ORIGINAL RESEARCH

Telemedicine Adoption in an
NCI-Designated Cancer Center During the
COVID-19 Pandemic: A Report on
Patient Experience of Care
Krupal B. Patel, MD, MSc1,2; Amir Alishahi Tabriz, MD, PhD, MPH3; Kea Turner, PhD, MPH3; Brian D. Gonzalez, PhD3;
Laura B. Oswald, PhD3; Heather S.L. Jim, PhD3; Oliver T. Nguyen, MSHI3; Young-Rock Hong, PhD, MPH4;
Nasrin Aldawoodi, MD5; Biwei Cao, MS6; Xuefeng Wang, PhD6; Dana E. Rollison, PhD7;
Edmondo J. Robinson, MD, MBA8,9; Cristina Naso, MEd10; and Philippe E. Spiess, MD, MS10,11

Background
ABSTRACT The onset of the COVID-19 pandemic presented a signifi-
cant challenge in delivering timely and value-based care
Background: Patients with cancer require timely access to care so to patients with cancer. Patients with cancer are at in-
that healthcare providers can prepare an optimal treatment plan with
creased risk for COVID-19–related morbidity and mortal-
significant implications for quality of life and mortality. The COVID-19
pandemic spurred rapid adoption of telemedicine in oncology, but ity1; thus, to minimize risk of COVID-19 exposure among
study of patient experience of care with telemedicine in this popula- these patients, many healthcare systems were forced to
tion has been limited. We assessed overall patient experience of care rapidly adopt models for delivering telemedicine visits
with telemedicine at an NCI-designated Comprehensive Cancer Cen- across the cancer continuum (eg, screening, diagnosis,
ter during the COVID-19 pandemic and examined changes in patient
treatment, and survivorship).2,3 Before the COVID-19 pan-
experience over time. Patients and Methods: This was a retrospec-
tive study of outpatient oncology patients who received treatment at demic, telemedicine was not commonly used to deliver
Moffitt Cancer Center. Press Ganey surveys were used to assess pa- cancer care. As we continue to navigate the COVID-19
tient experience. Data from patients with appointments between pandemic and consider the likelihood of future pandem-
April 1, 2020, and June 30, 2021, were analyzed. Patient experience ics, telemedicine will continue to be an integral part of
was compared between telemedicine and in-person visits, and patient
cancer care delivery.4–7
experience with telemedicine over time was described. Results: A total
of 33,318 patients reported Press Ganey data for in-person visits, and The Department of Virtual Health was established
5,950 reported Press Ganey data for telemedicine visits. Relative to within Moffitt Cancer Center (MCC) early in the pandemic
patients with in-person visits, more patients with telemedicine visits in response to cancer center restrictions that forced a dra-
gave higher satisfaction ratings for access (62.5% vs 75.8%, respectively) matic shift in cancer care delivery. This allowed for a coor-
and care provider concern (84.2% vs 90.7%, respectively) (P,.001).
dinated and sustained effort to support implementation of
When adjusted for age, race/ethnicity, sex, insurance, and clinic type,
telemedicine visits consistently outperformed in-person visits over telemedicine through the cancer center. Prior studies sug-
time regarding access and care provider concern (P,.001). There gest that patients were highly satisfied with telemedicine
were no significant changes over time in satisfaction with telemedicine during the COVID-19 pandemic across a wide range of spe-
visits regarding access, care provider concern, telemedicine technol- cialties,8–11 and studies have assessed clinicians’ experien-
ogy, or overall assessment (P ..05). Conclusions: In this study, a large
ces with rapid teleoncology delivery.12 However, there has
oncology dataset showed that telemedicine resulted in better patient
experience of care in terms of access and care provider concern com- been limited study of the experiences with teleoncology
pared with in-person visits. Patient experience of care with telemedi-
cine visits did not change over time, suggesting that implementing 1
Department of Head and Neck and Endocrine Oncology, Moffitt Cancer
telemedicine was effective.
Center, Tampa, Florida; 2Department of Otolaryngology–Head and Neck
J Natl Compr Canc Netw 2023;21(5):496–502.e6 Surgery, University of South Florida, Tampa, Florida; 3Department of Health
doi: 10.6004/jnccn.2023.7008 Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida; 4Department of
Health Services Research, Management and Policy, College of Public Health and
Health Professions, University of Florida, Gainesville, Florida; 5Department of
Anesthesia, Moffitt Cancer Center, Tampa, Florida; 6Department of Biostatistics
and Bioinformatics, Moffitt Cancer Center, Tampa, Florida; 7Department of
Cancer Epidemiology, Moffitt Cancer Center, Tampa, Florida; 8Department of
Internal and Hospital Medicine, Moffitt Cancer Center, Tampa, Florida; 9Center
for Digital Health, Moffitt Cancer Center, Tampa, Florida; 10Virtual Health
See JNCCN.org for supplemental online content. Program, Moffitt Cancer Center, Tampa, Florida; and 11Department of
Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida.

