During the COVID-19 pandemic, telemedicine was rapidly deployed to meet the clinical needs of patients with rheumatic diseases worldwide. Rheumatologists were forced to care for patients with all rheumatic diseases, regardless of disease activity, and limited evidence was available to guide provider decision-making regarding telemedicine appropriateness for outpatient rheumatology encounters. As the COVID-19 pandemic progressed, the ongoing provision of rheumatology telemedicine care in the U.S. was made possible by (1) emergency telemedicine waivers that permitted rheumatologists to legally practice across state lines; and (2) increased telemedicine reimbursement rates from the Centers for Medicare and Medicaid Services. Telemedicine research in rheumatology expanded exponentially, and patterns began to emerge regarding multilevel factors associated with telemedicine appropriateness for patients with rheumatic diseases. Rheumatology practice patterns also evolved to address the unique challenges of providing virtual care, such as the use of patient-reported outcomes and physical examination modifications to remotely assess disease activity. Moving beyond the COVID-19 pandemic, telemedicine has the potential to increase access to rheumatology care by utilizing finite rheumatology clinical resources in more efficient and innovative ways. However, barriers to more fully integrating telemedicine into routine rheumatology care remain, including training the rheumatology workforce, suboptimal reimbursement rates for telemedicine services, variability in state telemedicine laws, and the need to build telemedicine support networks of interdisciplinary and interprofessional care team members. As the use of telemedicine in rheumatology continues to evolve, it is vital for rheumatologists to maintain a patient-centered focus in the continued delivery of safe, effective, and equitable rheumatology care.
Key points
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Telemedicine is meant to complement, rather than replace, in-person rheumatology care.
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Several factors influence telemedicine appropriateness for outpatient rheumatology encounters, including rheumatic disease diagnosis, disease activity level, patient and provider preference, and the patient’s ability and preparedness to participate in a telemedicine visit.
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Telemedicine has been proposed as a way to expand access to rheumatology care, particularly for rural communities disproportionately affected by the rheumatology workforce shortage. To ensure equitable delivery of care, telemedicine initiatives must be aligned with the resources and needs of patients and their local communities.
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Telemedicine training for rheumatology fellows and established rheumatology providers is essential for expanding the reach of telerheumatology care, ensuring competency in telemedicine implementation and integration, and providing safe and effective patient-centered telemedicine care.
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Governmental decisions regarding telemedicine reimbursement rates and, to a lesser extent, state laws regarding telemedicine licensure are central to the persistence and future influence of telemedicine in rheumatology care.
Introduction
The coronavirus disease 2019 (COVID-19) pandemic dramatically altered the provision of rheumatology patient care globally, prompting the rapid rise of telemedicine. Suddenly, rheumatology practices were forced to adopt new telemedicine practice patterns to provide care for patients of all ages across the full spectrum of rheumatic diseases and disease activity levels. In a matter of weeks after COVID-19 was officially declared a pandemic by the World Health Organization (March 11, 2020), reports estimated 40% to 90% of outpatient rheumatology encounters worldwide were being conducted using telemedicine. This abrupt change in the delivery of rheumatology patient care spurred intense interest in establishing best practices for telemedicine, such that rheumatology telemedicine publications increased by more than 300% in the 4 years from the start of the COVID-19 pandemic (2020–2023) compared to the 4 years prior to the pandemic (2016–2019). Clearly, telemedicine has emerged as an essential component of rheumatology care delivery.
This narrative review outlines central aspects of telemedicine in rheumatology. Specifically, the authors review the available rheumatology telemedicine modalities, discuss telemedicine appropriateness in outpatient rheumatology encounters, explore ways in which telemedicine could be used to expand access to rheumatology care, summarize telemedicine initiatives in medical education, and highlight key factors that may determine the future of rheumatology telemedicine moving beyond the COVID-19 pandemic.
