Controversies in rheumatology: telemedicine—friend or foe?

Abstract

Telemedicine is increasingly used in rheumatology. While telemedicine guaranteed care of patients during the COVID-19 pandemic, it is now increasingly used to facilitate triage of patients, monitoring of disease activity, and patients’ education. In addition, tele-visits as well as remote physio- and psychotherapy are replacing traditional face-to-face contacts between patients and their healthcare provider. While this may save resources in a world in which the gap between the demand and the provision of healthcare increases, there is also a danger of losing essential information, for example by non-verbal communication, that can only be retrieved during face-to-face contact in the office. In addition, it may be challenging to build a trusting relationship between patients and healthcare professionals by virtual means only. Globally acting companies that see market opportunities already amply offer ‘simple’ technical solutions for telemedicine. While such solutions may seem (economically) interesting at first glance, there is a risk of monopolization, leaving the most valuable parts of healthcare to a small number of profit-seeking companies. In this article, the opportunities and threats of telemedicine in rheumatology are debated. A possible way forward is to complement traditional face-to-face visits with information gained by telemedicine, in order to render these consultations more efficient rather than replacing personal contact by technology.

Introduction

Telemedicine turned out to be a blessing for our patients with rheumatic and musculoskeletal diseases (RMDs) during the COVID-19 pandemic. In a survey among rheumatologists from 35 EULAR countries (1286 responders), it was noted that 82% of the face-to-face visits of new patients and 91% of follow-up visits had to be cancelled. In >80% of these, remote consultation was offered as a considerable alternative [1]. But the pandemic was (hopefully) an incident, and telemedicine was the best option to sustain contact with patients.

What will be the place of telemedicine after the pandemic? Will it increasingly replace face-to-face visits or will patients seek personal consultations again? What are the opportunities and threats of telemedicine in our field? These and other questions will be debated in the present article concluding with a consensus about the possible way forward for the sensible use of this technology in rheumatology.

Friend (Christian Dejaco)

Telemedicine can help us to preserve high quality of care despite dwindling human resources in rheumatology

In rheumatology, the gap between the provision and the demand of care is steadily increasing. This has several reasons such as an ageing population, implying not only a high rate of retirement of health-workers, but also an increasing request for their services, given that older people are more healthcare seeking than younger persons [2, 3]. Besides, advances in medical technology have not only led to the better survival of patients, but also to an increment of services potentially deliverable to single patients, a phenomenon that further contributes to the demand of care. The ACR projected in 2015 that in 2030, there will be a 50% shortage of rheumatologists [4]. Already today, the number of healthcare workers is significantly reduced (including all groups of health professionals such as physicians, nurses, physiotherapists and even administrative personnel). The consequence is a sharp reduction of service provision, and increasing waiting lists in several countries. The COVID-19 pandemic has further accelerated the attrition of health workers for a plethora of reasons.

Still, rheumatologists have the professional responsibility to maintain quality of care in rheumatology. The European Alliance of Associations for Rheumatology (EULAR), the ACR and other societies have developed recommendations for early referral and early diagnosis of rheumatic diseases, as well as statements about regular follow-up and treatment targets [5–7]. The EULAR recommendations for the management of early arthritis, for example, recommend that patients with suspected arthritis should be seen within 6 weeks of symptom onset [7]. To ensure a timely visit, many centres have implemented triage systems, such as ‘immediate access’ or ‘early arthritis’ clinics [8, 9]. Although these clinics seem to work well, they are time- and personnel-consuming and they may have disadvantages in rural areas, where travel distances are long. Treat to target (T2T) recommendations mandate follow-up visits every 1–6 months, with shorter intervals when disease activity is still high [6]. In real clinical practice, however, T2T is reportedly difficult to implement; one study observed that only 34% of patients had their visit within 3 months, even though they were not yet in remission [10].

To summarize, it looks as if the development of time- and labour-intensive professional management guidance does not keep pace with the availability of healthcare workers in many, if not all, EULAR countries.

Telemedicine might help to increase efficacy of triage and pre-diagnostic assessments

One opportunity of telemedicine is the ‘pre-assessment’, before a patient meets a healthcare worker. A short ‘virtual visit’, or some other means of communication between a dedicated healthcare worker and a patient may be instrumental in triaging patients, prioritizing referrals and ordering the necessary lab tests and examinations upfront. Such an approach is underpinned by evidence, demonstrating that the diagnosis made in a telemedicine visit has a high concordance with that established in a subsequent face-to-face consultation [11, 12]. Besides, patients’ satisfaction was high with the telemedicine approach.

