Hello, everybody. I'm Dr. Diana Cardenas, and I'm the president of the Foundation for PM&R. And I just stepped in to, before you start, to tell you that one of our newest initiatives is to raise funds for cancer rehabilitation research. And we really would like for everyone to make a donation, no matter how small. We are a nonprofit, or actually a charitable foundation for the whole field of PM&R. So we're trying to really get everybody to get in the habit of helping the future. Because without good research, it's going to be harder and harder for us to do what we want for our patients. If you want to donate, we send out emails all the time to academy members. And our executive director is Phyllis Anderson. But you can find us on www.foundationforpmandr.org. And it's really something that is important for your future and for here on out in our field. So please make every effort to give us a donation. Thank you. OK, so I think we're a few minutes after. So we'll go ahead and get started. So thanks, everyone, so much for joining us this afternoon. My name is Phil Cheng. I'm going to be moderating this session, which is telemedicine, cancer rehabilitation, practice data, and disparities. We do not have any disclosures. The agenda for the session is going to include a brief literature review, just of everything that's been going on in cancer rehabilitation telemedicine up till now. And then the rest of the time is going to be spent discussing our own personal experiences with telemedicine and our practices, largely through discussing various research projects that we've all been doing. Those research projects include patient and provider satisfaction, utility of telemedicine, practice patterns and disparities. Then we're going to finish with a question and answer session. So with that, I'd like to just introduce our panel. So everyone here is a member of the technology and telehealth subgroup of the Cancer Rehabilitation Physician Consortium of the AAPMNR. And I'm joined here today by Dr. Mary Bargo from the Metro Health System. I'm from Cedars-Sinai. We have Dr. Jasmine Zhang from the University of Pennsylvania, Dr. Amy Ng from MD Anderson, and Dr. David Leong also from the Metro Health System. So with that, I will hand it off to Dr. Bargo. Hi, everyone. I thought today I would start the session by really trying to focus on the big picture of cancer rehabilitation, telemedicine, to try to get a sense of where we might go from here. The rest of the talks today are really going to focus on processing all the changes we've been going through with the pandemic and telemedicine. I know everyone in this room has had experiences with it, too. And we're interested in hearing about that as well, and any of your ideas to piggyback on what we're saying today. We'll have some discussion time at the end. And it's really important to go through that process with all the changes that we've experienced. So in this session, though, I'd like to see any other overriding themes that could be helpful in moving us forward in this new landscape. So I'll start by going through this systematic review that came out earlier this year, very timely, on telehealth-based cancer rehab interventions on disability. And I'll just say at the beginning, I know I'm going to use the terms telemedicine and telehealth probably interchangeably. And I know that they're different. One's much broader than the other. So I apologize in advance if I'm sloppy with that. So the good thing about this review is it looks specifically at telehealth and disability, i.e. on function. And it looked entirely at randomized controlled trials examining telemedicine that were interventional trials, measuring disability either as the primary or a secondary outcome of the trial, and included at least one synchronous interaction between participants, the provider, and the telehealth patient to more closely mimic a real-world clinical interaction. So they didn't exclude if it was only a drug trial or if they only looked at psychosocial outcomes. They did look at psychosocial interventions, but not if it was only psych outcomes. They did not include if it was only looking at symptoms or impairments, and if it didn't have a quantitative methodology, it wasn't included. So there actually was a final sample of 68 randomized controlled trials looking at telehealth or telemedicine in cancer rehabilitation. With the time needed and the publication process of an RCT and all that, these were almost all pre-pandemic studies. You can see they come from a variety of different disciplines in terms of the disciplines generating these studies. The most common cancer patient group was breast cancer. So the types of intervention, really a varied group. The majority of these studies looked at psychological interventions, 43%. The next most common was physical interventions at 26%. I'm not gonna go through all the specific things that were looked at, but you can see that listed there. And then general health, things like health coaching and counseling, nutrition, speech therapy, pain management, and then there was one study on lymphedema self-management. And an interesting thing as far as the telehealth modality, the delivery method, the majority, 90%, like that's a lot, 90% of the studies had telephone as part of the delivery modality. And 38% of the studies, the telephone was the entire system of telemedicine. So other ones were like a mixed modality of telephone and some other telemedicine modality. And then also surprisingly common was a so-called hybrid kind of study where there was the telemedicine component, but also an in-person component. And a majority of studies also used multiple delivery methods so it's kind of interesting mix of things to think about in terms of directions to go in process. Besides telephone, other relatively common types of modalities were activity tracking, general internet portal, video conferencing, texting, and so on. And so it was overwhelmingly one-on-one patient care, but there were some looking at family or other group settings, or like individual and group type of program. So the outcome measures, so these were RCTs which have the primary outcome measure that the study's powered to, and then the secondary outcomes. So almost half of them had disability as the primary outcome measure of the study. And it was about three to one looking at patient reported outcome measures versus a measured mobility outcome measure. So PROs were the most common. And as far as the self-report outcomes, most commonly used in this literature are the FACT and the SF-36 physical functioning. It was actually interesting though about the facet fatigue scale and the EORTC, the European scale. The studies, it was three or four studies had used the facet fatigue scale, and it had a combined about a .8, so very high effect size for the studies using that tool. So either that's a particularly good tool for this type of study, or maybe fatigue is a particularly approachable intervention for telemedicine approaches. So that's just something to keep in mind. And then the EORTC scale, physical functioning scale, had the next highest effect size at .5, so a medium effect size. And the most common mobility outcomes were the six minute walk test, as we've seen in so many of our studies. And then other walking types of measurements, and then also sit to stand testing. So takeaway from this, it's a little bit hard to say. It's such a mix, right? Not really many, there's at least one study that has some physiatry component, but it's mainly other disciplines. But it does tell us telemedicine's not really new territory in cancer rehabilitation. There's really a great variety of studies. One question that got planted in my mind was this, was just the high use of the telephone modality. And is that still applicable? Is that a good modality? Or have we had a paradigm shift now where maybe that's a relic and it's time to focus on other modalities? There was one study included that I did wanna go in a little bit more depth. There was some physiatry involvement here. And even beyond that, it just really illustrates some of the different techniques that can be done to approach a telemedicine study. And this was by Andrea Cheville and her colleagues. And it looked at a large group of advanced cancer patients. So it's a challenging group that has access issues for in-person care. And it looks like a complicated slide, but I'm just gonna reduce it to a quick explanation. There are basically three groups. There was a control group that did not receive the intervention and two intervention groups, one of which had phone-based physical therapy for a walking program and a non-pharmacologic pain intervention program. The other group had that same phone-based PT and then also a nurse helping with medication management. And then there was a physiatrist in the wings screening new patients. And if a patient's improvement had stalled, then would intervene. And then there was also, in the background from the nurse, was an internist and palliative care oncologist assisting with that arm of the study. And then if a patient's PT program needed some evaluation or refinement, the patient could have a few sessions of in-person PT. So it was collaborative, it was also hybrid with the PT. And the results of the study are in the diagram in the middle where the bottom graph there is the control group and they did not really improve. The y-axis there is the AMPAC scale that was used and an improvement of one is considered clinically meaningful. So the other two lines there are the two intervention arms. So they both had clinically