The veterans affairs health care system national teleoncology service: veteran and provider perspectives and experiences

ABSTRACT

Purpose

The National TeleOncology Service (NTO) is a clinical service that enables VA oncologists, from across the country, to provide services via telehealth to Veterans with cancer. We sought to understand the early experiences of medical oncologists, Veterans, and clinical staff to inform the national NTO scale–out.

Materials and methods

We recruited clinicians who provided and/or Veterans who received care from three early adopting NTO sites. We purposively sampled Veteran participants who were: (1) diagnosed and/or treated December 2016 – March 2021 with prostate, non-small cell lung, non-Hodgkin's lymphoma, or colorectal cancer as confirmed by ICD–10 codes, and (2) obtained NTO-delivered care in October 2016 through July 2022 at one of the included NTO sites. We used rapid qualitative analysis.

Results

We conducted 3 provider focus groups and interviewed 15 Veterans. Participants noted the relative advantage of NTO over in-person care. A primary advantage of NTO is that it facilitates access to oncology specialists for Veterans who travel long distances. Clinicians and Veteran participants agreed that NTO service facilitates access to specialists for Veterans living far from VA medical facilities and community care and in areas lacking specialty oncologists. Although clinicians and Veteran participants agreed that NTO largely meets patient needs, some noted that NTO may not be personable.

Conclusion

There was consensus among clinicians that the NTO service, with its focus on specialized and individualized oncology care and increased access to care for patients through the virtual platform, is working well to meet the needs of Veterans with cancer.

KEYWORDS:

• Veterans health
• telehealth
• qualitative research
• cancer survivors

Introduction

In the US there has been a significant increase in telehealth use. In 2020 telehealth use accounted for nearly 25% of all health care encounters [1]. While the COVID-19 pandemic spurred a dramatic increase in telehealth-delivered healthcare, post-pandemic data demonstrate a steady use of telehealth visits, with an increased emphasis on video-based encounters [2]. Telehealth use can improve health care access, quality, communication, and outcomes across a variety of health conditions [3–6]. There has been differential use of telehealth-delivered care across specialties, with mental health services demonstrating higher adoption of telehealth [7]. While there are early signals of successful potential telehealth use among patients with cancer [8], less is known about telehealth preferences and experiences in the medical oncology setting.

The national Veterans Health Affairs Health Care System (VA) was an early adopter of telehealth-delivered care [9]. In the pre-pandemic era, the VA routinely provided many telehealth-care delivered services including primary care and mental health care. Telehealth use in the VA has increased by 3.9-fold from 10% prior to the pandemic to 38% currently [10]. Additionally, in fiscal year 2021, which is the most recent year with complete data, nearly 3.8 million Veterans had a telehealth visit [10]. While there is clear evidence that Veterans in the general VA population (e.g. non-cancer) used telehealth, less is known about telehealth use among Veterans with cancer.

The VA cares for approximately 46,000 Veterans with newly diagnosed cancer annually [11,12]. Additionally, nearly 38% of VA health care system users live in rural areas where oncologists may be in short supply [13,14]. Many aspects of cancer care can also be practically delivered via telehealth including cancer screening, patient monitoring and symptom management, treatment, and survivorship care. As a result, the VA launched the National TeleOncology Service (NTO) [13]. The NTO is a clinical service that enables VA oncologists from across the country to provide services via telehealth to Veterans with cancer who are in a different geographic area. As of fiscal year 2021, 23 VA clinics were served by or engaged in planning the delivery of NTO and there were 24 physicians providing care through an NTO virtual hub site [13]. NTO is continues to be scaled out nationally across the VA health care system. As NTO services are expanding rapidly and demand is high, this is a crucial time for an early evaluation to inform ongoing health services delivery to provide early information about clinician and Veteran experiences with NTO.

Our goal was to inform the refinement and scale-out of NTO. Using qualitative research methodology, we sought to understand early experiences of medical oncologists, Veterans, and other clinical staff to inform national NTO scale-out.

