where the demand is present to make sure that we provide oncology care to all areas of our community. And so with the pandemic, and quite frankly, the public health emergency was declared and CMS, they rose to the occasion. They were able to provide about 180 various waivers that allowed care to continue during the peak of the pandemic and beyond. And part of that was telehealth, it's having its moment mostly because it really was able to dampen the impact from a healthcare standpoint that the pandemic has caused. It allows the provider to continue that interaction, to continue that communication through to patients where PPE is an issue or social distancing is a mandate, or quite frankly, patients can't travel. But this is all in the backdrop of patients have become much more familiar with using their mobile phone or digital aspect to communicate with every aspect of their lives. And now, we really have been able to show the world how we can utilize technology to impact and improve upon healthcare. So it's been exciting to be a part of it. It's been exciting to be able to bring these services to our patients who, quite frankly, need it most. Our cancer patients, during this pandemic, were more than ever needing our services as a provider. And being able to utilize this tool to engage the patients and to provide such services was and remains to be key, in addition to kind of augmenting their onsite care. Onsite is still necessary, and in many cases, telehealth is not meant to replace a visit. It's really meant to augment that care and to provide that additional support that the patient can have for the betterment of their health. So it's been fascinating to walk through this with CTCA and in general.
Dr. Pat Basu: Thanks. Thanks so much, Dr. Rariy. I agree, you've been not just a spectator watching, but certainly a leader on the field leading this huge development in telehealth and telemedicine, so much so that I often say that, in a few years, I don't think we're going to call it telemedicine. We'll call it medicine, just the same way we don't call it tele banking when you deposit a check on your phone. We just call it banking. And you're exactly right, technology has changed our lives so dramatically, particular in the last 10 years, with the ordering things on Amazon, to getting a ride, to getting food delivered, that it absolutely is paramount that we use that technology to make healthcare more accessible, more affordable, and higher quality, and telemedicine is doing just that. In fact, you're exactly right that many of these solutions have actually been around for a number of years, but it was COVID and the government, in particular, bodies such as CMS, Centers for Medicare and Medicaid services, that really did pave the way for a dramatic increase in telehealth. Pretty shocking statistics for Medicare, that this year, in 2020, after the pandemic, that in April, 43. 5, so almost half of primary care visits for Medicare were delivered through a telehealth platform. And to compare that, that number was 0. 1% in February. So telehealth used to be one of those things that we used to talk about as coming or in the future or the inflection point, but clearly it's here. And the pandemic accelerated the value that telehealth provides from a distance and safety perspective. The barrier reduction provided by the Centers for Medicare and Medicaid and others was tremendous because, prior to that, Dr. Rariy, as you and I know, there was a lot of barriers to delivering telehealth. Some in my opinion were pretty antiquated. If you think about even just treating an upper respiratory infection in Illinois versus Indiana, a pretty similar infection, but yet you needed a license in the different state. And frankly, prior to some of these rules, you could not see that patient in the state next door. But we are in a period now where, thankfully, a lot of those regulations have been decreased. And what's your view on that? Are those changes you think here to stay?
Dr. Chevon Rariy: During the pandemic, we were able to see that telehealth is not just a convenience, but it was a necessity. And I think that was the silver lining, if you will, of the pandemic, where high- risk patients, those with cancer, those still actively undergoing cancer treatments could stay at home, could remain safe and could still access their much needed healthcare on a regular basis. It allowed hospitals to reduce the patient volume and maintain social distancing. And so the lawmakers, the insurance companies, I think everybody understood the necessity to take the guard rails off and allow telehealth to be the tool that we can enable help for those who need it the most, certainly at a time when it was needed. And so there are a number of different large organizations, there are a number of different providers, there are a number of different lobbying groups all asking for the same thing, which is to make a number of these waivers permanent, such that, when we come out of this pandemic, we're still as strong as we are now, where all of the benefits that we're describing with telehealth, and all of the learnings, quite frankly, that organizations have been able to appreciate and impact the care for their patients, that the rules and regulations continue to evolve to allow this type of beneficial healthcare to maintain and to continue to take place, and allow disruptive innovation, if you will, to emerge and to continue for the betterment of the patient. So you had mentioned early on the physical exam is necessary. It's a necessary tool to be able to diagnose and to be able to treat, but there are some things that we have learned, that we who have been in this space for years, you and I have learned before and now we're able to share that with the rest of the world, how you can still affectively navigate patients who need that high touch, and how you can continue to augment their care with telehealth, not completely replacing the care, but recognizing when they do need to come in, and quite frankly, when they don't, and when care can be delivered in a equal high quality fashion to those patients who don't need to come in for that visit.
