Journal of Surgical Oncology 2014;110:353–359

Telemedicine and Telesurgery in Cancer Care: Inaugural Conference at MD Anderson Cancer Center ROBERT L. SATCHER, MD, PhD,* OLIVER BOGLER, PhD, LAUREL HYLE, JD, MPH, ANDREW LEE, MD, ANGELA SIMMONS, MS, ROBERT WILLIAMS, MD, ERNEST HAWK, MD, MPH, SURENA MATIN, MD, AND ABENAA M. BREWSTER, MD, MHS Department of Orthopaedic Oncology, MD Anderson Cancer Center, Houston, Texas

Background: Despite the growing incidence of cancer worldwide, there are an insufficient number of primary care physicians, community oncologists, and surgeons to meet the demand for cancer care, especially in rural and other medically underserved areas. Teleoncology, including diagnostics, treatment, and supportive care, has the potential to enhance access to cancer care and to improve clinician education and training. Objectives: Major cancer centers such as The University of Texas MD Anderson Cancer Center must determine how teleoncology will be used as part of strategic planning for the future. The Telemedicine and Telesurgery in Cancer Care (TTCC) conference was convened to determine technologically based strategies for addressing global access to essential cancer care services. Results: The TTCC conference brought policy makers together with physicians, legal and regulatory experts to define strategies to optimize available resources, including teleoncology, to advance global cancer care. Conclusions: The TTCC conference discourse provided insight into the present state of access to care, expertise, training, technology and other interventions, including teleoncology, currently available through MD Anderson, as well as a vision of what might be achievable in the future, and proposals for moving forward with a comprehensive strategy.

J. Surg. Oncol. 2014;110:353–359. ß 2014 Wiley Periodicals, Inc.

KEY WORDS: teleoncology; cancer; telemedicine; telesurgery

INTRODUCTION Cancer will become the most common cause of death in coming decades [1,2]. The global incidence of cancer is projected to increase by 50% over the next 20 years, with the majority of new cases occurring in low and middle income countries, which control only 5% of the world’s resources [2,3] and have not historically been able to leverage their need for services into effective access to the same. Moreover, access to quality cancer care remains limited in many rural and remote areas. Teleoncology, including diagnostics (laboratory, radiology, pathology), treatment (surgery, radiation oncology, medical oncology), and supportive care (rehabilitation and palliative care), has the potential to enhance access to cancer care and to improve education and training [3–7]. Teleoncology is best used via consistent and long‐term application [4]. One of the most common uses of telemedicine is for convening virtual tumor boards in which physicians at remote locations present patient cases to an assembled group, usually led by clinical experts at a teaching hospital. Another growing use is for support services such as nutrition or psychiatric counseling, that is, cancer‐related services that do not include chemotherapy, radiation, or surgery. Both physicians and patients report high satisfaction in using teleoncology [3,4,7]. After initial apprehension, the acceptance barrier is typically removed on both sides because it is so convenient to use, reduces travel, and provides equivalent care [4]. The business case for teleoncology depends on certain criteria. Hede [4] demonstrated that to break even financially, the service had to save at least 5 hr of physician travel time per month. Another study at the University of Kansas Medical Center showed that costs associated with delivering cancer care by videoconferencing dropped from $812 per visit in 1995 to $251 in 2005, or less than the $332 cost of an in‐person visit [8]. The threshold for economic viability was reached when more than 200 patients per year were seen [8].

ß 2014 Wiley Periodicals, Inc.