meaningful improvement. The top one reached statistical significance and that was the PT alone arm of the study, which actually had more of the non-pharmacologic pain intervention than the other intervention group. It just so happened. So there were, I think, a lot of takeaways from this one. It used a phone-based model successfully. It was hybrid in the sense of a majority of the patients did also receive a few in-person PT sessions. It was really highly collaborative with PT and nursing and then several medical specialists as well. Accessible to a challenging population. It helped a challenging population. And it also raises interesting questions about physiatry role in program design, especially we have a large patient population out there and there's not that many of us. So we can think of ourselves as being on the front line of patient care with telemedicine as most of us certainly have been. But then is there also room for a model of care where maybe others in some circumstances are on the front lines and we are more in a team leader role or in the backfield for when we're especially needed. And just a quick word about this other study. This was a, by Lopez looked at, this was some early pandemic descriptive reporting of their program's experience. And just a couple quick takeaways. They noticed that during the pandemic their number of encounters like for all of their cancer rehab programs actually increased. And interesting observation to me was, they were noting the clinics in terms of in-person could be congested, there were space issues and that telemedicine was actually helpful in alleviating some of that. So going forward, I think we all experienced that at least in maybe some settings. So that is something to keep in mind in terms of leveraging telemedicine best to alleviate that kind of concern. Asynchronous telehealth could be a whole day of content. There's really thousands of apps out there, many applications of asynchronous telehealth in terms of tracking activity, tracking many other parameters, education, communication, the sort of aha moment that I had in working on this talk was that it's actually going on already in our lives and certainly in our patient care almost faster than we can keep up with it, certainly faster than we can optimize it. And then there's just so much room to use this to be more consistent and systematic in our patient care. But it's also a challenge to know what's best and optimize it. So in conclusion, just some things to think about. One-on-one patient care with telemedicine, it does seem to be part of new normal in many settings to a greater or lesser extent. But what about beyond that? I think we still have more questions and answers about where to go from here. What about the role of all technology, especially telephone, the role of newer technology, smartphone, interactive video? As I was thinking about this, it seemed to sort two ways. We can take what we're already doing and how can we systematize that and optimize that? As I mentioned regarding the asynchronous telehealth, everything going on there and how we're structuring our clinics. And then there's true telemedicine innovation. And so some of the things to think about there are the optimal delivery method for your settings. Do we want to think about collaborative models, hybrid models, multimodality models, synchronous and asynchronous approaches? So a lot of it will be individualized to settings, but there's a lot of tools and possible approaches. So on that note, I think I will turn it over to Phil. It'll have plenty of time for discussion after and questions. All right, thanks so much, Dr. Vargo, for that great overview. So we're gonna be switching gears here and just talking about some of the studies that we've done, starting with patient provider satisfaction, specifically with telemedicine cancer rehabilitation. Although I like to think that could probably be applied to rehabilitation practices in general. Okay, so this is a study we did when I was actually in my cancer rehab fellowship. And basically at that time at the institution I was at, this was at the initial outset of the pandemic and they were not permitting for us to do any in-person visits. So everything was through telemedicine. So this was a prospective survey study from March 2020 to May 2020. And again, it was a cancer rehab program and academic medical center. The participants were three cancer rehabilitation providers, two of whom are in this room, and 155 unique patients making for 166 encounters. About half the visits were through phone, half were through video, and the vast majority of visits were for follow-up as opposed to new patient visits. So we basically just came up with our own customized questionnaire and we just had patients and providers answer on a Likert-based scale. And we can see some of the patient responses to some of the questions on the left. So overall we can see that patients, they really like telemedicine. This was like when it was brand new. All these patients are totally used to just seeing their physicians in person. But in the green box we see that overall they felt that very much so the telemedicine visit was a good experience. But when we asked them the question if they preferred to see their doctor in person, their answers diverged quite a bit more. And then kind of on the provider side, when we asked them if an in-person physical exam would have changed the treatment plan, this was kind of surprising. Maybe not so much because so many of these visits were for follow-ups, but a lot of the time the providers for most of these encounters, they answered that an in-person physical exam would not have changed the treatment plan. Although I think it is important to acknowledge that maybe about 18% of these encounters, providers did state that a physical exam would have somewhat to very much so changed the treatment plan, which I think is interesting. But overall, is the patient's main problem being addressed by the telemedicine visit? so we asked this question to both patients and providers, and for the most part, both parties did say yes. So it seems like this can be effective, at least from a subjective, like I feel like this is helping me point of view. Another thing that we did is we stratified encounters, or we stratified satisfaction scores based off of the encounter type. So we classified every encounter as being for a new, worsening, or stable problem, and we just checked if there was any difference in satisfaction ratings. And then we also stratified satisfaction scores by whether the encounter took place through video or through phone. So for these particular questions, we did not find any statistically significant difference. However, for this question, to physicians of I would have preferred an in-person visit, there was a statistically significant difference when encounters were stratified by new, worsening, or stable problems, indicating that providers were less happy with the telemedicine encounter when patients were presenting for a new or worsening problem, suggesting that we should all probably maybe be pre-charting a little bit before we see patients to try to get a handle on what kind of problem they're coming in for, and that way we may be able to avoid superfluous visits, and a little bit later we'll talk about why that may be a problem. And then the kind of the last thing we did is just we looked at all the different services provided by all these encounters. And as you can see here, you can do a lot through telemedicine. You can basically do anything that you can in an in-person visit besides injecting them with whatever you inject people with. But we do see here that for the services of new diagnosis made, interventional procedures ordered, referrals made, and orthotics ordered, these occurred at much lower frequencies. I have a lot of regret that we didn't compare this to an in-person historical cohort, so I have no way of knowing if this is less than what normally would have been. But I do think it's interesting that some of these percentages are rather low. So with that, I would like to hand it off to Dr. Ng to share her research. Thanks, Dr. Chang. So like Dr. Chang did at Michigan, we also wanted to go back and look a little bit more about what happened as soon as COVID hit. And so I wanted to present today just on the months that followed. I have no disclosures to report. And really just to go back and look when we were forced to close our clinics, how did we pivot and how did we shift to telemedicine? We wanted to also see what percentage of patients were able to use telemedicine and a little bit of patient satisfaction and as the months of COVID continues, what kind of trends are we seeing? And we also had a second wave in July, so we wanted to take a look at that data as well. So we had a total of 573 patients, oh, I'm sorry. We had a total of 573 patients who were seen in our inpatient, I'm sorry, in our clinic. In-person visits, there were 108 visits and telemedicine, 425 visits. Our population majority were Caucasian or white at 405 visits or 71%. Our top three cancer diagnosis matches with the patient populations we usually see. Top ones are being hematologic, GI and breast cancer and mainly because we see a lot of prehab patients for hematologic and GI surgery as well. Of these patients, less than half had metastasis. This figure breaks down the months. So as we are progressing when March hit us, I'm sorry, when COVID hit us in March, throughout the months April, May, June and July, we were able to find some significance in in-person and the telemedicine