Dr. Pat Basu: Yeah, I could not agree with you more, Dr. Rariy. Your comment there on the physical exam reminds me, when we were seeing a lot of growth in patients at Doctor on Demand, one of the early questions that that people had around telehealth was would communication or would some of those diagnostic skills be lost from going to the bedside to going to a video visit format? And it's interesting. We did a fair amount of research on this space and we found that what had happened in modern medicine at the bedside due to the pressures, the administrative pressures, the insurance pressures that doctors face, even after those long wait periods the patients were spending to get an appointment, which was about three weeks, and the average wait time was about an hour, they would go in and their actual face- to- face interaction time on average was about eight minutes. And during that time, doctors were having to look to the side and chart, that one of the most intriguing comments that we got repeatedly in our telemedicine delivery was," The doctor looked at me the entire time and it was so refreshing." And I would read these comments over and over. And it was one of those areas where it just showed that not only could telemedicine be equal to the bedside, but in many cases, be better than. And for reasons such as that and others, going back to your point on the regulations, I agree with you that I think this is one of those few times it seems that in the year 2020 we can say these words, but telemedicine, telehealth has bipartisan support in a lot of areas of Congress and at the state House, which cannot be said for a lot of other areas. And so I agree with you. I think there's a real opportunity here to preserve the good aspects of telehealth, while shielding some of the potentially bad ones. And the government and insurance companies rightfully are always on the lookout for fraud, waste, and abuse that can occur anytime there's there's changes. But I agree with you, the data is showing overwhelmingly that this can increase access and increase affordability. Another reason why I think there's bipartisan support is the use cases for telehealth are tremendous. I mentioned radiology before. There's dermatology. There's behavioral health therapy. And then certainly, where you and I have our passion and devote our careers to is oncology and in cancer care. So let's talk specifically about the role of telehealth in cancer care therapy, Dr. Rariy. You mentioned something very important, which is unlike just the pure diagnostic specialties, internal medicine, primary care, mostly dermatology work where there's behavioral health, where there's almost this instantaneous," Okay, I can see how most of that can be delivered over telehealth," but patients often have a lot of questions around," Okay, but what about chemotherapy? What about radiation? What about surgery?" So let's kind of lay it out, the various use cases. What are the roles for telemedicine within cancer care and what are the areas where you mentioned you still need to come in? Can you kind of lay that balance out for our patients?
Dr. Chevon Rariy: Absolutely. So I'll start by saying first that telehealth can offer that peak into the patient's home. And for cancer patients, it's so vitally important. So if you can imagine, there's a lot of discussion about social determinants of health. How do we fully appreciate the social situation that a patient is going through, and quite frankly, once we can appreciate it, to provide solutions or areas in which a patient might need additional resources or additional help in order to execute on the care plan. So this telehealth provides a significant opportunity where one can garner that information from the patient just by their surroundings to better understand how we can support, as a provider, the patient in helping them to execute on their treatment plan and making sure that they're successful. So that is one important point I wanted to make and to bring through. Of course that is impactful for any patient, but I think it's particularly impactful for the cancer patient, who will be, invariably, experiencing chemotherapy agents, chemotherapy side effects, and hardships from their own response and reaction to the medication to help fight, to help beat that cancer, and onwards. A family member could be part of the conversation perhaps more readily in the patient's home than that could be had in a visit, especially if there's some travel that needs to occur with it. Additionally, there are opportunities where we could provide specific oversight for the cancer patients. So not only involving that telemedicine communication between the provider and the patient, but integrating the care team. So involving perhaps the pharmacist in that conversation, involving the social worker in that conversation, the nutritionist in that conversation. So really providing additional tools and interactions and integration with the care team for that patient while they're in their home. The patient, we spend most of our lives outside of the hospital walls, and yet it really took this year, the year of 2020 to fully appreciate how to best deliver that care in a broad sense to that patient outside of our four walls. So that could include providing an opportunity for stable patients to get distinct, perhaps safer chemotherapy agents in the home with less side effects, how to continue to keep them safe, how to continue to optimize their healthcare, and provide them with the opportunity to remain in the home, to get their frequent agents every few weeks that may occur. And for the stable patient who is on perhaps one of the newer medications that have less side effects, that could be safe to infuse in the home with a specialized chemotherapy trained infusion nurse. That is a significant opportunity that we have as providers and leaders within the healthcare space and within the digital transformation to provide those services for our patients in a safe way. And so there are opportunities, there are areas that we can absolutely leverage digital health and telehealth oversight to integrate the care of the cancer patient for the betterment of their health.
