Virtual oncology: Expert cancer care from anywhere

In this episode of the PermanenteDocs Chat, host Alex McDonald, MD, sits down with Tatjana Kolevska, MD, to explore how Kaiser Permanente is transforming cancer care with its Virtual Cancer Expert Review program. Learn how this innovative program ensures that every patient—no matter where they live—has access to the knowledge and expertise of top oncology specialists across the country.

Dr. Kolevska also explains how Kaiser Permanente’s integrated system supports prevention, early detection, and advanced treatment, all while keeping the patient at the center.

Highlights include:

• What makes Kaiser Permanente’s approach to cancer care unique
• How virtual expert reviews are improving outcomes and reducing unnecessary treatments
• The role of AI in supporting complex cancer care

Guest

Tatjana Kolevska, MD, medical director, Kaiser Permanente National Cancer Excellence Program

Podcast transcript

Transcript is autogenerated. Although edited for clarity, it should not be considered an exact replication of the podcast and may also be updated as needed.

Alex McDonald, MD: Hello everyone. Welcome to today’s Permanente Docs chat. I’m your host Alex McDonald. I practice family and sports medicine here as part of the Southern California Permanente Medical Group in Fontana, California. Today we are talking about cancer care here at Kaiser Permanente in the virtual cancer Expert Review program, which I think is really fascinating and I’m excited to welcome my guest, Dr. Kolevska. Thank you so much for joining us.

Tatjana Kolevska, MD: It’s such a pleasure to join you. Our Kaiser Permanente team is so proud of the virtual cancer [Expert Review] program, so I look forward to our conversation.

AM: Wonderful. Well, let’s take a step back here and start with my first question. Tell us who you are and what you do.

TK: I’m the medical director of the Kaiser Permanente National Cancer Program. We serve more than 12.5 million people. That’s the size of a mid-size European country. So we are true a large scale care delivery center. I also am the chair of the Northern California Medical Oncology Hematology and Infusion Centers and one of the directors of the clinical trials program because in cancer, where we don’t have good answers, we do and support tremendously clinical trials in clinical research. So I have that role as well. And I’m also a chair for the physician education program where I draw a lot of different aspects of how to provide physicians with the right information at the right time.

AM: Wonderful. So you have multiple different perspectives you can share from. Tell us first of all, how does Kaiser Permanente’s integrated system and value-based model help physicians and other clinicians deliver cancer care differently than other systems? What is unique about our system and can you share some examples?

TK: Of course. So the biggest point and focus and the only focus for cancer centers outside of our integrated health care system is people that have cancer that are sick. So I always frequently wonder, why do we call it health care when it’s actually a sick care? Because that’s the focus. And honestly, I can understand that in a fee-for-service environment for the medical team to be able to financially survive the fee needs to be collected, and prevention, screening, all of those parts reimbursed at a much, much lower level. So for an integrated health care model like Kaiser Permanente, we are prepaid. We put the member and the patient in the middle, and that’s the only thing that matters. We are able to provide 360-degree cancer care where everything starts with prevention.

By the way, 42% of cancers in the United States can be prevented. That means the town of a size of Seattle can be prevented from developing cancer every year if we all practice and include prevention in our programs, then we go to screening. We have one of the highest screening rates anywhere, treatment and survivorship as well. And I will never forget one of my patients, we had an office visit and I said, okay, you’re done right now with your colon cancer treatment. Now we are going to survivorship. So you need to go through screening and they’re going to call you for colonoscopy. And he’s looking at me and says, Dr. Kolevska, I’m not worried about it. You guys nag me, nag me, nag me until I do it. So that’s how the cancer actually was discovered in the first place. So that’s a big difference and I’m so proud to be actually able to practice in that kind of an environment.

AM: Again, wearing my primary care family medicine hat, I’m all about prevention, I’m all about screening. Why would we treat you for something like cancer when we can prevent it? Right? Cancer obviously is a very scary word, comes with a lot of baggage, both emotional and physical that comes with it. And so really I love this idea of putting the patient at the center of the system, but starting even before we even think about any medical problems and really, really prevention is the key. The other thing too, which I think is phenomenal that I’ve experienced from my perspective is I had a patient about a month ago who came in for a routine pap smear. There was a very large cervical lesion. I got her into coposcopy and biopsy within a week or two, I ordered a CT scan right there also because I was really worried.