496 © JNCCN—Journal of the National Comprehensive Cancer Network | Volume 21 Issue 5 | May 2023
Patient Experience of Care with Telemedicine ORIGINAL RESEARCH

among patients with cancer, given that telemedicine up- were first contacted via text; if they did not complete the
take has historically been limited.13–16 Moreover, the prior survey, they received an email 2 days later. If they did not
studies focusing on oncology have been snapshots of pa- complete the survey after 5 days from that email, they re-
tient experience of care (PEC) early in the pandemic. The ceived a second email, which was the final attempt to re-
current study sought to address these limitations by as- quest they complete the survey.
sessing the experience with telemedicine and in-person To assess the differences in PEC between telemedicine
visits among individuals with cancer using Press Ganey and in-person visits, select questions were used in the ac-
outpatient and telemedicine surveys of patients seen at cess and care provider categories as surrogates for patient
an NCI-designated Comprehensive Cancer Center, MCC, experience (see eAppendix 1, available with this article at
from April 2020 to June 2021, during the COVID-19 pan- JNCCN.org). To compare PEC with telemedicine visits ver-
demic. Information from this study may inform future in- sus in-person visits, we divided the study period into 4 time
terventions aimed at improving teleoncology delivery. intervals (April 1, 2020–June 30, 2020; July 1, 2020–October
31, 2020; November 1, 2020–February 28, 2021; March 1,
Patients and Methods 2021–June 30, 2021). PEC with telemedicine visits over time
Design and Participants was also assessed (see eAppendix 2 for questions) by di-
This was a retrospective study of patients seen at MCC. viding the study period into the same 4 time intervals.
Starting in April 2020, MCC instituted a synchronous video
telemedicine platform (Zoom) for outpatient telemedicine Statistical Analyses
Patient characteristics were summarized using descrip-
visits. All patients were offered telemedicine if deemed ap-
tive statistics, including median and range for continuous
propriate by the clinical team. Telemedicine visits were
measures and proportions and frequencies for categorical
not offered to patients who needed physical examinations
measures. Associations between continuous variables and
beyond what can be assessed during a telemedicine visit.
patient groups were assessed using the Wilcoxon test. As-
Patients who presented in person for chemotherapy infu-
sociations between categorical variables and 2 endpoints
sion and/or radiation treatment were excluded from the
were evaluated using chi-square or Fisher exact tests. To
analysis. This study was deemed exempt from Institutional
compare PEC between telemedicine and in-person visits
Review Board review with a waiver of informed consent
for access and care provider concern categories in the
from patients under protocol MCC 21557.
Press Ganey survey, mean score for each category from
the survey questions was calculated and comparisons
Instrument and Survey Administration
The Press Ganey (www.pressganey.com) Outpatient Med- were based on dichotomized score (5 vs , 5). To facilitate
ical Practice Survey and Telemedicine Survey were used comparisons between the in-person visits and telemedi-
cine across different settings, the estimated marginal
to assess PEC for in-person and telemedicine visits. The
means (EMMs) of survey outcomes (such as access, care
survey data were obtained from patient visits at MCC be-
provider concern, telemedicine technology, and overall as-
tween April 1, 2020, and June 30, 2021. The data con-
sessment) were estimated using the R package version
tained deidentified patient-level data with the following
1.8.2 “emmeans” (R Foundation for Statistical Computing).
variables: date of survey, visit type, clinic type, age, gen-
The covariates adjusted in estimating EMMs include age,
der, insurance, first visit (yes vs no), and Press Ganey
sex, race/ethnicity, insurance, clinic type, and visit type.
PEC scores. Patients were asked to rate each question
Pairwise comparisons of EMMs were performed between
(listed in eAppendices 1 and 2, available with this article
telemedicine and in-person visits at each time interval, as
at JNCCN.org) on a scale from 1 to 5 (1 5 very poor;
well as between the adjusted scores over time for each cat-
2 5 poor; 3 5 fair; 4 5 good; 5 5 very good). Visit type was
egory. Tukey’s multiple comparisons were used for adjust-
defined as the following: new patients were completely
ing multiple pairwise comparison between groups. All
new to MCC, established patients had received care at
statistical associations were evaluated at a significance
MCC previously but were referred to a new subspecialty for
level of P,.05. R was used for statistical analysis (R Foun-
consultation, and follow-up patients were being seen for
dation for Statistical Computing).
follow-up care by providers within the same subspecialty.
Clinic type was defined as the disease site clinic where
Results
the patients were seen. Press Ganey sent the surveys to
patients 2 to 3 days after they completed their in-person Patient Characteristics
or telemedicine visit. All new/established patients with a A total of 540,184 patients were seen in the outpatient
valid mobile telephone number or an email address were clinical setting for in-person visits, and 50,945 patients
eligible to receive the surveys, and then were eligible to re- were seen for telemedicine visits from April 1, 2020, to
ceive the same survey type once every 60 days. Patients June 30, 2021. Press Ganey survey response data were

JNCCN.org | Volume 21 Issue 5 | May 2023 497

 ORIGINAL RESEARCH Patel et al

available for 33,318 in-person visits and 5,950 telemedi-

Table 1. Patient Visit Characteristics
cine visits (eAppendix 3).
Table 1 shows respondent characteristics and group In-Person Telemedicine
Characteristic n (%) n (%) P Value
differences between patients who had telemedicine ver-
Total patient visits 540,184 50,945
sus in-person visits (eAppendix 3). Survey response rates
were 20.3% for in-person visits versus 25.9% for telemedi- Surveys sent out 163,850 22,988
cine visits. Statistically significant differences between Respondents 33,318 (20.3) 5,950 (25.9)
groups were noted in the following categories: a higher Median age (range), y 68.0 (18.0–101) 69.0 (18.0–98.0) ,.001
percentage of females in the telemedicine group (50.2%) Sex ,.05
and a higher percentage of males in the in-person group
Female 16,136 (48.4) 2,987 (50.2)
(51.6%); a higher percentage of white non-Hispanic pa-
Male 17,179 (51.6) 2,963 (49.8)
tients in the telemedicine group versus the in-person
group (85.4% vs 82.6%, respectively); a higher percentage Race/Ethnicity ,.001

of Medicare patients in the telemedicine group (65.6% vs White non-Hispanic 27,514 (82.6) 4,772 (85.4)
63.2%); and a higher percentage of follow-up patients White Hispanic 1,550 (4.65) 217 (3.88)
in the telemedicine group (78.7% vs 66.6%). Differences Black 1,574 (4.72) 222 (3.97)
were also noted in the percentage of patient visits in the
Other 2,679 (8.04) 380 (6.80)
breast, cutaneous, and endocrine clinics between in-
Insurance ,.001
person and telemedicine groups.
Private 10,011 (30.0) 1,727 (29.0)