Materials and methods

Study setting. We conducted this qualitative descriptive project [15,16] in the national VA health care system, with a focus on recruiting clinicians who provided care and/or Veterans who received care from the three early adopting NTO hub sites: Durham, NC; Omaha, NE; and Pittsburgh, PA.

Interview guide development. Our research was guided by the Consolidated Framework for Implementation Research (CFIR) [17,18]. The CFIR was developed by VA researchers, has been used across a variety healthcare settings, has been refined based on user feedback, and can be applied as a framework to guide examination of real-world implementation efforts to provide an indication of factors associated with implementation. CFIR is one of the most widely cited frameworks in the field of implementation science [19]. Guided by CFIR, our multidisciplinary team selected specific CFIR constructs across domains to develop a semi-structured qualitative interview guide for individual Veteran interviews and a separate qualitative focus group guide for VA clinicians. All members of the team have had training and experience in conducting qualitative data collection and analysis.

Data collection. We purposively recruited two participant populations – clinicians and Veterans – with the goal of achieving information power [20]. We invited clinicians from early adopting NTO sites: (1) Durham, NC; including Clarksburg, WV; Salisbury, NC; Salem, VA; Sioux Falls, ND and Fayetteville, AR; (2) Omaha, NE; including Lincoln, NE; Grand Island, NE; (3) Pittsburgh, PA; including Altoona, PA; Erie, PA. Focus groups were held during a standing NTO meeting time. A research staff person contacted all NTO providers who are invited to participate in the weekly standing meeting to offer them the opportunity to participate in a focus group. All clinicians provided telehealth-based oncology care. We held separate focus groups for physicians and non-physicians. We conducted separate groups to be mindful of professional dynamics and supervisory role considerations. Additionally, we split groups based on sample size considerations for conduct of virtual focus groups. All focus groups included a trained facilitator (HK or CB) and notetaker (JM or CB).

We purposively sampled Veteran participants based on the following characteristics: (1) diagnosed and/or treated from December 2016 through March 2021 with prostate, non-small cell lung, non-Hodgkin’s lymphoma, or colorectal cancer as indicated by ICD-10 codes, and (2) obtained telehealth-delivered VA cancer care in October 2016 through July 2022 at one of the included sites. We also reviewed the Veteran sample to ensure that there was diversity and representation regarding Veterans’ cancer type, race, and sex. Eligible Veterans were identified via the electronic health record. A research team member sent them a letter explaining the research and followed-up with a phone call to determine interest and availability to complete an interview. A research team member initiated a telephone call via MS Teams audio to conduct Individual interviews with Veterans (CB; Figure 1).

Figure 1. Study flow for veteran participants.

Both focus groups and interviews were conducted, recorded, and transcribed using MS Teams. Research team members also took structured notes using a standardized template. Clinician and Veteran participants provided verbal consent prior to conducting qualitative data collection. This study was approved by the Durham VA Institutional Review Board.

Data analysis. We used a rapid qualitative analysis approach with purposeful data reduction activities [15,16]. Throughout the data collection and analysis process, we considered information power as well as rigor [20]. The first step in data analysis involved two research team members (JM, CB) conducting interim analysis of the oncologist focus groups and non-oncologist focus groups, and one research team member (CB) conducting interim analysis of the Veteran interviews. Interim analysis consisted of reviewing templated notes to respond to “Top of Mind” questions. Interim analysis results were presented to the project lead and NTO leadership team for content-level feedback to focus data reduction activities on actionable information to inform NTO.

Next, using templated notes and feedback results from the interim analysis, research team members (CB & JM) independently summarized participant responses to each focus group question and subsequently combined summaries into an excel matrix. For Veteran interviews, one research team member (CB) summarized participant responses to each interview question and transferred summaries into a separate excel matrix. The senior qualitative researcher (HK) provided a close overread of Veteran interview findings. Any identified discrepancies with summaries were addressed by the research team.

