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REVIEW ARTICLE
Year : 2022 | Volume
: 17
| Issue : 7 | Page : 394-401
Telerheumatology during the COVID-19 pandemic: Impact on clinical practice, education, and research
Su Ann Yeoh1, Anastasia-Vasiliki Madenidou2
1 Centre for Rheumatology, Division of Medicine, University College London, London, UK
2 Department of Rheumatology, Salford Royal Hospital, Salford, UK
Correspondence Address:
Dr. Anastasia-Vasiliki Madenidou
Department of Rheumatology, Salford Royal Hospital, Stott Ln, Salford M6 8HD
UK
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/injr.injr_229_21
Telerheumatology, the use of telemedicine in the provision of rheumatology care, has been on the periphery of rheumatology practice for several years. However, the need for remote rheumatology service has emerged during the COVID-19 pandemic in order to help prevent the spread of the virus. EULAR and ACR published guidelines to address the rheumatological clinical needs safely. Synchronous and asynchronous telemedicine, including remote patient-monitoring systems, were used. The majority of telerheumatology studies focus on rheumatoid arthritis, which is reflective of the caseload in the rheumatology clinic. Connective tissue diseases are likely to pose more challenges for telemedicine use, given its multi-organ involvement and heterogeneity. The benefits of telemedicine include patient safety, minimizing travel time and time off work, and the evidence of patient satisfaction has supported this. On the other hand, the lack of clinical examination and privacy is a concern which patients might have about receiving telerheumatology care. Physicians are more comfortable providing telemedicine consultations for already-established patients, especially those with stable disease, and less with new patients. Rheumatology training has been disrupted, and rheumatology trainees were required to rapidly adapt their practices to telemedicine as outpatient clinics transitioned to virtual clinics. Tele-education and virtual rheumatology conferences have enabled education to be delivered in a more inclusive way. In conclusion, it is likely that hybrid models will be adopted for patient care after the pandemic. However, it is imperative that the patient is at the center of future telerheumatology service design.
Keywords: COVID-19, rheumatic diseases, rheumatology, telehealth, telemedicine
Telemedicine is a rapidly evolving field in health care, and various definitions exist to encompass the multiple purposes of telemedicine technology in health care. The World Health Organization defines telemedicine as “The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities.”[1] Telerheumatology, the use of telemedicine to provide rheumatology care, is not a new concept, and its use has increased over the past decade. Telerheumatology uptake has been variable and prior to the pandemic, telerheumatology mainly served as a potential solution for specialist shortage and a way of providing care to remote communities such as in Alaska and Australia.[2],[3] The novel coronavirus (COVID-19) pandemic has functioned as a catalyst, casting telerheumatology in the limelight as a means to deliver patient care remotely.
Here, we discuss the role telemedicine has played in rheumatology clinical care, training and education, and research, especially during the COVID-19 pandemic and the potential benefits and challenges.
GuidelinesThe rapidity of the COVID-19 pandemic necessitated guidelines to address rheumatological clinical needs safely. EULAR guidelines during the COVID-19 pandemic recommend that in-person consultations and regular blood monitoring can be postponed (to a maximum of 6 months) for patients with stable rheumatic diseases and those already safely established on anti-rheumatic drugs, with remote consultations if required.[4] The guidelines discourage communication by email due to privacy issues, unless approved secure communications systems are in place. EULAR guidelines also recommend a joint approach in decision-making to weigh the risks of an in-person visit against the limitations of telemedicine for patients who may require an in-person consultation (e.g., those with active disease, those who have recently started treatment, requiring dose adjustment, or those displaying evidence of drug toxicity).