During an ACR webinar in August, presenters discussed multiple aspects of telehealth in rheumatology, especially related to rheumatology fellowship training. They agreed that although telehealth represents one potential avenue to improve patient access to treatment for rheumatic disease, we must keep identifying the best ways to employ telehealth to enhance care.
Impact of Pandemic
Telemedicine broadly refers to the use of technology to deliver healthcare at a distance; telehealth includes an even broader scope of remote healthcare services, including non-clinical ones, such as provider training. Many telehealth options are now available, although insurance requirements and other constraints make some impractical; these include synchronous videoconferencing and audio-only visits, which many patients and care providers are now familiar with due to their expansion since the COVID-19 pandemic.1,2
Asynchronous interactions between patients and providers are another telehealth option; for example, these have been effective in helping patients with gout achieve their target serum urate levels.3 Asynchronous, provider-to-provider interactions using shared electronic health records (i.e., e-consults) are another important telehealth option. Additionally, telementoring (i.e., using remote technologies to train primary care providers in rheumatology topics) is another important avenue.
Dr. Danila
The moderator of the webinar, Maria I. Danila, MD, MSc, MSPH, a professor of medicine at the University of Alabama at Birmingham, received an innovation award in 2021 from the Rheumatology Research Foundation to study how telehealth impacts access and quality of care in rheumatology. Three recipients of the Foundation’s Clinician Scholar Educator Award, designed to enhance education in autoimmune and musculoskeletal diseases, also participated in the panel: Jason R. Kolfenbach, MD, Lisa A. Zickuhr, MD, MHPE, and Marcy B. Bolster, MD. All three are pursuing projects connected to designing fellowship curricula related to telehealth.
“I think it’s fantastic how proactive the ACR and the Foundation have been in promoting the use of telehealth as a modality to enhance the care we provide our patients, in terms of the support for research in this area and support for the patient experience,” said Dr. Bolster, associate professor of medicine at Harvard Medical School and director of the rheumatology fellowship training program at Massachusetts General Hospital, Boston. “I think that rheumatologists are being very proactive in this area.”
Expanded Rheumatic Care
The panel participants agreed the COVID-19 pandemic dramatically accelerated telehealth in unprecedented ways as the rheumatology community adapted to the immediate crisis. “Telehealth practice would not have been what it is today without the healthcare community’s capacity to rapidly redesign processes to deliver medical care to the members of our community,” said Dr. Danila.
Dr. Bolster pointed out that the pandemic “made it even clearer that we need to provide curricular design to strengthen the achievement of competency for our fellows to participate in telehealth.”
Dr. Bolster
Some providers have advocated for telehealth for years, partly to increase patients’ access to rheumatic care, particularly in rural or under-resourced areas, where providers may be scarce. A 2015 ACR workforce study projected that by 2030, demand for rheumatology providers will exceed supply by over 100%, due to multiple factors.4 Dr. Kolfenbach, associate professor at the University of Colorado Anschutz Medical Campus, Aurora, Colo., and medical director of the rheumatology fellowship program in became interested in telemedicine even before the pandemic, partly spurred by the need to bring rheumatology care to remote and underserved regions (e.g., rural areas of Colorado and Wyoming). “I think video visits are a great way for an individual patient to be served when they have to drive two hours away for a visit; it saves them time and resources,” he said.
Although virtual telerheumatology visits can play an important role in extending the reach of rheumatologists in some contexts, they do not directly increase the number of providers who can deliver rheumatology care. So they have limited capacity to meet the demand for more rheumatology clinicians.
Dr. Kolfenbach said e-consults may be an important way to help fill that gap. “Through e-consults, we can bring rheumatologic expertise to a local provider, [offering advice] on how to manage some conditions,” he said. “If we get an e-consult for gout, that same primary care doctor might then be able to apply the instruction we provide to a different patient the next time. You are able to touch even more people.”
However, Dr. Kolfenbach noted that among medical providers, e-consults are not as widely accepted as remote clinical videoconferencing visits. Through one aspect of his current project, he hopes to demonstrate that e-consults can be done safely and that they can provide healthcare savings while benefiting both patients and primary care providers. This may be especially helpful to provide reassurance to patients and guidance to primary care providers when an in-person rheumatology visit may not be necessary.