And then she got into oncology within a matter of a week or two. And again, it’s all part of the same system. And the oncologist connects with me and shares information with me as her primary care physician. And so we’re all collaborating together as opposed to separate isolated pieces which don’t communicate. There’s been good studies I think showing that when you keep primary care and you keep the primary care doctor involved throughout a patient’s cancer care or surgery or what have you, they end up doing better and there’s better communication and collaboration. Again, that’s my perspective. From your side of the things, how do you think that works as well,

TK: That’s an excellent, excellent point. Cancer care is very complex that at 38 different specialties in internal medicine that provides direct cancer care. So this is not indirect that provides direct cancer care to our patients. So from urology, head, neck surgery pathology, it’s 38 of them.

And  beauty of our system is that because it’s all one system, we have designed models where the patient is not sent to see every single doctor for the doctor to get paid because in fee for service, if the patient did not see a radiation oncologist, although they might not need radiation, the radiation oncologist is not going to get paid. So in our system, we all work together with the patient in the middle and then the patient is directed to see only the doctor and the team they need. So it’s not too confusing, not too much traveling and so on and so on. I so much agree with you.

AM: Yeah, I have a lot of patients who’ve reached out to me just for mental health support and during cancer care and treatment, which can be very emotionally taxing for families and patients. And I think that’s an important piece we always can’t leave out. So my next question here alludes a little bit to what you’re talking about, just treating the patient where they need to and keeping things focused and not overwhelming the patient or the system. And you obviously help run the Virtual Cancer Expert Review program. Can you tell us a little bit about that program, how it works and why it was created?

TK: The way how we went about this, Alex, is we know that in the United States, only about 20% of cancer patients live close to a cancer center to cancer experts only 20%. Our goal is to provide a hundred percent of expert care to all our members, all 12.5 million of them. Do they live in the isolated island in Hawaii or they live in Atlanta or Colorado, wherever they are. That was our goal. So we have free from the restraints that are put on fee for service where patients need to see doctors for their teams to get paid free. From that, we actually built a virtual cancer center. We just lifted everything and we built 11 different departments. So we have a department for breast cancer, department for gastrointestinal cancer sarcomas, so on and so on. That has staff, physicians from our experts, best experts across the country. And then we use technology team to build a technology for us to be able to have an expert from Los Angeles evaluate a patient with rare cancer in Denver, Colorado.

And that’s where that integrated system plays a big part too, because the primary care nodes, the radiology, the pathology, everything is in one place. It’s very different than the systems that some outside companies provide because majority of this patient review systems, the expert is reviewing a summary of the patient. We actually have the doctor go in the chart, review the chart, and also the scans themselves and give an opinion. So I’ll give you an example. One of the patients I’ve evaluated with melanoma from Atlanta, Georgia, there was a question about the patient is failing a treatment right now there’s growth on the CT scan, and the only thing that the treating oncologist needed to do is go in the electronic medical records, write an order right there. Instead of writing chest x-ray, they write expert review, please. That order goes to a national coordinator who let me know in San Francisco that I need to review the chart. I go in the chart, review it, and within two days the physician there has an evaluation and a guidance how to proceed.

When you think about this system, well, it seems pretty simple. I mean, you write an order, the doctor goes in and says, I must say that there’s so many complexities there, and I’m so fortunate to work for an organization that has teams that could approach all of those complexities. So we were able to put the system together. I was looking yesterday, we have 1,580 of these requests so far from about 350 oncologists that behalf across the nation, again covering 12 million people. And the satisfaction rate has been closing a hundred percent from our doctors. And honestly, I requested one, I had a patient with gynecologic cancer because one of our doctors was sick. I usually don’t see those patients. So it’s like, yeah, of course I’ll see the patient. And what I did is I requested an expert to come and review the chart. When the patient came, I knew exactly what to do. And I told the patient, I said, this is, I agree with this opinion, but this was actually reviewed by an expert. The patient was so thankful that they didn’t need to go. If they get second opinion, they didn’t need to drive anywhere, they didn’t need to talk to anybody. Actually, they got a second opinion without even asking for it.

