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Technology in medicine is no longer new or trendy. It’s pervasive. Rheumatologists may now assume a patient has searched online for information about his or her diagnosis or potential therapies.
Both physicians and rheumatology health professionals should acknowledge their patients’ Internet surfing and find out what they’ve read, says Betsy Roth-Wojcicki, RN, MS, CPNP, an advanced practice provider in pediatric rheumatology at the Medical College of Wisconsin and Children’s Hospital of Milwaukee.
“I often ask new patients or their parents, as part of the medical history, if they’ve gone to the Internet for information before coming to the clinic visit. By inquiring about their use of the Internet, a medical provider can clarify and accurately assess the information [the patient has] already obtained,” she says.
A 2013 study by the Pew Research Center, “The Internet and Health,” found that 59% of U.S. adults had looked online for health information in the previous year, and 35% of U.S. adults had used online information to try to diagnose their or someone else’s condition.1 The study also found that 35% of those “online diagnosers” said they did not visit a clinician to confirm that diagnosis.
What about patients with diagnosed rheumatic diseases, such as rheumatoid arthritis (RA)? A small study published in 2018 shows that even older RA patients turn to social networking sites, such as Facebook, to find information about disease self-management or therapies, and feel comfortable talking with fellow patients in online support groups.2 Tech health goes beyond the Web: New digital apps allow arthritis patients to track and download health data to share with their rheumatologists, and proprietary Internet telephony (such as Skype) and virtual reality (VR) are changing the practice of rheumatology.
To help rheumatology providers stay up to date, the 2018 ACR/ARHP Annual Meeting in Chicago will include sessions on new technology in rheumatology, from telemedicine to evidence on how health apps and sensors affect patient outcomes.
“Technology in medicine hasn’t reached the tsunami level yet, but I’d say it is a trend, and we are seeing a lot of buzz in this area,” says Swamy Venuturupalli, MD, FACR, attending rheumatologist at Cedars-Sinai Medical Center in Los Angeles and founder of Attune Health. He chairs the subcommittee planning the TechMed sessions for this year’s Annual Meeting, which will include a session called Digital Evidence: Do Apps, Sensors & VR Help Patients?
“There are more data available for rheumatology research,” says Dr. Venuturupalli. “Being able to monitor patients and having these objective measures of disease activity may also augment your decision-making capacity.”
Apps & Wearable Sensors
Many health smartphone apps and wearable devices, including shirts with sensors embedded in them, are available to track physical activity, heart rate, sleep and other data, says Dr. Venuturupalli. Some apps allow users to record daily pain or other symptoms that may help rheumatologists track disease activity or potential health problems to be addressed at the next appointment. In a 2016 pilot study of 28 patients with axial spondyloarthritis, sensors to track physical activity reached accuracy levels of 93.5% and, with more development, could offer a viable alternative to patient questionnaires or direct-observation tests.3
“The quality of these sensors has improved a lot in recent years. Previously, information like heart rate was not properly captured by phones, but these wearable sensors work much better. Also, the acceptability of patients to these devices is higher than in the past,” he says. “But healthcare professionals don’t have the capability to process all of these data coming to them.” At his hospital, health data collected through wearable sensors or watches are dumped into a patient’s electronic health record. “But all of these data are overwhelming to us at this point. It’s too much to expect a physician to be able to interpret all these data.”
Although health apps and sensors may dazzle doctors and patients, are they truly useful? This question will be explored at this year’s Annual Meeting, along with results from current studies on digital health, including the utility of biosensors to predict heart attacks in patients with cardiovascular disease, says Dr. Venuturupalli.
“How does adding these data to patient algorithms make patient outcomes better? We want our patients to do better, so maybe this can help. But if it’s a waste of time, maybe not,” he says. “Technology is getting better by the day, and it will be more informative and better quality in the future. We have to figure out where technology fits in for the treatment of our patients on a day-to-day basis.”
‘All of these data are overwhelming to us at this point. It’s too much to expect a physician to be able to interpret all these data.’ —Swamy Venuturupalli, MD
Dr. Internet Is Always In
The Internet has nearly unlimited amounts of information on rheumatic diseases and is always a swipe or click away, but this information is not regulated and may not be evidence based, says Ms. Roth-Wojcicki.
“As health professionals, we can guide patients or parents to help them find reliable material,” she says. She suggests her pediatric patients’ parents share any information they find online with her, so she can review it with them and comment on its accuracy.
Providers can also recommend websites that they find worthwhile or reputable, she says. “Many clinics have Web-based resources available for patients or parents, so having an open conversation with people regarding these topics can help prevent them from seeking information that’s not research based.”
