[Skip to Content]
[Skip to Content Landing]

Implementation and Outcomes of Virtual Care Across a Tertiary Cancer Center During COVID-19

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Can virtual care (VC) be rapidly implemented across a tertiary center during the coronavirus disease 2019 (COVID-19) pandemic, and what are service capacity and quality outcomes?

Findings  This cohort study of 22 085 VC visits at a single cancer center suggests feasibility of an agile service design process for implementation of VC at scale. This approach preserved outpatient caseloads and maintained care quality in all 6 care-quality domains of care quality laid out by the Institute of Medicine while rendering high patient and practitioner satisfaction.

Meaning  These data support the value proposition of VC to safeguard system capacity, while minimizing the disruption to patient care during a pandemic.


Importance  The coronavirus disease 2019 (COVID-19) pandemic has burdened health care resources and disrupted care of patients with cancer. Virtual care (VC) represents a potential solution. However, few quantitative data support its rapid implementation and positive associations with service capacity and quality.

Objective  To examine the outcomes of a cancer center–wide virtual care program in response to the COVID-19 pandemic.

Design, Setting, and Participants  This cohort study applied a hospitalwide agile service design to map gaps and develop a customized digital solution to enable at-scale VC across a publicly funded comprehensive cancer center. Data were collected from a high-volume cancer center in Ontario, Canada, from March 23 to May 22, 2020.

Main Outcomes and Measures  Outcome measures were care delivery volumes, quality of care, patient and practitioner experiences, and cost savings to patients.

Results  The VC solution was developed and launched 12 days after the declaration of the COVID-19 pandemic. A total of 22 085 VC visits (mean, 514 visits per day) were conducted, comprising 68.4% (range, 18.8%-100%) of daily visits compared with 0.8% before launch (P < .001). Ambulatory clinic volumes recovered a month after deployment (3714-4091 patients per week), whereas chemotherapy and radiotherapy caseloads (1943-2461 patients per week) remained stable throughout. No changes in institutional or provincial quality-of-care indexes were observed. A total of 3791 surveys (3507 patients and 284 practitioners) were completed; 2207 patients (82%) and 92 practitioners (72%) indicated overall satisfaction with VC. The direct cost of this initiative was CAD$ 202 537, and displacement-related cost savings to patients totaled CAD$ 3 155 946.

Conclusions and Relevance  These findings suggest that implementation of VC at scale at a high-volume cancer center may be feasible. An agile service design approach was able to preserve outpatient caseloads and maintain care quality, while rendering high patient and practitioner satisfaction. These findings may help guide the transformation of telemedicine in the post COVID-19 era.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: October 6, 2020.

Published Online: January 7, 2021. doi:10.1001/jamaoncol.2020.6982

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Berlin A et al. JAMA Oncology.

Corresponding Author: Alejandro Berlin, MD, MSc, Princess Margaret Cancer Centre, 700 University Ave, Office 7-317, Toronto, Ontario M5G 1Z5, Canada (alejandro.berlin@rmp.uhn.ca).

Author Contributions: Drs Berlin and Z. A. Liu had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Berlin, Lovas, Truong, Melwani, J. Liu, Badzynski, Morley, Bhattacharyya, Escaf, Moody, Goldfarb, Brzozowski, Cafazzo, Stewart, Krzyzanowska.

Acquisition, analysis, or interpretation of data: Berlin, Lovas, Truong, Melwani, Z. Liu, Carpenter, Virtanen, Morley, Bhattacharyya, Moody, Goldfarb, Cafazzo, Chua, Krzyzanowska.

Drafting of the manuscript: Berlin, Lovas, Truong, Bhattacharyya, Moody, Goldfarb, Chua, Stewart.

Critical revision of the manuscript for important intellectual content: Berlin, Lovas, Truong, Melwani, J. Liu, Z. A. Liu, Badzynski, Carpenter, Virtanen, Morley, Bhattacharyya, Escaf, Moody, Goldfarb, Brzozowski, Cafazzo, Stewart, Krzyzanowska.

Statistical analysis: Berlin, Z. A. Liu, Morley, Bhattacharyya.

Obtained funding: Berlin, Brzozowski, Cafazzo.

Administrative, technical, or material support: Berlin, Lovas, Truong, Melwani, J. Liu, Carpenter, Virtanen, Morley, Bhattacharyya, Escaf, Moody, Goldfarb, Brzozowski, Cafazzo, Krzyzanowska.

Supervision: Berlin, Lovas, Melwani, Virtanen, Bhattacharyya, Goldfarb, Cafazzo.