Several studies have demonstrated that effective physician‐patient communication can be experienced through technology‐based consultations [9–12] although concerns have been raised that it limits patient self‐expression [13] and its impact on clinical care is infrequently reported [12]. There is overall high satisfaction with the use of videoconferencing which has been employed worldwide to engage community oncologists, radiation oncologists and surgeons into oncology multidisciplinary tumor boards at academic centers [14]. Some physician reported difficulties with the use of telemedicine include the integration of the service into their daily routine [15]. Telesurgery is perhaps the most demanding application of technology to clinical practice. New technological developments in telecommunications have impacted surgical practice and education in multiple ways, including: telementoring; teleproctoring of surgical procedures; telesurgery (operating on a patient from a remote location); and teleconsultation [16,17]. There are a limited number of surgical procedures that have been tried using robotic systems. These include: laparoscopic cholecystecomy, coronary artery bypass grafting, radical prostatectomy, fallopian tube reanastamosis, gastric banding, mitral valve repair, Nissen fundoplication, nephrectomy,

Grant sponsor: MD Anderson’s Cancer Center Support; Grant number: CA016672; Grant sponsor: Minimally Invasive New Technology in Oncologic Surgery (MINTOS).; Grant sponsor: AT&T. *Correspondence to:Robert L. Satcher, MD, PhD, Department of Orthopaedic Oncology, MD Anderson Cancer Center, 1400 Pressler St., FCT10.5044, Unit 1448, Houston, TX 77030. Fax: þ1‐713‐792‐8448. E‐mail: [email protected] Received 25 February 2014; Accepted 13 April 2014 DOI 10.1002/jso.23652 Published online 29 May 2014 in Wiley Online Library (wileyonlinelibrary.com).

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pelvic lymph node dissection, pyeloplasty, retroperitoneal procedures, and transanal intrarectal resection [16,17]. Most significantly, there has been one international telesurgery case reported that proved the viability of remote surgery—a laparoscopic cholecystectomy performed on a patient in France by a surgeon who was 6,500 km away in New York [18,19]. The only system currently available for clinical use is the DaVinci telesurgery system, which costs $1 million—a cost that is prohibitive to many health care centers. The robotic arms and computer controller operate at an accuracy of approximately 5 mm, compared with 50 mm for the best microsurgeons [20]. Tremor is eliminated and movements can be scaled so that a 1 cm human movement translates to 1 mm of actual movement at the remote surgical site [21]. This allows surgeons to perform tasks that would otherwise be impossible, such as retinal vein cannulation [22]. Concerns about telesurgery include the high cost of surgical robot systems, legal liability, safety, and delays in the transmission of information from one site to another. The clinical trials reported have demonstrated that telesurgery is feasible for assisting and/or mentoring by an expert, and remote teaching of simple procedures such as endoscopy [23]. Additionally, it is recommended that telesurgery should only be performed after considerable instruction and practice using the telesurgical systems involved [24,25]. This can be accomplished via a virtual surgical training simulator, cadavers, animal laboratory, or a mixture of all three [24,26–28]. The issues of surgeon training and qualification, system instrument range, maintenance and certification, communication availability and reliability, and legal issues of liability, jurisdiction and informed consent must be addressed prior to using telesurgery in any practice. Although the Center for Medicare and Medicaid Services (CMS) has reimbursed for telemedicine services since 1998, restrictions have limited its use in many states, particularly for cancer care applications. CMS’ reluctance has historically been attributed to an underlying need to demonstrate patient safety and equivalence to an in‐person visit [29– 31]. However, CMS has begun to loosen restrictions on reimbursement [29,31]. The most common path being taken by states is to cover telehealth services in the Medicaid program. In fact, 42 states now provide some form of Medicaid reimbursement for telehealth services. Another avenue is for states to require private insurance plans to cover telehealth services. Seventeen states now require private insurance plans in the state to cover telehealth services. A confluence of better, less expensive technology, favorable federal policies, mandated insurance, and better physician acceptance is making teleoncology an attractive option to address the mismatch in cancer care supply and demand [5–8,30,32–35]. There are insufficient primary care physicians and oncologists to meet the demand for cancer care, especially in rural areas [4,34,36]. Increased access to cancer care can be accomplished using telemedicine, and major cancer centers such as MD Anderson must determine how teleoncology will be used as part of their strategic planning for the future [34,35,36–42]. The Telemedicine and Telesurgery in Cancer Care (TTCC) conference was therefore convened to determine a strategy through which cancer centers can begin to address these issues by

increasing its outward‐directed activities and focus using telemedicine and telesurgery technology.

