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\begin{document}

\title{Transition to a Virtual~ Multidisciplinary Tumor Board during the
COVID-19 Pandemic: The University of~ Pittsburgh Experience}



\author[1]{Harish Dharmarajan et al.}%
\affil[1]{Affiliation not available}%


\vspace{-1em}



  
  \date{May 18, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
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\selectlanguage{english}
\begin{abstract}
Multidisciplinary conferences (MDC) are an important component of head
and neck oncologic care including diagnosis, treatment, and
survivorship. Virtual MDC allows for improved collaboration between
providers at distant sites and proper allocation of healthcare resources
in a time of crisis. When approached systematically, a virtual MDC is
feasible to design and implement in a large academic medical center with
multiple satellite hospitals.%
\end{abstract}%



\sloppy


\textbf{Full author list}: Harish Dharmarajan, M.D.\textsuperscript{1},
Jennifer L. Anderson, M.D., Ph.D.\textsuperscript{1}, Seungwon Kim,
M.D.\textsuperscript{1}, Shaum Sridharan, M.D.\textsuperscript{1},
Umamaheswar Duvvuri, M.D., Ph.D.\textsuperscript{1}, Robert L. Ferris,
M.D., Ph.D.\textsuperscript{1}, Mario G. Solari,
M.D.\textsuperscript{1}, David A. Clump II, M.D.,
Ph.D.\textsuperscript{2}, Heath D. Skinner, M.D.,
Ph.D.\textsuperscript{2}, James P. Ohr, D.O.\textsuperscript{3}, Dan P.
Zandberg, M.D.\textsuperscript{3}, Barton Branstetter IV,
M.D.\textsuperscript{4}, Marion A. Hughes, M.D.\textsuperscript{4},
Katie S. Traylor, D.O.\textsuperscript{4}, Raja Seethala,
M.D.\textsuperscript{5}, Simion I. Chiosea, M.D.\textsuperscript{5},
Marci L. Nilsen Ph.D., R.N.\textsuperscript{1}, Jonas T. Johnson,
M.D.\textsuperscript{1}, Mark W. Kubik, M.D.\textsuperscript{1}

\textsuperscript{1}Department of Otolaryngology, University of
Pittsburgh Medical Center, Pittsburgh, PA

\textsuperscript{2}Department of Radiation Oncology, University of
Pittsburgh Medical Center -- Hillman Cancer Center, Pittsburgh, PA

\textsuperscript{3}Department of Medical Oncology, University of
Pittsburgh Medical Center -- Hillman Cancer Center, Pittsburgh, PA

\textsuperscript{4}Department of Radiology, Division of Neuroradiology,
University of Pittsburgh Medical Center, Pittsburgh, PA

\textsuperscript{5}Department of Pathology, University of Pittsburgh
Medical Center, Pittsburgh, PA

\par\null

\textbf{Funding} : There were no sources of funding for this project.

\textbf{Prior Presentations} : This project has not been presented or
published in prior meetings.

\par\null

\emph{Utility of a Multi-disciplinary Team Conference}

Considering the complexity of head and neck oncologic care, a
multidisciplinary team (MDT) approach in diagnosis, treatment, and
survivorship care is essential. The MDT is generally composed of a
diverse set of specialists: ablative and reconstructive surgeons,
radiation oncologists, medical oncologists, neuroradiologists,
pathologists, supportive and palliative care staff, speech language
pathologists, nutritionists, dentists, and physical and occupational
therapists\textsuperscript{1-4}. As head and neck oncologic staging and
treatment paradigms continue to evolve, there is a significant emphasis
on the value of a specialized multidisciplinary conference
(MDC)\textsuperscript{5}. The inherent purpose of MDC is to serve as a
quality checkpoint: to ensure a thorough evaluation of each case
regardless of the spectrum of care, whether pre-treatment, treatment, or
survivorship. This entails ensuring proper diagnosis, staging, treatment
planning, clinical trial enrollment, care coordination, management of
treatment complications, evaluating disease response, recurrence
monitoring, and survivorship outcomes\textsuperscript{4}. There is
strong evidence to suggest that MDC implementation may improve
pre-treatment evaluation (dental, nutrition)\textsuperscript{6}, proper
staging\textsuperscript{7,8}, and appropriate timely
treatment\textsuperscript{6-11}. It may also affect disease specific
survival\textsuperscript{11,12} and overall
survival\textsuperscript{10-15} but this is controversial. As MDC usage
has become more widespread, academic institutions are beginning to
evaluate MDC quality measures with respect to guideline adherence and
patient outcomes\textsuperscript{13}. Given its impact, MDC has become a
standard in head and neck oncologic care.