PEC With Access and Care Provider Concern Medicare 21,065 (63.2) 3,905 (65.6)
Press Ganey scores were compared between telemedicine Medicaid 463 (1.39) 56 (0.94)
versus in-person visits for 2 categories: access and care Other 1,779 (5.34) 262 (4.40)
provider concern (eAppendix 4, Figure 1). Compared with
Visit type ,.001
in-person visits, telemedicine visits were associated with
NP/EP 9,209 (27.63) 1,225 (21.3)
better experience of care regarding both access (62.5% vs
75.8%; P,.001) and care provider concern (84.2% vs FU 22,200 (66.6) 4,680 (78.7)

90.7%; P,.001), respectively. Clinic type ..05

Blood and marrow 683 (2.05) 199 (3.34)
PEC Over Time transplant

Experience of care scores were compared between tele- Breast 4,420 (13.3) 330 (5.55)
medicine and in-person visits over each time interval Cutaneous 4,299 (12.9) 145 (2.44)
(April–June 30, 2020; July 1–October 30, 2020; November Endocrine 1,211 (3.63) 411 (6.91)
1, 2020–February 28, 2021; March 1–June 30, 2021). Mean
Gastroenterology 3,701 (11.1) 660 (11.1)
scores were adjusted for age, sex, race/ethnicity, insur-
Genitourinary 4,344 (13.0) 794 (13.3)
ance, clinic type, and visit type (eAppendix 5, Figure 2).
For the access category, telemedicine consistently out- Hematology 5,434 (16.3) 894 (15.0)

performed in-person visits throughout all 4 time intervals Radiation therapy 3,788 (11.4) 572 (9.61)
(adjusted mean scores ranging from 4.64–4.66 across Sarcoma 1,322 (3.97) 250 (4.20)
time intervals for in-person vs 4.71–4.73 for telemedicine Thoracic 2,274 (6.83) 431 (7.24)
visits; P,.001). When the patients were asked to rate
Other 1,842 (5.53) 1,264 (21.23)
about care provider concern, telemedicine once again
consistently outperformed in-person visits across all 4 Abbreviations: EP, existing patients; FU, follow-up patients; NP, new patients.

time intervals (adjusted mean scores ranging from

4.70–4.78 across time intervals for in-person vs 4.85–4.86
Discussion
for telemedicine visits; P,.001).
Telemedicine has now been established as an essential
Adjusted mean scores for telemedicine visits for
access, care provider concern, telemedicine technology, component of care delivery, and thus, it is important to as-
and overall assessment scores were then compared be- sess patients’ experience with the care they receive through
tween the 4 intervals (eAppendices 6 and 7, Figure 3). teleoncology to ensure value-based care is delivered. The
For all categories, no statistically significant differences current study draws on the experience reported by almost
(eAppendix 8) were seen between each of the time in- 6,000 oncology patients who completed telemedicine
tervals, suggesting that the telemedicine experience was visits—a large cohort for measuring patient experience of
consistent across different time intervals. care over time with telemedicine—and contrasted their

498 © JNCCN—Journal of the National Comprehensive Cancer Network | Volume 21 Issue 5 | May 2023
Patient Experience of Care with Telemedicine ORIGINAL RESEARCH

Access 5.0
Telemedicine
P<.001
In-person
4.8

Adjusted Mean Score

Care provider concern
Telemedicine
P<.001 4.6
In-person

0% 25% 50% 75% 100%

4.4
PEC score: 1−2 2−3 3−4 4−5 5 Access
Care provider concern
Figure 1. Patient experience with access and care provider con- 4.2 Telemedicine technology
cerns with telemedicine consultation over the study period of April Overall assessment
1, 2020, through June 30, 2021. Patient experience for access and 4.0
care provider concern with telemedicine consistently outranked in- 202
0 020 21 21
une ct 2 b 20 e 20
person visits (P value represents proportional differences in patients −J 0 −O 0 −Fe 1 − Jun
020 20 2 20 2 02
who rated 5 for each category). Apr
il 2 July Nov ch 2
Mar
Abbreviation: PEC, patient experience of care.
Figure 3. Adjusted mean scores of patient experience with tele-
medicine over time. Mean scores (of 5) were adjusted for age, sex,
experiences with those who completed in-person visits, as race/ethnicity, insurance, clinic type, and visit type. No statistical
differences between mean scores for access, care provider concern,
measured by the Press Ganey survey results. In this study,
telemedicine technology, and overall assessment were noted across
patients reported consistently better experience of care any of the 4 time intervals.
scores with telemedicine compared with in-person visits
over the entire study period, both in access and with care
studies, patients have reported higher experience of care
provider concern. Although results were statistically sig-
scores with telemedicine than with in-person visits for
nificant for both categories, the actual differences were
several aspects of care: access, patient selection, support
relatively modest given the large sample size. Although
for the patients and providers, ability to interact face-to-
previous studies have compared PEC with telemedicine,
face, and travel-time savings.17,18
the current study additionally assessed telemedicine ex- Patients with cancer require timely care so that health-
perience of care over time and showed that results did care providers can prepare an optimized treatment plan
not differ over time, suggesting that telemedicine imple- with significant implications for the patient’s quality of life
mentation was excellent and is sustainable. and mortality; however, the COVID-19 pandemic has af-
At MCC, telemedicine usage includes virtual visits fected patients’ ability to access care. Patients with cancer
(ie, videoconferencing) between providers and patients are at increased risk for COVID-19–related morbidity and
in oncology. Telemedicine was used throughout the can- mortality.1,19 Delays in cancer care have been noted during
cer care continuum, including screening, diagnosis and the COVID-19 pandemic,20 with telemedicine proving to
follow-up, surveillance, supportive care, procedure prep- be an important aspect of care delivery.21 As evidenced by
aration and follow-up, and survivorship care. In previous our results, patients in the telemedicine group reported
higher PEC scores when asked about access compared
with the in-person group. Appropriate triaging, the ability
5.0
of family members to join the appointment, provision of
4.8 interpreter services, and clinician and patient support for
Adjusted Mean Score