Telemedicine
Telemedicine Modalities in Rheumatology
Telemedicine is defined as “the use of medical information that is exchanged from one site to another through electronic communication to improve a patient’s health.” Telemedicine can be either synchronous, meaning the patient, provider, and/or other care team members interact in “real time,” or it can be asynchronous when these interactions or exchanges of information are not occurring simultaneously. Synchronous telemedicine modalities include audio-only (ie, telephone) and video visits for outpatient encounters, real-time messaging or chat rooms, and telerheumatology consults for hospitalized patients. Asynchronous telemedicine modalities include patient–provider or provider–provider messaging through the electronic health record (EHR), electronic consults (e-consults) for new patients, electronic visits (e-visits) for established patients, review of clinical data within the EHR, collection and monitoring of patient-reported outcomes (PROs), remote patient monitoring (eg, home blood pressure), and the use of mobile applications and wearable technology.
The broad and ever-expanding range of telemedicine modalities available to patients and providers offers both opportunities and challenges to those looking to optimize the efficacy and efficiency of rheumatology care. Opportunity lies in telemedicine being more flexible, convenient, and requiring fewer resources than traditional care. One of its greatest challenges, however, is determining the appropriate use of telemedicine modalities to ensure the continued provision of high-quality, patient-centered care to patients with rheumatic diseases.
Telemedicine appropriateness in outpatient rheumatology encounters
Prior to the COVID-19 pandemic, almost no rheumatology visits were being conducted via telemedicine in the United States, and little was known about the appropriate use of telemedicine in outpatient rheumatology encounters. A systematic review performed in 2017 identified only 20 eligible studies, half of which were abstracts, to evaluate telemedicine use for the diagnosis and management of rheumatic diseases. While telerheumatology was generally viewed favorably, most studies also had a high risk of bias.
Similarly, few randomized controlled trials (RCTs) of rheumatology telemedicine interventions were performed in the pre-COVID era. Of interest, one RCT followed patients with rheumatoid arthritis (RA) randomized to a telemedicine intervention versus usual in-person care. The investigators found a combination of PROs and telephone visits achieved similar clinical outcomes compared to usual in-person care. However, it is difficult to know how best to apply these results in real-world practice since most patients included in the trial were in remission or had low RA disease activity at baseline.
The few studies describing the experiences of rheumatology practices using telemedicine during the pre-COVID era were primarily from small outreach programs staffed by only a handful of providers. , One study conducted in rural New England suggested that only 19% of patients in a general rheumatology practice were inappropriate for telemedicine. This estimate was based on provider perceptions of telemedicine appropriateness and primarily related to diagnostic uncertainty and medical complexity. This estimated percentage, however, lacks provider heterogeneity, as only 2 providers made the determination of telemedicine appropriateness for 97.7% of the patients, and it is thus difficult to generalize these results to a broader population.
Survey data collected from 45 rheumatology providers at the Veterans Health Administration (VHA) just prior to the COVID-19 pandemic showed most providers prefer to use telemedicine modalities to manage existing patients with a known diagnosis, rather than to evaluate and diagnose rheumatic diseases in new patients. Surveyed providers also responded that telemedicine was more useful for managing gout, pseudogout, osteoarthritis, and RA and less useful for managing vasculitis, systemic sclerosis, and systemic lupus erythematosus (SLE).
During the COVID-19 pandemic, many rheumatology providers reported positive experiences with telemedicine overall, , and a better understanding of some of the general factors associated with providers’ perceptions of telemedicine appropriateness began to emerge ( Table 1 ).
| May be More Appropriate for Telemedicine | May be Less Appropriate for Telemedicine | |
|---|---|---|
| Rheumatic disease diagnosis | Gout, pseudogout, Sjogren’s syndrome, OA, PMR, osteoporosis | SLE, scleroderma, vasculitis |
| Disease activity level | Low | High |
| Known to practice? | Yes, established patient | No, new patient |
| Modality of last visit | In-person visit | Telemedicine visit |
| Patient location relative to provider | In-state | Out-of-state a |
| Provider preference | Prefers telemedicine | Prefers in-person visits |
| Patient preference | Prefers telemedicine | Prefers in-person visits |
| Physical or mental disability b | No | Yes |
| Digital literacy | High | Low c |
| Access to compatible devices and internet connection | Yes | No c |
| Primary language other than English | Remote interpreter services available | No remote interpreter available |
| Other patient social factors | Situational | Situational |
a Telemedicine appropriateness for out-of-state patients dependent on individual state licensing laws.
b Including but not limited to visual, auditory, or cognitive impairment.
c May still be appropriate for audio only (eg, telephone) visits or video visits at a local clinic site.