visits in April, May, June and July at both the visit level and the unique patient level. However, in March, it was not significant. For the second wave in July, we also see that in-person, I think in June and July, we start creeping back up to in-person and I'll tell you why a little bit later, but as we start creeping up and in July, we had our second wave in Texas. And so basically, we were not allowed to see clinic patients again and we were told that we had to decrease the encounters. So I think that's where that drop of the in-person visits happened in July. This slide, we're showing the number of patients who actually came to the visit and this is both for the telemedicine and for the in-person visits. So mainly focusing on the purple slots versus the rest of the colors. The purple slots are showing as the months kind of go by that we have more and more people that are actually showing up to both their visits in-person and also arriving at their telemedicine visits. You will note that we start seeing a lot more cancellations again in July and maybe this is due to the second wave in COVID again. This is the graph showing the encounters and I'm sorry, it's a little busy and so I try to highlight what I wanted to show. So we were able to break down the types of encounters by months. So of course, in March, we had drastic cut as everything kind of went downhill, closing the clinic. So in comparison, we're able to ramp up again, April, May, June, and July. Our procedures, of course, remain very low and that's shown in the gray and the light orange. Those are the new consults for procedures and then doing the procedures in light orange and they remain quite low throughout these months. As we shifted and got used to how we're gonna use these virtual visits, our platforms were able to be more established. We see more follow-ups in pink continue to increase and then we have less consults initially, but then it kind of picks up consults for both initial in-person and also for prehabilitation programs in green and orange. We still, we're gonna see more consult, more prehab visits as the months go by. This one, we are here breaking down the visit types by the months in terms of in-person, which is in blue in the clinic versus the virtual visits. And at first, we couldn't get our act together. We really didn't know what to do in March. So everybody was just pulling out their phones and using FaceTime for our visits. So in March and April, we have high volume. We're still converting. We're trying to meet the needs of the patients. So we're going to use FaceTime. And then as the institution kind of developed what platform we're gonna use, towards the end of April, we started using Zoom. So FaceTime and telephone in the months of March, April, and then we start seeing in this purple, Zoom to virtual telephone or virtual FaceTime in purple kind of increase in May because we still weren't able to consistently use Zoom. But as the months kind of go on in June and July, we see that kind of decreasing as providers and patients themselves are able to use this virtual platform. And then in July, we're able to use Zoom in green. So here, in this chart, in this figure, this is about satisfaction and looking at the last two columns in the blue and green, either satisfied or very satisfied. In March, patients seemed pretty satisfied. And over the course of these months, we see kind of a dramatic change as we shift from the inpatient to more virtual. And we do see some kind of fluctuations in the satisfaction categories. Maybe in April when we're getting our act together, maybe not as satisfied, but towards the end in July when we're actually able to use the Zoom visits and we're doing it more proficiently and patients and providers are both able to use these platforms, we see an increase in our satisfaction. Here, we're looking at the post-visit satisfaction by the visit types. And as you can see, in clinic, we have very highly satisfied patients at almost 70, almost satisfied and very satisfied at almost 93% for the in-person visits. And then as we shift towards the, as we look towards the virtual platforms, we're seeing transitioning FaceTime early on. We were getting about almost 50%, like 49%. Telephone, not as satisfied, about 12%. And then Zoom, but converting, they were still able to be, saying that they were mostly satisfied at 39%. And then Zoom visits, we were able to achieve satisfaction, satisfied or very satisfied results at 62%. So we were also able to use Spearman's correlation, looking at in-person versus telemedicine. Post-satisfaction was significant. In-person visits were more, were associated with higher satisfaction throughout the months. We also wanted to look at reasons why patients thought that they really didn't, or patients didn't want to use telemedicine. And overall, the highest percentage was that either the patients themselves or another referring physician wanted these patients to be seen in person. So we had about 32% that requested and only wanted to be seen in person. And then about 22% were unable to use this telemedicine platform, either technology barriers or internet barriers, or even barriers to getting on to the platform. And we see that as a common trend and probably reflective of what was out there put in literature as well. But there were some other reasons, very small percent, but insurance wasn't improved. And then of course, I was telling you earlier that our clinic was closed down, and that's the clinic being unavailable in Orange. This figure really breaks it down by months. There are reasons why they decided, or why they couldn't use telemedicine, and what was the reason that was explained to us. And here, at the beginning, clinic was unavailable, as we stated in March. We had to shift and close down our clinics in person, and then we didn't really have a platform March and going into April. There was still a lot of fear, I think, also that drives this high percentage of why people were not even going to clinic or not using telemedicine. COVID was still on their minds, and really, last thing they wanted to do was to get into a visit with us. We do also see that patients were unable to use telemedicine which increased to 32% in April. And as the months went on, we see more and more of the patients' refusal to use telemedicine and really want to be seen in person, and the doctors, too, wanting their patients to be seen in person. So really, what we found in the earlier months of COVID was that although we had to shift and pivot, we did make a way for them, but patients and providers that referred their patients to us still actually preferred that their patients be seen in person. The good news was that, I mean, as we were able to show, we were able to pick up our clinic visits, we were able to provide the care to cancer patients who really needed it, even if we had to shift entirely to telemedicine. And as patients started to come back to person, we saw a second wave, and then eventually we saw a third wave. But even through all of this, we were able to shift and pivot, and I think that was the point of this analysis is that we were able to see that what we did, and we're still able to continue it throughout this pandemic and into this endemic. Thank you. All right. And I'll turn it over to Dr. Zhang. Hi, everyone. I'm Jasmine Zhang, I'm coming from Penn Medicine. It's really good to see everyone in person. I'm a little giddy about it, actually. The last time I was here at AAPMNR was in 2019, and at that time was when, actually, our CRPC telehealth subgroup was born, and then COVID hit. And I guess in that way, COVID was actually timely, maybe the one compliment I can give to COVID, because it really set the stage for us to really look at telehealth patterns in our cancer rehab physiatry practices. So for about the next 15 minutes or so, I'll go over what we found in a survey study that we did in 2021. So I have to say, probably at this point, most of you have had some experience with telehealth, so some of these results are probably not gonna be too surprising, but hopefully you'll be able to take something helpful away, and I'll share some of my surprises, or things that I was surprised by, based on our survey results at the end, and hopefully we'll have a good discussion. So this was our fabulous group that put together this survey study. Once our survey was created, it was sent out in 2021, in August of 2021, via several different methods, electronically. It was composed of open-ended questions, so questions like, based on your experience, tell us about disadvantages and advantages to telemedicine, and also close-ended questions, so for example, what percent of your practice is telephone encounters or virtual encounters? Data analysis was done via Excel, SigmaPlot, and our qualitative data was analyzed through thematic analysis. So we had 33 respondents total to our survey. Most of these physicians had entirely outpatient practices, and as you can see in the chart on the right, the gray denotes in-person visits, so most people had outpatient practices that were composed of in-person visit contexts, and this was followed by, in orange, video encounters, and then the blue denotes phone visits, so the minority of practices, or the minority of visiting contacts were actually telephone encounters. You may notice that respondent 14 had values that totaled over 100, clearly the overachiever in this group. We presented physicians with several different clinical scenarios or situations, and asked them whether they preferred, or they thought that phone visits were adequate, video visits