Telemedicine might assist treat-to-target strategies and improve the efficiency of monitoring

Solid evidence is available that telemedicine-based monitoring of disease activity in RMDs leads to favourable clinical outcomes [13]. One 6-month study, for example, compared app-based monitoring with conventional monitoring in patients with RA who received a new DMARD. A similar level of control of disease activity was obtained in both groups, but there were better quality-of-life and fewer face-to-face visits in the app-based group. This saved precious workforce resources, and the authors concluded that app-based monitoring was a good alternative to the conventional approach [14].

Another 12-month study revealed higher remission rates, better functional outcomes and less radiographic progression in the telemonitoring as compared with the usual care group [15]. Telemonitoring, led by a nurse, resulted in comparable disease control as monitoring by conventional face-to-face surveillance in another study; however, the number of life visits per year was reduced from 4.2 in the conventional strategy to 1.7 in the telemonitoring groups [16]. If implemented in clinical practice, telemonitoring would thus ensure best care according to T2T despite limited human resources. In addition, telemonitoring would enable the acquisition of multiple data between visits, whereas currently we often only have a snapshot of the patients’ actual situation, given that patients may have difficulties recalling the entire time period between two face-to-face visits.

Instantaneous reaction to minor flares and adverse events using telemedicine

Telephone calls and e-mail consultations for solving minor problems are already part of our daily routine. We advise patients to stop drugs in case of adverse events, we recommend analgesics, we start or increase glucocorticoid dosages in case of minor flares, and we discuss whether or not an unscheduled face-to-face visit is required [17].

Apart from the possibility of informing these consultations with data from telemonitoring, the question is whether this type of communication is still timely. People are used to chatting, and to receiving rapid answers. A patient—doctor forum, supplemented with video calls on-demand would probably be a modern alternative to telephone and e-mail consultations. How this should be organized in order to ensure that questions and answers are optimally understood, how to avoid overloading physicians administering such fora, and how to optimize cost-effectiveness of such strategies, are all questions that still need to be clarified.

Improving adherence to therapies, facilitating home exercise and diet and other interventions, all possible with telemedicine

Adherence to therapies, lifestyle change, and home exercise are components of the management of every RMD. Time in face-to-face visits for emphasizing the importance of these components, however, is limited. Telemedicine may help with filling in this gap, requesting only a limited amount of resources. A 6-month randomized controlled trial on 42 RA patients, for example, compared a group who received four educational telephone sessions with a group without an intervention. A better adherence to medication was demonstrated in the former group [18]. Another 16-week trial in 50 patients with systemic lupus erythematosus compared a mobile app allowing self-tracking of dietary, environmental and lifestyle triggers, as well as telehealth coaching, with usual care. Results showed greater improvement in health-related quality of life in the intervention group [19]. Concerning home exercise, 208 patients with hip/knee osteoarthritis were assigned either to five face-to-face plus telemedicine-based home exercise, or to a regimen with 12 face-to-face sessions. Improvement in function was similar in both groups, but with significant resource savings in the former group [20].

Telemedicine improves patient–doctor relationship

Based on all the arguments above, it seems obvious that telemedicine, used in the right way, can help saving resources, while maintaining (or even improving) the quality of care. It may not only increase the number of patients to whom care can be provided, but also improve the quality of a single face-to-face visit. It could be expected that patients attending a preliminary telemedicine consultation would be ‘better prepared’ for the specialist face-to-face visit with all pre-assessments done, and results from telemonitoring already available. Would this not leave more room for the precious doctor–patient interaction?

Communication via telemedicine certainly needs to be trained: How to prepare a teleconsultation, how to ensure time management, how to communicate information and how to manage technical problems are only a few of the many aspects that need to be addressed [17]. In addition, there are legal and ethical issues as well as technical and procedural barriers from the patients’ side that hamper the implementation of telemedicine into practice [21].

Should we leave telemedicine all to the free market?

The question is no longer whether telemedicine should be part of medicine. Telemedicine services are already abundantly present on the healthcare market. Several global companies have entered into this segment, promising simple technical solutions and—at least that is what they offer—sequential care with chats, video calls and home visits by a nurse or doctor when needed, as well as home delivery of drugs. The question is whether we as a medical society should leave this all to the free market, or whether public healthcare should gradually accept telemedicine wisely, and work on integrating it into regular clinical practice.

Foe (Robert Landewé)

Is the classic patient–physician obsolescent?