METHODS This review summarizes the content of the inaugural TTCC conference that was held on September 5, 2013, at the MD Anderson Cancer Center in Houston, Texas. The overall objective of the conference was to engage faculty, administrative professionals, and executive leadership in reviewing the current state‐of‐the‐art of telemedicine and potential uses of teleoncology and in identifying challenges to the implementation of these services. The main aims of the conference were to (1) frame the objectives for an institutional policy for the use of telemedicine and telesurgery, (2) identify the areas of need and the main challenges for using telemedicine and telesurgery as a platform for cancer care, (3) explore ideas for solving these obstacles, and (4) initiate collaborations and an institutional working group that will formulate a blueprint for a coherent telemedicine and telesurgery institutional policy. The Telemedicine Planning Committee consisted of a cross‐disciplinary representation of senior clinical faculty and administrative leadership. Teleoncology crosses traditional boundaries and mandates a collaborative approach in order to optimize its application to cancer care. The planning committee selected and invited nationally recognized thought leaders as participants including faculty, attorneys, billing administrators, governmental relations representatives, regional care center administrators, scientists, information technologists, and institutional academic and managerial leadership. Invited participants were asked to address legal, policy, clinical, and financial issues in telemedicine as they affect cancer care in order to define a pathway and strategy for advancing the use of teleoncology. Several breakout group sessions, consisting of 9–15 participants with a designated group leader, sought to define potential barriers and opportunities related to legal, billing, policy, and clinical practices (Table I) and to identify possible solutions that could serve as the framework of a comprehensive institution‐wide strategy for implementing teleoncology (Table II).

Why Teleoncology? Dr. Robert Satcher discussed the vision and principles agreed upon by the Telemedicine Planning Committee for using telemedicine and telesurgery to extend cancer care to patients in distant locations. The main principle was that implementing teleoncology successfully requires pragmatic selection of goals and methods on the basis of needs and resources rather than politics and publicity. Impediments to the wider use of telemedicine and telesurgery included both legal and business concerns, such as, how to bill for cancer virtual care? And how to manage the need to have a medical license in every state where telemedicine is practiced? Dr. Satcher noted that the demand for the eHealth platform comes from both physicians and patients, since many

TABLE I. Barriers to Using Teleoncology Billing

Legal and policy

Clinical

No procedures established to bill for tumor boards

Standardization of privileging procedures and credentialing requirements for each facility Distinct state requirements for licensure

Physician concerns

Initial patient evaluations: according to diagnostics or disease type CMS rural restriction for telemedicine reimbursement Limited private insurance reimbursement Defining a sustainable business model

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Separate or specific malpractice insurance policies for teleoncology Limited legal precedent to guide doctor–patient contractual issues with telemedicine Shared medical electronic record for teleoncology documentation

Diverse clinical needs according to subspecialty Cost effective technology integration Competition for patients Interstate and international teleoncology

Telemedicine and Telesurgery in Cancer Care TABLE II. Key Recommendations for Teleoncology Implementation Central coordination to optimize integration of technology Individualized technology solutions for clinical subspecialties Phased approach for implementation and funding Community physician integration according to financial and educational benchmarks Referral policy agreements between facilities “Buy in” from physicians and patients Establish clear goals of connecting physicians and patients internally and externally to improve access to cancer care

patients at MD Anderson travel great distances to receive care at the institution, and physicians are keenly interested in identifying ways of monitoring and caring for this increasing patient volume that would improve upon traditional approaches. It is anticipated that teleoncology will decrease the travel burden of stakeholders and improve access to cancer care. A series of advanced technology demonstrations by clinical faculty relevant to distance delivery of health care services has helped shape perspectives and increase confidence in teleoncology. These have included the use of robotic surgery, teleradiology consultations, videoconferencing for smoking cessation, and the use of tablet

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computers for patient rounds. Overall, interest in telemedicine has continued to accelerate, with the decentralization and expansion of MD Anderson via the Regional Care Centers (RCCs) and sister institutions serving as a catalyst and focal point for this demand.