were adequate, or in-person visits were adequate, and here we assumed that in-person visits were the gold standard, and so with our data analysis, we compared phone visits to in-person visits, and video visits to in-person visits, and you can see here, I'm not sure if there's a laser, oh, there is a laser, okay, and you can see here in the fourth column, in-person visits were significantly preferred over phone visits for every clinical scenario. However, when you looked at video visits versus in-person, that was no longer true, so there were certain clinical scenarios where it was not actually significantly preferred, and that was for stable problems, it was for medication management and counseling. Most responded that phone is appropriate if there is a barrier to video, and also that video is appropriate if there was a barrier to in-person. We also wondered about the role of the physical exam during these encounters. Here you can see the percentage of respondents who felt, or who did actually perform each physical exam component, and you can see that the majority of respondents actually performed general inspection, targeted inspection, range of motion, evaluation, and also cognitive evaluation, and then we wondered, is there a difference between those who utilize video more versus those who utilize video less, and we determined who were considered high video users versus low based on our data distribution, which showed that the average percentage of video contexts in practices was 29%. So we said anyone who did video 30% or more were considered high video users, and anyone whose practices were made up of 29% or less of video contexts were considered low video utilizers, and there was actually no significant differences between high and low video users if you look at the p-value column. Most respondents did report that zero to 20% of their video visits were converted into phone visits, and people seemed to prefer video, although 22% disliked both video and phone, but the majority of folks were actually satisfied for their telemedicine practice, so actually 81% of them were either satisfied or very satisfied. We then utilized four open-ended questions to further explore physician attitudes and experiences in telehealth. Again, the qualitative survey was analyzed through a thematic analysis. And so these were the five questions that were asked. The questions really focused on physicians' perceptions of advantages or disadvantages to telehealth, changes that they had made in their practices because of telehealth, and how telehealth probably, or how telehealth may have changed the landscape of cancer rehabilitation in their opinion. This is a word cloud generated from all the responses of our respondents. You can see there's certain words that really jump out at you, for example, patients, telemedicine, technology, and then also words pertaining to access. Through our analysis, we came up with four major themes, so benefits of telemedicine, new challenges of telemedicine, adapting to a new model, and uninterrupted practices. Specifically, with benefits of telemedicine, it was very clear that physicians felt that telehealth provided a convenience to patients that couldn't be provided with in-person visits. In addition, it seemed that folks felt that it improved patient accessibility, not just to general healthcare, but specifically to a rare specialty, cancer rehab. And so several providers did respond that cancer rehab really seemed to be able to now reach out and connect with patients who probably wouldn't have been able to come into clinic in the first place if it was an in-person visit that was offered. Others mentioned that telehealth really seemed to improve patient care, gave the example of being able to actually visualize a patient's home and provide recommendations on function and improving quality of life. And then several others actually mentioned how there were benefits of telemedicine for providers specifically. And it really seemed to center on productivity. So one clear example that someone provided when they anticipated that there was gonna be perhaps a long patient call, they offered a telephone encounter instead and that helped with their productivity. And of course, there were actually new challenges of telemedicine as well. I'm sorry, the formatting came out a little funny there. But in terms of new challenges, one of the big things that was brought up was the lack of a thorough physical exam and how that could lead to lack of confidence in prescriptions or actual ordering of interventions. Just like others who had discussed increased provider productivity, there were several responses as well about decreased provider productivity. So the fact that sometimes, even if they saw someone virtually, they still had to bring them in in person, and that could potentially delay treatment. And of course, there were technology barriers. So frustrations regarding patients who were unable to access technology or understand how to utilize the technology. One of the other major key points that came out was adapting to this new model. So having the ability to actually adapt and improvise. Folks talked about changes in their clinical flow, about expanding roles of support staff, and also ways that they had updated their hospital systems technology so that way they could better serve their patient population. And finally, there were those who had uninterrupted practices. And at the time of our survey study in August of 2021, some people responded that we haven't really figured out telehealth yet. And so clearly at this point, three years into COVID, two and a half, three years into COVID, all of us have read something or other about the benefits of telehealth, right? And not just in onc rehab, but maybe an infectious disease or cardiology or just oncology. And so probably it's not that surprising when we look at this data that our physicians that we surveyed also touted the fantastic benefits that telehealth could have. But I think what's really important here and what's really unique about this is that cancer rehab is such a rare and special specialty in the sense that there's very few providers in very geographically sparse locations. And so having the ability to utilize telehealth to rid of those geographic barriers is really important. And of course, as physiatrists, one of our big emphases is on providing recommendations for folks outside of the four walls of a hospital, right? And so having the chance to actually see into the patient's home and provide recommendations can really improve the breadth of our care. And then of course, there were some who had mentioned clinician productivity, and it seems like this is probably a little bit more dependent on the clinical scenario. We had several respondents who did note that they had to bring patients in, and this is pretty consistent with literature. For example, Lopez and colleagues in 2021 had looked at clinician practices in a cancer rehab setting and noted that 11% of those providers had to then bring patients in for in-person assessments after seeing them virtually. And of course, there's obviously these downsides. Technology illiteracy, lack of access to technology can result in new disparities and new barriers. In addition, the whole idea of a limited physical exam, we can probably safely say that for most medical specialties who conduct telehealth, that you're gonna have a limited physical exam, that's just the nature of it. But however, for physiatry, for PMNR, a practice that really emphasizes a detailed and thorough neuromusculoskeletal exam, is this a problem? And less than 20% of our respondents actually performed strength, sensory, or special testing. However, despite these downsides, there's obviously some clear benefits to telehealth, and 100% of our respondents did say that they wanted to continue and did plan to continue utilizing telehealth technology moving forward. And so despite all the downsides of it, it does seem like we have ways that we could use the digital technology to address some barriers. And so finally, what are maybe some ways that we can create a successful telemedicine practice based on what we've learned so far? So clearly, we have to be able to adapt. We have to be able to improvise and change some of our practices through support for getting updated technology, changing the support from our ancillary staff, and also triaging encounters. So perhaps looking initially at why the patient is scheduled, their chief complaint, and deciding then and there whether they really want an in-person visit versus a telehealth visit. And consider virtual visits maybe more for scenarios where they're coming in with a stable problem, they're coming in just to follow up on medication management, and or for education or counseling. And finally, though telehealth can really promote inclusion, it can also result in inequities. That much is clear. There was an article by Rosson and colleagues in 2019 that looked at eHealth receptiveness, specifically for a virtual rehabilitation in a population of patients in Denmark. And what they found, that 30% of those patients were not receptive to eHealth rehabilitation. And they discovered that there were several different characteristics that they all shared. One was those who had minimal social support. Another was those who had higher levels of distress or problems with self-management. Another was increased numbers of chronic problems aside from their cancer diagnosis. And also those who had low eHealth literacy. So being able to recognize these characteristics in our own patient population may help