Revolutionizing Rheumatology: Exploring the Impact of Telemedicine in Transforming Care

Telemedicine was catapulted into mainstream care near the beginning of the COVID-19 pandemic. As public health measures including lockdowns relegated individuals to home and temporarily limited in-person care services, many providers began to offer remote visits for patients when a face-to-face consultation was unfeasible. Physicians could now provide care via video, telephone, mobile health applications, digital therapeutics programs, self-sampling, wearables, and automatic voice assistant systems.

The benefits of telehealth are clear, such as reducing travel time and increasing flexibility and access to care. Rheumatic disease, particularly pediatric patients, has served as a proving ground for this technology as these patients often reside in areas where the availability of rheumatologists is severely limited. In the United States, for example, 6 states only have 1 pediatric rheumatologist, and 9 states have none.¹

But telemedicine is not without its challenges. Experts cite unfamiliarity with technology and access to internet as drawbacks to remote care, particularly for older patients and those who are less tech-savvy. Others detail limitations in managing patients with uncontrolled symptoms and severe disease activity.

As the field moves into a post-pandemic world, the future of telemedicine hangs in the balance.

Benefits of Telemedicine in Rheumatology

Paula Smith, PhD, a senior lecturer at the University of Bath, noted to HCPLive the stressors associated with traveling to medical centers, such as parking and expenses. By reducing the need for physical visits and providing convenience to patients who have to travel long distances, telemedicine has the potential to alleviate some of that hassle.

Telemedicine also eliminates the need for office staff and infrastructure for in-person visits. It allows for more flexibility in scheduling appointments, including evenings and weekends, without requiring additional staff support.

Many, like Susan Manzi, MD, MPH, professor of medicine and chair of the Medicine Institute at Allegheny Health Network, had no experience in telemedicine prior to the COVID-19 pandemic. However, Manzi found telemedicine to be a silver lining of the pandemic by offering a way to reach patients who may not have access otherwise.

“It also provides insight into patients' home lives and allows for input from family members who would not have been present during an in-person visit,” Manzi told HCPLive. “I continue to offer telemedicine appointments, and many of my patients now prefer a combination of video and in-person visits.”

Faisal Parlindungan, Sp.PD-KR, of the rheumatology division in the department of internal medicine, at the University of Indonesia Faculty of Medicine, echoed this approach to telehealth. He explained to HCPLive how some of his patients still prefer telemedicine because they can fit a consultation into their busy work schedules. Parlindungan emphasized telehealth appointments are hugely beneficial for stable patients requiring a routine follow-up visit. It’s also an effective way to monitor a patient’s responses to therapy, to assess disease activity, and to offer the chance to discuss any issues regarding their condition.

Manzi hopes the next generation of rheumatologists will embrace telemedicine even more, as they have real-world evidence to better understand its benefits. In specialties like pediatric rheumatology, where families often have to travel long distances, telemedicine can significantly improve access to care and reduce burdens on patients and their families.

During the early days of the pandemic, telehealth was the only option as in-person clinics were shutting down and access to healthcare and research became limited. Courtney Wells, PhD, MPH, assistant professor and field director of the University of Wisconsin-River Falls, touted the benefits of being able to reach people more easily. Regarding a study she and her team conducted in the early days of the pandemic, she noted “it was fascinating to connect with individuals from different parts of the country and hear about their experiences, such as those in rural Alabama, compared to my location in Minnesota.”

Felix Mühlensiepen, PhD, MPH, of the Center for Health Services Research in the Faculty of Health Sciences at Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany, pointed to the significance of telemedicine emerging just as the field of rheumatology was encountering an inflection point of increasing cases and decreasing specalists.

“Given the increasing prevalence of rheumatic diseases and the significant shortage of rheumatology healthcare professionals, synchronous and particularly asynchronous telemedicine, and other digital health services help ensure that high-quality rheumatology care continues to be available,” he explained.

Despite all its advantages, telehealth is not a one-size-fits-all option for rheumatology.

Challenges and Considerations

The limited ability to perform physical examinations may result in the oversight of certain aspects of a patient’s condition, which Mühlensiepen warned this may even impact the patient-doctor relationship. Further, certain patients may require additional tests and results to diagnose and plan treatment, leading to increased referrals for scans and blood tests.

Parlingdungan explained that he prefers to provide telemedicine consultation options to patients with “established diagnosis and in stable condition.”

“For new patients, I suggest a direct consultation be made as soon as possible after the initial telemedicine consultation,” Parlingdungan said.

Moreover, telephone consultations still require preparation time and may not significantly reduce the overall workload. Communication difficulties could arise due to poor telephone connections, hindering patients with hearing impairments, or preventing the involvement of family members who could provide valuable information. Smith and Manzi noted older patients and those unfamiliar with technology might face challenges in adopting such platforms.

Some individuals expressed reservations about telemedicine, citing issues with inadequate access to reliable WiFi. These patients may not have been familiar or comfortable with sharing their health information through technological platforms. However, according to research conducted by Wells and her team, most people were eager to receive care in any way possible, and telemedicine was a crucial option available during that time.

