Telemedicine, the coronavirus, and breast cancer

Efforts to stop the spread of COVID-19, the disease caused by the new coronavirus, focus on limiting how much you interact with people outside your household. For many people with breast cancer, one way the disease has changed life is by introducing them to telemedicine, a term for medical appointments held over phone or video. The practice was very limited until late March, but with healthcare providers looking for ways to support patients while limiting the number of times they come into the office or hospital, the practice has quickly taken off.

Living Beyond Breast Cancer CEO Jean Sachs, MSS, MLSP, spoke with medical oncologist Harold J. Burstein, MD, PhD, about the sudden rise of telemedicine and how to get the most out of remote visits. Dr. Burstein shares some of the new opportunities that telemedicine offers as well, including second opinions, connecting friends or family to listen in, and sharing materials.

Watch, listen, or read the transcript below.

Harold J. Burstein, MD, PhD
Dr. Burstein is associate professor of medicine at Harvard Medical School. He practices medical oncology at Dana-Farber Cancer Institute and serves as staff physician, medicine, at Brigham and Women’s Hospital. His research interests include new treatments for early-stage and metastatic breast cancer.

 

Jean A. Sachs, MSS, MLSP

Chief Executive Officer, Living Beyond Breast Cancer

Jean began her work with LBBC in 1996 when she became the organization’s first executive director; she was named CEO in 2008. Jean brings a lifetime of women’s advocacy experience to her role as CEO. She lives LBBC’s mission everyday by speaking with newly diagnosed women about their needs and gaps in support. Read more.

 

Jean Sachs (00:05):

Hi, everyone. It's Jean Sachs, the CEO of Living Beyond Breast Cancer. I am coming back to you again today. It is April 2, and like many in our community, we have been trying to do interviews a couple of times a week with some of the amazing doctors that are on the medical advisory board for Living Beyond Breast Cancer because we want to bring you content that is relevant and specific and also answers some of your questions.

Today we are really going to focus on telemedicine. We know many patients have already started doing this and so we want to get some insights from Dr. Harold Burstein from Dana-Farber Cancer Institute and Brigham and Women's Hospital. He is a medical oncologist and a clinical investigator in the breast oncology center. Thank you so much for joining us today.

Harold Burstein (00:59):

Very glad to be with you.

Jean Sachs (01:01):

Thank you. Before we start, because we know our audience is really interested in following our doctors, can you share your social channels?

Harold Burstein (01:11):

Oh wow, yes, of course. I enjoy Twitter and my handle is @DrHBurstein.

Jean Sachs (01:25):

And are you actually answering questions [on Twitter]?

Harold Burstein (01:28):

Yes and no. I do not answer individual patient questions on Twitter. I worry about confidentiality issues and we don't really want to be providing medical advice, so I rarely respond to questions like, “I have this clinical scenario. What would you do?” on Twitter. I will respond to inquiries from healthcare professionals on email, my email is HBurstein@partners.org, but I don't do that for all patients because otherwise we would just be deluged.

If you pose a compelling question, generally I will try and think about it and if I think I can say something useful, I would respond publicly, but it would not be a private communication.

Jean Sachs (02:14):

Okay. That's really helpful, thank you. We want to share as many places for people to get reliable information as possible.

Harold Burstein (02:22):

Well, I think that telemedicine conversation's very apt one for that, because I think this is going to really change the way people interact with healthcare in the future.

Jean Sachs (02:30):

Great, let's just start. Why don't you start by just telling us what is telemedicine? Why is it so critical right now? Just give the overview.

Harold Burstein (02:40):

Absolutely. Telehealth or telemedicine are blanket terms. They mean slightly different things to different people. Over the years it has ranged from talking to someone on the telephone to, in more contemporary practice, interacting with people over video conferencing. So this from Zoom or WebEx platforms to internal proprietary direct video conferencing that programs could have.

There has been interest in telemedicine or telehealth for a long time. The barrier historically has been that it's very difficult for medical centers and physicians and nurses to get reimbursed for telehealth services. As I'm sure the audience knows, there are a lot of rules about what you have to do in the way of actually seeing a patient and documenting the encounter to get paid by Medicare, Medicaid, or third-party payers, which typically follow the lead from Medicare, Medicaid.