make us a little bit more effective in our own practices as well. And I will just share one thing that kind of surprised me about this, and maybe this was just the way that our questions were worded, was that while there were some providers who talked about productivity, no one really mentioned how telehealth affected them, maybe on a personal level. So in terms of sustaining their own medical practices, how it might have saved them commutes to and from the clinician office. And I think that's a pertinent point to bring up, especially because I'm looking at articles, in the newspaper, and everyone's talking about physician burnout, and how numbers are high right now. And so I wonder as well, and I pose this sort of a question for you guys too, whether telehealth may help promote less of physician burnout, or is it contributing to the problem? So clearly there were some limitations of the study. This was purely observational. It was a survey study. It really was dependent on the recall of our physician respondents, all of which were practicing telehealth at the time. There were also a low number of responses, and that may also be just partly the nature of cancer rehab being a smaller subspecialty. But it did set the stage for us to ask a few other questions. So one was, are there differences in interventions between in-person care and telehealth care? And are there differences in interventions between virtual and telephone visit platforms? And I will pass it along to Dr. Leon, who will help answer some of that. I'm a current resident at Metro Health Rehab Institution in Cleveland, Ohio. I wanted to spend the next few minutes showing you some real life data on the cancer rehabilitation practice patterns through a multi-center retrospective chart review. So our outline's as follows. We'll first talk about the initial questions that led us to start this project, show some demographic data of the patient populations we serve, and then talk about two different analyses that we performed on the same set of data to generate some conclusions about our practice patterns in the setting of in-person versus telehealth. So as you have all personally experienced, outpatient PM&R practices had to make a sudden pivot in healthcare delivery during the COVID-19 pandemic with a new reliance on telemedicine and telemedicine modalities like telephone and video that were once purely adjunct. Because this increased usage and novelty of video visits, I would say little is known about if there's differences in physician practice patterns. We just heard from Dr. Chang and Dr. Zhang about some of the perceived pros and cons. And while benefits like increased access to healthcare for patients are more obvious, there are hypothetical concerns about over-reliance on tests or imaging in lieu of physical exam. This study aims to answer the following question. Are there significant differences in physician practice patterns as well as healthcare disparities between in-person and telehealth visits in cancer rehabilitation? So MetroHealth has partnered with three other institutions to perform this multi-center retrospective chart review across four outpatient cancer rehabilitation departments whose co-investigators you've already met today. So our inclusion criteria included outpatient cancer rehab encounters from March 2020 to August 2021 that were coded with a cancer diagnosis. And we excluded all non-cancer related encounters as well as procedure only encounters since those would not be comparable in in-person versus telehealth analysis. Apologize for some of the formatting and it seems like the fonts is a little light. But our total sample population was 13,151 encounters with 3,099 unique patients across four institutions. This table shows each institution's breakdowns of visits using each modality, in-person, telemed, and with telemedicine breaking down into phone versus video. Highlighted are the institution's percentage of telemedic counters and underneath the associated predominant telemed type of phone versus video. As you can see, there are significant inter-institutional differences in overall integration of telemedicine into their practice with ranges of 14.1% up to a majority of 53.8 of all visits. So additionally, there is preference for phone versus video with one institution vastly preferring phone compared to video of the other three institutions. We suspect this variability could be attributed to things like technological access, technological literacy of both the practitioner and the patient, and also patient and practitioner preference. Oh man, you really can't see these almost at all. I apologize. So for each encounter, we collected demographic data, new versus follow-up, physic diagnosis, and all orders placed. This table shows the demographics of the total sample. Age is listed as a mean with standard deviation listed in parentheses next to each. Gender and race are listed as percentages with standard deviations. So going from the top, I'd like to point out just a few trends. We had an age range of 57 to 64 with the average age of 63.8, but pretty reasonable agreement between all four institutions despite being in geographic different areas of continental US. We all had predominantly female populations across the institutions with some variability, with the highest being 73.4% in Institution 3. What is on the screen is the consolidated race and ethnicity data, but just for context, for the US estimated census data from 2021 with white or Caucasian being about 75.8% of the population, African American being 13.6, and Asian being 6%. So it's certainly encouraging when we think about the generalizability of this data set to other US institutions. Wow, man. So this chart shows new versus follow-up as well as all orders placed. So as you might have guessed, a new encounter occurred in person more often than via telehealth and vice versa. Follow-ups occurred more often with telemedicine rather than new. We use orders placed during each encounter to give us an objective measure of physician practice patterns, and these being our primary outcome measures. Orders can be categorized into four distinct domains, imaging, medications, procedures, and other. These orders were logged in a binary fashion, yes or no, to tell us if an image order, you know, for example, was placed rather than the individual quantities, say a cervical and thoracic X-ray being placed, counting as two. One of the major challenges when capturing and categorizing the data from Epic was that with other orders that were often placed, like medical equipment, therapy, labs, physician consults, home healthcare, those didn't quite fit into any distinct category. And then because of the differences in how we collected data across all four institutions, we had to create essentially a miscellaneous bucket that was accounted for about 40 different unique orders. I'm saying this so that you know, that we know, that this is a limitation of the study. Just to give one example, a medication was ordered 41% of the time across all encounters, but 38.5% of the time during in-person versus 44.4% during telehealth, and then with institutional ranges of 34% to 56.8%. So, we calculated relative risks of each primary outcome, imaging, medications, procedures, and other. The first three categories were all found to be ordered less during telemedicine visits compared to in-person, all of which with statistically significant findings. The bottom is any order placed, also with those statistical findings. Okay, okay. Sorry, yeah, if you have the app, you can pull it up, and that shows a darker font. I'm not sure exactly why it showed up this way. I apologize. So, based on these findings, we would say that, hey, maybe there are differences in how we are practicing, and it seems like we are ordering things less in a telehealth encounter compared to in-person. But instead of stopping there, we decided to use a second analysis of the same data using all unique patients rather than all encounters. The purpose of this was to analyze the data in a more apples-to-apples fashion. Our concerns for using the entire pool of encounters was that most cancer patients have a single first encounter but possibly many follow-ups using different modalities. Having the same patient be present in both the in-person and telehealth encounters would essentially muddy the water. Utilizing all 3,099 patients, a random encounter was then chosen and then sorted into in-person versus telehealth. This created two distinct and, more importantly, independent groups for comparison. So this chart is similar to our prior with descriptive data of age, gender, race, and new versus follow-up. So we do see differences in two of the groups, primarily in age and new versus follow-up, with leanings of older patients trended towards in-person encounters, and race did not seem to show any disparity. And then similar to the total encounter data set, telehealth occurred more often as follow-up rather than in-person, and new visits trended towards being more likely to be in-person. So we then found the individual frequencies of our outcomes and again calculated relative risk. So here we see actually something a little bit different. Imaging and other appeared to be the only categories with statistically significant findings, that we are less likely to order those in a telehealth encounter compared to in-person. I'm gonna jump so that you can see side-by-side, you would see side-by-side the random visit analysis versus the all visit analysis. So again, the random visits utilize all unique patients of 3,099 with one encounter each