\emph{COVID-19 Pandemic and Fragmentation of Care}

Due to the COVID-19 pandemic, head and neck care coordination has been
dramatically altered. In these uncertain times, limitations with
clinical resources and healthcare office availability have made it more
difficult for head and neck cancer patients to obtain multidisciplinary
care. In the usual timeframe, a new head and neck cancer patient would
be able to meet all the members of the MDT, finish pre-treatment
diagnostic studies, and receive a consensus MDC recommendation within
the span of about two to three weeks. In the current scope of
telemedicine, there is concern for possible delays along any of these
timepoints as well as the time-interval from diagnosis to treatment
initiation. The ability of MDT and MDC to modify care coordination is
essential in a time of crisis. The MDT framework allows patients to be
referred in a timely fashion between a network of specialty providers;
this way patients from regions of low resource availability (i.e.
personnel, equipment, operating room availability) can be guided to
areas which are able to deliver timely oncologic care. The MDC is
fundamental to this care coordination model.

At our institution, the University of Pittsburgh Medical Center, there
are multiple distant hospital campuses spread out across three states,
Pennsylvania, New York, and Maryland (Figure 1). New patients may be
referred to the head and neck MDT from any of these locations. However,
it is often that such patients may see a local primary care physician or
general otolaryngologist before being referred for evaluation by the
UPMC Head and Neck MDT. Due to the COVID-19 pandemic, any delays which
are associated with this pathway are likely to be exacerbated. In the
past few weeks, the MDT has adopted hosting a virtual MDC which is
accessible to remote UPMC locations away from Pittsburgh, PA. The
concept is to streamline head and neck oncologic care such that patients
in any region of the hospital system would be able to obtain timely
diagnosis and treatment plans. The virtual MDC offers flexibility for
both providers and patients. Regardless of whether patients are awaiting
an initial MDT evaluation or definitive treatment, MDC discussions
empower patient-centric care so that current needs are matched in an
appropriate fashion with available system resources.

\emph{Prior Experience with Virtual Tumor Boards}

Virtual MDC has been employed in multiple settings including evaluation
of lung cancer\textsuperscript{16,17}, hepatocellular
carcinoma\textsuperscript{18}, breast cancer\textsuperscript{19}, GI
cancer\textsuperscript{19}, malignant hematology\textsuperscript{19},
general oncology\textsuperscript{20,21}, and head and
neck\textsuperscript{22}. Utilization of virtual MDC has been associated
with improved referral coordination\textsuperscript{20}, decreased
delays in diagnosis and treatment\textsuperscript{16,18,20}, higher
frequency of MDT evaluation\textsuperscript{18}, and reduced
patient\textsuperscript{18,20} and provider travel
burden\textsuperscript{16}. Reported challenges in implementing a
virtual MDC program include reliable technical
setup\textsuperscript{16,20}, increased length of virtual case
presentations\textsuperscript{21}, paucity of community provider
cases\textsuperscript{19,20}, delay in receiving supporting information
such as imaging and pathology slides\textsuperscript{19}, and cost of
virtual informatics infrastructure\textsuperscript{17}. Even with these
barriers, it appears that virtual MDC participants in general either
endorse or find it comparable to traditional in-person
meetings\textsuperscript{19,21}. However, the extent to which a virtual
MDC affects guideline adherence and patient outcomes in comparison to a
traditional MDC is yet to be studied. As more data becomes available
with regards to MDC quality improvement, these relationships will be
detected.