AM: That is incredible. And the ultimate in patient-centered care and just utilizing our resources so expertly to really get the patient what they need. I think the phrase which comes to mind, which I use all the time, is medicine is a team sport. And this is such a wonderful example of that. We can’t all know everything. We can’t all be experts, but collaboratively and collectively, if we can get patients to see experts or get consultants from experts virtually without the patient having to go anywhere or develop a new relationship with a new physician, that is phenomenal. I remember very clearly during my intern year, during residency, I was in North Carolina and patients would travel from around the country to this acclaimed institution to get a second opinion or to see the world’s expert on X, Y, or Z. And my first thought is, okay, you flew here from across the country and you’re seeing an intern. That’s one thing. And then second of all, that’s a huge expense and time that a lot of patients and families just can’t afford, especially some of our more vulnerable or working class patients. And so the value and the equity built into the system is just phenomenal to really take care of patients. And that’s incredible.

TK: Alex, I have to tell you, we are actually moving a step further. So in end of April, we are going to have our first virtual consultation between a patient and an expert. So the patients can be anywhere in our enterprise because you reminded me of that. Nobody needs to travel anywhere. If we have a patient diagnosed with a rare cancer, let’s say sarcoma or an isolated island in Hawaii, and our sarcoma expert is in Oakland, they’re going to be actually having a virtual video visit where the patient will talk directly to the expert and the patients can invite all their family members, even if they’re in Washington or Japan or anywhere they are, they can actually all come and talk to the expert. And the second service that we are doing right now, which I absolutely and very proud of, is we are including AI to be a part of our team. The way how we are including AI is frequently right now in medicine because the doubling time is only three months. So every three months, the medical knowledge doubles. So

Very frequently as physicians, maybe sometimes we don’t know what we don’t know. And we are seeing that when experts reviews the case in about 30% of the time, the experts will actually change the treatment. We’ll give new treatments. So what are we doing right now? We are actually developing a technology team tool. AI that looks for complex cancer cases across the enterprise, pulls them out as soon as they’re diagnosed, and then have them be reviewed by an expert team. And they put a note in the chart as a guidance before the patient is seen by their frontline team.

So the frontline team actually has a guide of which direction to go. We have a publication in the Journal of Clinical Oncology for a program that we did as a pilot for this. And we saw that the amount of chemotherapy given to patients actually decreases when experts review the chart. It doesn’t increase. And that’s somewhat because if I’m not familiar with this, if I haven’t seen my last rare sarcoma, testicular cancer patient two years ago, I’ll just try to give them everything so that feels feel safer. And with this prospective complex case review, we piloted it already in Colorado, Hawaii, now we are spreading it across the enterprise. We will make sure that the rare cancers, the most complex cancers are actually reviewed before the frontline team and we help them all out.

AM: That is absolutely incredible. I’m speechless. Why would you not want to be part of a cancer Expert Review program like that where you can really make sure you get the best care at the best time? And again, we’re all human. We can’t know everything. And utilizing both people and technology to really provide the right care at the right time is absolutely incredible. So wow, I didn’t even know this doing my review for my research for this podcast, I was impressed, but I’m even more impressed now and hope all of our listeners are out there. Also,

TK: Alex, I’m just going to share one last fact and that is, what does all this do? So what? If you’re a Kaiser Permanente member, you’re 20% less likely to prematurely die from cancer than the members in your community.

20%. Prevention, screening, treatment, survivorship. That’s what it does.

AM: That’s an absolutely stunning statistic, and I want more of our doctors to know that, and that will, I think, probably build more confidence, quite frankly, in the care we provide. Exactly. Well, tell us, again, I don’t want to be a naysayer. Tell us some of the, what are the challenges here? Are we kind of meeting capacity for this system? Are there access challenges in terms of getting patients into this program or was this the solution for access challenges to address patient care? Can you talk about some of that piece of things,

TK: Alex? That’s a key to everything. Honestly, if you’re building a model on a solid foundation, then it’s going to keep on growing. So from the very beginning, the way how we approach this is together with our health plan partners. So I’m a medical director of the program and I work with Misha McKinney from our health plan partners and rebell this together. So we knew that trying to tell our experts, you’re going to review this case on a Saturday at 10:00 PM on your own time, and then we are just going to have a medical assistant from your team do the administration part. And the medical assistant is, let’s say, on a family leave, then the work doesn’t get done. So we actually tried that in the past and we saw that that’s just, it’s not going to optimally work. So what we did is we had all eight regions, leaders from all eight regions come together and design a technology and workflows that work for all eight regions. That was the biggest challenge. So we actually also backfilling the time for the physicians. So we actually given the time for them to review the chart, because