Conflict of Interest Disclosures: Dr Melwani reported receiving funding from the Princess Margaret Cancer Foundation at University Health Network. Dr Goldfarb reported receiving personal fees from Boehringer Ingelheim, McKesson, Creative Destruction Lab, and the Neighbourhood Pharmacy Association of Canada outside the submitted work; receiving grants from the Sloan Foundation, the Social Sciences and Humanities Research Council of Canada, the National Science Foundation, Google, WPP, the Net Institute, Plurimus Corporation, and the Social Science Research Council; running a consulting company, Goldfarb Analytics Corporation, that advises organizations on digital and artificial intelligence strategies; receiving payment for lectures from Amazon, Bloomberg, BMC, Boehringer Ingelheim, eBay, Facebook, Google, the Hospital for Sick Children, Indigo, INTACT, McKesson, Microsoft, Netflix, Neoway, the Neighbourhood Pharmacy Association of Canada, Pinterest, RBC, ScotiaBank, Sisense, and Zetta Venture Partners; serving as the chief data scientist at the Creative Destruction Lab; and holding shares in many technology and health care companies. Dr Krzyzanowska reported receiving grants and personal fees from Eisai, grants from Exelixis and Ipsen, and personal fees from Bayer outside the submitted work. No other disclosures were reported.

Funding/Support: This study was supported by the Princess Margaret Cancer Foundation.

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: This work would not have been possible without the trust of our patients and the instrumental and passionate engagement of the staff of the Princess Margaret Cancer Centre.

Pan American Health Organization.  Framework for the Implementation of a Telemedicine Service. Pan American Health Organization; 2016.
Dinesen  B , Nonnecke  B , Lindeman  D ,  et al.  Personalized telehealth in the future: a global research agenda.   J Med Internet Res. 2016;18(3):e53. doi:10.2196/jmir.5257PubMedGoogle Scholar
Hollander  JE , Carr  BG .  Virtually perfect? Telemedicine for Covid-19.   N Engl J Med. 2020;382(18):1679-1681. doi:10.1056/NEJMp2003539PubMedGoogle ScholarCrossref
Yu  J , Ouyang  W , Chua  MLK , Xie  C .  SARS-CoV-2 transmission in patients with cancer at a tertiary care hospital in Wuhan, China.   JAMA Oncol. 2020;6(7):1108-1110. doi:10.1001/jamaoncol.2020.0980PubMedGoogle ScholarCrossref
Liang  W , Guan  W , Chen  R ,  et al.  Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China.   Lancet Oncol. 2020;21(3):335-337. doi:10.1016/S1470-2045(20)30096-6PubMedGoogle ScholarCrossref
Stickdorn  M , Hormess  M , Lawrence  A , Schneider  J.   This Is Service Design Doing: Applying Service Design Thinking in the Real World: A Practitioners’ Handbook. O’Reilly Media Inc; 2018.
Institute of Medicine, Committee on Quality of Health Care in America.  Crossing the Quality Chasm: A New Health System for the 21st Century. National Academies Press; 2001.
Cox  A , Lucas  G , Marcu  A ,  et al.  Cancer survivors’ experience with telehealth: a systematic review and thematic synthesis.   J Med Internet Res. 2017;19(1):e11. doi:10.2196/jmir.6575PubMedGoogle Scholar
Smith  WR , Atala  AJ , Terlecki  RP , Kelly  EE , Matthews  CA .  Implementation guide for rapid integration of an outpatient telemedicine program during the COVID-19 pandemic.   J Am Coll Surg. 2020;231(2):216-222.e2. doi:10.1016/j.jamcollsurg.2020.04.030PubMedGoogle ScholarCrossref
Kasle  DA , Torabi  SJ , Savoca  EL , Judson  BL , Manes  RP .  Outpatient otolaryngology in the era of COVID-19: a data-driven analysis of practice patterns.   Otolaryngol Head Neck Surg. 2020;163(1):138-144. doi:10.1177/0194599820928987PubMedGoogle ScholarCrossref
Spiegelman  J , Krenitsky  N , Syeda  S , Sutton  D , Moroz  L. Rapid development and implementation of a Covid-19 telehealth clinic for obstetric patients. NEJM Catalyst [Internet]. 2020. Accessed September 4, 2020. https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0170
Lonergan  PE , Washington  SL  III , Branagan  L ,  et al.  Rapid Utilization of Telehealth in a Comprehensive Cancer Center as a Response to COVID-19. Health Informatics. 2020;
National University Cancer Institute of Singapore (NCIS) Workflow Team.  A segregated-team model to maintain cancer care during the COVID-19 outbreak at an academic center in Singapore.   Ann Oncol. 2020;31(7):840-843. doi:10.1016/j.annonc.2020.03.306PubMedGoogle ScholarCrossref
Mehrotra  A , Chernew  A , Linetsky  D , Hatch  H , Cutler  D . The Impact of the COVID-19 Pandemic on Outpatient Visits: A Rebound Emerges [Internet]. The Commonwealth Fund. 2020. Accessed September 4, 2020. https://www.commonwealthfund.org/publications/2020/apr/impact-covid-19-outpatient-visits
Flodgren  G , Rachas  A , Farmer  AJ , Inzitari  M , Shepperd  S .  Interactive telemedicine: effects on professional practice and health care outcomes.   Cochrane Database Syst Rev. 2015;(9):CD002098. doi:10.1002/14651858.CD002098.pub2PubMedGoogle Scholar
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience

Lookup An Activity


My Saved Searches

You currently have no searches saved.


My Saved Courses

You currently have no courses saved.