\emph{Virtual MDC Experience at University of Pittsburgh Medical Center}

UPMC conducts a weekly MDC to discuss care of head and neck cancer
patients. The MDT consists of providers from Otolaryngology-Head and
Neck Surgery, Medical Oncology, Radiation Oncology, Neuroradiology,
Pathology, Oral and Maxillofacial Surgery, Nursing, and Palliative and
Supportive Care. MDC was conducted primarily in person prior to the
COVID-19 pandemic. The conference was held in the Otolaryngology-Head
and Neck Surgery department conference room with an associated
teleconference line. Remote participants were able to join MDC via
teleconference but were not able to observe any of the imaging reviewed
during the conference.

During the present COVID-19 pandemic, MDC has been transitioned to a
remote, virtual format utilizing video teleconference via Microsoft
Teams. This format allows for both audio and video participation as well
as screensharing. Data shared through Microsoft Teams is secure, meeting
HIPAA compliance standards. In order to access the application, MDT
members must login via their institutional access; this prevents other
users from gaining access to the MDC. At the start of the meeting, the
neuroradiologist shares his or her screen, which allows attendees to
view radiological images that are reviewed during the conference. Screen
sharing of Microsoft PowerPoint slides also allows for brief
presentations on relevant clinical topics. MDC is organized by an
otolaryngology resident, who assembles the list of patients to be
presented at the conference. A preliminary list of patients is
distributed to the MDT at least 24 hours prior to MDC in order to allow
for providers to prepare for patient presentations. The organizer
distributes the final list to MDC participants and hosts the video
teleconference. Additionally, the chair of Otolaryngology-Head and Neck
Surgery helps to lead patient discussions. Notes summarizing the MDC
discussion and final recommendations are placed in each patient's chart
at the conclusion of the conference.

\emph{Early Impressions of the Virtual MDC}

UPMC has conducted three fully remote MDC sessions. A brief survey was
distributed to participants in order to query opinions regarding the new
format. Responses were obtained from 19 participants from a variety of
specialties including Otolaryngology-Head and Neck Surgery, Medical
Oncology, Radiation Oncology, Neuroradiology, and Pathology (Table 1).
Survey respondents included both attending physicians and graduate
medical trainees. Most respondents had attended at least two virtual MDC
sessions (84.2\%). The majority of respondents (57.9\%) indicated they
preferred the virtual MDC format compared to the traditional in-person
format. Furthermore, a majority of respondents (78.9\%) also indicated
they preferred to continue the virtual MDC format once in-person meeting
restrictions have been lifted. Virtual MDC and in-person formats were
felt to facilitate patient discussion with similar ease.

\emph{Advantages and Disadvantages of a Virtual MDC}

A virtual MDC improves ease of attendance, particularly for off-site
providers. This encourages greater participation for community
providers. Our most recent virtual MDC allowed the inclusion of
additional providers from a UPMC campus 200 miles from our main center
in Pittsburgh. Additionally, eliminating the need to travel from local
hospitals within the UPMC system decreases time and burden previously
required for providers to attend MDC. The virtual format provides
flexibility to on-site providers as well, which promotes attendance.
Images are more easily viewed by both the neuroradiologist and MDC
participants when a virtual format is employed. Furthermore, by
attending MDC at their workstation, providers have real time access to
patient records, which can be reviewed to assist with clinical decision
making.

One disadvantage of a virtual MDC is the lack of personal interaction
during discussions of patient care. This results in decreased
camaraderie between providers across specialties. Additionally,
interactive conversations with multiple speakers can be challenging
using the videoconferencing software. Software difficulties including
difficulty with screen sharing and audio were challenges primarily
during the first virtual MDC sessions. However, this has been improved
in subsequent sessions. Finally, some participants found it more
difficult to follow the list of patients discussed during virtual MDC.