[4] In addition, an ACR working group published strategies to enable rheumatoid arthritis (RA) disease activity and functional status to be performed in a telemedicine setting to enable monitoring of RA patients during the pandemic. Patient questionnaires for functional status (e.g., Health Assessment Questionnaire [HAQ]-II, MDHAQ) and disease activity scores (e.g., Patient Activity Scale PAS-II) did not require significant modification. However, for disease activity scores such as Simplified Disease Activity Index (SDAI) and Disease Activity Score (DAS-28) scores, modifications to allow for telehealth monitoring include replacing provider-reported joint counts with patient-reported counts. If testing of acute phase reactants is not feasible, Crohn’s disease activity index may be used in the place of SDAI, and DAS-28 scores may also be calculated without acute-phase reactants.[5] For pediatric rheumatology, the ACR recommended that consideration should be made for telemedicine-based clinical assessment and treatment during the pandemic,[6] with already-existing American Telemedicine Association “Operating Procedures for Pediatric Telehealth” as a guide.[7]
Telemedicine Protocol Created during COVID-19In line with guidelines, telemedicine was either introduced in services which did not utilize this prepandemic or reconfigured. Examples include a Colombian ambulatory care cohort of 5597 patients with RA who were converted to telemedicine care. Patients were given the option of consenting to teleconsultation, requesting an in-person consultation or to decline a consultation. This model used a standardized protocol of assessment of RA, including using Patient Activity Score (PAS) and HAQ and COVID-19 symptoms. In-person consultations were arranged for those thought to have high disease activity through telemedicine.[8] Other centers with well-established virtual monitoring infrastructures, such as in Singapore, expanded their workforce to accommodate the increase in demand for telemedicine,[9] whereas some reconfigured their service to incorporate a protocol with the purpose of screening patients to determine whether urgent in-person clinic was required, while conducting a consultation to address disease-related symptoms and COVID-19 symptoms,[10] and telemedicine platforms integrated into medical records were introduced to improve real-time interaction and sharing medical record/results with patients.[11] Some services also prioritize new patient appointments for in-person consultations, while follow-up appointments are telephone consultations.[12] In addition, the mandated in-person joint counts for biologics prescription applications were temporarily relaxed by some services.[13]
Modalities of TelemedicineSynchronous
Synchronous telemedicine involves real-time interaction either between provider and patient or between provider and presenter at a remote site who is conducting an in-person consultation with the patient.[14] This includes telephone consultations and videoconferencing. Multiple videoconferencing platforms have been reported to be used including Zoom, InTouch, Doxy.me, Google Hangouts, Apple Facetime, Skype, Updox, VSee, WhatsApp, Telegram, and Messenger. The telecommunications platform used also depends on infrastructure and local trends of platform use, i.e., WhatsApp, to provide patient care in India[15] and Africa,[16] and WeChat in China,[17] and also local regulations. Allowances were also made for certain platforms, which are not usually approved under regulations, to be used.[18]
Nurse-led advice helplines and virtual monitoring clinics had been in place even pre pandemic and increasingly practised to provide a streamlined rheumatology service.[19] In some countries, rheumatologists already had prior experience with telephone consultations pre pandemic, as described in a Dutch survey of rheumatologists’ telemedicine use during COVID-19.[20] In the United Kingdom, the pandemic necessitated a shift from physician in-person consultations to telemedicine, in particular telephone visits.[21]
Asynchronous
Asynchronous telemedicine does not involve real-time interaction.[14] Examples include email exchanges, store and forward referrals/consultations, electronic consultations (e-Consults),[22] and more recent systems such as remote patient monitoring systems and mobile health applications.[23]
Nurse-led advice helplines can also be administered asynchronously, through which patients can get in contact with their local rheumatology team when needing advice or experiencing a flare.
