PRO capture can also inform the medical, functional and psychosocial needs assessment required for CCM.
Finally, by summarizing patient symptoms and function, PRO capture can facilitate the communication required between providers in RTM and CCM programs. Both of these can enhance revenues for rheumatologists.
Widened Reach
The experience we describe above with mobile health applications for rheumatology is not isolated. Studies from China, Norway, the U.K., the Netherlands and likely other locations around the globe suggest the potential for the use of apps to enhance rheumatologic care.10,11
Another approach to reducing the demand for rheumatology consultations seeks to improve clinic efficiency through precision scheduling of initial consultations, specifically those requested following a positive ANA test result. These consultations are frequent, rather conservatively estimated at 10–15% of the consultations at some rheumatology practices, but often do not result in the diagnosis of a systemic autoimmune disease because a positive ANA has a low positive predictive value (10–15%) for autoimmune disease.12,13 Accordingly, inappropriate ordering of ANA testing by primary care clinicians has been criticized as wasteful as part of multiple Choose Wisely campaigns.14,15 The recognition of differential risk among those on a rheumatologist’s wait list calls into question the typical first-come, first-served scheduling paradigm pursued in many U.S. rheumatology clinics.
Efforts to create triage strategies for patients with arthritis based solely on the information contained in referral letters is often inadequate.16,17 A risk model based on machine learning and logistic regression of EHR data, which identifies ANA-positive patients who are at high risk of receiving a systemic autoimmune diagnosis, has been developed and preliminarily validated.18 Of note, a single predictor contributed far greater risk for such a diagnosis than all of the others included in the final model, the presence of a disease-specific autoantibody.
Although indiscriminate referral for positive ANAs is not useful, triage based on the results of disease-specific laboratory testing prior to rheumatology consultation (i.e., pre-consultation laboratory triage) may be worth exploring.19 In adapting this approach, those patients with positive disease-specific results can be scheduled to urgent clinic appointments held open to ensure such patients are seen in a timely manner, while those with negative results remain in the general queue.
Optimizing the performance and accuracy of disease-specific laboratory tests is critical for the success of such triage approaches. Regardless, triaging consultations by priority level ensures that face-to-face consultation time, the vanishing resource of the supply-demand mismatch inherent in the rheumatology workforce shortage, is applied to those patients in greatest need and at highest risk of permanent damage from inordinate wait times.