The Pew Research Center report found that 43% of adult Internet users searching health information online were researching a certain medical treatment or procedure. Evan Leibowitz, MD, MS, a rheumatologist at Valley Medical Group Prospect Medical Offices in Midland Park, N.J., says his patients often ask him about studies they’ve read online about such arthritis supplements as glucosamine and chrondroitin sulfate.
“I respond to patients’ questions with something like, ‘That’s a good question. Unfortunately, the supplement you are asking about has not yet proved to be safe or effective. Also, we cannot predict how it will interact with your current medications,’” says Dr. Leibowitz, who adds that he discusses pros and cons of therapies his patients research online. “I tell them I’d prefer for them to spend the money on a tai chi or yoga class, to get a therapeutic massage or try acupuncture.”
The Internet and social media sites, such as Facebook, are an open door for patients seeking information and a useful tool for those who know how to use them, says Jeanne Scott, MSN, AGPCNP-BC, a rheumatology nurse practitioner at Cheshire Medical Center in Keene, N.H.
“Social media is great for emotional support with peers or those likewise diagnosed. However, I worry about the reliability of the information being shared,” says Ms. Scott. “Too often, I see misinformation repeated over and over. When you see or hear something often enough, you mistake it for fact. Unfortunately, the Internet can also be an outlet for non-experts to weigh in. Their opinions may not be evidence based, but based on personal experience.” Ms. Scott says she spends a lot of time correcting misinformation, dispelling myths her patients have picked up online and helping them set reasonable expectations for their therapy.
Telemedicine & Virtual Reality
Some of Ms. Scott’s patients must travel for two hours for clinic appointments. Although her department does not currently use telemedicine for rheumatology care, the technology is used for emergency medicine triage. The clinic’s parent network, Dartmouth-Hitchcock Medical Center, does use telemedicine for rheumatology. She uses email through online patient portals. “It’s an effective communication for quick updates and requests. Patients may change their mind after an encounter about wanting a joint injection and request a procedure-only visit,” she says. “We must learn to think outside the box for our patients. It’s important for us to not only train and produce competent providers who will increase access locally, but to create access for the communities that are limited geographically or physically from getting the care they need. I believe telemedicine is an answer to this.”
At the Annual Meeting, Ms. Scott is coordinating a telemedicine panel with an occupational therapist, nurse practitioner and physician. They will discuss how they use telemedicine to deliver rheumatology care to incarcerated patients and those who live in rural areas. Although telemedicine, which may utilize voice-over-Internet protocol, email or other technologies, will not replace face-to-face clinic visits, but expand rheumatology providers’ reach and provide easier follow-ups, says Ms. Scott.
Digital Evidence will include a presentation on data to support the use of VR, a technology Dr. Venuturpalli’s hospital has used to address acute pain. VR uses three-dimensional (3-D), multisensory imagery to distract patients from painful or distressing stimuli. Patients use headsets to look at imagery on a screen. In 2017, his colleagues published the results of a clinical trial that found 65% of patients with stroke, seizure and epilepsy reported reduced pain after using VR compared with 40% of controls who did not use VR.4
“VR may work because of the distraction of being out of the place you’re in,” says Dr. Venuturupalli. More research is needed to learn how VR may work in chronic pain. “VR can also be used for simulation training for medical students or practitioners doing a procedure for the first time, or educating patients on how to do movement therapy.”
He’s conducting a new clinical trial on an immersive blend of VR and biofeedback, which uses sensors on the body to help patients learn to control such functions as heart rate or muscle tension, which “may be a good way to control chronic pain and be a helpful tool for rheumatologists,” he says. “If used along with VR, biofeedback can be even more effective at treating chronic pain.”
Susan Bernstein is a freelance medical journalist based in Atlanta.
References
- The Internet and health. Pew Research Center/California Health Care Foundation Health Survey, August 7–September 6, 2012. 2013 Feb 12.
- Des Bordes JKA, Gonzalez E, Lopez-Olivo MA, et al. Assessing information needs and use of online resources for disease self-management in patients with rheumatoid arthritis: A qualitative study. Clin Rheumatol. 2018 Jul;37(7):1791–1797.
- Billiet L, Swinnen TW, Westhovens R, et al. Accelerometry-based activity recognition assessment in rheumatic and musculoskeletal disease. Sensors (Basel). 2016 Dec;16(12):2151.
- Tashjian VC, Mosadeghi S, Howard AR, et al. Virtual reality for management of pain in hospitalized patients: Results of a controlled trial. JMIR Mental Health. 2017 Jan–Mar;4(1):e9.