versus all 13,151 encounters. While the all visit analysis is certainly interesting, the random visit relative risks certainly have higher quality. I think the things that we can draw from this is that both analyses show that imaging was the only category with statistically significant findings in which we are less likely to order during a telehealth encounter compared to an in-person encounter. This seems to go against the idea of utilizing imaging in lieu of physical exam. Medication management potentially occurs as often or slightly less compared to in-person. Procedures approach significance in the random visit analysis, and interestingly is the only one category that may reflect higher probabilities of being ordered in a telehealth visit. Although based on how we polled data, we did take out all in-office procedures, so this number may be falsely elevated. With other orders, again, given the heterogeneity of the category, it's hard to pin down any definitive conclusions about which, whether the random visits or all visits had any productive findings. And then finally, with any orders similar to medications and procedures, the higher quality analysis shows no difference in overall practice patterns. So I'd say the big strength of this study is potential for generalizability, given multiple institutions in distinct regions of the U.S. with a large sample size and racial demographics that match the U.S. census data from 2021. Given it's a retrospective design, we're at the mercy of physician charting and our ability to extract data from Epic. Given four institutions, we all had slightly different ways of collecting that data through IS, and so the data set essentially had to be parsed down to a common format, sacrificing detail for homogeneity and ability to analyze. As Dr. Ng described, there are changing circumstances with the pandemic timeline, with one extreme example being all visits converting to telehealth with no in-person. And we as physicians are constantly evaluating patients to deem them appropriate for telehealth versus in-person or not, based on our own perceptions of telehealth's ability to provide and deliver healthcare. COVID, to some degree, has equalized things when things were all virtually temporary, and again, all of this data was taken within that bubble of the COVID pandemic timeline. So we are, you know, one future direction is to collect baseline data prior to, to give us a better sense of how our practice patterns may have changed in relation to the pandemic, in addition to telehealth versus in-person. So it seems like telemedicine has strong overall integration and within their institutional differences in how we adopted it, but the majority of our sample of the 13,151 encounters, 51% of all those encounters were through telemedicine. We did not see major disparities in race, but we did see some in age. The question is whether or not we find that that's clinically meaningful or something we relatively expected. Technological disparity, technological literacy, and patient-physician preference all kind of influenced that. It seems that telemedicine is most conducive to medication and procedure management, although certainly more study needs to be conducted. But we did not see any indication of overuse of tests or imaging in lieu of physical exam. And kind of just the flat number is that 54% of all visits, we had some kind of intervention being ordered as we kind of defined by this study. So, I have some future directions listed, but I'd also like to pose three hypothetical questions to you guys in preparation for our Q&A. How many of the telehealth encounters would have actually occurred in person if we did not offer the telehealth modality? And then, why does telehealth change how we order imaging specifically? And if we don't order it over telehealth, are we ordering it in person to compensate? And finally, what is the role of telehealth in your own practice, and what are you comfortable managing over this modality? Thank you. Thanks so much, Dr. Liang, strong work getting through those difficult-to-see slides. Okay, so, yeah, kind of as we've been talking about this entire time, or we're kind of alluding to, you know, all these, we've been alluding to all these other directions that we do wanna take this. So I think one of the big things that we've kind of been talking about is, like, what's the role of physical exams? So, like, I think as, you know, physiatrists, we all pride ourselves on doing a physical exam. It's like, so many of the diagnoses we make are clinical. So, you know, if we're not really doing physical exams, and it's not changing our treatment, you know, are we just wasting a bunch of time doing this, or are we missing stuff? So I think, you know, this is something that really needs to be looked into in the future, and this really goes along, like, I can't really find a good picture representing, like, patient care. But anyways, that's, you know, what that healthcare provider's trying to do with that patient, trying to make sure that she's happy, and that she's getting good outcomes. So, you know, we've shown that, you know, people, both patients and providers, they're satisfied with this. They like it, they feel like it works, but is it actually working? So, you know, we need, like, clinical trials, like testing in-person visits, versus probably not just telemedicine visits, because most people are really practicing, like, a hybrid model now of it, both in-person and telemedicine visits. But we have to start tracking, like, patient-reported outcomes, clinical outcomes, and, like, you know, actual, like, functional outcomes to see, you know, if this is as good as what we were normally doing. I think really important is, you know, the monetary aspect. So there's a recent article in JAMA that's actually suggesting that because we, because of telemedicine now, a lot of providers in numerous different specialties are performing visits at a much higher frequency, and patients are following up much more frequently, and obviously that's more expensive. But is it actually more expensive if you're doing, like, a phone visit once a week, which, you know, I actually do for a lot of my more palliative care patients? Is that cheaper? Are you keeping them out of the hospital, or are you keeping them from over-utilization of other healthcare services? And because nobody, I don't think, really knows what the future of reimbursement in this arena is, and, you know, if they will continue to reimburse video visits and, you know, phone visits as they've been doing, I think this will have significant, you know, just reimbursement implications. And then, as we've been touching upon this entire time, equity, so, you know, I think we all wanna believe that telemedicine is going to make care more equitable, because we'll just be able to reach out to people, you know, wherever they are, to really overcome geographic barriers. But kind of, as we've been talking about, I think we need to tread carefully as to not be creating new disparities in care for people who are unable to either obtain the resources to engage in these technologies, or who do not have, you know, the skill set or the comfort level to engage in these technologies. And then, finally, you know, really realizing the promise of what telemedicine has to offer. And, you know, this is what everyone says, like, you know, because of telemedicine, we'll be able to talk to people anywhere, and especially for, you know, sequestered services. So this is a map of NCI, Designated Cancer Centers in the United States. And for anybody who practices cancer rehabilitation, I would bet strong money that you work, like, near one of these dots. And, you know, there's vast areas of the country where people just are not getting these services. So it's about how do we reach these people now, actually? Because we have, you know, all the tools, but it's about developing an intervention to actually capture these patient populations so we can get them these resources that, you know, assumedly, they're not currently getting. So with that, we thank you all for your time, and, you know, spending your last session of the day with us on the first day of this conference. And we'd like to enter our question and answer period. And really, I think we wanna know from you, because we're gonna keep studying this stuff and doing other, we're gonna keep doing other projects, but, like, to you, what do you think is important? What should we be focusing on? I think it's something we'd all really, really like to know. Wow, this is great. So the future is now. Soon we'll have Spock scanners, you know, da-da-da-da-da-da-da-da, and then they just read everything out like on Star Trek. So, Dr. Lisa Merritt, I'm based between California and Florida, and I've been doing cancer rehab. In fact, I went to one of the earliest meetings at MD Anderson, back in the late 80s. And so I think this is great work that you're presenting. I did have a few observations and some questions. First of all, with respect to the language around using disparities, I think it's important to clarify no disparities in utilization or something like that, because I doubt that you eliminated disparities in cancer incidents, or, you know, which is something that we need to be really careful that people don't think that this is gonna be some panacea, because clearly it's not. And along those regards, I was curious to see at MD Anderson, in your presentation, it was 70% white participation. And I wonder if part of that might have been some of the challenges that we've observed in terms of technology