Background: Residents of communities without local access to clinical oncology care face significant challenges that can be addressed through the use of technology. Teleoncology uses secure, interactive video- and audioconferencing and telephone communication to remotely deliver quality cancer care.
Objectives: This article introduces the role of the oncology nurse navigator (ONN) as a collaborative caregiver and virtual resource for patients and teleoncology providers.
Methods: The literature on telehealth, nurse navigation, and teleoncology was reviewed to describe the ONN role and its integration with eHealth technologies.
Findings: As a member of the interprofessional provider team, the ONN works collaboratively with patients and their family members and serves as a virtual resource. The ONN also provides clinical communication among clinical oncology providers and support staff. The ONN supports eHealth as a method of providing clinical care to patients close to their homes.
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The digital revolution paved the way for the development and implementation of innovative healthcare delivery models, including a shift from healthcare professionals dispensing medical knowledge to patients combing the Internet for answers. As health care moves into the next decade, partnerships involving patients and providers that use current technology are emerging (American Hospital Association, n.d.). Oncology practices also are embracing technologies that provide virtual medical consultations and oncology treatment to patients in areas where a lack of healthcare expertise may exist (Doyle-Lindrud, 2016). This article provides an overview of teleoncology and introduces telenavigation through the collaborative role of the oncology nurse navigator (ONN), who provides care in comprehensive cancer centers and clinic practices in the community.
“Telehealth” is an umbrella term that is defined as the use of telecommunications technologies in the delivery of health care when the medical provider and the patient are in different locations (Health Resources and Services Administration, 2019). Telehealth applied in the oncology setting is termed “teleoncology” and describes the use of interactive video- and audioconferencing and telephone communication in the care of patients with cancer (Hazin & Qaddoumi, 2010). Rationale supporting teleoncology includes a predicted shortage of oncologists in the wake of an aging population and the disparity in oncology professionals practicing in urban versus rural areas of the United States (Charlton et al., 2015). Teleoncology has been used to provide genetic counseling, improve access to clinical trials, supervise remote cancer treatment, address symptom management, and provide survivorship care (Sirintrapun & Lopez, 2018). In addition, patients with cancer face physical, economic, and psychosocial barriers that can be addressed by nurses and other healthcare providers using teleoncology services (Larson et al., 2018). Teleoncology is a collaborative service that involves oncologists, nurses, and additional support staff (e.g., financial advocates, social workers, schedulers) (Doolittle & Spaulding, 2006).
The term “televisit” describes the virtual connection of patients and oncology providers using interactive video- and audioconferencing. A significant advantage of televisits supported by interactive video- and audioconferencing is that patients, their family members, and healthcare providers are able to see and interact with one another during the consultation. Imaging and pathology reports can also be viewed on the screen during the visit (Hazin & Qaddoumi, 2010).
“Telenavigation” is a relatively new term primarily used in the literature to describe remote stereotactic manipulation in the surgical setting (Ewers & Schicho, 2009). Telenavigation is used in the current article to refer to a novel role for oncology nurse navigators (ONNs) working alongside medical oncologists providing teleoncology services. Managing cancer treatment from afar requires significant care coordination (Doolittle & Spaulding, 2006). As a result, telenavigation emerges as a way for ONNs to improve care coordination, support provider communication, address patients’ logistical challenges, provide patient and family education, deliver survivorship care, and diminish other barriers facing patients with limited oncology access. Based on the nurse navigator core competencies, nurse navigators are well positioned to act as the lynchpin of care coordination, education, and patient support in a teleoncology service (Baileys et al., 2018). ONNs can also support rural clinic nurses who may not specialize in oncology nursing.
Telenavigation and the Oncology Nurse Navigator
Oncology nurse navigation emerged from the success of community-based programs focused on overcoming health disparities (Freeman et al., 1995). As patient navigation moved into hospital-based and private oncology settings, RNs frequently filled the navigator role (Wagner et al., 2014). To navigate a plan of care, nurses apply medical knowledge; the nursing process (i.e., patient assessment, identification of outcomes, planning, coordination, implementation, and evaluation); and nursing skills (e.g., health promotion, teaching) (American Nurses Association, 2015; Baileys et al., 2018). To support shared decision making, nurses provide disease and treatment education. They also recognize patients’ psychosocial and emotional status, which can influence treatment choices and treatment adherence (Baileys et al., 2018).