The Center for Medicare and Medicaid Services — CMS — had some very specific rules that enabled certain kinds of telehealth or telemedicine. It was very narrowly constrained, and in general it was designed to reach people in very remote areas of the country who did not have access to physicians or nurses or other healthcare providers. So, for certain very specific zip codes, they could have interactions digitally that could be billed for. But then you had to be a specific telehealth center and you had to only work with certain populations.

That was the fundamental barrier, because the technology has come a huge way. We're doing this today on Zoom. That's just one of many platforms that you can now have fast, reasonably private, HIPAA-protected conversations over. So the barrier wasn't the technology, the barrier was getting paid.

In the past there have been ways to get around this. We, as a group, have tumor boards for instance, where we have an internal video link and we talk to our satellites or we talk to groups around the world and we will discuss cases. Many patients may know that there are proprietary platforms, Best Doctors and others, where you can go to them and, for a fee, set up a separate consultation that could be done over video or on the telephone. So there were ways around this, but it was very complicated.

That all changed about 10 days ago. Overnight CMS said because of the COVID-19 pandemic, we will allow people to bill for phone consultations and video consultations in a way that they were never permitted to before. And that has led to an explosion — pardon the pun, but it has gone viral — of interest in telehealth and telemedicine. We at Dana-Farber, along with all the major hospitals around the country, have rapidly been using that tool to connect with our patients while we're living through this pandemic.

My short-term impression is that this is a remarkable tool, long overdue, and that there are real strengths here for patients and for clinical teams.The growing hope amongst many is that this is a feature of medicine that's here to stay.

Jean Sachs (06:01):

I'm very pleased to know that in the insurance world was responsive to this, because clearly it's so important.

I have so many questions, but my first one is what's it like, from your perspective, interacting with a patient this way? And then what are you sensing with your patients, particularly your breast cancer patients who often have very close relationships with their medical oncologist, those living with metastatic [breast cancer] or those that are relying on you?

Harold Burstein (06:31):

It's not a surprise, but the strength of the telehealth or video consultation really depends on the strength of the relationship you have with the patient beforehand. For an oncologist, we think we have very strong relationships with our patients. We've often been following them for years and years and years. This feels like a very comfortable, natural way to engage with people. It doesn't solve all of the issues. There's not going to be a substitute for our physical exam in the long run or for certain [in-person] conversations in the long run. But for people who are doing well on chronic medications, for people who have symptom issues that they want to bring immediately to the attention of the team, for patients who are even getting active chemotherapy, but you've been involved in their care and know them well, this has allowed a virtual connection, a telecommunication connection that is really very effective.

I think patients have been generally very happy to speak to us and connect with us. I would liken this to any relationship. If you're talking to your grandmother on the phone, you can go a long way because you know grandma and you know what she's like and you know what her home looks like and she knows what you look like. You know when you say certain things that it's going to be interpreted the right way. Those are all things that really make for successful virtual connections.

Interestingly, it also works for second opinions. We've been doing a lot of second opinions using this kind of platform in the past 2 weeks now, and I think for many patients it's a real godsend.

It's always difficult to travel to a major medical center. It takes time. You have to park. You have to check in. There's a lot of logistics. The ability to get a good second opinion where you're mostly talking about things in the breast cancer space, like pathology, staging, information, treatment history, what are the options that can go towards giving people a roadmap that they can either then follow up with their own local primary oncology team, or in many instances they're now saying, wow, that was really helpful, I want to set up a permanent relationship with Dana-Farber, and we're working on putting those kinds of things in place. So, there's clearly an upside to all that can be done here.

Jean Sachs (08:45):

Second opinions was absolutely one of my questions. How long is a telemedicine visit? What will insurance pay for?

Harold Burstein (08:54):

So I'm not an expert on billing rules, but in general they are typically, I would say 15 to 30 minutes. They are more or less the durations of a regular encounter and they are billed using time rubrics that are well established from Medicare and Medicaid. I spend 25 minutes with a patient, the majority of that time discussing this, that, or the other thing. New patient consultations can be longer. We've actually had patients who have had conversations about goals of care, end of life discussions, and those obviously can go longer as well.

Jean Sachs (09:36):

That's helpful. Are you seeing any patients in person? And how are you figuring out who gets to have an in-person visit?