barriers that patients have in general. My organization, Multicultural Health Institute, helps care coordination and navigation. And even patient portals are often challenging for certain patient populations. And we need to be sensitive to that. I think there's also the issue of high touch versus high tech, and certain cultural perspectives, even though physicians may feel that we're doing a good job, and we don't have to necessarily examine patients from certain patient perspectives, if the physician doesn't touch them, they don't feel like they've really been properly evaluated, and we should respect that. And the quality of that interaction from the patient perspective. I did also wanna know, I was curious, have we looked into this approach from care coordination billing standpoints? Because some of these telemedicine visits and follow-ups that are conducted by physicians are also, can be conducted by office personnel. And there are codes where people who are checking, for example, those palliative patients, those people who really need close follow-up, and encouragement, and help bridging their meds and all, you can actually bill, and there's, Medicare did increase some of that reimbursement for care coordination navigation. Could be a way that we can help incorporate this for some people in private practice, and things like that who don't have a big academic institution. I, for example, use MediciMD, which is not very expensive, but it is an approved telehealth portal that we switched to and pivoted during the pandemic. The other thing that I'm concerned about is, you know, what happens with people who are avoiding coming in because of contagion and infectious things. So I think that this proves to be a good alternative for them, but I don't know if we even kind of checked for that, you know, in terms of follow-up. And I know we missed a lot of people with screening, and we see that there's going to be an increased incidence and more complications, and it would be interesting to know, for example, Breast Cancer Awareness Month, we're doing some major screenings and things like that. And we know that black women have a lower incidence of breast cancer, but already have a higher mortality rate. So is this going to widen that, because even more of them failed to get their mammogram, failed to get the screening, failed to get the access? Is there a way to look at that as we go forward? In terms of disparities, I think it's really important, the power of this work, to help link people to care. And then the last thing I had a question of was, I'm sorry, I'm done. Can't read my own handwriting. I think that it's really important to remember that there can be language barriers as well, and that we also, you know, how do we bridge translation issues and needs from a telemedicine perspective? Unless if you have a, you know, like I speak Spanish, so it would help me if I had to call my Spanish-speaking patients. In fact, they would be happier than going to see somebody who didn't speak Spanish. So, you know, where there are some linguistic components to that dimension as well. So I just wanted to ask if in future work, are we going to look at some of those cultural linguistics, racial ethnicity components from that perspective? It would be helpful. Wow, thank you so much. That was so incredibly detailed, and yeah, thank you for paying attention. That was really amazing. Okay, yeah, there's, I think there's just so much to unpack there, but okay, I'll maybe just start with two of maybe the points that I thought were really interesting that you came up with. Okay, so the last thing, you know, regarding language. So, you know, we have a huge data set now, and we're going to splice this like a million different ways. And, you know, one of the things that we definitely want to look at is based off of, you know, ethnic background as well as like socioeconomic background, which we're going to proxy using zip codes. So that's definitely something that we're interested in looking at, just really the social economic disparities that may or may not be occurring. Like, just with telemedicine use. Regarding your comment about how we navigate the language barrier, everybody can kind of share what they do, but this is what I do. Because on, we use a platform called Marty, and it's just like an iPad, and you know, you press like the button, like selects whichever language. But sometimes I'm like talking to somebody on the phone. And basically I had to do like connect the speaker to the speaker, so I put like, you know, the speakers close to each other so they can kind of hear it because we can't, we don't have like a way of connecting for video visit directly, like through like the same phone that you're using. I don't know if anything I'm saying is making sense right now, but basically, you know, it's putting like a speaker next to a speaker so the translator can hear, you know, the interpreter can hear the patient on the other line. I don't know how other people bypass that. That's like my very rudimentary approach. So I've been at MD Anderson for about 11 years now. And in that 11 years, ever since I've started doing research, my data set has always been about 70 to 75% predominantly Caucasian. I would say probably in the last 10 years, we maybe have seen a little bit more in the ethnic minority maybe, but honestly, to tell you the truth, all of our data sets are skewed heavily towards Caucasian. Part of that is, you know, possibly, I mean, I'm hypothesizing, I don't think that there's actually been any research as to why we can't recruit more minorities into our studies or, and I think it's also reflective of the patient population that we're seeing at Anderson. Most, I would say that we have a county hospital, so when we focus on doing research, you know, with a larger percentage of minorities, we have to go to the public hospital and we do our research. We recruit minority patients through that hospital, Ben Talb, because recruitment at MD Anderson, we will never get our numbers in order, in that short period of time. And this has been true since I've been there for about 10 years. That would be a very interesting study to maybe figure out why, you know, this patient population are not coming to us and because, you know, we, is it because of insurance or is there something more that's driving patients not to seek care from our institution? And that's something that's very interesting and we have been thinking about as well. To the interpretation or the language barrier question, we have always had access to LanguageLine and then once we had the virtual platform established where we went with Zoom, the translator interpreter were able to get the interpreter on the Zoom video call with us too. So sometimes the interpreter wouldn't show their face, but they were on the phone and they would interpret through that platform. But possibly, you know, maybe patients also weren't aware that that was also a possibility, but we have made great strides to get interpretation services for our patients and access and decreasing the barriers to access through communication as well. I understand, Dr. Ng, earlier today in a conversation we were talking about that in terms of the racial disparities data, that actually the Caucasian population was utilizing telemedicine less. So we, I did take a look and it's not published, I just got the results back last week, so I didn't have time to really sit in and alter my slides, but some of the newer data that I've been examining up until August 30th this year, right, or 2021, we looked at looking at minorities versus Caucasian and looking at that data, some of the exciting preliminary data that we were able to find out was that instead of my hypothesis that we have a lot of barriers for minority population being able to use telemedicine, we were actually finding that our minority population was using more telemedicine than the Caucasian's population. So that was interesting data. And also the reverse of my hypothesis is that usually for telemedicine I would have thought that most of our MD Anderson patients that live far away, far from MD Anderson would have preferred the virtual platform, but those are the ones actually using the in-person, going to in-person and not using telemedicine. So there's a lot to dissect and there's some exciting, you know, data that just we're analyzing now that just came back. So I think we have a lot more to say soon. And just one other comment about possibly people just dropping off period with the pandemic. We do plan on looking at some pre-pandemic data, which obviously is all gonna be virtually all in person and comparing that to these pandemic numbers. So at least from a rehab standpoint, we should be able to get a sense of that. Thanks for the talk, everyone. This has been great. Segway into that last comment. So I also thought it was a little bit interesting, especially because some of these centers I've also based in Texas. So I know that that demographic of some of those slides did not necessarily match the demographic of the local population. Although once you kind of stratify across all of them, it seemed to be more reflective of the national population. One thing that my institution did at UT Southwestern that was kind of interesting, our cancer center actually looked at the broadband maps, heat maps of our city, where we looked at broadband connectivity. And what was interesting is that, not surprising, there was a lot lower broadband in like heat zones in areas that were poor and at lower socioeconomic status. And coincidentally, those parts of our city also