telemedicine may have contributed to patients in the tele-

4.6 medicine group reporting higher scores when asked about
care provider concern compared with the in-person group.
4.4
Rather than using an on-demand telemedicine model
4.2 Telemedicine In person
in which patients log in to a portal and request a consulta-
Access Care provider concern tion when needed, at MCC, providers determined the ap-
4.0 propriateness of telemedicine consultation and scheduled
020 020 021 21 the appointments virtually. This allowed patients to be tri-
ne 2 ct 2 eb 2 ne 20
−Ju 0−O 0−F −Ju aged, as providers could deliver an appropriate level of
il 20
20
ly 2
02
ov 2
02 021
Apr Ju ch 2
N Mar care and reduce the number of in-person visits required
Figure 2. Adjusted mean patient experience scores with in-person after a telemedicine appointment. A family member or an
versus telemedicine visits over time. Mean scores were adjusted for informal caregiver could still be meaningfully engaged in
age, sex, race/ethnicity, insurance, clinic type, and visit type. Patient treatment decisions even when they were unable to join
experience for access and care provider concern with telemedicine
consistently outranked in-person visits across all 4 time intervals.
the in-person visit due to visitor restrictions during the
Differences between telemedicine versus in-person visits were pandemic, geographic distance, or inconvenience. During
statistically significant for each category. the most extensive pandemic restrictions, hybrid visits

JNCCN.org | Volume 21 Issue 5 | May 2023 499

 ORIGINAL RESEARCH Patel et al

were established at MCC to minimize transmission risk. and convenience. However, Press Ganey provided deiden-
During these visits, the patient was seen in the clinic tified data to MCC, and thus we could not correlate dis-
and caregivers joined from a nonclinic but on-campus tance traveled with patient-reported experience.
location. Interpreter services were also added to the One of the important aspects of implementing tele-
telemedicine visits to provide an equitable experience medicine is to provide adequate support for both patients
to both English-speaking and non–English-speaking and clinicians, and this is reflected in consistently high
patients. Finally, for select patients who required an scores for the telemedicine technology category, without
evaluation by multiple subspecialty clinicians, a multi- any statistical differences across the study period. Screen-
disciplinary consultation was performed during a sin- ing tools have been developed to assess patients’ readiness
gle appointment, replicating the experience offered to for telemedicine, and additional personnel, such as social
our patients during in-person visits. workers, have been deployed to assist with this process.44–47
We previously reported clinicians’ perspectives on us- As noted previously, establishing the Department of Virtual
ing telemedicine for oncology.12 For clinicians, educational Health at MCC early in the pandemic was an impor-
materials were developed to support technological assis- tant aspect in the implementation of telemedicine. The
tance, equipment, and template modifications to facilitate department provided dedicated clinical and administra-
clinician–patient interactions. These factors were shown to tive support to facilitate several touchpoints with patients
be important contributors to motivating clinicians to adopt before their actual visit and to understand patients’ sup-
telemedicine and improving clinician satisfaction.22–27 port needs. Appropriate patient-facing and provider-facing
Clinicians have expressed concerns that telemedicine educational materials were developed and are readily ac-
could possibly hamper in-person clinic visit interactions, cessible to help with connectivity.
where a face-to-face discussion enables clinicians to as- Despite extra support, the digital divide will be an
sess patients’ nonverbal cues and receptiveness to the important hurdle, especially in terms of disparities in in-
assessment and plan.12 Nonverbal interactions such as ternet access, devices, and technical proficiency.48–51 A
these are critical in eliciting and appreciating patient dis- 2018 report found that 20% of Americans have access to
tress28 and lead to higher patient satisfaction and quality the internet only through smartphones, with the most
of care.29 In a surgical setting, for example, a randomized common reason being high broadband costs.52 A study
clinical trial of clear versus covered masks demonstrated of .600,000 Medicare beneficiaries demonstrated that
that patients preferred to see their surgeon’s face, and pa- 26% did not have access to either a computer with high-
tients rated surgeons with clear masks as demonstrating speed internet or a smartphone with a wireless data plan.
more empathy and building trust.30,31 Some telemedicine Individuals who were older (aged $85 years), Black or
platforms allow for these face-to-face communications. Hispanic, widowed, or lacking more than a high school
Previous studies have demonstrated that patient–clinician education reported limited digital access.51 Some health-
communication via telemedicine platforms can establish care systems have also loaned devices to patients and
close relationships when appropriate steps are taken.32–36 have partnered with cell phone carriers and community-
Our data suggest that when appropriately used for appro- based organizations to provide infrastructure for pa-
priate patients, telemedicine can provide just as much tients to connect to the internet.27,46,53 For the hybrid
of a connection and favorable patient experience as in- visits at MCC, iPads were provided to connect with care-
person visits. givers who could not be present in the clinic.
Telemedicine can reduce the costs of travel and park- Although experience of care scores from the Press
ing, housing arrangements, and lost income from missing Ganey survey provided important insights and reaffirmed
work for both patients and their caregivers. Transportation the processes established to ensure the highest standard
has been noted to be the highest out-of-pocket nonmedi- of cancer care is delivered, there are some limitations to
cal cost for patients receiving cancer treatment, and those the data reported in this study. While this study reports
with inadequate transportation are more likely to miss ap- on a large cohort of telemedicine patients, the study pop-
pointments and rely on emergency department care.37–41 A ulation was from a single cancer center. Given the limita-
recent study noted that the number of people living out- tion of anonymized data that is provided by Press Ganey
side a 60-minute driving range of major hospitals almost to the institution, authors did not have the ability to take
doubled because of rural hospitals closing.44 Telemedicine nonindependence of observations during statistical analy-
has the potential to deliver high-level care from a dis- sis; that is, some patients may have completed a combi-
tance.43 It is possible that patient experience may vary nation of outpatient and telemedicine surveys multiple
based on distance from the cancer center because tele- times over the study period. Additionally, the study does
medicine may provide an opportunity for indirect patient not measure PEC longitudinally for the same patient. Al-
cost savings (lost productivity due to visit time and costs though statistical adjustments were made, it is important
associated with transportation) and improve patient access to note that the comparisons of access and care provider