Disease Activity and Rheumatic Disease Diagnosis
The first publications in the COVID-19 era emphasized provider perceptions of which rheumatic diagnoses were most appropriate to be seen via telemedicine. A survey evaluating provider perceptions of telemedicine appropriateness among 103 VHA rheumatologists noted high levels of telemedicine appropriateness (>90%) for outpatient management of gout, osteoarthritis, osteoporosis, and polymyalgia rheumatica. These data, along with a follow-up survey, further clarified that VHA rheumatologist also believed telemedicine was appropriate for several other rheumatic diseases, including RA (>80–90%), the seronegative spondyloarthropathies (>80–90%), and the collectively. Essentially, lupus, scleroderma, and vasculitis were all grouped together in the survey. Evaluated lupus, scleroderma, and vasculitis (>70–80%), but only if the veteran’s symptoms were stable. ,
As the pandemic progressed, additional longitudinal data provided further insights into how both rheumatic disease diagnoses and disease activity levels may influence provider perceptions of telemedicine appropriateness. An overview of the evidence to date on telemedicine appropriateness in some of the most common rheumatic diseases is provided in Table 2 . In patients with RA, moderate-to-high disease activity appears to be negatively associated with provider perceptions of telemedicine appropriateness, while patients with low disease activity or remission may be more appropriate to be seen via telemedicine. , Another study from a single academic health system used longitudinal data on provider perceptions of telemedicine appropriateness in individual outpatient encounters (N = 10,551 in training set) to create a predictive model of telemedicine appropriateness for future outpatient rheumatology encounters across all rheumatic diseases (area under the curve [AUC] 0.83–0.86). In this study, higher Routine Assessment of Patient Index Data 3 (RAPID3) scores were associated with lower predicted telemedicine appropriateness. Certain diagnoses like inflammatory arthritis, SLE, myositis, and scleroderma were also less likely to be appropriate for telemedicine in the final predictive model, whereas Sjögren’s syndrome was more likely to be appropriate for telemedicine. Further research is needed to clarify disease-specific factors associated with provider perceptions of telemedicine appropriateness across the spectrum of rheumatic diseases.
| Rheumatic Disease | Evidence for Telemedicine Appropriateness |
|---|---|
| Gout |
|
| Rheumatoid Arthritis |
|
| SLE |
|
| Osteoarthritis |
|
| Osteoporosis |
|
| Fibromyalgia |
|
| Other Rheumatic Diseases |
|
Telemedicine and the Physical Examination
The inability to perform an in-person physical examination is a recognized limitation of telemedicine. The absence of a visual assessment is particularly notable during audio-only (eg, telephone) visits, where the possibility of performing a modified telemedicine examination does not exist. The inability to perform a physical examination may lead to diagnostic uncertainty and an inaccurate assessment of disease activity, , and this has been associated with unfavorable provider perceptions of telemedicine appropriateness, both for new patient evaluations and in medically complex patients with an unclear diagnosis. , Thus, rheumatology providers often prefer telemedicine encounters with established patients, particularly for those who are seen frequently and/or were not last evaluated using a telemedicine modality. ,
In the absence of a physical examination, PROs have been proposed as a potential mechanism to not only help capture disease activity but also to inform treatment decisions during telemedicine encounters. , Adaptations are also feasible for many aspects of the rheumatology physical examination during video visits to more accurately assess disease activity, including but not limited to the following , :
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Joint range of motion maneuvers
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Patient self-examination for tenderness or swelling of joints and entheses with provider guidance or in-app tools
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Use of well-established virtual neurologic examinations
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Assistance of a family member or presenter to assess strength
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Guided patient self-examination for lymphadenopathy
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Review of patient photos for skin rashes or other lesions
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Use of home devices to obtain vital signs (eg, scale, home blood pressure monitor, smartphone, wearable device)