Interdisciplinary working
Collaborative working between specialties within a hospital setting using telemedicine has been demonstrated during the pandemic, such as in the case of rheumatologists providing remote consultations to the thoracic medicine/surgery team for rapidly deteriorating COVID-19 patients with cytokine storm in a timely manner.[24] Telemedicine modalities which bridge primary care and hospital medicine – such as e-Consults which allows primary care providers to obtain patient-specific advice from specialties using secure electronic platforms – have been found to increase during the pandemic. However, there was also an increase in recommendation of a subsequent specialty appointment following these specialty e-Consults, especially for specialties such as rheumatology, suggesting that e-Consults may not be a replacement for specialty review during the pandemic.[22]
Remote patient monitoring systems
Examples include a randomized controlled trial using “SATIE-PR” application pre-COVID-19: smartphone application connected with dynamometer for handgrip strength and analyzed in conjunction with patient self-reported Routine Assessment of Patient Index Data 3 (RAPID-3), tender and swollen joints, and general questions (fever, medication changes, flares, pain visual analog scale) and laboratory data received from the patient.[25]
Reumanet Bernhoven is an eHealth platform in the Netherlands which records patient medical data, allows patients to monitor their disease activity with patient-reported outcome measures (PROMs), provides patient education and lifestyle advice, and in addition also contains a messaging function for patients to contact their health provider. RA patients in remission or low disease activity who utilized this eHealth platform were then integrated into a self-management outpatient clinic which allowed them to self-manage their RA and reduce the frequency of visits.[26]
During COVID-19, a short messaging system tool co-designed by RA patients to supply monthly Rheumatoid Arthritis Impact of Disease (RAID) scores to their care provider had also been used, with a bi-directional text functionality to allow communication with their provider if input is required.[27]
Other modalities which complement remote patient care include mobile health technology (smart phone health trackers, wearable technology), telemonitoring of kinesiotherapy for hand function,[28] disease-specific content accessed via websites, social media, patient forums, and patient education/self-management videos. An interactive biologic self-injection education video was implemented by a service in the United Kingdom to support transition of patients receiving intravenous tocilizumab to subcutaneous delivery during the pandemic and demonstrated to be feasible and cost-effective.[29]
Multidisciplinary team (MDT) and Health SystemsThere is a paucity of data on how telemedicine is being used by rheumatology nurses and allied health professionals during COVID-19 to meaningfully analyze the effectiveness and practitioner/patient acceptance of these services. The Virtual Monitoring Clinic in a hospital in Singapore is run by advanced practice nurses and pharmacists trained to conduct tele-consultations, request blood tests, and prescribe medications for patients with a range of rheumatological conditions including inflammatory arthritis, gout, and connective tissue diseases, and this setup enabled the service to be well-positioned during the COVID-19 pandemic to enable patients to be monitored safely while maintaining safe-distancing.[9] An audit of telephone follow-up appointments of a small United Kingdom podiatry department cohort of postintervention patients performed pre pandemic has reported that this could be a feasible and potentially cost-effective measure.[30] However, to understand how rheumatology as a whole has been affected by the increase in telemedicine and its role in future service design, further study of telemedicine service use by other rheumatology health-care professionals is warranted.
Rheumatic ConditionsThe majority of telerheumatology studies focus on inflammatory arthritis, specifically RA, which is reflective of the caseload in the rheumatology clinic and the availability of validated PROMs for disease activity monitoring such as RAID and RAPID3 scores. A study investigating the association between RAID scores and DAS28-CRP showed that 97% of those with RAID scores of <2 were in remission (DAS28-CRP <2.4) and 98.5% were in low disease activity/remission states (DAS28-CRP ≤2.9)[31] suggesting that this may be feasibly used in a telerheumatology setting.
Less so has been reported about axial spondyloarthritis (SpA), but this may be feasible with the Bath Ankylosing Spondylitis Disease Activity Index and Bath Ankylosing Spondylitis Functional Index scores, although physical examination elements such as the Schober’s test are more challenging.[32] In Canada, telemedicine has been used to provide a service for osteoporosis patients,[33] which relies less on clinical examination in comparison to other rheumatic conditions.
A study among Veteran Affairs physicians showed that some rheumatological conditions are considered to be the most appropriate modality for telephone telemedicine visits, such as gout, osteoporosis, polymyalgia rheumatica, stable RA and SpA, and osteoarthritis, whereas in-person follow-ups were considered the best modality for lupus, scleroderma, or vasculitis, requiring immunosuppression or glucocorticoid dose changes, or RA/SpA requiring active medication changes.[34] Connective tissue diseases (CTDs) are likely to pose more challenges for telemedicine use, given its multi-organ involvement and heterogeneity, as well as some treatments requiring hospital attendance for infusion treatments.[14] However, management of CTD may be feasible for a short period of time, for example, during COVID-19, telemedicine was used to provide care for systemic sclerosis patients who were not able to reach the hospital through a variety of modalities including video call, telephone, email, Skype as well as a triage for potential COVID-19 infections prior to a hospital visit.[35]