Dr. Pat Basu: I love that word, integrate. I think it's such an important aspect of the role of telemedicine in cancer care in particular. Let's be clear, when a patient needs radiation therapy or when a patient needs surgery, and for many aspects of chemotherapy, the patients does need to be seen in our hospitals and clinics. However, and this is why I love that word integrate, telehealth is a dramatic, dramatic solution to provide the glue, provide the connective tissue between those visits, before those visits, after those visits. It's such a powerful tool. As I said, at the beginning, one of the best aspects of telehealth is that it reduces time and distance to an incredible specialists such as yourself. You did mention something that I want to do a deeper dive into. We talked about the need obviously to come in and get surgery in person, radiation therapy, lifesaving therapies for cancer care. I sort of think of it as these important spites of lifesaving care that we deliver in the hospitals and in the clinics, and telehealth use to sort of bridge the gap in between many of those things. But there's one use case that you and I are excited about, where we might be able to deliver more cancer care therapy in the home through infusion of various chemotherapy drugs. You are really leading that effort nationally and pioneering that. So can you give our audience a little bit of an insight into oncology infusion at home?
Dr. Chevon Rariy: So it is not a new concept. In Europe, it's almost commonplace where, again, in particular, for patients who are relatively stable and who are eligible who receive frequent chemotherapy agents, it's an opportunity to provide care where the patient's at, to provide care by highly skilled trained nurses who come to the home and they're trained in chemotherapy infusions. And it's important to understand that there are particular agents which lend themselves well to being infused in a setting outside of the hospital, while there are other agents which do not. Similarly, from the patient standpoint, there are particular patients who are medically stable and can tolerate that infusion in the home, and there are those who may not be able to, and there are those in between who might move from one area to the other. What the initiative entails or what the program entails is the patient has a visit with their provider through this telehealth service, or I should say that there's a on- site visit. They might see the provider and have the surgical procedure that's necessary, have the radiation treatment that's necessary, and now they're moving on to a more stable chemotherapy regimen, where they're coming every three weeks or perhaps every four weeks, long travel. They may have to take time off of work. They may have to engage their caregiver and their caregiver has to take time off of work. And it might be a three- day endeavor for a 30 minute infusion, if you will. We're essentially looking at what the rest of the world is doing. I think the United States is a little bit late to adopt this, but it's an opportunity that we can really be able to meet the patients where they are, and that's in their home for those specific patients, for those specific agents, whereby a trained home health nurse can meet the patient in the home and provide that same chemotherapy agent for that 30 minute infusion in the home in a safe manner, with oversight through telehealth from the medical oncologist continuing to monitor their symptoms, provide education that's needed. If the symptoms need to be escalated, there's a way to communicate with the care team. And you're providing that wraparound care, is what I'd like to call it. So we're in a state where we have the tools to better improve the patient's care and continue that interaction with the patient more than a three- month basis. So like you had mentioned, to augment that care in addition to the face- to- face. The face- to- face we wouldn't replace. That's still necessary. The high touch is still a part of that, but now we can extend that to those services in addition to your face- to- face. And what a remarkable opportunity we have to be able to move or to offer that to our cancer patients, where, quite frankly, they have the support of their loved ones in their home. They have the safety, not only from the pandemic, but just in general, peace of mind, less time off of work, more convenient. And they can still get the treatment that they need to get up the next day and to do what they are passionate about themselves, without having to take an extended period of time or an extended period of time off. So our goal here at CTCA and with this program is to empower the patient to be able to move beyond their cancer and provide them with the tools to do that.
