Virtual Visits Facilitate Health and Wellness During Pediatric and AYA Cancer Treatment

By Peter Anderson, MD, PhD

We take a lot for granted in our lives, which, when faced with a cancer diagnosis, can start to unravel. Providing cancer care is not just about following recipes. It’s about helping families understand the principles of therapy so they can go through a very trying time in their lives with less toxicity. I see virtual visits as one way to provide convenient, unhurried care to my patients and their families. Virtual visits are opportunities to catalyze better cancer care and help patient families to feel more informed about their decisions.

Today I conducted three virtual visits – each for different reasons. One was with a patient who would be traveling to Cleveland Clinic Children’s for specialized therapy from a southern state. Another was with a patient who was weighing therapy decisions; specifically, whether to opt for standard-of-care treatment or a clinical trial. Still another was a reality check of sorts for the family about the need begin planning a transition to end-of-life care.

One meaningful benefit of these unhurried virtual visits is that I am able to recommend ways to improve life. I want patients and families to feel like their lives are about more than just cancer. And that their friends/family and healthcare team – wherever they’re from – really want them to do more than survive. We want patients to thrive.

Building Therapeutic Alliances

Parents are among the most significant advantages we have in pediatrics. They not only help with compliance, but also, with the especially protective feelings they have for their children, they ensure their child receives the best and most compassionate care possible.

It can be frustrating for parents to advocate for their children by telephone or email. As in face-to-face interactions, parents can see for themselves that my concern is sincere and trust that I am experienced. (I’m afraid my gray hair gives the latter away.)

Virtual visits are one that way we can develop what I refer to as therapeutic alliances, or relationships in which physicians are responsive to patients’ circumstances, and involve patients and their families in information gathering and sharing, goal-setting and decision-making. Virtual visits for pediatric cancer are one way for us to share and care without sacrificing the nuances of face-to-face communication. When a question from a parent arrives by email, it can be difficult to determine how that individual is really feeling about their life circumstances. With virtual visits, you can see people, often in their everyday environments of car, work or home. They just need a computer or phone to do a virtual visit. If they are miserable, you can see it.

Preparing for a Virtual Visit

I took a page from the airlines, which has implemented self-service technology at airports to reduce costs and increase efficiencies, but also to give more control to travelers in terms of flight and seat selection, and self-service check-in kiosks. If travelers feel anxious or prefer in-person interactions, they have the option of using ticketing agents. Otherwise, they have the ability to upload a picture of their identification, find their flight information and pay for checked baggage from the kiosk.

Similarly, when opting for a virtual appointment with me rather than in-person visits, patients upload their own scans and send me a short health summary that includes contact information for the entire care team. To prepare for an appointment, I review the patient-submitted information and identify opportunities for improving health and wellness.

Generally speaking, there are six significant ways that these visits can address optimizing health and wellness during cancer treatment. These opportunities almost always include: local control of cancer sites; chemotherapy; diagnostic tests and scans; side effect anticipation and reduction; social or quality of life issues and potential solutions to make it better (e.g., work, school, next vacation, occupation aspirations, use LivExtraordinary to share their story and organize their team); and, finally, appropriate follow-up steps (i.e., what to do next). At the conclusion of each virtual visit, I send parents or patients (young adults) an electronic copy of the visit summary and sometimes power points of important scan images, some articles and/or PDFs from clincaltrials.gov to have for their records and share with other caregivers and treatment teams at their discretion.

Increasing Access Without Overburdening Staff

Institutionally, improving access is a key objective at Cleveland Clinic. I have been working to improve patient access to oncologists, surgeons, radiation oncology, interventional radiology, diagnostic studies, and clinical trials since 2015. Virtual visits are one way we can facilitate better access.

Providing this access is so valued by leadership that my department chair, Rabi Hanna, MD, asked me to carve two mornings per week from my schedule for them. This appointment blocks allow me the opportunity for three virtual appointments per day, twice per week. Scheduling is easy, and I know that I will have 40-60 minutes to spend with each patient and their caregivers.

Instead of receiving random emails and phone calls with little snippets of information asking for life-or-death decisions, virtual visits are more thoughtful. They are high-tech, yet relaxed. I have the opportunity, in advance, to study a patient’s scans and pathology reports, and to search for regimens, interventions and clinical trials that might be a good match for their situation at Cleveland Clinic or elsewhere.

It does take more time to prepare a thoughtful visit summary, but I save time later by using the snipping tool when completing my notes in the patient’s medical record (i.e., Epic) as a distance health encounter. The time spent in preparation also allows me to get to know each patient’s case, and permits a deliberate, thoughtful analysis and approach to plan of care that is not episodic, but strategic. It’s like taking five minutes now in order to save five hours later — for both me and the patients and their caregivers.

I also use the visit summary and family photos when requesting prior authorizations and/or sending appeal letters for medical services. I want to do it only once — so I need to present the most articulate and compelling (at-a-glance) case possible. I attach a patient picture (which is in the visit summary) to a friendly letter. I find these pictures of patients when they are healthy can help insurance companies to know that patients can get better with the plan of care that is recommended. Instead of letting insurance companies wear you down, I help them make the correct decisions.

Children, adolescents and young adults (AYA) have a whole life to live – it’s worth our combined efforts.

Dr. Anderson is a staff physician in the Department of Pediatric Hematology, Oncology and Blood & Marrow Transplantation.