Harold Burstein (09:46):

This past week I've been all virtual, but we have a rotating schedule where there will be providers on campus, so that there are always physicians and nurses both on campus and working from home. It's been impressive what we can do, helping people work from home. But it's also obviously important for people to be on site. There are always issues that arise in the care of cancer patients where you need physical eyes, hands, ears. We exchange with our colleagues to support each other in those roles and it's allowed us to keep a lot of people home, protecting resources right now, obviously limiting the use of PPE [personal protective equipment], limiting exposure of staff and patients to possible infection while still caring for a very large numbers of patients.

Jean Sachs (10:32):

I don't know if you can answer this, but I'm curious. Are you encountering any patients that might not have a strong internet connection or a laptop? Are you finding people doing this on their phone?

Harold Burstein (10:47):

We are. Obviously not everybody has computers. Certain people just have iPhones. The good news is you can call people and just talk to them. There are certain video platforms that work nicely over the iPhone. If you live in a place that has poor cell phone reception, then it's more of a challenge. Those are the kinds of things that, in the future, hopefully telemedicine will make better.

Some of the cool things that you can imagine beginning to happen as the space matures: you can do home EKGs [electrocardiograms]. My wife's a cardiologist and they have devices that they can ship a patient and you put the leads on the chest on specific spots and you can get a pretty quick look at an EKG that works very nicely. If you have that and a pulse oximeter and a blood pressure cuff, you can actually do a lot from home. And those things cost hardly anything. I mean, it's very small numbers of dollars to ship those out. I think that's a kind of thing that, in the next wave, we'll be looking towards and obviously it puts a premium on having connectivity at home: phone service, radio, all that working.

Jean Sachs (11:58):

That's helpful. You've kind of answered this, but if you have a couple of tips of how a patient should prepare for their first telemedicine visit. I've definitely talked to some women for whom it's coming up and they're a little anxious.

Harold Burstein (12:13):

The first thing to say is that I'm doing some homework ahead of time. That always makes for a better consultation, whether it's virtual or in person. Thinking through what your questions are thinking through what you don't know and what you'd like to know is really helpful. Having a little personal agenda ahead of time is very helpful.

If you're talking about multidisciplinary care for newly diagnosed disease, it's the usual set of questions: What's my stage? What are my types of breast cancer? What are my treatment options? If someone has advanced breast cancer, they're often talking about, here's my treatment history, what are my choices moving forward? That sort of preparation helps a lot.

The other thing that's really great is to have a second pair of eyes and ears. This is really true for any consultation. Bringing a friend or a buddy or a family member or a spouse or a partner is really great. And the nice thing about like a Zoom video hookup is you can have multiple people join in.

We've been doing these with — actually one of the ironies is you can often connect really nicely with people they know — their kid lives in California, they’ve got an uncle in Miami, their husband is home, their daughter lives in New York, and everybody can join in. That's actually a really great thing because then people can have a really effective communication.

One of the things I try to do is use the whiteboard function in Zoom. Oftentimes we mentioned drugs or we mention a roadmap of treatment: we know this is the first step, this is the second step, here's the key piece of information, here's how we think about an Oncotype DX score. I usually write all that down for the patient on a flowchart when I'm with them in the room, here's the first box and here's the second box. You can do that on some of these platforms, and that's a nice thing. You can save that and then send an email version of that to the patient. So you can create permanent materials out of the consultation that I think are very nice substitutes for the pieces of paper we used to write down, and then patients would put on their refrigerator with a magnet or keep in their folder at home or what have you. Those are all really simple things.

I think people get very self-conscious about what do they wear or, what's the background. There are all these things you can read about now. Like what should the background look like on your Zoom video conference? These days people are so happy just to connect, I really wouldn't worry about that too much. But if you want tips on that, you can find them online. I wouldn't get hung up on that.

Jean Sachs (14:53):

I think we're all, depending how old we are, it's not a very forgiving camera.

Harold Burstein (15:00):

No, and the lighting is bad. The kids are good at this cause they know how to take a good selfie. So they're like, oh yeah, you gotta look down on somebody, don't want to look up their nose and all these kinds of things. The same rules apply for video conferencing.

Jean Sachs (15:13):

Right. I think that's really important. It's very helpful to know that you can bring, you can still invite your friends and family to these appointments. That was something I hadn't thought about. But if anyone is preparing, they ought to think about that.