The clinician focus groups and Veteran patient interview analysis matrices focused on CFIR key constructs. For each construct, two research team members (JM and CB) summarized main findings based on the summarized focus group data, and one research team member (CB) summarized main findings based on the summarized interview data. Key construct findings were then demonstrated by quotes from the focus group and interview participants in the matrices. Any discrepancies between summaries were again noted and addressed by the qualitative research team. The matrices with key constructs, findings, and illustrative quotes were then reviewed by the senior qualitative researcher (HK) and the project lead (LZ). The project lead then mapped the summary matrix to the current context of NTO and vetted the matrices with NTO leadership. Following separate analysis and vetting of the clinician and Veteran patient data, we integrated the analysis results below to facilitate their presentation.

Results

Participant sample. For the clinician focus groups, we sent invitations to 19 physician oncologists and 17 other clinicians. This resulted in three separate focus groups. One focus group was attended by 3 physician oncologists, one was attended by 5 other clinicians (2 nurse practitioners and 3 registered nurses), and the third focus group was attended by 4 other clinicians (1 nurse practitioner and 3 registered nurses). Clinician focus groups lasted approximately 29 min. We interviewed 15 Veterans whose median age was 72.4 years. The sample was predominately white (60%) men (87%). The participants were diagnosed with prostate (n = 7), lung (n = 3), colorectal (n = 4), and non-Hodgkin’s lymphoma (n = 1). For the Veteran interviews, we mailed 127 invitations and conducted 15 interviews (Figure 1). Veteran interviews lasted approximately 36 min.

General Veteran Experiences. Veteran participants’ experiences with the NTO program ranged from one to several NTO appointments, including video calls from their spoke site or phone calls and/or video calls from their homes. Among Veterans who had video appointments from their spoke site, clinical staff connected them to the video appointment and often stayed to assist with taking notes and asking questions of the oncologist. Participants typically had vitals and labs taken at their spoke site before the appointment so that results could be discussed with the oncologist. Patients’ family members could accompany them to appointments to ask questions about the patients’ treatment and health. Among Veterans who had NTO phone calls from home, NTO oncologists discussed their health status, lab results, and impact of treatment during the phone calls; participants often went to their local VA clinic before their phone appointment for labs, scans, and/or treatment.

Relative advantage. Clinician and Veteran participants noted the relative advantage of NTO over traditional in-person care. According to both participant groups, a primary advantage of NTO is that it facilitates access to oncology specialists for Veterans who may have to travel long distances to appointments and who may not have access to an oncologist at their local VA clinic (Table 1). Clinicians also noted that NTO provides teams of providers and staff to facilitate better care coordination and expedite necessary follow-up services for Veterans diagnosed with cancer. According to clinicians, NTO keeps Veterans engaged in the VA healthcare system which understands their unique needs and facilitates access to an array of multidisciplinary supportive services, including social workers and dieticians, not available in community care.

Table 1. Participant key quotes.