happen to be heavily black and Hispanic. And I wonder if that might count for some of those disparities we're seeing is, we kind of all carry these in our pockets, but we assume everybody has one. Everybody can just connect all the time. When you're connecting to a video, the quality of your signal matters. And we've all tried to connect to that patient. Also, it's glitchy. It's not working. So I would just call them. Now we lose that face-to-face. We lose that in-person. So just more of a comment on that. I think it'd be interesting, as you guys look into this a little bit deeper, is maybe look at some of that kind of local heat maps in your population. I'm not sure how they got that, because I just saw that presented in data from our cancer center. But I don't think it was that cumbersome to get. So maybe just a thought about something you could kind of look into a little bit more that might answer some of those questions for you. That's a really great suggestion. Thank you. Yeah, we're really interested in that too, in terms of, especially Dr. Leong and I being at a county hospital, a safety net hospital. We do have patients with internet access issues. Still, a lot of them do have smartphones. People have choices how they spend their money, even with limited resources. But many still don't have smartphones. So we were the heavy telephone center. So that's a particular interest of mine. Are there real differences in the quality of the care between the typical telephone and video encounters? And maybe for some types of visits, there's not. Clearly, there's limitations. But most people can get to at least a regular phone. Yeah. Hi, I'm Jessica Chang. I'm the first and only physiatrist at City of Hope. And my institution's really interested in creative ways to reach patients in ways that are convenient for them. And so that got me thinking about telemedicine, and I really appreciate all the work you've done already. My question is thinking of having clinic by myself with little therapy support. I noticed on the Chang slides, there was a very small column, one-digit percentile of objective measures that were done, like six-minute walk test. And so I was curious if in your experience or in the literature, if there's any ways described more specifically of how you do a tele six-minute walk test or other objective measures that are as reliable as can be and safe? Yeah, no, that's a really, really good question. Somebody can correct me if I'm wrong, if anyone out there knows. I mean, I haven't actually seen any validation studies for any of those kinds of metrics being validated through telemedicine. I mean, I know for a bunch of physical exam maneuvers, there was a paper in the Mayo Clinic Proceedings, and they basically just talked about all the common tests we do, like spiralings or shoulder impingement signs. But they noted that through versus in-person and virtual, none of it's been validated, so who knows what the sensitivity of it is when you do it through video. It's probably the same. Who knows? I don't know. But I definitely haven't seen it for any kind of clinical metrics. But I guess you're looking at for research perspective, you're looking at these metrics? I would hope it could be used for research retrospectively, but right now, I'm just setting up my clinic and trying to think of how to be the PT if I have to be and have some metric that I could look at and show my value. The Academy, it wasn't specific to cancer rehabilitation, but they did have a session early pandemic talking about the physical exam. Yeah, that rings a bell. Thank you so much for reminding us of that. Hi, thank you very much for the presentation. I'm Bruce Gans. You asked about other things that you might be able to look at with your data or need additional data and you also mentioned that you don't know how long the spigot's gonna be open for reimbursement for the telemedicine visits. It's likely that when Medicare and then commercial insurers follow along, they will start trying to clamp down because there's a very big fear that it's a right for fraud, waste, and abuse. Overutilization is what they would say. So one of the things that could be extremely helpful is if there were criteria or data to identify what makes a telemedicine visit clinically appropriate and justifiable so that the payers will eventually not be able to say no because we only wanna pay for one a year or whatever. So anything you can do to demonstrate quantitatively sort of the legitimizing reasons why this was a clinically appropriate visit and appropriate for reimbursement will ultimately be extremely helpful contribution. Yeah, no, that's a fantastic suggestion. I think everyone here completely agrees with that, yeah. I think the trouble will be like which metric are we going to choose to show that it is useful or appropriate. But I think definitely healthcare utilization. That would be like low hanging fruit at least to start with. Just like EV visits, urgent care visits, hospitalizations. Hi, Adrian Christian from Miami. One of the thoughts that I have because I see a lot of folks with telemedicine is that there's certain types of cancers and stages of cancer that are more amenable to telemedicine, others that are not. So for example, I find it very helpful with our brain cancer patients and our advanced lung cancer patients who for one reason or another cannot come in. And in those populations, you could do a lot of clinical decision making that can help the patient and at the same time not impose on them to come in. On the flip side of this, I find it very challenging to do this with head and neck cancer patients or with very subtle shoulder motion problems in breast cancer patients. So I think looking at different populations I think could be very helpful as to identifying which are the patients as Dr. Gantz may have mentioned alluded to that are ones that we could make meaningful contribution to the care of the individual. Just a comment. Yeah, no, absolutely. Thanks so much. And I just want to add, we're not like a closed club. Like anybody can join us and like do stuff with us. That'd be great actually. Yeah. So yeah. Just throwing that out there. I just had two quick questions if you don't mind answering two. But I actually do VA spinal cord. So I'm a little out of my element, but I know the VA at least in the spinal cord world really pushes like telemedicine. I feel like we do a lot of it. And I was just wondering the studies you presented earlier where you did a pretty good literature review if there was anything specific to like VA, cancer rehab, telemedicine, or has that been looked at yet? I've seen a lot of, well not a, quite a few spinal cord rehab, telemedicine studies, but not like spinal cord cancer studies. Or just general cancer rehab either, nothing that you saw? General. Like just cancer rehab in general, not just spinal cord, but just cancer rehab. No, this was about it. Okay. So that didn't come up. For like physiatry cancer. Sure, sure. Yeah. No. Okay. Yeah, there's very little. So there's actually, there's going to be, hopefully, I think there should be like a white paper coming out soon just regarding like telemedicine for like all the like rehabilitation. I mean, I think that's including like SCI. So I would look out for that. But when I was like discussing this with like everyone else, like doing their literature reviews, as far as, there's a ton of stuff for like skilled therapy. So like there's a ton of stuff for physical therapy, occupational therapy, and like advocacy, like in telemedicine. There's like almost nothing for physiatry practice. So we just need people to like do this stuff. Nice. Okay. Thanks. And the other question was with the data Dr. Leung presented, he mentioned that there was less imaging ordered from telemedicine visits, which I thought was kind of counterintuitive. I don't know if you had thoughts on why that was the case. Not to put you on the spot. Yeah, no, that's okay. So yeah, this was something that I had been thinking about as we were processing the data. And, you know, we have a certain, you know, patient in mind of, you know, who are you going to evaluate from a telehealth standpoint or in person? So we're already deciding kind of like pre-sorting who should we already take in? And is the acuity high enough that we want to put our hands on them to be able to do a physical exam? And often those are musculoskeletal related issues that we would then pursue some type of, you know, imaging, you know, to help diagnose. I think that also then it does potentially, you know, we have not shied away from our kind of standard of care and we aren't over utilizing these types of imaging or say lab tests to say compensate for the lack of physical exam either. Although the imaging is the only one that is statistically significant and there is kind of heterogeneity with the two different analyses that we did. I think imaging is the only one that we can, you know, relatively say that there is less, but we're unsure about the others as of right now. Got it, thanks. So I think we're at the top of the hour, but like I said, we're all happy to talk further and collaborate with anybody who has great ideas and something a lot of you do, so thank you so much. Thank you.

cancer rehabilitation research

donations

telemedicine in cancer rehabilitation

phone-based physical therapy

COVID-19 pandemic

patient satisfaction

survey study on telehealth

physician preferences

benefits and challenges of telemedicine

establishing a successful telemedicine practice

physician practice patterns

healthcare disparities