Selected Programs Utilizing Teleoncology A summary of programs using telemedicine is included (Table III). Dr. Ana Marie Lopez demonstrated in her presentation titled “Tele‐ Cancer Virtual Care” that Arizona has used telemedicine for consultation (acute and follow‐up), clinical trial assessment, and education (e.g., lectures, tumor board, chart rounds) in cancer care. For breast cancer care, telemedicine has improved the velocity of the critical care pathway (a standard eight‐step process to determine treatment) via the use of teleradiology, telepathology, and teleoncology consultations. This strategy has made possible the establishment of a same‐day breast biopsy clinic—accomplishing on 1 day what formerly took 4–7 days. Reimbursement of care has been addressed via parity legislation and there is Medicare and Arizona Health Care Cost Containment System coverage, as well as private payer coverage, for both teleconsultants (hub) and clients (facilities fees). Dr. Robert William’s presentation titled “Telemedicine and the Ontario Telemedicine Network—Past, Present, and Future” described

TABLE III. Examples of the Use of Telemedicine for Specialized Comprehensive Care University of Arkansas

Phased implementation of comprehensive telemedicine care 1. 2. 3. 4.

Start with pilot programs Seek federal and state appropriations funding Program expansion with Medicaid contracts Further expansion to sustainability with grant funding and stimulus seed funding

Arizona Telemedicine Program: Tele‐Cancer Virtual Care

1. 2. 3. 4.

Comprehensive use of telemedicine for cancer care and education (tumor boards, lectures) Acute and follow up consultation Clinical trial assessment Bundling of oncology services: Increased efficiency of Breast Critical Pathway for diagnosing and treating breast masses from 4–6 weeks to Same Day by using a. Teleradiology b. Telepathology c. Teleconcology consultation

Kansas Medical Center

1. To break even, teleoncology service had to save at least 5 hr of physician travel time per month 2. Cost of videoconferencing for patient visit has fallen and is less than in person visit 3. Acceptance of technology by physicians and patients is predictable

Ontario Telemedicine Network

1. Largest teleoncology network in North America a. 1,600 sites b. 3,000 systems c. 40–50% annual growth since 1997 2. Barriers overcome a. Cost b. Operational strategy c. Physician remuneration d. Fear of technology in medical culture 3. Strategy for continued growth a. More integration of mobile devices and tablets with goal of one tool for care coordination b. Video conferencing for more personalized care c. Self management and health surveillance tools d. Technology “prescriptions” consisting of App formulary e. Technology enabled integrated care pathways

Memorial Sloan Kettering Cancer Center

Stem cell transplant patient monitoring. Study designed to: 1. Assess patient and physician acceptance of telemedicine 2. Perform comprehensive patient evaluations using telemedicine 3. Assess benefit of using telemedicine from physician and patient perspectives

University of Texas Medical Branch

1. Large scale electronic medical record system 2. Statewide system for primary care and specialty medicine 3. Started with grant funding and isolated programs; grew after instituting centralized management

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the efforts of the Ontario Telemedicine Network, which is one of the largest and most active telemedicine networks in the world, with more than 1,600 sites and 3,000 systems. The Ontario Telemedicine Network (OTN) was established in 1997 with the vision that telemedicine will be a mainstream channel for healthcare delivery and education. Using innovative technology, OTN streamlines the health care process to bring patients the care they need, where and when they need it. An independent, not‐for‐profit organization, OTN is funded by the Government of Ontario.