CFIR domain: construct	Veteran quotes	Provider quotes
Intervention Characteristics: Relative Advantage	It’s very important because rather than having to go to [HUB SITE NAME REDACTED] to sit down and see a doctor for 10–15 min, you can stay home and not have to worry about getting into the traffic and all that. And you can get the same information over the phone through telecommunications that you would by going to [HUB SITE NAME REDACTED] … That has been a plus – especially back during the pandemic. The advantage for me is to see her. That would be the advantage to me. It doesn’t make it … any less real over the phone, but it makes it more comforting for me to see her … for me it feels more real … it feels more legitimate … it’s eye to eye, face to face, you know. And we’re looking right at each other and talking. And she’s dedicated to me. She’s paying attention to me and I’m paying attention to her … And that’s where the comfort level comes in. It’s just much more comforting that way than somebody on a phone, you know.	The ability for the Veterans across the country, especially in more rural areas or in areas without access to a bigger center, have the opportunity to see a cancer specialist who focuses on their area of disease. I think that’s probably the biggest advantage. Some of these VA centers also do not have oncologists. So, I think just a broader availability to get care closer to home. The communication, even though its virtual and remote, it’s really expedited. If I was in physical VA, there’s no way I’d be able to communicate with the pharmacist, the social worker, the scheduler, the nurse, the lab, in a matter of minutes.
	Veteran Quotes	Provider Quotes
Inner Setting/ Implementation Climate: Tension for Change	"I couldn’t make it without it … I don't see where anyone could go through a serious life-threatening disease or illness without some type of care. I think you would just die prematurely … So, it's absolutely essential” “Without the video, our unit at [HUB SITE NAME REDACTED] would be in big trouble because of the turnover of oncology doctors[…]So the video conference gives you hope … when you hear that, ‘well, your doctor isn’t here anymore’ is rather depressing at times. You think, ‘well, now what? Are we going to get a doctor or not?'” “Well … it's vital … There's no alternative at this point.”	"I do feel that a lot of veterans want to stay locally and don’t want to go a different community center, they feel comfortable in the VA system, so for those patients I do think it’s important and at many of these sites the closest even community care center is quite far, so I think it is advantageous to those patients.” “I think it's [the NTO program] done a really good job so far. There's always kinks that could be worked out in a new program and things that could be worked a different way. But if these patients had been trying to get all of their oncology care through care in the community, and go through multiple different providers, and possibly multiple different facilities, and they have various people in their care in the community department that are going to be gathering these records and bringing them forward; whereas with NTO we have one team that's looking over every aspect of care for this one patient, so there's less of chance that these things are going to be lost in translation somewhere.”
	Veteran Quotes	Provider Quotes
Outer Setting: Patient Needs and Resources	"I'm just really grateful. They've been really good at it. It's convenient to do it over the phone. I don't have to drive two hours to [HUB SITE REDACTED] to see somebody that's just going to tell me the same thing I can get over the phone. And the treatment I've been able to do it on a outpatient basis in my hometown, you know, close by where I live … And with her [the oncologist] on the phone just made it convenient way to do it instead of being a real hassle like it could have been.” “The very nice thing about it was we [he and his wife] had every opportunity and were encouraged to take that opportunity to speak our mind, to ask questions, to evaluate treatment outcomes and projections and everything such as that. I mean, it was very professional, and in fact, I felt absolutely comfortable in that environment of talking to a screen with a picture on it with moving lips.” “Because of the seriousness of my illness, I would have rather it been face-to-face with the doctor. And it was a new experience, you know, something new in my life, and … it was devastating. I guess the human TLC part of it, you know, the doctor, being able to sit there with the doctor for comfort and assurance was different, but I found that comfort and assurance um through the staff that were there and my family that was with me.” “I think … you lose just a little of the personal touch between the doctor and the patient by doing the video conference … I kind of like to have a doctor there, but uh it’s been okay, and I don't think it’s been anything that would affect anything.”	"Traditionally it's been more general oncologists taking care of patients and I know in my personal experience working with the National TeleOncology program and taking over the care of patients who previously had been cared for by a general oncologist, is that they didn’t have as nuanced care as I think that they are getting through having specialists with a special focus in their type of cancer or blood disorder. So, I think that that is a reason for why it's [the NTO program] an essential part of the care that veterans can receive and even in places that are staffed at a high level, but they may not be staffed with a certain specialist in that disease area.” “We've had patients tell us that they realize there is a team behind it. It's not just the doctor and the nurse that's in the call, they realize they've got the pharmacist, the practice providers, that they have a whole group of people that are working for them. More than once we've had patients really compliment us on that process.”
	Veteran Quotes	Provider Quotes
Process: Reflecting and Evaluating	"[…] I think that they do need to send them, you know, to a person who can show them how to pull it [video calls from home] up … whether it be on their phone, if they have a tablet or whatever, and iPad … and so they can help them get it set up I think would be very beneficial and … .I think the Veterans would feel a lot more comfortable knowing they had proper training on how to use teleoncology.” “I would say communication. Keep trying to improve that … a lot of times there are questions that you have and you should feel free to ask of them. And they've been pretty good about that. But see, I'm not a doctor or anything, and sometimes I have questions … they [doctors] don't always understand the question or something. Just get it cleared up and answer it in a way so they [patients] understand … and … provide an opportunity that you could either call back or answer it or get it cleared up would be helpful.” “Some of the Veterans that I know they do need that assistance [with TO] and some of them are not necessarily computer savvy … But that would be the only drawback I see … I mean, there's many, many volunteers that are willing to go to their house and hook them up or bring a laptop, or, I mean, those are just physical things. And I'm sure they could be all handled down the road."	They created a great foundation, I believe, and I think that's crucial to the success of the program. They brought in 99% excellent providers and care coordinators. “Another thing that would be useful is an assessment for physicians how much time they are working … because I fear that on face value it might look like a physician has a lot of free time, and so more work is going to be put on them.”

