Telehealth in rheumatology: From ‘boutique industry’ to ‘unavoidable reality’
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It is quite possible that, when all is said and done, the most lasting impact of COVID-19 on rheumatology will be the overwhelming uptake of telemedicine in daily clinical practice.
The question, then, is what telerheumatology will look like when the pandemic subsides.
“Before COVID, telemedicine was a boutique industry in rheumatology,” Daniel Albert, MD, vice chair of faculty and academic affairs in the department of medicine at Dartmouth-Hitchcock Medical Center, in Lebanon, New Hampshire, told Healio Rheumatology. “That changed 180 degrees with the pandemic.”
Although few would argue that the COVID-19 pandemic is over, there appears to be a consensus that the increasing reliance on telemedicine is here to stay. It is critical, then, at this moment, to codify what the shape of that reliance will take as the world moves back to some version of normalcy in health care delivery.
In a paper published in the Journal of the American Medical Association, Shachar and colleagues addressed this very topic.
“To maintain the impetus for change and the momentum for telehealth services that have resulted from the COVID-19 pandemic, the U.S. cannot revert to pre-pandemic telehealth regulations,” they wrote. “Neither can the U.S. simply adopt the recent changes, because they lack nuance to support clinicians while ensuring safety and privacy for patients: A third regulatory path is needed.”
Those recent changes largely pertained to insurance coverage and HIPAA regulations for telehealth applications, which were relaxed during peak COVID-19 transmission. There is currently significant debate about whether insurance carriers as well as federal and state regulators will or should revert back to pre-pandemic protocols or adjust to new paradigms.
The patient voice is likely to be critical in this discussion as well. On the one hand, patients frequently prefer telehealth because it saves them time and travel costs. However, many patients lack reliable access to technology or the know-how to use available tools. These hurdles must be overcome.
For Christine Peoples, MD, director of the Telerheumatology Program at the University of Pittsburgh Medical Center (UPMC), the issues may be even more fundamental than that.
“The term ‘telemedicine’ is used frequently, especially with the current COVID-19 pandemic,” she told Healio Rheumatology. “But there are several different modalities of telemedicine, so it is important to define exactly what we are talking about if we are to use these various modalities successfully and in the best interest of the patient.”
Those modalities can range from live, face-to-face conversations via video to email communications, she added. Knowing where and when to deploy which type of approach is essential.
Ultimately, the uptake and effectiveness telerheumatology may come down to buy-in from rheumatologists. In this area, too, there are certainties and uncertainties.
“The average rheumatologist is 58 to 60 years old, but a lot of our colleagues are in their late 60s or early 70s,” Alvin F. Wells, MD, PhD, director of the rheumatology and immunology center, and adjunct assistant professor, at Duke University Medical Center, said in an interview. “I sometimes say that many of them are like politicians: They like to press the flesh.”
The implication is that some rheumatologists may want clinical practice to return to the pre-pandemic model for the very practical reason that the physical exam is so necessary to the specialty. However, such a return to the pre-pandemic status quo remains unlikely, according to Wells.
“The analogy I like to use is that COVID has been the fuel on the telemedicine fire,” he said.
Source: Christine Peoples, MD.
‘Establish a Relationship’
The most frequently cited concern from rheumatologists who are reluctant to continue using telerheumatology post-COVID-19 pertains to the physical exam.
“This was the most common concern of rheumatologists in the pre-COVID era when they considered telemedicine,” Elizabeth Ferucci, MD, a rheumatologist at Alaska Native Medical Center, in Anchorage, said in an interview. “It remains an important consideration, but now that more rheumatologists have some experience, we are all learning what we can and can’t do using telemedicine and when to request an in-person visit for the purpose of an exam.”
The emerging consensus is that for many patients, particularly those with painful or inflamed joints, an in-person initial consultation followed by some form of remote monitoring can be an effective paradigm. However, it is important to understand that even among rheumatologists who accept that telehealth is the future — those like Jasvinder A. Singh, MBBS, MPH, of the Birmingham VA Medical Center and the University of Alabama at Birmingham — there is a range of opinions on the matter.
“Some may be more liberal than I am and some more conservative about the necessity of an in-person initial visit,” Singh told Healio Rheumatology. “To be honest, I am a little leery of it myself.”
Ferucci, who has long been using telehealth and is a strong proponent its more widespread adoption moving forward, likewise acknowledged that an in-person visit to the clinic for patients with new or complicated disease is often still necessary. Such in-person visits can provide a critical understanding of the nature of the patient’s disease.
“We still prefer to have an in-person exam at the initial consult visit, both to allow for a detailed physical exam when establishing a diagnosis, as well as to establish a relationship,” said Ferucci.