OTN’s Role in Virtual Care OTN was established to develop and support telemedicine solutions that enhance access and quality of healthcare in Ontario, and inspire adoption by healthcare providers, organizations, and the public. They currently have four channels of virtual care, (1) Elective Virtual Ambulatory Care: In 2012–2013, OTN supported over 300,000 provider/ patient real‐time video consultations in over 40 specialty services. The top 5 therapeutic areas were mental health, internal medicine, primary care, oncology, and surgery. Store forward asynchronous consults were supported in dermatology and ophthalmology, (2) Urgent/Emergent Virtual Acute Care: OTN supported telestroke (for tPA), acute burn, crisis psychiatry, trauma, critical care, and long‐term care, (3) Learning and Meetings: OTN supported 19,000 education events last year, reaching over 400,000 learners, using multipoint videoconferencing, webconferencing, and webcasting technology, and (4) Chronic Disease Management: OTN supported patients in their home with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). The program focuses on coaching patients and better enabling them to self‐manage their illness. Substantial reductions in hospitalization and emergency room visits have been demonstrated. Going forward, OTN’s role includes supporting a single, harmonized collaboration model. Their focus is on improving adoption by providers, organizations, and clinical programs; and simplifying the process of organizing and doing telemedicine. In support of this goal, OTN offers online tools to find consultants, appropriate patient sites, and book telemedicine events. Video can now be done from PCs and laptops as well as traditional videoconferencing systems. While their Telehomecare program uses remote monitoring devices and supporting software to bring care closer to home. OTN also offers technology support, provisioning, training, scheduling, referral management, and privacy/ security support to their members.

OTN’s Business Model OTN makes it simple and efficient for their members to connect with other providers, as well as offer virtual care to patients. Any organization or provider connected to the healthcare system must first become a member in order to access OTN’s services. Their membership base is expanding at an accelerated pace. In 2011–2012 alone, 268 organizations joined OTN while 434 videoconferencing systems were added to the network. OTN is primarily funded by the Ontario provincial government through the Ministry of Health and Long‐Term Care (MOHLTC). The MOHLTC funding supports membership for any organization that receives more than 50% of its annual revenue from the MOHLTC, as well as for physicians. OTN has a collaboration agreement with Keewaytinook Okamakanak Telemedicine that enables the seamless provision of telemedicine services to many rural and remote First Nations Reserves. Canada Health Infoway has also provided funding for several significant developmental projects over the past 6 years. The diffusion of telemedicine is accelerating and is en route to reaching the next level—becoming an everyday part of the healthcare system in Ontario. As both a catalyst for telemedicine and a service Journal of Surgical Oncology

provider, OTN is leading the change to continue to simplify its use for institutions, providers, and patients.

Legal Considerations in Telemedicine Brett Young, JD, indicated that the primary legal issues for telemedicine are licensure, credentialing and privileging, defining the applicable standard of care, and addressing state and federal regulatory and statutory issues. Ten state medical boards issue special telemedicine licenses, including Texas, and each of these boards have distinctive requirements and features. For credentialing and privileging, The Joint Commission default rule is used, in that the originating site is responsible for the credentialing process. Overall, concerns were raised that there is little legal precedent to guide contractual arrangements regarding telemedicine. Most current regulation and statutory law regarding payment, reimbursement, billing practices and privacy is at the federal level; most current regulation and statutory law regarding licensure, prescribing, malpractice, and scope of practice is at the state level.

