From left: Cancer Diagnostic Service team members Luke Arney and Louise Schneider

Sometimes, a routine medical examination leads to more questions than answers. But for patients with suspicious and complex symptoms that point to cancer, not receiving concrete answers right away about their diagnosis can be especially scary.

Take, for instance, a patient who met with her Partners HealthCare-affiliated primary care physician (PCP) for a routine lung cancer screening. While a chest CT scan didn’t show signs of lung cancer, it did reveal a bone lesion and pathologic rib fracture, a form of rib injury caused by disease rather than blunt trauma. Additional tests suggested cancer, but her doctor wasn’t sure.

Such a patient poses an unusual challenge. A referral to an appropriate oncologist is difficult because a cancer diagnosis has not been made, but the next steps in the diagnostic workup aren’t always clear either for PCPs. Yet the prospect of a cancer diagnosis also creates stress, so everyone wants answers as soon as possible.

The Cancer Diagnostic Service (CDS) at Dana-Farber/Brigham and Women’s Cancer Center (DF/BWCC) aims to alleviate that uncertainty and make the determination of a cancer diagnosis faster and simpler for patients and their providers. Initially piloted as a virtual clinic to help Partners-affiliated PCPs streamline and expedite a diagnosis for patients with suspected cancer, the CDS recently graduated from its pilot phase and began seeing patients in its new physical space on the main campus.

While the service’s biggest users at the moment are PCPs within Partners, including those at the Brigham, it is expected to grow into a regional resource for referring physicians at other health care organizations as well.

“When there is a strong suspicion of cancer without a definitive diagnosis, it can be difficult for patients and physicians,” said Lindsay Carter, MD, MBA, medical director of the Cancer Diagnostic Service. “As doctors order additional diagnostics test for their patients or seek input on the appropriate next steps, there can be significant delays and unnecessary tests. We created the Cancer Diagnostic Service to streamline the process to help doctors reach a timely diagnosis so that treatment can begin without delays.”

The patient with suspicious findings on her lung CT was referred to the CDS, where she was diagnosed with adenocarcinoma – a form of cancer – following a CT-guided biopsy. She was then seamlessly transferred to a thoracic oncologist at Dana-Farber Cancer Institute (DFCI) to begin treatment.

A More Seamless Approach

During the center’s six-month pilot, which began in October 2016, providers used Epic’s E-consult function to consult virtually with CDS staff. Of the 82 cases evaluated by the clinic’s staff – an internist, physician assistant and consulting BWH and DFCI oncology specialists – 70 percent of patients were recommended for and received a full diagnostic work-up. Among that group, nearly two-thirds were ultimately diagnosed with cancer and referred to oncologists or surgeons.

The pilot generated an overwhelmingly positive response from PCPs. “It’s scary when your patient has cancer, and it was really nice to have someone guide you as you make diagnostic decisions,” wrote one physician in a feedback survey. Others praised the rapid response and seamless process in reaching a diagnosis.

With funding from the Brigham Care Redesign Incubator Startup Program (B-CRISP) and DFCI, the CDS opened its physical space on Oct. 20 in the Brigham Medical Specialties Suite at 45 Francis St. The team sees patients on Wednesday mornings and Friday afternoons. Patients are scheduled for an appointment within five business days of the referral.

“After a referral, the CDS takes ownership of each patient’s case and coordinates the diagnostic work-up. We communicate detailed results and a suggested treatment plan to both patients and referring providers,” said Ryan Leib, MBA, administrator for the CDS and director of Ambulatory Practice Management at DFCI. “Now that we have an established physical location, we are reaching out to the referring physician community to inform them about this unique service.”

To refer a patient the Cancer Diagnostic Service, call 857-307-5775. Partners HealthCare physicians may also submit an Epic order to Ambulatory Referral to DF/BWCC Cancer Diagnostic Service.  

Ash Nadkarni demonstrates a virtual visit in her office at 850 Boylston St.