Note: These 12 selected Veteran quotes represent exemplars from 10 different Veteran participants, two of whom had two quotations. These eight selected provider quotes represent exemplars from six different provider participants, two of whom had two quotations.

Whereas clinicians described the systems level advantages of NTO and how these benefit patients, Veterans reported on the personal advantages of NTO over traditional, in-person care. Veterans noted the convenience of avoiding long travel distances to their appointments, especially when they have multiple appointments, are not feeling well due to having cancer or other health issues, or during the pandemic. A few Veterans mentioned that the main advantage of NTO for them is not virtual over in person appointments, but rather the option for video calls over phone calls, because video calls allowed them to still see their oncologist which feels like an in-person visit.

Tension for Change. Clinician and Veteran participants agreed that the NTO program is strongly needed to facilitate access to specialists for Veterans diagnosed with cancer living far from VA medical facilities, in areas that lack specialty oncologists, and in areas far from community care. Veterans emphasized that NTO was vitally necessary to their health because there was no cancer care available at their local VA clinic.

Patient Needs and Resources. There was consensus across clinicians that the NTO program, with its focus on specialized and individualized oncology care and increased access to care for patients through the virtual platform, is working well to meet the needs of their Veteran patients diagnosed with cancer. Veterans also agreed that NTO is meeting their needs by providing them with access to a team of knowledgeable and caring oncologists, helpful and comforting support staff, and effective and state-of-the-art cancer treatment without having to endure long distance travel to medical visits. Some veterans described the convenience of also receiving their cancer treatment and lab tests at their local VA or community care center through the NTO program. Veterans were pleased that NTO doctors and staff were responsive to their needs and questions and encouraged their family members to attend their cancer care appointments and ask questions about their treatment and care. Furthermore, Veterans reported that the logistics of NTO have largely met their needs, including access to well-functioning technology for video calls at their local VA, punctual appointments, smooth appointment scheduling, and prompt sharing of test results and other medical information between their local VA staff and NTO oncologist.

Although clinician and Veteran participants agreed that NTO is largely meeting patient needs, some noted that one disadvantage of NTO is that it is not as personable as in-person care. One Veteran stated that she would have preferred in person doctor visits over video appointments to receive comfort and assurance from her doctor in person due to the seriousness of being diagnosed with cancer. Another participant explained that he would have preferred in person visits to see his oncologist’s reactions and concern for him in person, and another participant explained that meeting in person would have allowed him to be more “candid” with his oncologist. Nevertheless, Veterans reported that NTO had not changed their relationship with their cancer doctor whom they described as knowledgeable, patient, thorough, and concerned about their health. Additionally, clinicians explained that although Veterans were initially skeptical about meeting with their provider virtually, they ultimately “felt that they were in the same room” with the oncologist and appreciated that NTO specialists are more knowledgeable than onsite general oncologists.

Reflecting and Evaluating. Clinician and Veteran participants were asked to reflect and evaluate on the progress and quality of their experiences with NTO implementation. Non-oncologist clinicians reported that the current NTO program is successful in terms of staffing, teamwork and coordination, and prompt, remote communication between teams; however, they also reflected that NTO could delay care due to a need for more oncologist physicians to support rapidly increasing demand for NTO. Oncologists had suggestions for improving communication and distribution of administrative tasks, such as scheduling and ordering labs, among NTO team members to enhance patient care and avoid physician burnout. Veterans also suggested improving communication, but between providers and patients, by ensuring Veteran patients feel comfortable asking questions, clinicians provide clear responses, and Veterans can contact providers if they have questions after their appointment.