Barriers and Solutions to the Implementation of Telemedicine and Telesurgery Clinical practice I. This group, led by Dr. Oliver Bogler, discussed the goals of teleoncology in the institution and agreed that the pathway for establishing teleoncology must be consistent with the institutional mission of MD Anderson, which is to eliminate cancer in this nation and the world. The other essential caveats of the institution’s mission are education and caring for underserved patients. Thus, most broadly, the goals of teleoncology would be to connect physicians internally and externally and with patients wherever they are located. The demand for using teleoncology exists at every level, most obviously to connect MD Anderson physicians with community doctors and, counter intuitively, for internal communications within the main campus. It was pointed out that, at the regional care centers (RCCs), telepresence is currently used to interact with community health care providers for cancer prevention programs, such as tobacco use cessation. From a practice perspective, the challenges center on identifying the best way of integrating technology in a cost‐effective and therefore sustainable fashion. The panel cited a strategy that would achieve these goals, namely, a phased process that would initially rely primarily on grant funding to establish which pilot programs could be scaled up and implemented for clinical practice. The group also emphasized the fact that central coordination was necessary to ensure compatibility of system technologies that connect RCCs with partners in the cancer network and the main campus. Overall, the group agreed that any effective strategy of teleoncology practice must produce the same outcomes as the current institutional practice model, regardless of location. Clinical practice II. This group was led by Dr. Robert Williams and focused on the specific question of how to best connect physicians at MD Anderson’s main campus with those at affiliated sites, such as the RCCs and sister institutions. It was noted that multidisciplinary care for colorectal cancer was currently widely distributed and available at all sites, including the main campus, RCCs, and affiliates. As a result, there are approximately 20 separate tumor boards meeting at different times of the week for colorectal cancer within the MD Anderson network. By coordinating existing tumor boards via telemedicine, care could be delivered more efficiently and more economically. Coordination would ensure that patients are triaged to the appropriate care center that offers the best treatment for each patient, including clinical trials and other options. In addition, patients who could receive care closer to home (at an RCC, for instance) would be identified and provided with appropriate options. The group noted that financial remuneration is currently a disincentive for peripheral sites such as the RCCs to participate in teleoncology, given the risk of losing patients to the main campus for

Telemedicine and Telesurgery in Cancer Care their surgery and ongoing care and, in some cases, to community physicians who can provide the same level of care. The consensus was that there needed to be agreements between the RCCs and the main campus regarding telemedicine services that would foster relationships between providers and appropriately build on each facility’s respective expertise and capabilities. Such agreements would help clarify where patients would be initially seen and diagnosed and where they would receive follow‐up care. Overall, the group concluded that there was no “one size fits all” solution for all specialties and subspecialties. Each clinical service is unique and consequently has issues and constraints that need to be explored and solved with individualized teleoncology programs and interventions. Buy in from physicians is essential. In pursuit of this strategy, one must determine from physicians what aspects of cancer care within their disciplines and current patient populations would be most suitable for teleoncology. Solutions that MD Anderson identifies in this context could become a valuable tool to provide clinical and business models for other institutions struggling to make these same types of decisions. The group recommended that the best way to approach this problem would be to move forward in introducing a teleoncology standard operating procedure within each separate clinical department, and to tailor services offered to be compliant with current regulations and statutory provisions. Finding an appropriate alliance between physicians at the RCCs and the main campus regarding teleoncology services will require negotiation, discussion, and shared decision making. It would be relatively difficult to establish interstate teleoncology care, at least as a threshold matter on a first venture into this arena. As the discussion clarified, the challenges for using teleoncology within Texas are significant and interstate teleoncology adds additional challenges, most notably with physician licensure and billing issues. Therefore the group recommended that the interstate teleoncology case not be included in the initial phase of MD Anderson’s institutional strategy. However, this could be considered in a second phase that might also consider international teleoncology. Strategically, virtual care is best carried out with two levels of organization, a centralized component and a remote component. The centralized component is important to ensure integration of the technology. Other components that would likely be centralized include the development of personnel training modules; standard operating procedures and quality control; an overall plan for equipment acquisition and maintenance; global network development; regulatory and statutory compliance; scheduling of centrally available resources; institutional change management and adoption; and marketing. Components that are best managed via decentralization include the specific architecture for local clinical departments and end users. Because individuals and groups will use technology in their own preferred and unique ways, attempts to impose a generic solution on everyone will usually produce suboptimal outcomes; however, lack of any centralized structure will also produce suboptimal outcomes, so a balanced approach is essential. The best approach is therefore one that empowers individual departments and organizational components within the context of shared framework of appropriate parameters to let decide where, how, and what to do, in order to participate in the teleoncology network. Physician input on how telemedicine can best be used effectively is also essential and should be frequently assessed. Billing Considerations. This group, led by Dr. Andrew Lee, focused on the development of a comprehensive reimbursement policy. A case study was used that highlighted the billing issues that would be encountered for the hypothetical scenario of having a surgeon at the main campus operate robotically on a patient at a remote site in the state of Texas (including at an RCC). Dr. Glen Hammock pointed out that the business case for such scenarios should be defined before considering the details of billing. For telerobotic surgery to be economically viable, a minimum case volume would be needed. This Journal of Surgical Oncology