When Ash Nadkarni, MD, of the Department of Psychiatry, was offered the opportunity to start seeing some patients through virtual visits, she jumped at the chance.

For patients with medically complex conditions, getting to a behavioral health appointment can be physically challenging. As one part of her practice, Nadkarni provides psychiatric care for patients with inflammatory bowel disease through BWH’s Crohn’s and Colitis Center. The ability to follow up with select patients in this group through the use of technology such as video conferencing on a computer or mobile device wasn’t just a matter of convenience – it was also about having compassion for patients’ physical limitations.

“A lot of times, these patients are medically ill, and appointments in person can be uncomfortable for them,” said Nadkarni, one of about 200 clinicians participating in the Brigham’s telehealth initiative. “Virtual visits really give them improved access to care.”

The telehealth program at BWH, launched in early 2015, uses web-based and video technologies to connect patients and providers in virtual visits. Now in the process of wrapping up its pilot stage, the initiative has facilitated about 600 virtual visits among outpatient clinicians in various specialties. Today, BWH clinicians collectively see approximately 10 to 20 patients per week through virtual care. That is expected to climb to 100 per week over the next year as the program expands.

The program has several goals, according to Adam Licurse, MD, MHS, Telehealth medical director.

Telehealth provides more timely access for appointments, as providers don’t need exam room space and can fill a last-minute cancellation slot with a virtual visit on short notice. And because there is no need to drive, park or sit in a waiting room to see a provider, patients may find virtual visits to be more convenient and therefore are more likely to keep their appointment. The expected result of all this: improved patient outcomes and reduced costs of care.

“Virtual care is becoming a vital clinical service, and the initial successes of our pilots have empowered us to expand these efforts across the Brigham in the coming years,” Licurse said. “By offering several telehealth tools across the clinical spectrum, we hope patients can access care in whatever way works best for them – whether they’re at home, work or a clinical setting. Combined with the right level of in-person care, virtual care can be a better option for many patients, and we look forward to delivering this type of care to more patients locally, nationally and internationally, and meeting the needs of new populations as our programs grow.”

For the Right Patients, at the Right Time

The program initially engaged departments whose providers saw patients with conditions that required frequent follow-up visits and infrequent physical exams, and who lived in Massachusetts but had difficulty coming to their provider’s office, Licurse said. Candidates for the pilot were further narrowed down to patients with inflammatory bowel disease, diabetes during pregnancy, mood disorders, hypertension, ischemic heart disease, prostate disease and airway disorders.

BWH’s telehealth initiative has since expanded to include e-visits to provide urgent care for patients with common, acute symptoms. Patients can submit text-based inquiries through a patient portal, and if their symptoms match the covered conditions, a clinician will typically respond within a day.

“For certain common and irritating symptoms, seeing one’s provider in the office is often less important than obtaining a speedy and reliable answer,” Licurse said. “From early experiences, we know that a 15-minute office visit for urinary symptoms or a cough can be done in less than five minutes through this program.”

For Nadkarni, virtual visits are like other tools available to clinicians—such as the Patient Gateway online portal—to help provide greater access for patients. Since initially piloting the technology with patients referred from the Crohn’s and Colitis Center, she has expanded her use of virtual visits to other patients in her practice.

“One of the things I realized was that virtual visits are useful not exclusively for some patients, but for all patients at certain times,” she said. “For some patients, it takes so much time to come in—some have to take a half-day off of work, which can be a huge inconvenience. It can also be challenging for patients with young children to find child care so they can come to an appointment.”

Although the conversations a patient has with a psychiatrist can be sensitive and sometimes difficult, the trust and intimacy such discussions require isn’t diminished when they take place through a webcam, Nadkarni says.

“Patients tell me they feel heard because I’m looking directly at the screen for the whole appointment,” she said. “There’s no question that when the doctor is beside you and treating you there, that’s a human element that cannot be replicated by virtual visits. But when we use virtual visits appropriately, for the right patients at the right time, that experience isn’t lost.”