PediatricsVideo tele-consultations may be appropriate for established patients, and while this may not be suitable for young patients, remote consultation with their parent/caregiver may be appropriate to discuss symptoms or drug side effects. It has been suggested that virtual examination may be appropriate for some patients, such as video pediatric Gait Arms Legs Spine (video-pGALS), a modification of the pGALS assessment which includes components from the pediatric Regional Examination of the Musculoskeletal System, and the Childhood Myositis Assessment Score. The parent/caregiver may also supplement the assessment with information such as presence of swelling or warmth.[36] However, it is recognized that video consultations may pose unique challenges when it comes to certain circumstances such as discussing sensitive topics with the patient without the parent/caregiver present, or the lack of nonverbal cues complicating assessment of potential safeguarding concerns around child abuse.[37]
Benefits, Effectiveness, and AcceptabilityTelemedicine has been purported to have potential benefits to address workforce shortages or disparities in the distribution of rheumatologists. Waiting times for a rheumatology consultation may be reduced using telemedicine potentially as a triage tool to select patients who require further investigations, such as in the case of E-consults for positive ANA.[38]
Telemedicine also offers the potential of redesigning in-person visits to occur as directed by patient outcomes and changes in clinical/functional scores rather than predefined scheduling, where an appointment may be arranged when there is less of a clinical need rather than at a point where an appointment would have maximum value and impact. In a prepandemic systematic review, telemedicine has been found to be effective[39] and has also been reported to be noninferior to in-person consultation, in particular for follow-up of established RA patients.[32] A study on a Swiss cohort reported no worsening of patient-reported outcomes in RA, SpA, and PsA via a web app during the COVID-19 lockdown period (which resulted in a rapid drop in in-person consultations and an increase in the web app usage) compared to prepandemic.[40] More recently, a randomized controlled trial of “connected monitoring” using a smartphone application which records and sends patient-entered data to an investigative team which monitors remotely and determines the need for a phone or physical visit, compared to the control group (physical routine monitoring), reported fewer physical visits in the connected monitoring group with no differences in clinical and functional outcomes.[25]
“Wasted” slots due to “no-shows” or appointment cancellations may be circumvented by telemedicine consultations and improve patient attendance.[41] A retrospective observational study in systemic sclerosis patients demonstrated a higher proportion of patients who did not use telemedicine had discontinued treatment during COVID-19 on their own accord compared to those who accessed telemedicine, suggesting that telemedicine may be used to encourage treatment continuation/adherence or recommencement.[42]
The benefits of telemedicine have also been supported by evidence of patient satisfaction of telerheumatology pre-pandemic[23] as well as during the COVID-19 pandemic.[32] Most patients across a range of rheumatic diseases were satisfied with their routine face-to-face appointment being switched to virtual consultations during the COVID-19 pandemic.[21],[43],[44] Virtual consultations were also well received by new patients after excluding those with early inflammatory arthritis and other urgent conditions. However, a smaller percentage (up to 60%) considered further virtual consultations to be acceptable,[45] with virtual consultations better received by patients with low disease activity.[46] The benefits included patient safety during the pandemic, convenience, minimizing travel time, and therefore, time off work.[3] Reassuringly, patients have also been receptive of novel technology such as that described in a qualitative analysis of patients perceptions and acceptance of a novel remote RA monitoring system, as a complementary element of RA care rather than a replacement of in-person visits.[47]
The lack of clinical examination[3] and privacy[48] is a concern which patients might have about receiving telerheumatology care. Other patient factors also play a part in determining their acceptability and satisfaction of telerheumatology. Communication difficulties due to hearing or speech impediment and difficulties describing the exact location of the issue or specific symptoms[49] may hinder a successful telerheumatology encounter. Older patients found virtual consultations more challenging.[48] Patients with lupus nephritis were more reluctant to accept virtual consultations due to the requirement for blood tests and medications, which is more ideally performed on the day of an in-person consultation.[48]
Physicians are also more comfortable providing telemedicine consultations for already-established/follow-up patients especially those with stable disease but less so with new patients.[34] A study during the COVID-19 pandemic of RA, PsA, ankylosing spondylitis, and systemic lupus erythematous showed good sensitivity and specificity of video consultations compared to in-person visit 2 weeks later, in determining if treatment alterations were required due to inadequate disease control.[50]
However, it is important to be cognizant of the fact that different modalities of telemedicine may yield different diagnostic accuracies (71% for telephone consultation compared to 97% for video consultations compared to in-person consultation) and subsequently may have an impact on patient satisfaction.[51] In addition, telemedicine may not be appropriate for all types of patients or disease types. It is important to bear in mind the limitations of telemedicine where this may be more appropriate for specific stages of care, i.e., follow-up rather than diagnosis,[14] for selected patients, such as RA patients with a stable disease course not requiring treatment alterations, be it uptitration or tapering of medication, and less appropriate for flares, complex patients, or those needing therapeutic or diagnostic procedures.