Dr. Pat Basu: Well, Dr. Rariy, there's a statement that you made there around meeting the patient where they are, which I love that concept. I love it because too much of medicine is not patient centric. Oftentimes it seems if you're a patient, the system cares about everybody except for the patients, and this idea of meeting the patient where they are, in this case, literally meeting the patient where they are at their home, but figuratively, I know you and I love this concept of patient centeredness. And in a healthcare system that is all too often inconvenient and has way too much discomfort, bringing the feeling of convenience and comfort and designing a healthcare system the way one would want it to be designed, one would want for their mother to engage in from a mother standard of care perspective, and I think through some of your examples, it's really brought to light the idea that telemedicine does just that. And for our audience, I want Dr. Rariy to do this with the following lens. So many of the innovations, not just in healthcare, but in our lives, are very difficult to see in the present time. If we were to ask each other would we be ordering groceries at home consistently 10 years ago, or depositing checks remotely 20 years ago, or FaceTiming with our loved ones 15 years ago, many of us would say," Wait a second, how's that going to work?" And that is the exciting thing about innovation. That is the exciting thing about leaders such as Dr. Rariy is they make what seemed impossible possible in a lot faster of a time period. So with that, Dr. Rariy, maybe paint the future for us. What can we expect in the years ahead as an impact to telemedicine going forward?
Dr. Chevon Rariy: Absolutely. So I'll start off, I have no crystal ball, but I think the key thing to take away is that with innovation, it's following the vision that is key, that is imperative, not following the path. So it's important to have that vision of the future. And more often than not, it's something that may not be present today. But if the vision is there, no matter how we get there, we'll end up with that thought. So for instance, within the healthcare space, I would say it is imperative for us to end or to land that vision where we can have a more convenient way of receiving care, we can have a more patient- centric care experience. We can have a more accessible healthcare system. The United States spends a significant amount of funds, of money on healthcare, more than anyone else in the entire world, and yet our outcomes are not significantly improved. We need to get to the point where we are matching that vision of healthcare with the expectations of the patient, and quite frankly, having the outcomes to show for it. So that vision, it might involve a very different lens than what we experience today, but it's important to recognize that there is a way to receive healthcare for the majority of individuals, increase access, increase convenience, increase its quality, increase or make it more equitable, to be more inclusive, and quite frankly, to provide care beyond the brick and mortar, beyond the fixed timeframe, but really 24 hours, seven days a week. We have the technology and we need to move in that direction where we're really... If you don't have health, there's not much else that we have. And so it's vitally important to improve upon and to provide that healthcare for individuals so they can continue to live their passion. And that's my goal. That's my vision. That is what I can say that we'll continue to work towards. And with the silver lining of the pandemic, again, it has provided those opportunities that you can have those innovative healthcare space so you can be able to integrate many different functions all into one formidable program. So whether those functions involve looking at it from a systems perspective is entirely important when we're looking at transformative change. It will not happen in a silo. It will not happen focused on technology and very individually focused on medicine. It's really the integration of them all. It's the integration of services, of technology, of marketing, of patient experience, of compliance, of the legal opportunities and of operations. And it's really that excitement of systems thinking and integration that we'll be able to, again, meet the patient where they're at and to provide them with high quality care that supersedes our expectations.
Dr. Pat Basu: Absolutely. Well, I share your vision and your passion for telehealth. It calls to mind one of my favorite quotes by the late Bobby Kennedy, who said," Some see things as they are and ask why, others see things that never were and ask why not." And I think that is the spirit, that is the aspiration of what we can do as humanity, what we can do to advance healthcare for our patients. And again, thanks to innovative leaders such as yourself, Dr. Rariy, thanks to a national leader in telehealth that you are, I think we're going to see a brighter future for our patients. So thank you for that. Thank you for all that you're doing. Thanks for taking time away from your busy schedule to come on the show, and appreciate it. And we'll talk to you soon.
Dr. Chevon Rariy: Absolutely. Thank you so much, Pat, for having me. This has been fun.