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could be accomplished either by having all surgeries performed at one site or by using a transportable robot at different centers. This would complicate an already complicated billing case, in that it would be more difficult to designate who was getting paid for which services. Some additional difficult billing scenarios were immediately identified, such as the case of a surgeon in network using a facility that is out of network, or vice versa. There was a consensus recommendation that the professional fee should go to the primary surgeon and the facility fee to the remote site. It was also noted that if there was a robot that could service multiple centers, the centers could and likely would be able to share the equipment costs. Additional services that use teleoncology include both tumor boards and multidisciplinary conferences with the RCC and the physician’s network. The current practice at MD Anderson has been to conduct these conferences without billing. It was agreed that tumor boards should provide quality assurance in making the initial diagnosis. Initial evaluations could be organized and billed at a given site according to testing (e.g., pathology, radiology) or according to disease type (e.g., breast cancer, prostate cancer). Patient follow‐ups would then utilize teleoncology modalities. The overall effect would be to increase access to care and to improve the velocity of cancer care to underserved populations. The final topic discussed was the current reimbursement policy for telemedicine services. Texas has laws that specify the parity of telemedical services for billing purposes. Unfortunately, CMS imposes criteria that have historically limited the use of telemedicine billing codes to defined rural areas as defined by population density. Thus, it is currently thought that CMS and most private insurers (who tend to follow CMS criteria in this area) would not likely provide reimbursement for the telemedicine services that MD Anderson is currently considering for patients in or near the main campus or RCCs (all are within the greater Houston area). However, certain rural community‐based centers brought into the network might qualify. Additionally, certain services for patients who travel from a rural environment might qualify, such as follow‐up via videoconference. Policy Considerations. This group was moderated by Angela Simmons. The participants focused primarily on policy issues surrounding the use of teleoncology within Texas. Because funding for telemedicine services has been budgeted at both the federal and state levels and because current funding, reimbursement and policy issues are shaped significantly by regulatory and statutory issues, the challenge is to eliminate policy, regulatory, and statutory barriers on both a state and federal level in a way that would allow effective reimbursement. The barriers to using teleoncology within Texas are centered around CMS codes that specify that telemedicine can only be used in rural areas, where rural is defined according to population density. There are efforts under way in the Texas Legislature to expand the rule designation to underserved urban areas and, more significantly, to expand coverage based on diseases that require a subspecialist, such as cancer. The other parallel strategy under way is to eliminate the Medicare urban distinction. The consensus of the group reflected the majority opinion that policy barriers would be lessened in the near future. A number of significant barriers for implementing teleoncology outside of Texas were identified, including, most prominently, licensure, and billing. In the interstate case, 38 states require that a physician also has full medical license in the patient’s state in addition to their home state. For out‐of‐state Medicaid, out‐of‐network health plans, and similar circumstances, a number of significant issues would complicate billing. Therefore, the group strongly recommended that MD Anderson focus on how to best use teleoncology to expand access to its network of care within Texas. Legal Considerations. This group was led by Laurel Hyle, JD, MPH. The group proposed establishing a legal teleoncology policy for the institution, which was envisioned to include clinician practice standards presented in an easy to use format, such as a flow chart. It