When added to a teleoncology service, the ONN provides an additional layer of patient support. The ONN role includes facilitating care transitions; identifying and addressing ongoing barriers to care; supporting patients’ physical, psychosocial, and spiritual needs; and acting as one point of contact for patients, their family members, and interprofessional teams (Baileys et al., 2018; Cantril & Haylock, 2013). Through the use of televisits, ONNs can deliver these services virtually to patients at a location near their home, regardless of the distance they may be from a specialized cancer clinic or comprehensive cancer center. Telenavigation provides a method for ONNs to connect patients to resources that are close to where they live and to assist with coordinating and consolidating appointments when patients need to travel for care. Clear communication can occur when the ONN acts as one point of contact for patients and the healthcare team. Because not all teleoncology locations use the same electronic health record system, telenavigation requires diligent communication with the distant team and referring provider through secure email or text, telephone, and/or fax. Figure 1 summarizes patients’ system-related barriers to care and corresponding telenavigation interventions. To address the needs of patients and their family members, ONNs can suggest the use of oncology-related mobile applications, or apps (see Figure 2).
Clinic and Infusion Center Nurses
Clinic and infusion center nurses can facilitate televisits, arranging the televisit and/or providing patient assessments to share with the clinical provider team (Spaulding & Doolittle, 2008). In addition, clinic and infusion center nurses can be aware of healthcare services that are physically located near the patient (e.g., imaging, diagnostic procedures), which can be mobilized, if needed. In collaboration with ONNs, clinic and infusion center nurses can identify patient needs and reiterate patient education, relaying consistent communication to patients, their family members, and clinical providers in the community.
Intermountain Healthcare Teleoncology Program
Intermountain Healthcare is based in Utah and serves a large population of patients with cancer within its catchment area, which includes 215 clinics and 24 hospitals; its telehealth services are provided across a six-state area (Intermountain Healthcare, n.d.-a). Intermountain Healthcare aims to provide the right care at the right time and in the right place, something that can be accomplished through the use of teleoncology (Intermountain Healthcare, n.d.-b). Intermountain Healthcare identified a large population of people who had to travel a long distance to receive cancer care at one of the six Intermountain Cancer Centers. As a result, in 2015, Intermountain Healthcare began to develop a teleoncology program (Maddox & Albritton, 2019).
Some of the early barriers identified by patients using teleoncology services were perceived lack of care coordination, lack of knowledge about what to expect during a televisit, need for a better understanding of where to go for additional workup, and lack of a main point of contact (Intermountain Healthcare, n.d.-b). In response, Intermountain Healthcare implemented two changes in an attempt to overcome these barriers: The distant clinic nurse acted as a navigator, and ONNs from the comprehensive cancer center contacted patients by telephone and sent them written information to support disease- and treatment-related education provided via telephone. However, care coordination between the comprehensive cancer center and the distant location still was not ideal.
Consequently, to support patient care and teleoncology program expansion, a master’s degree–prepared nurse was hired to act as a specialized teleoncology nurse navigator for the system (Intermountain Healthcare and all its telehealth locations) and charged with developing a standardized telenavigation process. Figure 3 details the steps in the standardized nurse navigator workflow, which served as a template for developing the telenavigation process at Intermountain Healthcare; several items were added to create a navigation workflow specific to telenavigation. One significant addition to the telenavigation process was the ONN using interactive video- and audioconferencing to connect with patients and their family members when they were at the infusion center, which had telecommunications equipment.
About 21,000 people live in the 1,918-square-mile Sevier County where the first Intermountain Healthcare teleoncology program was trialed. The nearest comprehensive cancer care services are between 90 and 135 miles away. During a three-year period (2016–2018), 158 patients with cancer participated in the teleoncology program. Data analysis found that the teleoncology program produced nearly $3.6 million in pharmaceutical, infusion clinic, radiology, and laboratory service revenue that was previously captured by other facilities. The patients avoided about 340,000 miles and 4,800 hours of travel, which equated to a reduction in carbon emissions of about 106,000 kg. Collectively, patients saved about $333,000 in travel costs and potential lost wages from taking time off from work to attend oncology appointments. The analysis did not include money and time saved by patients’ family members who would have had to take time off from work to drive patients to and attend their appointments or procedures. Patient-reported benefits included improved family relationships, the ability to keep working longer, reduced financial stress, greater community and religious support, and increased quality of life (Maddox & Albritton, 2019).