Telemedicine and DisparitiesThe breadth of reporting of telemedicine has uncovered regional differences in the health service and health inequities, which may influence the delivery of care. Telemedicine infrastructure may not exist in some countries, and even if present, technological barriers including variable network access may become a factor in determining the success of telemedicine. In addition, competing health priorities[52] and the economic crisis brought about by the COVID-19 pandemic may limit development of the appropriate infrastructures.[53] Housing instability such as in the case of overcrowding[54] or frequent house moves, may also present additional constraints on an adequate telemedicine consultation. The use of telemedicine also may vary according to age, employment, education level,[55] gender, and geography (i.e., rural vs. urban).[56] A study on people who receive benefits from Medicare highlighted disparities in digital access where a higher proportion of those with no digital access were those of older age, lower socioeconomic status, and communities of color.[57] The affordability and access to types of telemedicine may also widen disparities, and certain conditions may be underserved by a telephone consultation compared to a video consultation.[57] For those with digital access, technological proficiency and literacy are additional barriers to patients accessing care via telemedicine.[58]
However, telemedicine has also been used as an endeavor to address disparities in the context of providing access to those who live in areas where health-care services are limited such as in rural and remote areas of Australia, which may save patients’ time, the burden of having to travel to and from consultations, and patient expenses.[3] During the COVID-19 pandemic, this has enabled vulnerable patients to access care without unnecessarily exposing them to COVID-19.[13]
Education and TrainingRheumatology training has been disrupted by trainee redeployment, postponement of exams, and cancellation of in-person teaching.[13] Rheumatology trainees were required to rapidly adapt their practices to telemedicine as outpatient clinics transitioned to virtual clinics which required skills in addition to traditional clinical skills. As a result, the need to appraise current rheumatology curricula and integrate telemedicine competencies recommended by the Association of American Medical Colleges[59] has emerged as a priority. On the negative side, the lack of hands-on evaluation of patients raised concerns about trainees’ progression and the development of specific skills, such as procedural competence.[13] The COVID-19 pandemic has also impacted on the undergraduate rheumatology teaching. Didactic teaching was delivered remotely and access to clinical areas was minimized to assist with social distancing. Therefore, medical students practiced less history taking and clinical examination,[13] confirming that medical education via electronic platforms cannot act as a substitute for clinical training.
The benefits of tele-education was more evident in its ability to reach rheumatologists worldwide with the increase of educational content being moved to online platforms inspired/necessitated by the COVID-19 restrictions which has enabled education to be delivered in a more inclusive manner.[60] Rheumatology societies across the world increased their provision of online resources, such as webinars. Teaching sessions delivered on virtual platforms, such as Zoom or Microsoft Teams, enable interaction through live video audience participation or can be watched on demand.[61] Rheumatology conferences took place virtually, such as ACR and EULAR. This resulted in increased participation as this allowed for flexibility in accessing education, such as in the case of individuals being unable to travel to conferences due to work or personal commitments or the cost of conference, resulting in increased participation.[61] However, downsides of virtual events include potential technical issues and lack of in-person interaction.
Social media, in particular Twitter, played a major role in enabling rapid and timely discourse and sharing of knowledge in the midst of the evolving COVID-19 research landscape.[62] Preprint servers, such as medRxiv, were also instrumental in disseminating COVID-19 research in a timely manner.
A remarkable result of technology in enabling worldwide collaboration was the rapid formation of an international registry of rheumatology patients with COVID-19, the COVID-19 Global Rheumatology Alliance,[63] which consisted of rheumatologists and allied health professionals, as well as patient partners, from which many relevant COVID-19 publications of large registry data have emerged to guide clinical practice.
ConclusionTelerheumatology use has increased and evolved with the COVID-19 pandemic in patient care, clinical practice, training and research, and in fostering global collaborations. It is likely that hybrid models will be adopted for patient care with in-person visits interspersed with telemedicine. However, it is imperative that the patient is at the center of future telerheumatology service design, taking into account patient suitability for telemedicine, proximity, and patient choice.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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