It’s a big job, I must say I’m doing it myself. So it is a big job. And right now we are trying to adjust the program to the needs of the referring physicians and also to the complex case review part. We are facing a lot of headwinds with a second opinion program because for that, we need to license our physicians in all the states where we provide care. And I must say I got my last license more than 20 years ago, and I forgot how tedious that work is. And it’s quite interesting that in the United States, if you’re providing care in 20 states, each and every state, you have to go from scratch. And so it takes a lot of the time. So we are working with our government relations folks to try to see how do we influence that on a national level. So actually we can expedite types of care like this, but really investing in the program from the very beginning, understanding that the staffing is really necessary, that this is not weekend project was really critical. The understanding between the health plan partners and the Permanent Medical Group team as well.

AM:

Yeah, no, again, it’s a team sport and I think, again, making sure doctors have the time to do this work is so critical and that we make sure we find that balance. I mean, there’s not enough doctors as it is. There’s too much work as it is, and so how do we make sure it’s sustainable for the physicians to really help the patients in front of them and not be overwhelmed? So I’m glad to hear that it’s built on a sustainable model also. You mentioned that 20% survivorship or improved survivorship compared to other studies. What other outcomes, what other studies have you done regarding the Virtual Expert Cancer Review program and what else makes you most proud? I mean, it sounds like there’s some amazing opportunities for continued growth and development, but there’s a lot of great work that’s being done already.

Tatjana Kolevska, MD:

When we were starting this kind of a program, it never existed before. So there were a lot of anxieties that are natural in this kind of environment. Will the doctors refer the cases? Will they like the recommendations? Will the experts make themselves available to review the cases and so on and so on. So what we saw is that more than 95% of our users, and we have more than 300 users in the United States, these oncologists, so actually really, really liked the program. So the second part is that in more than 30% of the cases, when the expert made a recommendation, the treatment that was planned to be given changed. So we are really making a difference.

This was in a 30% range, when we published the New England Journal of Medicine publication last month, I was looking at, because this program gets cases all the time, I was looking at it last night, and right now our users report that more than is 60% of the time the treatment was changed based on the expert review. So that to me is the biggest testimony of this case. What I’m most proud of my team, they’re absolutely amazing. The teams, how we came together from the all eight regions in the United States at Kaiser Permanente from Washington, Mid-Atlantic, Colorado, Georgia, Hawaii, California Northwest, we just came together and we all agreed immediately on something we would like to provide consistency in our care everywhere. And we would like a hundred percent access to experts for all cancer patients. So that’s what I’m most proud of.

AM: Yeah, no, that’s phenomenal. This has been such a great conversation. I do. We want to keep this brief and high yield for our busy physicians. Last question here, and I think this is such a great example of value-based care, but what does practicing value-based care mean to you?

TK: So to me, the most important part of value-based care is as we started our conversation, is putting the patient in the middle.

That’s the first. The second part is building everything. We do all our care to be built between the frontline teams. They have to have a huge say. They don’t always, they patients and they together need to build the care. Actually, nationally, we did organize a patient advisory board with patient advisors from all eight regions. So whatever we are designing, including all the programs that I mentioned today, they meet, they let us know, gave us feedback, we adjust. So that building together with the patients and frontline teams care that really serves the patients to me, provides the highest, highest value anywhere. And for value-based care to work, it’s very important that a word value means the same thing to the three parties that are involved in healthcare, the health plan, the medical groups, and the patients. The users. So if we all agree that a patient should be in the middle, that that’s the value needs to be built around, then I think that would provide a bigger success.

AM:

That’s amazing. Our patient advisory committee here has a motto, nothing about us without us. And I think your program here is such a great example of that. This has been such a phenomenal conversation and I really hope that all of our physicians out there listen and share with their colleagues. This is just amazing work you’re doing. So thank you. Thank you for joining us. Thank you for your work and really thank you for sharing your insights today, Dr. Kolevska.

TK: Absolutely. Thank you so much for inviting me and thank you to the whole Kaiser Permanente team for everything you do. Thank you.