Need: Allow rural cancer patients in a region inclusive of 26 counties in Iowa, Minnesota, and South Dakota to have access to tertiary-level chemotherapy regimens in rural infusion centers.
Intervention: With telehealth-based oversight from a tertiary care oncology team, 3 rural infusion teams were trained to coordinate cancer treatment plans and administer complex chemotherapy regimens.
Results: Almost 130 patients were transitioned to receive chemotherapy in a rural infusion center, translating to over 1,000 infusion visits and saving patients/families nearly 65,000 trip miles, 1,800 travel hours and $71,000.
For hematologists, oncologists, and
oncology-trained advanced practice professionals in
tertiary care centers, the delivery of complex modern
cancer chemotherapy regimens is routine. Prior to
patients receiving infusion treatments, these
practitioners provide a thorough review that includes an
evaluation of recent laboratory and radiology results and
a assessment of a patient's current physical condition.
For patients in clinical cancer treatment trials,
stringent guidelines often specify direct oversight by
these specialty providers. In addition, specialty
supervision is often needed when a patient's cancer
requires a treatment regimen using medications with
significant side-effect potential. Though routine in
tertiary centers, these advanced treatments are outside
the expertise of rural primary care physicians. If rural
patients require these specific regimens but have
transportation and other socioeconomic barriers, they may
be unable to access cutting-edge cancer interventions.
Sanford Vermillion Medical Center, Vermillion, South
Dakota, led the Rural Virtual Infusion Project to
overcome barriers to modern cancer care by using
Along with the Vermillion team, 2 additional rural
partners were involved with the project: Douglas County
Memorial Hospital, Armour, South Dakota, with outreach
into Iowa and Sanford Worthington Medical Center,
Worthington, Minnesota, with a population of nearly 35%
non-White, non-English speaking residents. The rural
teams also included infusion nurses and pharmacists.
Hematologists and oncologists with Sanford Hematology and
Oncology, Sioux Falls, South Dakota, joined as the
tertiary care partners, along with their
oncology-certified nurse practitioners, oncology-certified registered
nurses, and pharmacists. Sanford's Sioux Falls-based
health information technology specialists were also
project team members. During early planning, the project
partners found literature looking at specifics of
telehealth oncology office visits, but few
published models mirrored their anticipated infusion
treatments. This discovery became an opportunity to
invite the tertiary center's research team to contribute
to the project.
Specialty oversight for rural areas was the prime
objective of the project. A solution emerged based on the
existing infusion center model in the tertiary care
center where a Certified Nurse Practitioner (CNP) was
physically present to oversee the 24-chair/4-bed center.
In that setting, the CNP reviews laboratories and
treatment plans for the day's scheduled patients and is
immediately available for any patient concerns, nursing
concerns, medication side effect problems or infusion
reactions. If needed, the CNP also has ready access to
on-site hematologists and oncologists. At the conclusion
of project planning, the final care model used telehealth
to virtually integrate the rural infusion sites into
tertiary infusion center's workflow.
Basic telehealth equipment and communication strategies
were used, including a designated telephone, an
electronic health record (EHR) allowing two-way
communication and order placement, and videoconferencing
when needed. Workflow planning focused on the standard
oncology 3-step verification process: provider treatment
plan review and sign-off; nurse assessment of patient
readiness, treatment plan and order review, followed by
the release of the chemotherapy order to the pharmacy;
and pharmacist order review with drug order verification
and final release of the medication to the infusion
Multiple levels of security and approval were required to
make special EHR software modifications so
interoperability allowed virtual communication between
tertiary and rural teams. The tertiary team members were
credentialed for telehealth privileges in the rural
healthcare organizations. Rural infusion staff
participated in rigorous clinical training sessions to
gain needed certification for partnership with the
tertiary team. Research team members presented available
clinical trial information.
Expanded local chemotherapy
cancer treatment options, including engagement in
clinical trials if eligible.
For rural infusion staff:
Tertiary care center staff provided timely
communication and the needed specialty oversight to allow
their rural partners to deliver advanced cancer treatment
As a result of the tertiary center's oncology CNP
providing direct oversight for rural infusion center
patients, from a baseline of 6 patients, 127 patients
were transitioned to receive local care — translating
into over 1,000 infusion visits and saving
patients/families nearly 65,000 trip miles, 1,800 travel
hours, and an estimated $71,000.
Additionally, local infusion
care prevented treatment lapse that might occur due
to weather-related travel barriers.
Patients had the opportunity to not only receive
tertiary-level oncology care in their local communities,
but they could
participate in clinical trials if eligible, an
opportunity that often affords improved quality of life
during and after treatment and potentially contributes
to expanding cancer knowledge and future cancer
treatment, according to the National Cancer Institute.
Rural site lessons learned during this project led
Increased EHR interoperability
allowed for the needed timely communication between
the tertiary and rural sites.
Improved rural infusion site workflow efficiency.
Consideration by the rural sites to engage in
other partnerships to provide oversight for
colorectal and pancreatic cancer patients receiving
continuous 24/7 chemotherapy treatment through
portable infusion pumps.
Lessons learned by hematology/oncology specialists:
Increased familiarity with care
delivery using telehealth infrastructure led to an
increased comfort with transitioning patient care to
a rural infusion center.
Increased cancer trial referrals for rural
Increased comfort with telehealth in general
which likely drove the 170 percent change in
specialists' telemedicine visits documented from year
to year during the grant cycle. Specifically, in the
2nd grant cycle year, 38 to 102 visits and in the 3rd
grant year, 102 to 277.
Safety-oriented workflows proved effective when 4
medication variances did not reach patients.
Though CNP coverage will continue for the initial
rural sites requesting the service, physician-level
services will need a reimbursement model to continue,
with a current consideration being given to a
volume-based subscription fee.
At each rural site, administration/management teams
will need to balance gains through virtual infusion
services against the cost and requirements of the
Low patient volume at one site.
Success for a project associated with high-risk
medications requires an interdisciplinary core team to
focus on universal adoption of the tertiary center's
mandatory infusion policies and procedures in order to
keep the tertiary center's program accreditation and
Universal adoption of standardized work flows.
Need for an EHR with adequate interoperability to
meet project needs.
Quality telehealth equipment purchases need to be
made with endorsement of both tertiary and rural sites.
Development of a Community Awareness Campaign prior
to implementation that includes direct mailings, radio
spots, Facebook presence, and other social media and
community outreach activities.
Be prepared that word-of-mouth promotion of the
program's success may prompt service requests from other
rural community areas surrounding the tertiary care
Please contact the models and innovations contact directly for the most complete and current information
about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The
programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural
community should consider whether a particular project or approach is a good match for their community’s
needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep
in mind that changes to the program design may impact results.