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would also be necessary to establish oversight in the form of a committee or similar entity that would be charged with implementing the policy, overseeing compliance, and establishing a process for adjudicating queries and appeals, including a process for clinicians to submit teleoncology proposals to for approval so that there would be a unified standard for teleoncology activities. The group identified key issues to be defined for any teleoncology practice. For example, does the activity meet the CMS eligibility criteria of being in a rural area? Does it involve Native Americans or the prison population? Is the activity educational or clinical or involve research? Are there non‐physician providers? And is the activity in compliance with federal and state law and regulatory provisions? Additional recommendations included providing a clear structure and process for physicians and/or staff involved with teleoncology care to be appropriately credentialed, and to be included in the malpractice coverage plan. In the event that the clinical activity required a partnership with an outside entity (such as an international partner), it should specify which practice guidelines and quality assurance measures will be followed, such as Joint Commission, Clinical Legal Education Association (CLEA), or CMS. For partnerships, an audit would also be necessary to ensure that the proposed partners have the capabilities that have been agreed upon and meet ongoing quality of care standards. Another area of concern identified by the group was medical record documentation, especially in any situation involving MD Anderson and a non‐MD Anderson entity. The group recommended that a prospective electronic medical record system be established, along with standards ensuring that appropriate documentation is obtained and available to MD Anderson as well as to partnering institutions. The same guiding philosophy of appropriate sharing of clinical information that is used with the medical records system at the main campus should be implemented for the teleoncology practice.

CONCLUSIONS The broad concept of delivering clinical health at a distance has tremendous potential for cancer care from a clinical perspective, ranging from the use of information and communication technology to monitor patients’ daily regimens and compliance with treatment, to a platform that can deliver the full spectrum of health care services via telepresence without the need for long‐distance travel by experts or patients. For MD Anderson, current telemedicine initiatives include the use of surgical tele‐discharge programs and a smoking cessation program that uses web collaboration tools to reach patients in their homes. However, the official strategy for using teleoncology at MD Anderson remains undefined. The TTCC conference brought together physicians, legal and billing experts, and policy makers to define a pathway and strategy for advancing the use of telemedicine and for the development of a teleoncology policy. Barriers to implementing teleoncology were identified, along with proposed solutions, within the areas of billing, policy, legal issues, and clinical practice. From this work and discourse, the TTCC conference provided insight into the present state of teleoncology at MD Anderson and articulated a vision for the future, and recommendations for moving forward with a comprehensive teleoncology strategy that may be applicable to other cancer centers. Overall, teleoncology is not an all‐encompassing panacea for the distant delivery of quality health care and if a comprehensive strategy is not followed, teleoncology can exacerbate existing problems in cancer centers by introducing systemic inefficiencies, unnecessary expenditures on technology, unnecessary malpractice risks, and suboptimal delivery of care. Implementation of technology should be controlled centrally but guided by local department/center of care needs; input should be sought from all involved stakeholders and teleoncology should be introduced to physicians, patients, and other stakeholders as a pragmatic means of meeting patient and clinician needs as well as enhancing access to cancer care to underserved regions in the US and throughout the world. Journal of Surgical Oncology

ACKNOWLEDGMENTS The authors wish to acknowledge other members of the TTCC conference planning committee members: Angela Bailey, Richard. Champlin, Corliss Denman, Edward Diaz, Miriam Flores, John Frenzel, Virginia Garcia, Lawrence Jones, Maher Karam‐Hage, Sharlene Kmiec, Gabriel Mena, Sharon Pepper, Peter Pisters, Kent Postma, Michael Riben, Alma Rodriguez, Margaret Row, Kathleen Schmeler, Jesse Selber, Angela Simmons, Kyle Taylor, S. Walters, Max Weber, Sarah Thomas (Coordinator), Regina Raju, and Kenneth Coleman. This work was supported by the MD Anderson’s Cancer Center Support Grant CA016672, Minimally Invasive New Technology in Oncologic Surgery (MINTOS), and a grant from AT&T.

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