Harold Burstein (15:25):

Absolutely. So we've been sharing, either you can set up a conference call or you can, connect, I'm not trying to plug Zoom, but that's the platform we use and you can get many people linked into it all around the country, even around the world. That's been really terrific. Or just have your child sit there with you, or your spouse or partner sit there with you, and that's a really helpful thing so that everybody hears the same thing. Right now I'm in the middle of the epidemic. We are not letting visitors into our hospitals and that's been a really difficult thing for patients. The ability to talk with them while they're also in the presence, even if it's virtual, of their family members and friends is a great asset for virtual communication right now.

Jean Sachs (16:16):

We are very lucky to have technology. It's clearly really helping us. I think you already addressed this, but I just want to give you a chance to reiterate what you said: when we get through this epidemic do you see this practice continuing? Do you think insurance will continue to pay for it? Is this something that will just be part of our routine care?

Harold Burstein (16:41):

I really hope so. I think this is going to be the single biggest transformation of how we actually deliver healthcare since the invention of the modern hospital itself, about a hundred years ago, because this is going to, fundamentally, allow for patients to interact with their healthcare team in a very compelling way, but without having to go in to see the provider. And it means that in the future, possibly, if you have a new symptom or a concern, it's going to be much easier to get hold of your clinical team — the nurses, the physician assistants, the physicians — and get some immediate input without getting in the car, driving, all this kind of stuff.

For academic folks, I think there's a huge opportunity because they like to broaden their geographical reach. And now it's as easy to see someone at Dana-Farber if you live in Montana as it is if you live in the back Bay of Boston. There are potentially big opportunities to extend the reach of the great hospitals of this country in a way that hasn't been done before.

There are now rules that are allowing radiologists and pathologists to work from home as well and professionally bill for their fees. That will also have big implications for how we're able to connect people to specialty care that is uniquely available at tertiary hospitals in a way that hasn't been accessible to people before. The question will be, is there, from the government, the willingness to continue to pay for this, and that will become a political question.

I think one of the things, for patients, is if they have a virtual consultation, if they use telehealth during this crisis time, make some notes about the experience. Record your reflections and if you think this is a good thing, maybe it will be time in the future to let people know that. Not just the medical team, [politicians] don't do things cause the medical team likes them, they do things because people like it. And if you said, wow, this was a great thing, it allowed my kid to get checked out by their pediatrician without having to drive in there on a day that I had to work. Or it allowed my mother to connect with her rheumatologist on a date and I didn't have to pick her up, bring her into the hospital, and get seen, she got the care she needed and everybody else could do their job or be at home safe from the infection. Those are the kinds of moments where you go, aha, this is a new way of looking at how we deliver medical care.

Jean Sachs (19:21):

I can see it being such a game changer. I think about all the people that work and have to take a half a day off of work. We know many women that drive hours. It's a financial win. And I would assume maybe you even stay more on time and you're able to keep your schedule.

Harold Burstein (19:42):

Well, let's not get carried away! No, the schedule is a working model. As I tell our patients, even in the clinic, it's a working model. It takes time to do these and we're all just finding our way into it. But at the moment, I would not say we're any more on schedule than other times.

Jean Sachs (20:02):

Right. Not that you don't love sitting in the waiting room, but anyway.

Thank you so much. This has incredibly helpful and I've been ending all my interviews, just thanking you and all the healthcare professionals that are on the front lines of this epidemic. We know that this is very, very stressful. We know you're incredible professionals, how much you care about your patients, and all of you are taking risks that many of us are not having to take. I just really want to thank you, for your compassion and for your bravery.

Harold Burstein (20:39):

I'm not sure how brave any of us really are, but it's a challenging time for everybody. Look, going to the grocery store feels like an act of bravery these days, and I think everyone's trying to find the new rhythms and new operations that work for people amid the crisis and obviously we all are incredibly grateful to the nurses, the physicians, the healthcare providers, and the clinic staff who are interacting day in and day out on the front lines. And we hope they stay safe.

Jean Sachs (21:14):

We all do as well at Living Beyond Breast Cancer.

I want to thank everyone for tuning in. Remember, Living Beyond Breast Cancer has ongoing resources and support. We have closed Facebook pages. Just look at our website. We're happy to join you. There's amazing conversations, very supportive, very private ways for you to get immediate connection and support. We have a lot of resources also on managing your care during this COVID-19 pandemic, so stay connected to us. And remember, we also have a helpline so you can be matched to another woman who's in a similar situation. So be safe and take care.