500 © JNCCN—Journal of the National Comprehensive Cancer Network | Volume 21 Issue 5 | May 2023
Patient Experience of Care with Telemedicine ORIGINAL RESEARCH

concern between telemedicine and in-person appoint- Acknowledgments

ments were based on differently worded items and, in the The authors would like to sincerely thank Cristina Perez,
case of access to care, a different number of items. The dei- Terry Payton, and Matthew Sears from the Moffitt Patient Ex-
dentified data did not capture patient-level variables, such perience team for their assistance in providing the anony-
as income, education, comorbidities, or purpose of visits mized patient experience of care data; Kavita Ghia from the
(ie, discussing treatment options, changing treatment, or Moffitt Collaborative Data Services Core for providing demo-
discussing results). Patients’ expectations of their care de- graphics data on all visits seen at Moffitt; and April Manna for
livery during the pandemic in itself is a confounder. This administrative assistance. Editorial assistance was provided
by the Moffitt Cancer Center’s Office of Scientific Publishing
was a research study leveraging PEC survey data, and thus
by Daley Drucker and Gerard Hebert; no compensation was
inherent limitations to this type of study apply, including
given beyond their regular salaries. We would like to thank
selection and respondent bias. Although we adjusted for
donors to the COVID-19 Fund at Moffitt Cancer Center for
the type of clinic visit and which clinic patients were seen
their generous support, which helped to fund research to im-
in, the types of patients who were seen in person may be
prove the quality and cost savings offered through Virtual
systematically different from those seen in virtual visits (eg, Health.
more acute or complex problems), which may affect their
experience with care. Respondent bias is also an important
Submitted July 10, 2022; final revision received November 30, 2022;
limitation of a research study leveraging PEC survey data, accepted for publication February 2, 2023.
where patients who are more or less satisfied may be more
Previous presentation: Part of this manuscript was presented at the
likely to respond. Additionally, response rates to PEC sur- ATA2022 Annual Conference & Expo; May 1–3, 2022; Boston,
veys tend to be low and thus a selection bias can be intro- Massachusetts.

duced by nonresponders that can limit generalizability of Author contributions: Conceptualization: Patel, Alishai Tabriz, Turner,
Gonzalez, Naso, Spiess. Data curation: Patel, Naso. Formal analysis: Patel,
findings across all patients. Future qualitative studies will Cao, Wang. Methodology: Patel, Rollison, Naso, Spiess. Writing: Patel,
be required to provide further insights on PEC with tele- Alishai Tabriz, Turner, Gonzalez, Oswald, Jim, Nguyen, Hong, Aldawoodi,
Rollison, Robinson, Naso, Spiess.
medicine. Finally, although patient experience was positive
Disclosures: Dr. Gonzalez has disclosed serving on an advisory board for
with telemedicine, long-term data are necessary to deter- Eli Lilly; and as a consultant for Sure Med Compliance, Elly Health, and
mine whether quality of care and oncologic outcomes are KemPharm. Dr. Jim has disclosed serving as a consultant for Janssen
Scientific Affairs and Merck & Co., Inc.; as a principal investigator for Kite
equivalent to in-person visits. Pharma; and as a consultant for SBR Life Sciences. Dr. Rollison has
disclosed holding an executive position, serving on a governance board, or
being employed by NanoString Technologies, Inc. The remaining authors
Conclusions have disclosed that they have not received any financial consideration from
Telemedicine implementation resulted in higher PEC rates any person or organization to support the preparation, analysis, results, or
discussion of this article.
during the study compared with in-person visits in the ac-
Funding: This work was supported in part by the Biostatistics &
cess and care provider concern categories. Over-time anal- Bioinformatics Shared Resource at the H. Lee Moffitt Cancer Center &
ysis of telemedicine data showed no difference in PEC Research Institute and funded in part by Moffitt’s Cancer Center Support
Grant (P30-CA076292).
scores for telemedicine, suggesting that implementation of
Correspondence: Krupal B. Patel, MD, MSc, Department of Head and
telemedicine was effective and has the potential to be an Neck and Endocrine Oncology, Moffitt Cancer Center, 12902 Magnolia
important adjunct in cancer care delivery. Drive, Tampa, FL 33612. Email: krupal.patel@moffitt.org

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See JNCCN.org for supplemental online content.