The telenavigation process streamlined collaboration among the ONN, the distant clinic nurse, and the oncology team. The standardized telenavigation process includes specific touchpoints when the ONN and the patient and their family members connect. The Intermountain Healthcare ONN noted that using interactive video- and audioconferencing instead of telephone communication alone supported the use of visual aids in real time. Patients and the ONN reported that virtual face-to-face interaction enhanced their relationship. One patient remarked that “it’s nice to put a face with the name.” Video- and audioconferencing also helped the ONN pick up on visual cues that may have been missed via telephone communication alone.
Since implementation of the designated teleoncology ONN role, patients have reported a better understanding of their treatment choices and potential side effects. One patient stated that they would not have undergone cancer treatment if the ONN had not explained the teleoncology process and how to manage side effects during treatment. The patient’s reluctance to undergo treatment was related to the difficulty of navigating travel, the need to attend various appointments related to the cancer diagnosis, treatment with various unfamiliar medications, and the cost of cancer care. The following case study details a patient’s experience with a standardized telenavigation process.
Teleoncology Case Study
R.B. is an 80-year-old man who lives 170 miles from comprehensive cancer care services. He was referred to the teleoncology program for his diagnosis of metastatic lung cancer. R.B. had to travel a total of 340 miles to undergo staging studies at the nearest place with comprehensive cancer center services. The ONN arranged for a local nonprofit organization to pay for an overnight hotel stay near the hospital. The ONN and medical oncologist were not located at the hospital where R.B. was scheduled to undergo the staging studies. Therefore, the ONN arranged for R.B. to videoconference with herself and the medical oncologist while he was at the facility where the staging studies would take place. This intervention saved R.B. from having to make another trip for the medical oncology consultation. During this consultation, the ONN introduced the concept of telenavigation, explained how the teleoncology process worked, and supported shared decision making by providing education on lung cancer and the recommended treatment. The ONN learned that R.B. lived alone but had social support through his local church, friends, and neighbors. The ONN shared this information with the distant clinic nurse so that both nurses could ensure that R.B. continued to have adequate support at home.
For R.B., the nearest location with teleoncology capabilities was an infusion center 93 miles from his home, reducing the round-trip commute from 340 miles to 186 miles. R.B. said that this decrease in travel saved him money, reduced his risk of an automobile accident, and increased his time at home. R.B. completed all of his oncology visits at the infusion center through interactive video- and audioconferencing. Throughout his care, the clinic nurse met R.B. and his daughter in the clinic, obtained vital signs, conducted a hands-on assessment, and assisted the oncologist as needed. The ONN was R.B.’s main point of contact to coordinate his infusion appointments, laboratory studies, and radiology services. In addition, when R.B. had questions about nutrition or needed clarification on how to manage side effects, he called the ONN, who facilitated answers and resources and communicated the encounter to the clinic nurse and oncologist. In this way, patient education was consistent. The ONN developed charts and calendars of appointments and treatments to cater to R.B.’s preferred visual approach to learning and took time to address his anxiety related to his diagnosis of cancer and its treatment. When the oncologist requested follow-up scans, the ONN collaborated with the radiology department at the distant site and coordinated other services into one visit to avoid additional travel and expense. Again, this information was communicated to the clinic nurse. The clinic nurse routinely communicated R.B.’s treatment tolerance and the need for any additional resources to the ONN and members of the oncology team.
During R.B.’s survivorship visit with the ONN, he reported increased energy, improvement in his ability to breathe, and an overall better quality of life. He also expressed his satisfaction with coordination of care and attentiveness of the ONN and clinic nurse. Throughout active treatment, R.B. spent quality time with his family, visited with neighbors, and attended his grandchildren’s events. He reported that these simple pleasures were made possible because of teleoncology services, which allowed him to experience the physical and emotional benefits of expert care while only having to travel 93 miles each way every three weeks.
Interactive real-time technologies are extending the reach of oncology nurses beyond telephone-centered interventions. Patient and nurse interactions can occur from wherever the patient is located using secure web-based health-related apps. Artificial intelligence (AI) is being used to identify patients who can benefit from virtual interactions with ONNs; these ONNs are considered virtual nurse navigators (VNNs) (Crawford et al., 2019).