For hundreds of years, the prevailing model of healthcare provision has been the consultation between the health-seeking patient on the one hand, and the expert consultant (usually the physician) on the other. Such consultations usually have the model of a face-to-face conversation between the patient and the healthcare provider, within the privacy of the office, so that confidentiality can be assured. Legally established professional secrecy is intended to protect the patient and to encourage them to share strictly private, but potentially relevant, information with the doctor. A face-to-face encounter allows the healthcare provider to obtain an otherwise intangible impression of the health and general appearance of the patient, and to put it into a societal context. Would this valuable exchange of information be lost in a world in which telemedicine dominates, all in favour of efficiency and cost saving? And who would be the guardian of data protection when information is collected via apps, chats and other forms of virtual communications? These are important questions to which an answer must be provided, before we carelessly resort to telemedicine in an attempt to appease healthcare payors.

Mutual trust, communication and skills

It is beyond any doubt that the precious relationship between patient and doctor relies on mutual trust. The doctor has to be certain that the patient informs them appropriately without any abstention; the patient should be confident that the physician treats the information respectfully and trustfully, and does not share it with others. It is also beyond any doubt that the level of trust for effective and satisfactory communication requires the exchange of verbal and non-verbal communication: first impressions collected in a face-to-face meeting may have more impact than a series of telephone calls. Core elements of patient satisfaction reportedly are, among others: expectation to be heard, being in control, time spent, dignity and continuity of care [22, 23].

Patients in general highly value face-to-face encounters. Especially in rheumatology, where patients and physicians often share a common history for many years, it is important to build a relationship based on trust. In a study querying RA patients about what they find important in their communication with healthcare providers, Mahmood et al. found that patients rate factors such as shared decision-making, interest in the patient’s personal life as well as education and insight higher than the time-to-visit, accessibility of healthcare providers or management of patients according to international recommendations [24].

It is widely accepted that healthcare providers, whether they are physicians, physician assistants or nurses, need professional communication skills or abilities. Such abilities are, among others, to listen, to understand patients’ experiences, to empathize and to explain [23]. It is perhaps less well understood that face-to-face contact is part and parcel of such skills, and that face-to-face contact helps building trust. It can be doubted that telemedicine can substitute for the vested merits of face-to-face consultations.

Physicians favour proper communication with patients; who benefits most from telemedicine?

Advocates propagate telemedicine because of a more efficient information exchange. Apps administered and completed by patients are considered to assist the doctor in decision making and to facilitate, for instance, T2T management; virtual consultations are thought to save time for the patient (who does not have to travel) and the healthcare provider. Once accepted as a standard model, nurses may apply telemedicine and take over the role of physicians, etcetera. The arguments favouring telemedicine, however, are largely related to cost-effectiveness, sprung from the brains of administrators, payors and politicians, rather than from physicians who may favour a proper patient–physician communication.

‘App-based medicine’ or video calls have been shown to be ‘safe’ according to disease activity or patient experience measures, but this is only partly reassuring given that formerly mentioned intangible communication skills could easily be missed in such studies.

That telemedicine-based information exchange (e.g. app-based learning) may assist in educating patients about their disease and treatment is not disputed, but the question is whether they can really replace face-to-face encounters.

And last but not least, there is the tenacious problem of digital illiteracy, nowadays an important hurdle even in developed countries [25]. Dismissing digital illiteracy as a transient menace that will solve itself over time, would unacceptably add to an already existing level of inequity in healthcare provision.

Conclusions (both authors)

It seems clear that, in spite of a market-driven proliferation and the pressure from payors and administrators, telemedicine cannot fully replace the classic face-to-face encounter between rheumatologist and patient. Such an encounter still forms the basis of proper healthcare. But telemedicine can help to better inform the healthcare provider, to exchange information, to monitor patients between visits and as learning devices for patient education. A careful balance is always the key: providers and users of telemedicine need to be educated to use the technology in an adequate way, the free market should be kept at arm’s length, and telemedicine applications should be considered as quality enhancers rather than as cost-reducers.

Data availability

The data underlying this article are available in the article.

Funding

No specific funding was received from any bodies in the public, commercial or not-for-profit sectors to carry out the work described in this article.

Dislcosure statement: C.D. has received grant support by AbbVie and consulting/speaker’s fees from Abbvie, Eli Lilly, Janssen, Galapagos, Novartis, Sparrow, Pfizer, Roche and Sanofi, all unrelated to this manuscript. R.L. has received grant support by AbbVie, UCB, Pfizer and consulting/speaker’s fees from Abbvie, Eli Lilly, Janssen, Galapagos, Novartis, Pfizer, UCB, all unrelated to this manuscript, and is chair of EULAR’s committee for the Quality of Care.

References