Other studies have used presenters, or individuals who accompany the patient to facilitate a remote physical examination. Varying levels of presenter training and medical knowledge, as well as the time and financial investment required to train presenters, have led to mixed reviews of this approach. ,
Provider Perceptions of Video versus Audio-only Visits
Since at least the early 2000s, there has been uncertainty regarding whether video versus audio-only visits are most appropriate for outpatient rheumatology telemedicine encounters. One of the earliest studies to address this issue was performed in the United Kingdom, in which 100 patients presenting for new rheumatology consultations were first evaluated by a rheumatologist over the telephone, then by a video visit with the same rheumatologist, and subsequently were seen in person by the same rheumatologist. This study found the diagnostic accuracy of video visits (97%, κ = 0.96) was higher than that of telephone visits (71%, κ = 0.62) compared to a gold-standard in-person visit. More recently, a study of outpatient rheumatology encounters during the COVID-19 pandemic found providers were more likely to rate video visits as appropriate for telemedicine (80% of 1406 visits rated as telehealth acceptable) compared to telephone visits (64% of 515 visits rated as telehealth acceptable).
Compared to audio-only visits, video visits offer several potential advantages to providers, including the ability to perform a modified physical examination, see and respond to patient nonverbal cues, interact with patient family members and other caregivers, and evaluate the patient’s home environment. , , Potential disadvantages to providers of video visits compared to telephone visits include the cost of purchasing and maintaining compatible equipment, software, and information technology support services, and difficultly integrating video visits into clinic workflows with simultaneous in-person encounters. , In the United States where 81% of patients have a smartphone device, video visits are likely to be the predominant telemedicine modality in the future, although the continued provision of telemedicine via telephone is crucial to ensure adequate access to patients with barriers to participating in video visits. As the use of telemedicine in rheumatology continues to evolve overtime, the ongoing alignment of telemedicine care delivery with the resources and needs of patients and their local communities must remain a central priority. ,
Legal Requirements for Practicing Telemedicine
The legal landscape of providing telemedicine services changed drastically during the COVID-19 pandemic and has continued to evolve following the revocation of emergency telemedicine waivers in the United States. Most telemedicine rules and regulations are determined at the state level. In most cases, rheumatology providers must meet the licensure requirements of both the state where the provider is located and the state where the patient is located to legally practice telemedicine. With the current rheumatology workforce shortage, rheumatologists commonly provide care for patients from multiple states. Per the US Health Resources and Services Administration, several options exist for licensing across state lines, including cross-state licensure, full licensing, licensure reciprocity, compacts, and the use of telehealth registrations. Again, these requirements differ from state-to-state in the United States and are likely to change over time. It is the responsibility of each rheumatology provider to familiarize themselves with the regulations of their current and proposed telemedicine practice environments to ensure their licensure complies with state telemedicine laws.
Changes in Reimbursement
The rise of telemedicine in current US rheumatology practice not only reflects the unprecedented circumstances surrounding the COVID-19 pandemic but also changes to the governmental reimbursement structure for telemedicine visits. In 2020, Congress passed the Coronavirus Preparedness and Response Supplemental Appropriations Act, which increased the Centers for Medicare and Medicaid Services (CMS) reimbursement rates for telemedicine visits to a level similar to in-person visits. Many of these COVID-era changes are still in effect until at least December 31, 2024; the future of reimbursement for telemedicine services remains unclear. While some extent of telemedicine use in the outpatient rheumatology setting is likely here to stay, a shift to pre-pandemic reimbursement rates for telemedicine visits may negatively impact provider preferences for telemedicine and, in turn, its complementary role in the outpatient management of patients with rheumatic diseases.