\emph{Recommendations for Hosting a Virtual MDC}

In order to transition from a traditional to a virtual MDC framework, we
suggest using the ``Model for Improvement'' created by the Associates in
Process Improvement\textsuperscript{23}. This methodology entails a
cyclic four step process: plan, do, study, and act. This will help to
ensure the reliability and accuracy of a virtual MDC setup. Summarized
below are the corresponding sections for each process step.

\begin{enumerate}
\tightlist
\item
  Virtual MDC Planning The dedicated MDC organizer should meet with the
  institution's IT staff to brainstorm ideas for the virtual MDC.
  Questions to consider include the cost of implementation, necessary IT
  infrastructure, security measures, number of participants anticipated,
  feasibility, ease of collaboration across MDT, and approximate
  timeline for implementation. Once these essential topics are addressed
  and discussed with MDT leadership, the organizer should proceed to
  hosting a few trial MDC sessions in lieu of the weekly traditional
  meetings. A simple survey addressing the ease of communication,
  participant preferences, and comments may then be conducted. This will
  help to gauge the degree of buy-in from MDT members at the onset of
  the project. Based on the survey responses, we encourage discussion
  within the MDT regarding the specific advantages and disadvantages to
  implementing a virtual MDC. We anticipate that if there is a
  significant preference for one format, there will be strong support
  from MDT leadership to institute such a system.
\item
  Virtual MDC Implementation There are several factors which affect the
  degree to which MDT members can interact in a virtual setting: time,
  ability to hear colleagues, visualize case imaging, and see other MDT
  members\textsuperscript{24}. The organizer must find the best time to
  host the virtual MDC so that as many MDC members can participate as
  possible. In addition, all MDT members need adequate time to prepare
  for case discussions; thus, new case submissions and the meeting
  agenda should be finalized at least a day in advance permitting
  same-day case additions if needed. On the matter of virtual MDC
  workflow in comparison to traditional meetings, Kane and Luz found
  that teleconferencing was associated with a greater time spent per
  case (147\%), increased participant turn duration and total
  attendance, decreased number of total participant turns per minute and
  percent of informal conversation\textsuperscript{25}. Patients with
  advanced T and N staging will require more discussion and time
  allocation as compared to those with early stage disease whose
  treatment may be planned via a protocol\textsuperscript{26}. Thus, it
  would be beneficial to prioritize discussion of advanced stage and
  complicated cases earlier in the teleconference when all members are
  available. Virtual MDC can be set up to allow either one or more MDT
  members to talk at once. However, it is often the case that there is
  one MDT member who has the floor at any given time while other
  participants are muted in order to reduce background noise. In this
  way, the speaker's dialogue is easily understandable. Sometimes, in
  traditional settings, there is risk of multiple people speaking at
  once or poor voice projection across the room (i.e. room acoustics or
  variable seating arrangements) that may make the meeting's sound
  quality inconsistent. With the virtual MDC, participants may have to
  wait a bit longer to respond to discussions rather than speaking in
  freeform, which would be the standard in traditional meetings. If the
  teleconference connection quality is reliable, there should not be any
  problems with MDT members hearing their colleagues. We recommend a
  virtual MDC setup in which individual MDT members can share their
  computer screen with others. In this manner, the MDT radiologist
  should be able to access individual patient scans and share them on a
  single centralized display. This tremendously improves the ease of use
  for the radiology team. The radiologist can prepare the pertinent
  imaging slides ahead of time and be ready to share this information
  rather than having to reload all the images on a new computer at the
  meeting hall. In a similar fashion, the pathologist may be able to
  share the final pathology report, stains, or any pertinent microscopy
  findings with the entire team. If there is any need to verify case
  information, participants can check the electronic medical record in
  real time as well. In terms of seeing other MDT members, individuals
  can choose to utilize videoconferencing, but the informal
  conversations in a traditional meeting are hard to replicate in a
  virtual setting. If interested, MDT leadership may choose to hold a
  once monthly or quarterly in-person meeting to support the team
  camaraderie.
\item
  Assessing Virtual MDC Performance In order to evaluate the quality
  metrics of a virtual MDC, there must be proper, systematic data
  collection. It is vital that each case discussed at the MDC have
  documentation linked with the patient's electronic medical record.
  This information should be accessible to all MDC participants in case
  specific members are unable to attend a session. The documentation
  system should be design in a systematic manner and be
  goal-oriented\textsuperscript{27}. If data recording is standardized,
  the MDC case database will serve as a central resource for reviewing
  patient diagnostic pathways, treatment plans, outcomes, and guideline
  adherence. This has immense implications for analyzing patient data
  across the spectrum of care including survivorship. There are a few
  options for building a virtual MDC documentation database.
  Rangabashyam \emph{et al} . utilized the REDCap web application,
  Research Electronic Data Capture (https://www.project-redcap.org/), in
  order to document each aspect of MDC case presentation: scheduling,
  biodata, diagnosis, presentation, imaging, histopathology, management
  plan, MDC discussions and decisions\textsuperscript{28}. This system
  proved to be efficient as it could be embedded into the existing
  electronic medical record system. A few institutions have developed
  methods to independently assess MDC. Harris \emph{et al} . implemented
  an MDT meeting observational tool (MDT-MOT); this rating system
  allowed observers to evaluate ten different teamwork domains pertinent
  to the MDC and had good criterion validity\textsuperscript{29}.
  Virtual MDC can be assessed in terms of process and outcome
  measures\textsuperscript{30}. Process measures include time interval
  to case presentation from initial request, percentage of relevant
  member participation, and overall attendance. Outcome measures include
  percentage of cases following MDC recommendations, correlation of MDC
  recommendations with guidelines, time to treatment initiation,
  disease-specific and overall survival, and patient quality of life and
  satisfaction. Regardless of the methodology in assessing virtual MDC,
  the underlying principle is to have each institution critically review
  its own MDC and the outcomes associated with its discussions.
\item
  Process Modifications Based on data analysis from the virtual MDC
  sessions, quality improvement projects can be appropriately tailored.
  There are many areas to focus on including preventing delays in
  treatment or referrals and improving adherence to MDC recommendations.
  The expectation is that each of these new quality improvement projects
  will also follow the ``plan, do, study, and act'' process.
  Furthermore, adjustments can be made to the virtual MDC setup if data
  analysis shows that there is a specific area of weakness that can be
  addressed.
\end{enumerate}