502 © JNCCN—Journal of the National Comprehensive Cancer Network | Volume 21 Issue 5 | May 2023
 JOURNAL OF THE NATIONAL COMPREHENSIVE CANCER NETWORK

Supplemental online content for:

Telemedicine Adoption in an
NCI-Designated Cancer Center During the
COVID-19 Pandemic: A Report on
Patient Experience of Care
Krupal B. Patel, MD, MSc; Amir Alishahi Tabriz, MD, PhD, MPH; Kea Turner, PhD, MPH;
Brian D. Gonzalez, PhD; Laura B. Oswald, PhD; Heather S.L. Jim, PhD; Oliver T. Nguyen, MSHI;
Young-Rock Hong, PhD, MPH; Nasrin Aldawoodi, MD; Biwei Cao, MS; Xuefeng Wang, PhD;
Dana E. Rollison, PhD; Edmondo J. Robinson, MD, MBA; Cristina Naso, MEd;
and Philippe E. Spiess, MD, MS

J Natl Compr Canc Netw 2023;21(5):496–502.e6

eAppendix 1: Telemedicine and Outpatient Questions in Key Categories of Access and Care Provider
eAppendix 2: Telemedicine Experience Press Ganey Questions
eAppendix 3: Patient Characteristics Over Different Time Intervals
eAppendix 4: Comparison of Access and Care Provider Concern Between In-Person Versus Telemedicine
eAppendix 5: Telemedicine Versus In-Person Adjusted Mean Score Differences in Access and Care Provider
Concern Over Different Time intervals
eAppendix 6: Telemedicine Scores Over Time for Access, Care Provider, Telemedicine Technology, and
Overall Assessment Categories
eAppendix 7: Adjusted Mean Score Differences in Access, Care Provider Concern, Telemedicine Technology,
and Overall Assessment Over Different Time Intervals
eAppendix 8: Difference Between Time Intervals for Telemedicine Access, Care Provider Concern,
Telemedicine Technology, and Overall Assessment

© JNCCN—Journal of the National Comprehensive Cancer Network | Volume 21 Issue 5 | May 2023
 Patel et al – 1

eAppendix 1. Telemedicine and Outpatient Questions in Key Categories of Access and Care Provider
Telemedicine In-Person
Access Ease of scheduling appointment Wait time between calling and first scheduled appointment

Ease of contacting Courtesy/Concern of staff who made appointment

Reach office staff on phone with ease
Care provider Care provider concern for questions/worries Doctor’s concern for questions and worries

eAppendix 2. Telemedicine Experience Press Ganey Questions

Category Questions
Access 1. Ease of arranging your virtual visit
2. Ease of contacting us (eg, email, telephone, web portal)
Care provider 1. Concern the care provider showed for your questions or worries
2. Explanations the care provider gave you about your problem or condition
3. Care provider’s efforts to include you in decisions about your care
4. Care provider’s discussion of any proposed treatment (eg, options, risks, benefits)
5. Your confidence in this care provider
6. Likelihood of your recommending this care provider to others
Telemedicine technology 1. Ease of talking with the care provider over the virtual connection
2. How well the video connection worked during your virtual visit
3. How well the audio connection worked during your virtual visit
Overall assessment 1. How well the virtual visit staff (including the care provider) worked together to care for you
2. Likelihood of your recommending our virtual visit service to others

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2 – Patel et al

eAppendix 3. Patient Characteristics Over Different Time Intervals

April 2020–June 2020 July 2020–October 2020 November 2020–February 2021 March 2021–June 2021

In-Person Telemedicine In-Person Telemedicine In-Person Telemedicine In-Person Telemedicine

Characteristic n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Total patient visits 88,932 13,390 145,608 13,337 145,519 11,600 160,125 12,618

Surveys sent out 27,530 4,227 43,243 3,675 44,363 5,641 48,714 9,445

Respondents 5,507 (20.0) 1,020 (24.1) 8,377 (19.4) 845 (23.0) 9,816 (22.1) 1,649 (29.2) 9,618 (19.7) 2,436 (25.8)

Median age (range), y 68.0 (18.0–94.0) 69.0 (18.0–92.0) 68.0 (18.0–99.0) 69.0 (19.0–96.0) 69.0 (18.0–98.0) 69.0 (20.0–97.0) 68.0 (18.0–101) 69.0 (18.0–98.0)

Sex

Female 2,655 (48.2) 492 (48.2) 4,092 (48.9) 415 (49.1) 4,748 (48.4) 834 (50.6) 4,641 (48.3) 1,246 (51.1)

Male 2,850 (51.8) 528 (51.8) 4,284 (51.1) 430 (50.9) 5,068 (51.6) 815 (49.4) 4,977 (51.7) 1,190 (48.9)

Race/Ethnicity

White non-Hispanic 4,582 (83.2) 817 (84.8) 6,925 (82.7) 635 (87.0) 8,053 (82.0) 1,319 (84.6) 7,954 (82.7) 2,001 (85.6)

White Hispanic 273 (4.96) 41 (4.26) 403 (4.81) 29 (3.97) 450 (4.58) 72 (4.62) 424 (4.41) 75 (3.21)

Black 242 (4.39) 47 (4.88) 422 (5.04) 26 (3.56) 447 (4.55) 59 (3.78) 463 (4.81) 90 (3.85)

Other 410 (7.45) 58 (6.02) 627 (7.48) 40 (5.48) 865 (8.81) 110 (7.05) 777 (8.08) 172 (7.36)

Insurance

Private 1,643 (29.8) 301 (29.5) 2,566 (30.6) 241 (28.5) 2,874 (29.3) 476 (28.9) 2,928 (30.4) 709 (29.1)

Medicare 3,462 (62.9) 660 (64.7) 5,212 (62.2) 562 (66.5) 6,348 (64.7) 1,083 (65.7) 6,043 (62.8) 1,600 (65.7)