Variability in Preference for Telemedicine among Rheumatology Providers
There continues to be significant variability in provider preferences for using telemedicine in outpatient rheumatology encounters. Previous studies have shown that providers who see more patients via telemedicine are more comfortable using telemedicine and are more likely to offer telemedicine in the future. , These observations raise questions of how rheumatology provider preferences for telemedicine could be positively influenced in the future. Important questions also remain regarding ways to implement telemedicine to allow providers to practice more efficiently and confidently while enhancing patient care. The answers are likely complex, although they may involve strategies such as intentional telemedicine training for rheumatology providers across the spectrum of clinical experience (eg, telemedicine skills workshops for continuing medical education credits), standardized telemedicine physical examination techniques, improved telemedicine clinical support, enhanced pre-visit screening for telemedicine appropriateness with risk prediction models, increased integration of PROs, continued equivalent time-based reimbursement for telemedicine visits, and the introduction and implementation of tools to guide shared decision-making conversations with patients regarding the use of telemedicine modalities for future visits.
Patient Preferences for Telemedicine
Although there remains much to learn about patient perspectives and engagement in telemedicine for those with rheumatic diseases, patients generally appear to view telehealth favorably. , , , In one survey performed by the Global Rheumatology Alliance in 2021, 61% of 596 adult rheumatology patients reported they viewed telemedicine as at least as effective as in-person visits. This positive view of telemedicine effectiveness was more prevalent among younger patients, male patients, and patients from North America. However, patients who completed this survey also identified certain situations in which telemedicine may be less effective than in-person visits, including reviewing laboratory results, managing a disease flare, discussing signs or symptoms of their disease, and making medication changes. As with providers, there is also significant variability in patient preferences for telemedicine, and patients who have positive perceptions of telehealth overall may report higher telemedicine effectiveness. Various studies have described the potential cost savings of telemedicine for patients in terms of both actual travel expenses and time (ie, lost work productivity/income), which may be attractive to patients who are working, in school, have childcare needs, or live in rural areas with longer commutes. , ,
Patient Barriers to Telemedicine
However, it is also important to be cognizant of barriers patients may have to engaging with telemedicine. , Several studies in the US general population have suggested that traditionally minoritized populations, including Black and Hispanic patients, non-English-speaking patients, individuals over the age of 65 years, patients with higher area deprivation index scores, and patients with lower educational attainment levels, may be (1) less likely to use video visits compared to telephone visits, , and were (2) more likely to present to either the emergency room or in-person office visits than see providers using a telemedicine modality during the COVID-19 pandemic. In a large US community practice network of patients with rheumatic diseases, similar sociodemographic factors were associated with a higher likelihood of canceling a rheumatology clinic visit during the COVID-19 pandemic, and older age, male sex, a higher area deprivation index, and rural residency were associated with a lower likelihood of having an outpatient rheumatology visit using a telemedicine modality.
It is hypothesized that these sociodemographic factors are surrogates for the “digital divide,” or disparities in the access and use technology for telemedicine and other purposes due to social, linguistic, functional, financial, educational, environmental, and other barriers. These barriers may, in turn, influence necessary aspects of preparedness to successfully utilize telemedicine. In 2018, a study from the National Health and Aging Care Study of Medicare beneficiaries estimated that up to 38% of adults aged 65 years and older may not be ready for video visits due to a combination of inexperience with or infrequent use of technology, lack of access to Internet-enabled devices, poor digital literacy, and/or physical disability (ie, difficulty hearing, seeing, communicating, or with cognitive processing). Challenges like poor broadband Internet or cellular network accessibility in rural areas, costly Internet or data plan subscriptions, expensive smartphone or computer devices, the ability to read and respond to prompts in a mobile application or computer program, and limited access to on-demand interpreter services also contribute to the digital divide in patient with rheumatic diseases. , , These factors may also lead some patients to prefer in-person visits, or telephone visits over video visits despite their limitations. As the rheumatology community considers how to best use telemedicine to enhance patient care, it is important to preemptively recognize these potential barriers and incorporate adaptations to telemedicine initiatives to prevent and address health care disparities in access to telemedicine care.