Dr. Kolfenbach
“These services provide a lifeline for communities where there isn’t a rheumatologist around,” he said.
To build her project, Dr. Bolster used a preexisting relationship between Massachusetts General Hospital, Boston, and the Rosebud Sioux Tribe on the Rosebud Indian Reservation (Indian Health Service) in South Dakota, an area without on-site rheumatology care. One component used a format similar to project ECHO (Extension for Community Healthcare Outcomes), first developed in 2003 to use virtual collaboration and case-based learning to give specialist training to primary care providers.5
Massachusetts General Hospital rheumatology fellows presented virtual didactic conferences based on rheumatology cases to primary care providers at Rosebud and its surrounding health centers. These sessions were precepted, so fellows received feedback and guidance, while primary care physicians, nurse practitioners and physician assistants received helpful education. Another initial part of Dr. Bolster’s Foundation grant—having fellows provide precepted, in-person assessment to patients at Rosebud followed by precepted, virtual follow-up care—was disrupted by the timing of the pandemic.
This underscores another important contrast between deliberately employed telehealth and the telehealth experience many were thrust into in March 2020: Dr. Bolster points out the benefits of an initial in-person visit were quite clear even before the pandemic. Instead, Dr. Bolster’s project pivoted so the rheumatology fellows, with her precepting and supervision, could gain experience participating in an e-consult service to provide helpful information that becomes part of the patient’s medical record.
Shared Decision Making
Dr. Zickuhr, assistant professor of medicine in the Division of Rheumatology and associate director for the rheumatology fellowship program at Washington University School of Medicine in St. Louis, focused her research project on best practices for shared decision making during virtual care encounters.
Dr. Zickuhr said multiple studies have shown that medical providers often think they are engaging patients in shared decision making during in-person visits, but patients often do not share this perspective. Shared decision making requires effective communication, respect for patient autonomy and active, patient-centered participation.6 Some of these factors may be especially challenging to achieve during virtual encounters.
Dr. Zickuhr
Dr. Zickuhr noted that several patient advocacy groups reported the move to telemedicine during the pandemic made patients feel they had lost their voice. This improved somewhat as both providers and patients became more comfortable in the new medium, but Dr. Zickuhr explained that providers need to be aware of this possibility and work to actively keep centering on patients’ experiences, needs and perspectives.
In her work, Dr. Zickuhr has held a series of focus groups with both medical providers and patients with chronic conditions, mostly rheumatologic disorders. “We found that both parties generally agree that decisions can be made during telehealth appointments, and that there are pros and cons to in-person vs. telehealth care,” she said.
Dr. Zickuhr pointed out that technology can enhance the way clinicians impart information—for example, by sharing a screen shot, putting information in a chat conversation or even continuing a conversation with a provider through shared message exchanges in a secured patient portal.
Telehealth also presents certain challenges, such as those inherent to a virtual physical exam. Dr. Zickuhr noted that unlike certain other specialties, such as neurology, rheumatology doesn’t yet have studies comparing whether one can reliably and effectively gather the same information virtually as one can via an in-person exam, and this remains an important area for future study.
In her own research, Dr. Zickuhr has found that strong physician/patient relationships are a critical part of supporting shared decision making during virtual encounters. Improved shared decision making may both be a cause and result of these strong relationships, leading to better patient adherence while also enhancing the patient experience.7 Dr. Zickuhr hopes to further study best practices for virtual encounters and incorporate them into a curriculum for rheumatology fellows.
Telehealth Competencies
Achieving mastery of telehealth requires a range of skills, not just those related to the quality of the medical assessment itself. All three panelists were part of an ACR group that co-authored a recent paper on rheumatology telehealth competencies. They adapted these from an initial version from the Association of American Medical Colleges and modified them to address aspects relevant to rheumatology fellows at their level of training.8,9
These competencies describe skills that rheumatology trainees should achieve across multiple domains, including those pertaining to patient safety, appropriate telehealth use, equity and access issues, communication concerns, data collection and diagnostic assessment, technology considerations, ethical practices and legal requirements, as well as the interface of telehealth with broader healthcare systems.9
“The rheumatology telehealth competencies add to our tools for evaluating and assessing fellows,” said Dr Bolster. “Importantly, competency isn’t only for in-person visits—it really should also include the unique aspects of virtual care that we can provide.”