Medicaid 79 (1.43) 6 (0.59) 129 (1.54) 1 (0.12) 125 (1.27) 26 (1.58) 130 (1.35) 23 (0.94)

Other 323 (5.87) 53 (5.20) 470 (5.61) 41 (4.85) 469 (4.78) 64 (3.88) 517 (5.38) 104 (4.27)

Visit type

NP/EP 1,386 (25.21) 238 (23.4) 2,424 (28.96) 224 (26.54) 2,733 (27.84) 342 (20.69) 2,666 (27.75) 466 (19.11)

FU 4,121 (74.78) 782 (76.7) 5,953 (71.07) 621 (73.5) 7,083 (72.15) 1,307 (79.3) 6,952 (72.26) 1,970 (80.9)

Clinic type

Blood and marrow 136 (2.47) 57 (5.59) 186 (2.22) 39 (4.62) 183 (1.86) 62 (3.76) 178 (1.85) 41 (1.68)
transplant

Breast 765 (13.9) 51 (5.00) 1,160 (13.8) 44 (5.21) 1,285 (13.1) 85 (5.15) 1,210 (12.6) 150 (6.16)

Cutaneous 769 (14.0) 37 (3.63) 1,072 (12.8) 23 (2.72) 1,259 (12.8) 30 (1.82) 1,199 (12.5) 55 (2.26)

Endocrine 114 (2.07) 76 (7.45) 284 (3.39) 62 (7.34) 403 (4.11) 102 (6.19) 410 (4.26) 171 (7.02)

Gastroenterology 618 (11.2) 131 (12.8) 961 (11.5) 99 (11.7) 1,078 (11.0) 173 (10.5) 1,044 (10.9) 257 (10.6)

Genitourinary 690 (12.5) 141 (13.8) 1,144 (13.7) 112 (13.3) 1,274 (13.0) 229 (13.9) 1,236 (12.9) 312 (12.8)

Hematology 897 (16.3) 152 (14.9) 1,381 (16.5) 166 (19.6) 1,572 (16.0) 264 (16.0) 1,584 (16.5) 312 (12.8)

Radiation therapy 591 (10.7) 89 (8.73) 796 (9.50) 70 (8.28) 1,203 (12.3) 137 (8.31) 1,198 (12.5) 276 (11.3)

Sarcoma 241 (4.38) 37 (3.63) 348 (4.15) 30 (3.55) 365 (3.72) 78 (4.73) 368 (3.83) 105 (4.31)

Thoracic 400 (7.26) 90 (8.82) 538 (6.42) 88 (10.4) 686 (6.99) 103 (6.25) 650 (6.76) 150 (6.16)

Other 286 (5.19) 159 (15.63) 507 (6.05) 112 (13.24) 508 (5.18) 386 (23.38) 541 (5.62) 607 (24.93)

Abbreviations: EP, existing patients; FU, follow-up patients; NP, new patients.

© JNCCN—Journal of the National Comprehensive Cancer Network | Volume 21 Issue 5 | May 2023
 Patel et al – 3

eAppendix 4. Comparison of Access and Care

Provider Concern
In-Person Telemedicine
Score n (%) n (%) P Value
Access 32,808 5,910 ,.001
1–2 61 (0.19) 13 (0.22)
2–3 289 (0.88) 41 (0.69)
3–4 1,863 (5.68) 245 (4.15)
4–5 10,080 (30.7) 1,131 (19.1)
5 20,515 (62.5) 4,480 (75.8)
Care provider concern 21,610 5,846 ,.001
1–2 295 (1.37) 17 (0.29)

2–3 219 (1.01) 21 (0.36)

3–4 609 (2.82) 71 (1.21)
4–5 2,284 (10.6) 436 (7.46)
5 18,203 (84.2) 5,301 (90.7)

eAppendix 5. Telemedicine Versus In-Person Adjusted Mean Score Differences in Access and Care
Provider Concern
Telemedicine Mean Score In-Person Mean Score
Time Interval (lower limit–upper limit) (lower limit–upper limit) P Value
Access
April 2020–June 2020 4.73 (4.69–4.79) 4.66 (4.64–4.68) ,.001
July 2020–October 2020 4.73 (4.69–4.78) 4.64 (4.62–4.66) ,.001
November 2020–February 2021 4.75 (4.69–4.78) 4.65 (4.63–4.67) ,.001
March 2020–June 2021 4.71 (4.69–4.78) 4.64 (4.62–4.66) ,.001
Care provider concern
April 2020–June 2020 4.86 (4.82–4.90) 4.78 (4.75–4.80) ,.001
July 2020–October 2020 4.88 (4.82–4.90) 4.77 (4.75–4.80) ,.001
November 2020–February 2021 4.87 (4.82–4.92) 4.71 (4.68–4.75) ,.001
March 2021–June 2021 4.85 (4.80–4.90) 4.70 (4.67–4.74) ,.05

Mean scores were adjusted for age, sex, race/ethnicity, insurance, clinic type, and visit type.