\emph{Next Steps}

Virtual MDC is feasible to design and implement in a large academic
medical network. We are currently working to establish connections with
the entire network of UPMC hospitals so that head and neck oncologic
care can be centralized, especially in times of crisis. Changing from a
traditional to a virtual MDC will require us to revisit the methods of
electronic documentation and subsequent data use in tracking outcomes.

\par\null\par\null\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

\end{center}
\end{figure}

Figure 1. UPMC System Map

Listed is the approximate distance to satellite hospitals (in miles)
from Pittsburgh, PA, and the estimated driving time in hours.

\par\null\par\null\selectlanguage{english}
\begin{table*}[H]
\centering
\normalsize\begin{tabulary}{1.0\textwidth}{CCCC}
Table 1. MDC participant survey responses &  &  &  \\
 &  &  &  \\
 &  & Number & Percentage \\
Role in MDC & Otolaryngologist & 9 & 0.47 \\
 & Medical Oncologist & 2 & 0.11 \\
 & Radiation Oncologist & 3 & 0.16 \\
 & Neuroradiologist & 4 & 0.21 \\
 & Pathologist & 1 & 0.05 \\
 & Palliative and Supportive Care & 0 & 0 \\
Graduate Medical Trainee & No & 15 & 0.79 \\
 & Yes & 4 & 0.21 \\
Number of virtual MDC attendend & One & 3 & 0.16 \\
 & Two & 7 & 0.37 \\
 & Three & 9 & 0.47 \\
MDC format preference & Virtual & 11 & 0.58 \\
 & In-person & 5 & 0.26 \\
 & No preference & 3 & 0.16 \\
Ease of format & Virtual easier & 6 & 0.32 \\
 & In-person easier & 6 & 0.32 \\
 & Same ease for both virtual and in-person & 7 & 0.37 \\
Format preference for future MDC & Virtual & 15 & 0.79 \\
 & In-person & 4 & 0.21 \\
\end{tabulary}
\end{table*}Table 1. MDC participant survey responses

\par\null

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{\label{775366}}

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