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\begin{document}

\title{The New Reality Is Virtual}



\author[1]{William Carroll}%
\affil[1]{New York University School of Medicine}%


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  \date{May 23, 2024}


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The New Reality is Virtual

William L. Carroll, MD*

Perlmutter Cancer Center, NYU-Langone Medical Center, New York, New York

*Correspondence to: William L. Carroll, MD Division of Pediatric
Hematology-Oncology, Departments of Pediatrics and Pathology, Perlmutter
Cancer Center, NYU-Langone Medical Center, 560 East First Avenue, Smilow
Room 1211, New York, NY, 10016

E-mail: William.carroll@nyulangone.org

The COVID-19 pandemic led to a precipitous and severe disruption to
healthcare delivery and consumption worldwide. Ongoing analyses (and
debate) about the effectiveness of early response measures will
continue, but there is no doubt the pandemic brought about dramatic
changes to health care, some of which are likely to last.

The health care industry is built on a model of in-person visits between
patients and providers, which is reinforced by economic incentives.
However, tremendous pressure was put on health care systems to pivot
quickly from in-person visits given the explosive spread of COVID-19.
Non-essential in-person visits and elective procedures were reduced, or
paused, allowing hospitals to marshal capacity for a surge in COVID-19
cases and to mitigate risk of infection to patients and staff. Patients
deferred care, in many cases with negative results\textsuperscript{1}.
Outpatient in-person volume plummeted over 40\%\textsuperscript{2}.

In any crisis, opportunities emerge and telehealth visits surged
providing a safe alternative to in-person visits\textsuperscript{3}.
Telehealth or virtual visits are not novel and has been in place since
the mid 1990's especially for rural care but regulation and
reimbursement limited its application\textsuperscript{4}. With changes
in payer reimbursement, telehealth visits increased dramatically. Early
in the pandemic up to a third of office visits were through virtual
care. This trend was most pronounced in primary care and mental
health/psychiatry but whether it can be applied safely to patients with
complex conditions requiring therapy with medications associated with a
narrow therapeutic index like cancer is less certain.

In this issue of \emph{Pediatric Blood and Cancer} Rabinowicz et al,
raise the question of how essential are in-person visits during
maintenance therapy for B acute lymphoblastic leukemia (ALL), the most
common childhood cancer\textsuperscript{5}. The authors conducted a
retrospective study to determine if an in-person visit was essential to
detect an abnormal finding on physical examination especially if it
resulted in a change in medical management. They excluded patients
during the first three months of maintenance when more frequent
laboratory evaluations are needed to titrate medication dosages, when
children required intrathecal or intravenous therapy, or when other
specialists saw patients. All others could be considered candidates for
virtual care delivery. Seventy-five children with 240 routine visits
were analyzed. Fourteen were associated with a new abnormal finding and
in only six cases was a direct physical examination deemed required for
diagnosis. Only three such visits resulted in a change in medical
management. Based on these results, the authors argue, justifiably, that
there is a large potential for virtual visits during maintenance
treatment.

The results of this study are not surprising especially as most
patients, including the fourteen with new findings on exam in this
report, will have symptoms (not analyzed in the study) alerting parents
and providers to new medical conditions warranting in-person visits.
Most ALL treatment protocols mandate physical examination with routine
laboratory monitoring on a monthly basis and it is hard to justify more
frequent intervals in the absence of follow up medication adjustments or
specific problems. There might a subset of families with particular
hardships related to travel where the in-person interval can be extended
further. COG protocols now use every 12 week vincristine/decadron pulses
with intrathecal methotrexate administration. Home phlebotomy services
have been piloted to obtain laboratory blood draws and perform port
flushes\textsuperscript{6}. Virtual visits can be used to ascertain any
side effects, adjust medications, and emphasize compliance. Another
positive aspect of the pandemic is the widespread adaption of at home
viral testing and there is no doubt that COVID-19 has changed the future
of in-home medical diagnostics.