Moving Forward
Many of his patients have found occasional virtual visits very convenient, especially if they live several hours away, Dr. Kolfenbach noted. “For example, if someone gets a bone density scan and they are a candidate for treatment, they might set up a video visit,” he said. “Before, they might not have initiated treatment until the next time they saw me in person, months later.”
Dr. Zickuhr agreed that since the start of the pandemic she has noticed more patients engaging with telehealth as a choice that makes sense for their lives, whether that’s through exchanging virtual messages with providers or having an audio-only or video virtual visit. Dr. Bolster pointed out that from the provider side, it gives another opportunity to check in more frequently with some patients when that may be helpful.
However, Dr. Bolster said, “I also think that as a specialty we are still learning about the right times for a virtual visit. Because there are times that it is truly beneficial for a patient to come in.” She noted that from pre-pandemic data we know some patients are not as well suited for in-person visits, so it is important to consider aspects such as the disease type, level of disease activity, the systemic nature of the disease and the clarity of diagnosis.10,11 Additionally, some patients face important barriers to virtual care, such as limited access to technology. Providers must consider these potential barriers when considering telehealth options for specific patients.
“We learned from being thrust into virtual care that we can use it to enhance the care we are already providing our patients,” said Dr. Bolster. “We don’t need to replace our care like we did in March 2020; now we can use it as another facet of how we take care of our patients.”
“I think that we’ve laid the foundation of telemedicine,” added Dr. Zickuhr. “Now we get to fine tune it and make it something that is really effective for both patients and providers.”
Ruth Jessen Hickman, MD, is a graduate of the Indiana University School of Medicine. She is a freelance medical and science writer living in Bloomington, Ind.
References
- Danila MI, Sun D, Jackson LE, et al. Satisfaction with modes of telemedicine delivery during COVID-19: A randomized, single-blind, parallel group, noninferiority trial. Am J Med Sci. 2022 Nov;364(5):538–546.
- Miloslavsky EM, Bolster MB. Addressing the rheumatology workforce shortage: A multifaceted approach. Semin Arthritis Rheum. 2020 Aug;50(4):791–796.
- Yokose C, Jorge A, D’Silva K, et al. Using electronic visits (e-visits) to achieve goal serum urate levels in patients with gout in a rheumatology practice: A pilot study. Semin Arthritis Rheum. 2020 Dec;50(6):1382–1386.
- Battafarano DF, Ditmyer M, Bolster MB, et al. 2015 American College of Rheumatology Workforce Study: Supply and demand projections of adult rheumatology workforce (2015–2030). Arthritis Care Res (Hoboken). 2018 Apr;70(4):617–626.
- Agley J, Delong J, Janota A, et al.. Reflections on project ECHO: qualitative findings from five different ECHO programs. Med Educ Online. 2021 Dec;26(1):1936435.
- Bae JM. Shared decision making: relevant concepts and facilitating strategies. Epidemiol Health. 2017 Oct 30;39:e2017048.
- Deniz S, Akbolat M, Çimen M, Ünal Ö. The mediating role of shared decision-making in the effect of the patient-physician relationship on compliance with treatment. J Patient Exp. 2021 May 20;8:23743735211018066.
- Borondy Kitts A, Chandra S, Evans N, et al. Association of American Medical Colleges. Telehealth Competencies across the Learning Continuum. AAMC New and Emerging Areas in Medicine Series. Washington, DC: AAMC; 2021. https://www.aamc.org/data-reports/report/telehealth-competencies
- Zickuhr L, Albert DA, Herndon C, et al. Addressing competency in rheumatology telehealth care delivery. Arthritis Care Res (Hoboken). 2022 Sep;10.1002/acr.25023.
- Ferucci ED, Holck P, Day GM, Choromanski TL, Freeman SL. Factors associated with use of telemedicine for follow-up of rheumatoid arthritis. Arthritis Care Res (Hoboken). 2020 Oct;72(10):1404-1409.
- Kulcsar Z, Albert D, Ercolano E, Mecchella JN. Telerheumatology: A technology appropriate for virtually all. Semin Arthritis Rheum. 2016 Dec;46(3):380-385.