Telemedicine Appropriatness: Section Summary
Ultimately, the decision to schedule the next outpatient rheumatology encounter as a telemedicine visit should involve shared decision-making between the patient and their rheumatology provider, incorporating a combination of the patient’s underlying rheumatic disease diagnosis, current disease activity, functional status, various sociodemographic factors including patient barriers to accessing both in-person and telemedicine care, and patient and provider preferences for telemedicine. Tools to assist in this shared decision-making process are in development, but further research is needed to assess their validity and generalizability in broader rheumatology populations.
Expanding patient access to rheumatology care using telemedicine
Telemedicine has been proposed as an integral piece of a multifaceted approach to increase access to rheumatology care. Wait times for new rheumatology consultations are already among the longest of any internal medicine subspecialty, and regional differences in the distribution of rheumatology providers across the United States have resulted in disproportionately lower access to rheumatology care in areas with comparatively lower population densities. Unfortunately, patient access to rheumatology care is expected to decline over time. The 2015 American College of Rheumatology (ACR) Workforce Study found the demand nationwide for rheumatology clinical services was expected to exceed the supply of rheumatology clinical full-time equivalents (FTEs) by 102% by 2030 based on a variety of factors, including an aging US population, projected retirements of “baby-boomer” rheumatology providers, and a projected increase in part-time rheumatology providers. This workforce shortage is expected to worsen access to rheumatology care, particularly in areas already impacted by the maldistribution of rheumatologists across the United States. ,
While the use of telemedicine will not increase the total number of rheumatology clinical FTEs available to care for the aging US population, telemedicine offers an alternative approach to utilize finite rheumatology clinical resources in more efficient and innovative ways to reach patients in communities with poor access to rheumatology care. Even before the COVID-19 pandemic, telemedicine initiatives were being employed to improve access to rheumatology care in rural and under-resourced communities. Two similar telemedicine initiatives were separately implemented in the Alaska Tribal Health System (for patients with RA) and rural New England (for patients with any rheumatic disease) in the early to mid-2010s. , Both initiatives used rheumatologists working remotely to conduct video visits with patients at local health centers using a presenter (eg, a medical assistant) to operate the technology used for the visit and to facilitate the physical examination. While the total number of patients and providers in these studies was relatively small by today’s post-COVID standards, both studies successfully modeled a potential synchronous approach to rheumatology video visits that simultaneously overcame barriers to telemedicine care, such as limited broadband Internet availability, access to a smartphone or computer, and low technologic literacy. Similar initiatives have since been adopted by larger health systems, including the VHA, which now provides remote telemedicine access points in local communities to nearly 9 million veterans through their Accessing Telehealth through Local Area Stations (ATLAS) program.
E-consults have also been proposed as a way to improve access to rheumatology care by decreasing wait times for patients who need to be seen in person, providing more rapid diagnostic and therapeutic advice to primary care providers (PCPs), and decreasing resource utilization by more effectively triaging referrals for common questions, such as the evaluation of positive antinuclear antibodies. , , In one study from a single academic health system, 91% of the 221 e-consults submitted received specialist advice within 72 hours of submission, and the average wait time for an in-person visit following an e-consult referral was 17 days shorter than for a traditional referral. While the use of e-consults in rheumatology continues to expand, reimbursement rates from CMS remain suboptimal, which may limit the potential impact of e-consults on access to care.
Another novel approach to expanding access to rheumatology care in under-resourced communities is through initiatives like Project Extension for Community Healthcare Outcomes (ECHO). Project ECHO was developed in 2003 by the University of New Mexico to increase access to specialty care in rural and remote communities using a hub-and-spoke care model. , Using this model, Project ECHO Rheum leverages technology to coordinate larger networks of rheumatologists and PCPs by delivering education in rheumatology topics to PCPs and connecting local providers at community sites (spokes) to specialists at academic medical centers (hubs). Project ECHO Rheum has provided virtual education to over 2230 clinicians and serves as an example of how to utilize shared knowledge and experiences, multiple points of patient contact, and both local and specialty resources to enhance rheumatology care in local communities.