Clinicians noted that technology use can be challenging for some Veterans, such as older patients, and Veterans suggested having more information and training for NTO patients about how to access video calls from their home and about the NTO program generally. Veterans also suggested addressing technical challenges by providing a mobile nurse or recruiting volunteers to visit Veteran patients at home to help them connect to NTO appointments, especially for Veterans who may not have a computer. Nevertheless, Veterans reported confidence in their ability to successfully use telehealth for their oncology appointments, as those who attended their appointments via video at their local VA relied on NTO staff to connect them to virtual appointments, check their vitals, and follow up on requests from their oncologists. Participants who accessed their appointments from their home were also confident in their ability to do so by phone but not as confident about video appointments due to technical limitations.

Furthermore, Veteran participants reported that NTO would be very helpful for Veterans like them, particularly those with mobility issues, who are not feeling well, who lack transportation and/or support getting to medical appointments, and who live far from their cancer doctor. However, participants also mentioned that Veterans may need additional support to successfully use NTO, including assistance connecting to virtual appointments from home, transportation to spoke site, physical support getting to appointments due to feeling weak, clinical staff support at spoke site to connect to video calls, and an initial in-person visit with their oncologist for those newly diagnosed with cancer due to the emotional gravity of a cancer diagnosis.

Conclusions

The VA health care system has been a significant and early adopter of telehealth [21], yet telehealth use in medical oncology remains relatively novel. Within the VA, telehealth has been used for specific purposes, such as virtual tumor boards, remote cancer survivorship care, and genetic testing and counseling, among others [22–26]. Building from these early experiences, the NTO is a growing national program to provide nearly comprehensive and remotely delivered care to Veterans seeking care across the cancer care continuum [13]. Early evidence from the VA suggests that telehealth for Veterans’ cancer care is associated with high patient satisfaction and positive financial and environmental impacts [8]. A limitation of our work is that it is U.S.-centric and focused on U.S. Veterans. However, in our study, both clinician and Veteran participants that we interviewed had mostly positive remarks regarding NTO. One specific area of shared positive remarks was that both participant groups appreciated that NTO overcomes traditional barriers to accessing cancer care such as transportation and travel times. Transportation is a well-documented barrier to cancer care among Veterans; [27–30] thus, for Veterans with transportation problems NTO may provide a significant advantage over traditional in-person care. Similarly, both clinicians and Veterans reported that NTO is beneficial in providing access to specialists who live in isolated areas that lack specialized cancer services. This is of critical importance because approximately one quarter of Veterans live in highly rural areas [31] and Veterans are less likely to undergo certain cancer services like cancer screenings [32]. Historically, when a service is not available in a timely manner close to a Veterans home, the VA may pay for a Veteran to receive needed care from local provider in their community. However, in most of rural America there is a shortage of oncologists, which is resulting in poor treatment access [33–35]. NTO may fill a critical gap for Veterans needing cancer services that are unavailable close to their home. Moreover, telehealth has been proposed by leading cancer care delivery experts as a mechanism to overcome this workforce problem [36] and the NTO is well suited to address this. Interestingly, while clinicians noted that technology comfort and access may present a problem for some Veterans, most Veterans did not share this view. Veterans suggested that more information and training in technology use would be beneficial but reported a high degree of confidence in their ability to use telehealth. While NTO is well received overall, our research uncovers additional research questions. For example, what is the best way to assess a Veteran’s preferences regarding NTO use versus in-person care and how the quality and outcomes of NTO compare with cancer care provided in-person within the VA. While some questions remain, our early findings strongly support the relative advantage of NTO over traditional in-person care to fill critical cancer gaps and increase accessibility to specialized cancer services for Veterans, regardless of where they live.

Disclaimers

The contents do not represent the views of the US Department of Veterans Affairs or the US Government.

Previous presentations

This work has not been previously presented or published.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by United States (U.S.) Department of Veterans, National Oncology Program; Center of Innovation to Accelerate Discovery and Practice Transformation at the Durham VA Health Care System.