Dr. Debra Roter, Johns Hopkin University Distinguished Service Professor in the Department of Health, Behavior, and Society at the Bloomberg School of Public Health, has been working with her team to adapt the intervention so that it can be delivered remotely. All changes will make it much more convenient for patients to participate.
The COVID-19 pandemic has brought many dramatic changes to our everyday life. As millions of Americans have opted to stay at home as much as possible, clinical practices have been expanding telemedicine efforts to reduce the risk of transmission, interacting with patients remotely via technology such as cell phones and other communication applications. While telemedicine has been available for many years, the use of these services has dramatically increased this year. The Cleveland Clinic recently reported logging more than 60,000 telemedicine visits in March. Before the global pandemic, it averaged about 3,400 virtual visits per month.
Johns Hopkins Medicine, an Alliance to Advance Patient-Centered Care grantee, has similarly seen a significant spike in the use of telemedicine services, especially for vulnerable or immuno-compromised cancer patients. The Kimmel Cancer Center and Johns Hopkins research partner Peninsula Regional Medical Center (PRMC) are now utilizing telemedicine for most outpatient services, which includes any visit that does not require an overnight hospital stay. The use of these services has generated renewed interest in effective patient-provider communication as anxiety about medical visits increases for cancer patients and care partners. They need the right tools to approach an interaction with their physician.
Dr. Debra Roter, Johns Hopkin University Distinguished Service Professor in the Department of Health, Behavior, and Society at the Bloomberg School of Public Health, was ready to implement her in-person communication intervention when the pandemic hit. Her original plan had been to work with cancer patients and care partners in doctors’ waiting rooms, right before a visit. Originally, patients in the office would have been asked to review very brief video clips tailored to their background, diagnosis, and stage of treatment. These videos include topics ranging from symptoms and treatment effects to emotional distress and care partner burden. They are designed to assist patients and care partners with communicating physical, psychosocial, and mental health-related concerns more effectively and to take on a more active role in treatment decision-making. This might mean asking for resources and assistance or engaging in problem-solving discussions.
Now that waiting rooms are largely empty, Dr. Roter has been working with her team to adapt her program to the new normal. All changes to the intervention will make it much more convenient for patients to participate. Patients and care partners will now be able to review the intervention on their own time, whereas, initially, they would have needed to arrive at their visit 45 minutes early and stay 30 minutes later. Under the new plan, clinical staff will reach out to patients and care partners ahead of their next telemedicine visit to provide remote assistance in accessing and using the intervention website. Patients will then be able to review the videos, now consolidated into four distinct 15-minute video programs, each one featuring different patient/partner characters representing patients from different backgrounds, diagnoses, and stages of treatment. The videos include a 2-3 minute introduction to the patient and the care partner roles describing common physical or psychological issues from their unique point of view. This is then followed by 20-second videos in which skills are named, described, and demonstrated by each character.
Dr. Roter is very confident that the use of telemedicine will not require any significant alteration to the core content of the intervention: “We believe that the COVID-related changes made to our protocol serve patient needs not only in safeguarding their health. The intervention may be helpful to them in better communicating with their clinicians in telemedicine visits.” She is similarly very confident in the effectiveness of telemedicine as a whole: “Several studies found no evidence that doctor-patient communication was less effective or markedly different in telemedicine relative to in-person visits. Patient satisfaction was often found to be higher for telemedicine visits.” She has conducted several studies on the effectiveness of virtual visits, including a randomized clinical trial in 2009. The study found that telemedicine did not negatively affect a physician’s interpersonal skills, patients retained their confidence and trust in their physicians, and patients registered higher levels of satisfaction. This was most likely due to the convenience of a doctor’s visit that did not require any travel.
While telemedicine is a convenient option, it cannot completely replace traditional visits in every situation. Dr. Roter specifies that there are particularly sensitive issues that cannot be easily addressed within a telemedicine format, but these instances are rare. Still, she expects telemedicine to soon become the predominant format of care delivery, even beyond the current health crisis as medical systems will not be “going back to normal” anytime soon. Adapting the intervention from in-person to virtual was a necessary change: “I will be very surprised if there is a return to normal procedures at the hospital, or the university for that matter, before the spring of 2021. I think that the vulnerable cancer population we work with will not feel confident or comfortable in returning to everyday exposures for a very long time, extending even beyond 2021.”
Her team is now wholly focused on delivering the intervention through telemedicine visits, and she’s confident that her program will help patients have more effective and satisfying medical visits. This is an important assurance at a time when certainty is at a premium.
Debra L. Roter, DPH
Debra Roter is a Johns Hopkins University Distinguished Professor in the Department of Health, Behavior, and Society at the Bloomberg School of Public Health with joint appointments in the Schools of Medicine and Nursing and the Sidney Kimmel Comprehensive Cancer Center.
Her research has focused on the study of patient-clinician communication and its consequences for the last 35 years addressing all aspects of the field including the design and evaluation of communication skill training interventions for patients, patient care partners, and clinicians. She is well known for a coding method for analysis of medical dialogue, the Roter Interaction Analysis System (RIAS). that has been translated into 15 languages and is the most commonly used system of its kind worldwide. She has authored some 300 articles and several books in the area of medical communication.
 Agha, Z., Schapira, R. M., Laud, P. W., McNutt, G., & Roter, D. L. (2009). Patient satisfaction with physician–patient communication during telemedicine. Telemedicine and e-Health, 15(9), 830-839.