Educational initiatives in telemedicine
Training the current and future rheumatology workforce in telemedicine modalities is another vital piece of ensuring delivery of high-quality specialty care to patients with rheumatic disease. Prior to the COVID-19 pandemic, telemedicine training was not included in the ACR Core Curriculum Outline for rheumatology fellowship training programs. However, several timely surveys of rheumatology fellow-in-training (FITs) highlighted the urgent need for intentional telemedicine training for rheumatology FITs to address the abrupt clinical practice changes caused by COVID-19. One survey of 132 rheumatology FITs conducted by the ACR FIT Subcommittee showed that by June 2020, 91% of rheumatology clinics staffed by FITs had incorporated telemedicine. In contrast, a survey of 24 rheumatology FITs administered by the Carolinas Fellows Collaborative in 2019 showed no FITs had been exposed to telemedicine training in medical school, internal medicine residency, or rheumatology fellowship, and a survey of 302 rheumatology FITs from the Global Rheumatology Alliance found only 13% of trainees reported exposure to telemedicine prior to the pandemic.
To address the need for telemedicine training for rheumatology FITs, an ACR working group created rheumatology-specific telehealth competencies to outline the essential skills required to care for patients with rheumatic diseases using telemedicine. These rheumatology-specific telehealth competencies were adapted from the Association of American Medical Colleges Telehealth Competencies and were designed to guide both curricular development and the evaluation of proficiency in telemedicine care. , Importantly, the telehealth competencies provide telemedicine training guidance for both rheumatology FITs and established rheumatology clinicians, and focus on the following domains: (1) patient safety and the appropriate use of telehealth; (2) access and equity in telehealth; (3) communication via telehealth; (4) data collection and assessment via telehealth; (5) technology for telehealth; (6) ethnical practices and legal requirements for telehealth; (7) and system-based requirements for care.
Practically speaking, these rheumatology-specific telehealth competencies offer guidance on the skills needed to provide high-quality patient-centered care using telemedicine modalities, such as how to identify which patients are appropriate to be seen via telemedicine, adapt the history and physical examination to account for the limitations of telemedicine, , recognize and address patient barriers to care, and develop a good “Web side” manner to build trust and rapport with patients. Establishing telehealth competencies has also allowed for the objective assessment of telemedicine skills, using tools like a virtual rheumatology objective structure clinical examination to evaluate mastery of and identify gaps in telemedicine skills for FITs. , Learning these telemedicine skills is meant to complement rather than replace in-person training at the bedside, and early exposure to telemedicine with a high number of repetitions using telemedicine modalities has the potential to positively impact provider perceptions of telemedicine moving forward. ,
It was recognized early in the pandemic that virtual education sessions offering both synchronous and asynchronous learning have the potential to reach large, global audiences, as evidenced by the Virtual Rheumatology Learning series developed by the ACR that attracted 1982 learners from 55 countries between April and May 2020. Such initiatives have the potential to rapidly disseminate educational content and could conceivably be adapted to teach foundational and advanced telemedicine skills to rheumatology providers worldwide. The ultimate goal of providing training in telemedicine skills for FITs and established rheumatology providers is to strengthen the rheumatology workforce, ensuring competency in telemedicine implementation and integration, expanding the reach of subspecialty care, and providing safe and effective patient-centered telemedicine care that enhances and complements in-person care. Investing time and resources in telemedicine skills training will also position the current and future rheumatology workforce to be leaders in the field of telemedicine innovation and offer a potential avenue for expanding access to rheumatology care to rural and under-resourced communities.
The future of telemedicine care in rheumatology
In addition to training the current and future rheumatology workforce, several other key factors will be central to the persistence and future influence of telemedicine in rheumatology care.