For example, Sarah Cannon Cancer Institute in Nashville, Tennessee, leveraged AI to search its cancer registry for pathology on newly diagnosed patients with early-stage (stage I or II) colorectal cancer. On identification, a VNN contacted patients via telephone and educated them about colorectal cancer while stressing the importance of follow-up colonoscopies. By doing so, VNNs ensured that patients were connected to a healthcare provider who would deliver follow-up care. Patients identified with later-stage colorectal cancer (stage III or IV) were referred to an ONN close to their local area for face-to-face navigation as needed. The AI-supported program extended the reach of the ONNs and achieved a 98% rate of follow-up care in 332 patients with stage I or II colorectal cancer (Crawford et al., 2019).
Schaffer et al. (2019) performed a mixed-methods analysis examining the effect of a VNN program on patients’ self-advocacy. VNNs and oncologists reviewed patients’ records to identify potential clinical trials and other resources from which patients could benefit. The VNN telephoned patients, offering support and resources, and promoting patient self-advocacy. An online assessment measuring patients’ prior cancer knowledge and whether the VNN program increased patients’ cancer knowledge and self-efficacy was completed by 95 participants. Results were statistically significant in two areas: increased knowledge related to cancer (p < 0.0001) and improved cancer care coordination (p = 0.018). The Schaffer et al. (2019) study suggested that patients’ self-advocacy could be enhanced through VNN contact.
Implications for Nursing
Telenavigation provides a high-touch (i.e., close relationship between organization and clients) patient-centered service that supports patients, their family members, and the teleoncology team. Patients have reported that having a virtual connection to an ONN helped them navigate a technologically enhanced approach to cancer care; for example, the Intermountain Healthcare ONN is often responsible for explaining the teleoncology and televisit process, consolidating appointments when the patient has to travel, providing personalized education, and coordinating care between the comprehensive cancer center and a distant location.
Innovative technologies, like AI identification of early-stage patients with cancer, enable oncology nurses to reach patients soon after diagnosis, when education and support are crucial (Schaffer et al., 2019). Web-based technologies, like patient portals, can facilitate patient–provider communication. Smartphone apps can connect patients to others with a similar cancer diagnosis, help them keep track of their appointments, and manage the symptoms of cancer treatment.
Oncology nurses should advise patients on reliable apps and information and correct misconceptions that may come from unreliable sources. They should scrutinize information patients get from the Internet and the apps they may be using. Not all apps are of equal quality in information or function. In 2017, it was estimated that there were more than 300,000 health-related smartphone apps available, with 200 new apps being added daily (Adam et al., 2019). In a review of publicly available apps, Adam et al. (2019) found 151 apps that had been created for people diagnosed with cancer. Each of these apps fell into one of five categories: imparting information about cancer, planning and organizing cancer care, interacting with others, enacting management strategies and adjusting to life with or beyond cancer, and getting feedback about cancer management.
Smartphone apps and online resources (e.g., Cancer.net, National Comprehensive Cancer Network guidelines) can also help oncology nurses stay current with new treatments and support ongoing education; apps using AI algorithms can supplement critical thinking by providing algorithms that oncology nurses can follow. Oncology nurses can expect to see new roles emerge as technological advances are applied in the oncology space (Brynjolfsson et al., 2018). As teleoncology programs expand across the United States, there is an opportunity for clinic nurses to work with ONNs in collaborative teleoncology roles. Clinic nurses and ONNs can enhance the teleoncology process by working synergistically on behalf of patients, their family members, and oncology providers.
Establishing clear role delineation and a standardized telenavigation process is imperative to supporting successful delivery of oncology care. Development of a structured process enables members of the teleoncology team to identify their individual roles in patient care and avoids having multiple people working on the same task. In addition, clearly identified teleoncology roles (see Figure 4) contribute to each team member working at the capacity of their licensure or training.
Patients living in areas that lack oncology providers can receive cancer care close to home through teleoncology. Teleoncology saves patients time and money while allowing them to remain close to their social support systems. The success of a teleoncology program relies on collaboration between ONNs and clinic nurses. The next evolution of the ONN role may be harnessing the latest technologies to extend the width and breadth of the ONN influence on behalf of patients with cancer and their family members.
About the Author(s)
Kimberlee Emfield Rowett, MSN, MBA, RN, is an oncology nurse navigator at Intermountain Healthcare in Provo, UT; and Deborah Christensen, MSN, APRN, AOCNS®, OCN®, is a system lead for oncology navigation at Intermountain Healthcare in St. George, UT. The authors take full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. The article has been reviewed by independent peer reviewers to ensure that it is objective and free from bias. Rowett can be reached at email@example.com, with copy to CJONEditor@ons.org. (Submitted December 2019. Accepted February 19, 2020.)
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