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eAppendix 6. Telemedicine Scores Over Time for Access, Care Provider, Telemedicine Technology, and
Overall Assessment Categories
Score April 2020–June 2020 July 2020–October 2020 November 2020–February 2021 March 2021–June 2021
Access
1–2 0 (0.00) 4 (0.48) 3 (0.18) 6 (0.25)
2–3 12 (1.19) 5 (0.60) 12 (0.73) 12 (0.50)
3–4 58 (5.73) 25 (2.98) 64 (3.91) 98 (4.05)
4–5 228 (22.5) 186 (22.1) 307 (18.7) 410 (16.9)
5 714 (70.6) 620 (73.8) 1,252 (76.4) 1,894 (78.3)
Care provider concern
1–2 1 (0.10) 4 (0.48) 2 (0.12) 6 (0.25)
2–3 5 (0.49) 0 (0.00) 9 (0.55) 13 (0.54)
3–4 17 (1.68) 16 (1.90) 28 (1.72) 40 (1.65)
4–5 130 (12.9) 111 (13.2) 182 (11.2) 307 (12.7)
5 858 (84.9) 710 (84.4) 1,410 (86.5) 2,051 (84.9)
Telemedicine technology
1–2 5 (0.49) 6 (0.72) 7 (0.43) 10 (0.41)
2–3 13 (1.28) 9 (1.07) 22 (1.34) 18 (0.74)
3–4 59 (5.82) 34 (4.05) 63 (3.85) 75 (3.10)
4–5 161 (15.9) 134 (16.0) 219 (13.4) 355 (14.7)
5 775 (76.5) 656 (78.2) 1,325 (81.0) 1,959 (81.1)
Overall assessment
1–2 0 (0.00) 5 (0.60) 0 (0.00) 4 (0.17)
2–3 5 (0.50) 3 (0.36) 6 (0.37) 16 (0.67)
3–4 36 (3.56) 22 (2.64) 35 (2.15) 47 (1.95)
4–5 154 (15.2) 108 (12.9) 187 (11.5) 280 (11.6)
5 815 (80.7) 696 (83.5) 1,398 (86.0) 2,059 (85.6)

© JNCCN—Journal of the National Comprehensive Cancer Network | Volume 21 Issue 5 | May 2023
 Patel et al – 5

eAppendix 7. Adjusted Mean Score Differences in Access, Care Provider Concern, Telemedicine
Technology, and Overall Assessment Over Different Time Intervals
Time Interval Adjusted Mean Score Lower Limit Upper Limit
Access
April 2020–June 2020 4.74 4.69 4.79
July 2020–October 2020 4.73 4.69 4.78
November 2020–February 2021 4.75 4.69 4.80
March 2021–June 2021 4.71 4.64 4.77
Care provider concern
April 2020–June 2020 4.84 4.80 4.87
July 2020–October 2020 4.84 4.80 4.87
November 2020–February 2021 4.85 4.81 4.89
March 2021–June 2021 4.83 4.78 4.87
Telemedicine technology
April 2020–June 2020 4.79 4.74 4.84
July 2020–October 2020 4.77 4.72 4.82
November 2020–February 2021 4.80 4.74 4.86
March 2021–June 2021 4.74 4.68 4.81
Overall assessment
April 2020–June 2020 4.84 4.80 4.88
July 2020–October 2020 4.82 4.78 4.86
November 2020–February 2021 4.84 4.79 4.89
March 2021–June 2021 4.80 4.75 4.84

Mean scores were adjusted for age, sex, race/ethnicity, insurance, clinic type, and visit type.

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6 – Patel et al

eAppendix 8. Difference Between Time Intervals for Telemedicine Access, Care Provider Concern,
Telemedicine Technology, and Overall Assessment
Adjusted
Time Interval Difference Lower Limit Upper Limit P Value
Access
July 2020–October 2020:April 2020–June 2020 20.001279 20.008485 0.005926 0.968407
November 2020–February 2021:April 2020–June 2020 0.005082 20.000941 0.011104 0.132253
March 2021–June 2021:April 2020–June 2020 0.004863 20.000764 0.010490 0.117672
November 2020–February 2021:July 2020–October 2020 0.006361 20.000220 0.012942 0.062520
March 2021–June 2021:July 2020–October 2020 0.006143 20.000078 0.012364 0.054454
March 2021–June 2021:November 2020–February 2021 20.000219 20.005021 0.004583 0.999427
Care provider concern

July 2020–October 2020:April 2020–June 2020 0.002294 20.003603 0.008191 0.749627

November 2020–February 2021:April 2020–June 2020 20.000027 20.004961 0.004907 0.999999
March 2021–June 2021:April 2020–June 2020 0.000114 20.004493 0.004721 0.999908
November 2020–February 2021:July 2020–October 2020 20.002321 20.007710 0.003068 0.685372
March 2021–June 2021:July 2020–October 2020 20.002180 20.007271 0.002911 0.689344
March 2021–June 2021:November 2020–February 2021 0.000141 20.003795 0.004077 0.999721
Telemedicine technology

July 2020–October 2020:April 2020–June 2020 20.000474 20.007952 0.007005 0.998468

November 2020–February 2021:April 2020–June 2020 0.003036 20.003213 0.009286 0.595834
March 2021–June 2021:April 2020–June 2020 0.001122 20.004715 0.006960 0.960424
November 2020–February 2021:July 2020–October 2020 0.003510 20.003324 0.010344 0.550217
March 2021–June 2021:July 2020–October 2020 0.001596 20.004864 0.008056 0.920768
March 2021–June 2021:November 2020–February 2021 20.001914 20.006900 0.003072 0.757168
Overall assessment
July 2020–October 2020:April 2020–June 2020 0.001255 20.005723 0.008233 0.967223
November 2020–February 2021:April 2020–June 2020 0.001824 20.004001 0.007650 0.852177
March 2021–June 2021:April 2020–June 2020 0.001414 20.004025 0.006854 0.909077
November 2020–February 2021:July 2020–October 2020 0.000569 20.005815 0.006954 0.995764
March 2021–June 2021:July 2020–October 2020 0.000159 20.005875 0.006194 0.999889
March 2021–June 2021:November 2020–February 2021 20.000410 20.005064 0.004244 0.995908

Mean scores were adjusted for age, sex, race/ethnicity, insurance, clinic type, and visit type.

© JNCCN—Journal of the National Comprehensive Cancer Network | Volume 21 Issue 5 | May 2023