Research in Telehealth

Smith collaborated with Fiona Gillison, PhD, professor in the Department for Health at the University of Bath, on a qualitative study focused on the impact of telemedicine using telephone consultations. As part of the study, investigators interviewed healthcare professionals and patient groups in rheumatology, cardiology, gerontology, and dermatology, among others, to understand the effects of telemedicine.

Their findings demonstrated telemedicine, specifically telephone consultations, proved to be beneficial for patients with stable rheumatic diseases during maintenance visits, with patients who were comfortable and able to communicate effectively over the phone were more likely to find this approach helpful.² However, investigators cautioned it was not deemed suitable for initial consultations, as a physical examination is often necessary for new referrals.

Many doctors began researching the potential benefits of telemedicine as a direct result of the COVID-19 pandemic. Some, like Parlindungan, had never used remote consultations prior to the lockdowns in 2020. Now, he and other rheumatologists find telemedicine to be a valuable asset to routine care, particularly for existing patients and those with stable disease activity.

His work evaluated telemedicine in rheumatology among a cohort of Indonesian patients, including the reception of telemedicine, treatment interruptions, and health care disruptions. Results found telemedicine was able to successfully address barriers to care access both during and after the pandemic.³

Another recent systematic review of randomized controlled trials demonstrated that telerehabilitation can improve the symptoms of quality of life, depression, and pain intensity and catastrophizing in adult patients with fibromyalgia.⁴

“Telerehabilitation can provide accessible and continuous rehabilitation medical services for patients with fibromyalgia who cannot attend traditional face-to-face services or are geographically remote, and it could enable patients to manage their disease at any time and place in a timely and appropriate manner,” investigators noted.

What is the Future of Telemedicine in Rheumatology?

“Telemedicine is here to stay,” Smith said. “Government and hospital directives aim to increase its use to accommodate the growing number of referrals. However, there will likely be a need for refinement in determining which patients are suitable for telemedicine. Repeat visits for clinically stable patients may be more appropriate, while first visits would still require face-to-face consultations.”

Smith believes the most significant ongoing challenge in optimizing potential of telemedicine lies in accurately identifying patients who can benefit from remote care versus those who necessitate in-person assessments.

Manzi hopes telemedicine will continue to grow as society shifts towards remote work and patients become more comfortable with telemedicine because of the pandemic. She emphasized many patients now question the need to travel long distances, take time off work, and incur expenses for in-person visits.

Telemedicine could prove invaluable in remote areas with limited access to rheumatologists. Although in-person visits will always have their importance, many feel a hybrid model offering telemedicine as an option would increase a practice’s capacity to accommodate a larger number of patients, reduce no-shows, and provide care to underserved regions.

Parlindungan also highlighted the potential of telemedicine for research purposes, such as monitoring the effectiveness of therapy with patient-reported outcomes without the need for in-person consultations. Additionally, he noted the development of artificial intelligence could greatly advance the field of telemedicine.

“The field of rheumatology care is currently undergoing a digital transition, serving as a role model for other medical specialties,” Mühlensiepen said. “Telemedicine, (mobile) health, and other digital health approaches are gaining increasing prominence in international annual meetings.”

Although a proponent of expanded use, Mühlensiepen emphasized the importance of understanding and analyzing the perspectives of both patients and healthcare professionals regarding the implementation of telemedicine and digital health services in rheumatology care. He suggests incorporating user-centered research to better understand the experiences and needs of all stakeholders and involve users when developing these innovative care approaches.

“By prioritizing user perspectives, we can ensure that telemedicine and digital health solutions effectively meet the requirements and expectations of those they aim to serve,” he said.

Although it will take time to identify and evaluate the most effective solutions for supporting rheumatology care, it is evident to many of the key opinion leaders in rheumatology telemedicine will continue to play a significant role in the field and have eyes set on the future.

References

1. ^{Arthritis Foundation. (n.d.). Pediatric rheumatologist workforce shortage map - arthritis foundation. Pediatric Rheumatologist* Workforce Shortage Map. Retrieved February 25, 2023, from https://www.arthritis.org/getmedia/e13d8176-cac4-4780-a0fd-cdc72d48838f/pediatric-rheumatologist-shortage-map-022019.pdf}
2. ^{Grey E, Brown F, Smith P, et al. Patient-clinician dynamics in remote consultations: a qualitative study of cardiology and rheumatology outpatient clinics in the UK. BMJ Open. 2023;13(5):e070923. Published 2023 May 30. doi:10.1136/bmjopen-2022-070923}
3. ^{Parlindungan F, Sumariyono S, Hidayat R, et al. Learning from the COVID-19 pandemic: health care disturbances and telemedicine as an alternative rheumatology practice in Indonesia. BMC Health Serv Res. 2023;23(1):451. Published 2023 May 8. doi:10.1186/s12913-023-09389-5}
4. ^{Pine L. Telerehabilitation improves quality of life in patients with fibromyalgia. HCPLive. https://www.hcplive.com/view/telerehabilitation-improves-quality-of-life-in-patients-with-fibromyalgia}