The authors provided a thoughtful, balanced analyses and discussion of
the pros, including decreasing the burden of care (e.g. school absences,
time off work for parents, and transportation costs) and cons of virtual
visits. Two important considerations are warranted when deciding on
frequency of virtual vs. in-person visits. First, a ``digital divide''
is well described where limited access to high-speed internet services,
lower socioeconomic status and limited English proficiency are barriers
to access. Second, medical monitoring is only one part of a broader
strategy in pediatric cancer care to decrease the physical,
neuropsychological, educational and financial burden of cancer on
children and their families. Thus, children and their families may
routinely interact with physicians, nurses, social workers, physical
therapists, child life therapists, teachers and psychologists as part of
a personalized care model during clinic visits. Such multidisciplinary
services may be difficult to replicate through virtual care delivery.

It is also time to consider other aspects of digital technology that can
enhance the health of our patients and their
families\textsuperscript{7}. Mobile health is especially attractive as
the overwhelming majority of adults and adolescents have access to a
smartphone\textsuperscript{8}. Applications such as MyChart (EPIC)
allows patients and parents to view their electronic record in real time
and interact with providers. Multiple studies have shown that
customized, interactive apps can also be used to augment education about
disease and management, manage side effects such as nausea and vomiting,
and promote medication adherence\textsuperscript{9,10}. It is time to
accelerate the implementation of these tools in every day practice.

The article by Rabinowicz and colleagues should motivate us to consider
implementing and expanding adaptive strategies developed in response to
the COVID-19 pandemic to improve patient care for children and their
families with cancer. Virtual visits can never completely replace
in-person visits where emotional bonds and trust between providers and
patients are required to promote optimal outcomes. However after such
relationships are cemented early in treatment virtual visits can reduce
the burden of therapy without sacrificing quality.

1. Quarello P, Ferrari A, Mascarin M, et al. Diagnostic Delay in
Adolescents with Cancer During COVID-19 Pandemic: A New Price for Our
Patients to Pay. \emph{J Adolesc Young Adult Oncol.} 2021.

2. Dupraz J, Le Pogam MA, Peytremann-Bridevaux I. Early impact of the
COVID-19 pandemic on in-person outpatient care utilisation: a rapid
review. \emph{BMJ Open.} 2022;12(3):e056086.

3. Uscher-Pines L, McCullough C, Dworsky MS, et al. Use of Telehealth
Across Pediatric Subspecialties Before and During the COVID-19
Pandemic.\emph{JAMA Netw Open.} 2022;5(3):e224759.

4. Werner RM, Glied SA. Covid-Induced Changes in Health Care Delivery -
Can They Last? \emph{N Engl J Med.} 2021;385(10):868-870.

5. Rabinowicz R, Maguire B, Hitzler J, Punnett A. How Essential are
In-Person Clinic Visits During Maintenance Treatment of Children with
Acute Lymphoblastic Leukemia? \emph{Pediatric Blood \& Cancer.} 2022.

6. Sisler I, Cohen D, Skinner LA, Aiken C, Laver J. Feasibility of a
Pilot Home Phlebotomy Program for Pediatric Hematology/Oncology Patients
During the COVID-19 Pandemic. \emph{J Pediatr Hematol
Oncol.}2022;44(1):e185-e187.

7. Keesara S, Jonas A, Schulman K. Covid-19 and Health Care's Digital
Revolution. \emph{N Engl J Med.} 2020;382(23):e82.

8. Nievas Soriano BJ, Uribe-Toril J, Ruiz-Real JL, Parron-Carreno T.
Pediatric apps: what are they for? A scoping review. \emph{Eur J
Pediatr.} 2022;181(4):1321-1327.

9. Heneghan MB, Hussain T, Barrera L, et al. Access to Technology and
Preferences for an mHealth Intervention to Promote Medication Adherence
in Pediatric Acute Lymphoblastic Leukemia: Approach Leveraging Behavior
Change Techniques. \emph{J Med Internet Res.} 2021;23(2):e24893.

10. Semerci R, Akgun Kostak M, Taskin C. The effect of using an
interactive mobile application for the management of
chemotherapy-induced nausea and vomiting in children: Randomized
controlled study. \emph{Eur J Oncol Nurs.} 2022;58:102121.

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