First, governmental decisions regarding telemedicine reimbursement rates are likely to have the most immediate and far-reaching impacts on provider perceptions of telemedicine, the volume of telemedicine visits in rheumatology, and future investments in telemedicine technology and support staff by health care systems and community practices. In the United States, the CMS rules that provide similar reimbursement rates for telemedicine and in-person visits are still in effect until at least December 31, 2024 ; however, there is uncertainty surrounding whether these rates will be extended and, if so, for how long. Long-term CMS commitments to equal telemedicine reimbursement rates could cement telemedicine as a permanent option for rheumatology care delivery. Likewise, increasing CMS reimbursement rates for services like e-consults has the potential to decrease new patient wait times and improve access to rheumatology care. , ,
State laws regarding telemedicine licensure may also affect the reach of telemedicine in the future. This is particularly relevant for regions of the United States with poor access to rheumatology care. More standardized, collaborative approaches to telemedicine licensure across state lines at the state or federal government level could facilitate the wider implementation of telemedicine initiatives and help offset the supply and demand mismatch for rheumatology care in under-resourced areas.
Finally, training a support network of interdisciplinary and interprofessional care team members is critical to reaching the highest number of patients using telemedicine in the setting of a limited rheumatology workforce. Hub-and-spoke models, like Project ECHO Rheum, have helped empower PCPs to provide care to patients with rheumatic disease in local communities, using a combination of educational initiatives and remote rheumatology support. Nursing-led telemedicine interventions have been successful in managing gout , and monitoring patients with low RA disease activity. Pharmacists have also been effectively utilized to remotely manage chronic diseases, such as diabetes, hypertension, and heart failure. Though the rheumatology-specific literature on pharmacist-led interventions is limited, pharmacists have been successfully deployed to monitor patients with stable inflammatory arthritis and could play a vital role in monitoring laboratories, screening for side effects, assessing medication adherence, and providing medication self-efficacy training for patients. While these approaches may not be appropriate for all patients with rheumatic diseases, designing and implementing guideline-driven or protocol-driven care delivered by nurses and pharmacists with oversight by rheumatologists for patients with certain rheumatic diagnoses (eg, gout, osteoporosis, RA, seronegative spondyloarthropathies) and low disease activity levels has the potential to expand access to rheumatology care while also addressing shortages in the rheumatology workforce.
Summary
Telemedicine is meant to enhance the care of patients with rheumatic diseases rather than replace in-person care. The use of telemedicine in rheumatology will continue to evolve, and the infrastructure and principles the larger rheumatology community develops now will lay the foundations for future generations of rheumatologists and patients. The World Health Organization provides excellent guidance with its statement: “it is imperative that telemedicine be implemented equitably and to the highest ethical standards, to maintain the dignity of all individuals and ensure that differences in education, language, geographic location, physical and mental ability, age, and sex will not lead to marginalization of care.” As the use of telemedicine moves beyond the COVID-19 pandemic, it is vital that rheumatologists maintain this patient-center focus in the continued delivery of safe, effective, and equitable rheumatology care.
Clinics care points
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The decision to schedule the next outpatient rheumatology encounter as a telemedicine visit should involve shared decision-making between the patient and their rheumatology provider.
- •
Video visits offer clear advantages to providers over audio-only visits (ie, telephone visit) for the assessment and diagnosis of rheumatic diseases; however, patient barriers to participating in video visits are common and must be considered before determining the appropriate telemedicine modality.
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PROs (eg, RAPID3 in RA) conducted prior to or during the visit may help capture disease activity and inform treatment decisions during telemedicine encounters.
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Adaptations are feasible for many aspects of the rheumatology physical examination during video visits to more accurately assess disease activity.
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Additional research is needed to further our understanding of telemedicine appropriateness for specific rheumatic diseases and disease activity levels.
Related posts:
The Impact of Coronavirus Disease 2019 on Patients Living with Rheumatic Diseases
The Burden of Post-Acute Sequelae of Coronavirus Disease 2019 in Individuals with Rheumatic Diseases
Interventions to Improve COVID-19 Vaccine Hesitancy
Flares of Systemic Autoimmune Rheumatic Disease Following Coronavirus Disease 2019 Vaccination
Review of Immunologic Manifestations of COVID-19 Infection and Vaccination
Coronavirus Disease-2019 in the Immunocompromised Host
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