“In addition, there are also times when a physical exam is very important, such as a follow up visit for a patient who has both RA and fibromyalgia, and is having increased pain,” she added.
In a perfect world, most experts would be happy to conduct a regular physical exam on every patient. However, the reality is that the rheumatology workforce shortage has forced thousands of patients around the country to travel significant distances just to see their doctor.
Or at least they used to, prior to the widespread uptake of telemedicine.
“In our model, we provide academic rheumatology care to patients living in underserved rural areas of Pennsylvania who are unable to travel to see a rheumatologist in Pittsburgh,” Peoples said, noting that registered nurses (RNs) located in rural telehealth centers have had extensive training in the rheumatology physical exam.
Patients travel a much shorter distance to the rural telehealth center and the visit is conducted virtually using synchronous audiovisual technology, with Peoples in Pittsburgh and the patient in the room with the “tele-presenting” RN, she said.
“With the increasing demand, especially for new patient appointments, and the COVID-19 pandemic, UPMC has broadened the options for rheumatology telemedicine care to include electronic consults, or e-consults, and Rapid Access Video Encounter (RAVE) visits,” Peoples said. “E-consults are ordered through the electronic medical record and a board-certified rheumatologist will review the patient’s chart and provide recommendations within 72 hours of the request.”
The goal is to address a key question or questions effectively and efficiently, and the patient may or may not need a rheumatology evaluation at the conclusion of the e-consult. RAVE visits serve as rheumatology triage, conducted through brief home audiovisual visits, to determine the most appropriate next step. According to Peoples, the take home message is that there are several modalities being used to manage patients in an increasingly digitized world.
More Than ‘Calling the Patient Back’
Representing one of the options for telerheumatology care, the e-consult described by Peoples is often necessary as many patients lack access to video technology, which remains a problem in telehealth across specialties. Using this modality, a question can be addressed efficiently and promptly without the need for video.
“The advantage of the e-consult is that everything is documented in the patient’s electronic medical record, and the service is billed to the patient or their insurance carrier,” Peoples said. “Then any doctor who sees that patient can see the recommendations documented clearly.”
There are other solutions for patients who lack technology, according to Wells.
“A lot of local libraries now have a telemedicine room,” he said, noting that the rooms are private and equipped with audio and video equipment.
In addition to these real-time, face-to-face interactions, the umbrella of telehealth can also involve remote patient monitoring, in which clinicians can track various types of patient data, from step counts and heart rates to glucose levels, often using a smartphone.
“There are smartphone devices that connect this information directly to a doctor’s chart,” Wells said.
He noted that companies like Amazon and Google are spearheading these efforts. However, such devices have not reached full penetration into the U.S. health care system.
Meanwhile, patient electronic health records are increasingly being made available across distances and health systems using so-called “store-and-forward” practices. Under these practices, one provider can gather the information for another provider to access and assess at a later time.
However, not all telehealth approaches need to be so technologically advanced.
“Before the pandemic and before the rise of telemedicine, we used to call it ‘calling the patient back,’” Singh said. “But this is a form of telemedicine, and it can still be effective.”
In a similar vein, although some patients still do not own a smartphone, most do, which allows them to take pictures of rashes and other trouble spots on the body and then send them to their rheumatologist.
Albert pointed out, however, that even this seemingly simple approach can come with pitfalls.
“Sometimes you can see the image well enough to make a judgment, sometimes not,” he said. “Phone pictures are often better than video, but it is understandable that some practitioners feel uncomfortable using this approach with no recommendations to guide the process.”
While rheumatologists await telehealth recommendations, understanding specific clinical scenarios can help improve the use of technology not only in patient management, but also patient outcomes.
‘Skin, Joints, Muscles and Bones’
It is important for rheumatologists to focus on accomplishing specific goals for any given visit when using telehealth, according to Wells.
“Of course, our patients have a lot of comorbidities such as diabetes or gastrointestinal issues,” he said. “But when I am conducting a video telemedicine visit, I am focusing on the skin, joints, muscles and bones.”
If those other complaints and complications become problematic, Wells offered a few recommendations.
“Primary care providers and other specialists can and should manage those comorbidities,” he said. “But if we as rheumatologists do want to manage them, we should make a separate appointment or offer a different type of consultation to deal with those.”
According to Wells, narrowing the focus of every visit can save time for both doctors and patients, and be a generally more efficient way to manage even the most complex cases.
“In our clinic, we deal with sleep, weight loss, libido issues, a number of problems that our patients experience,” he said. “I just do these visits separately.”
This approach bleeds into the business end of practicing medicine, Wells added.
“Your lawyer or accountant will bill you for time spent on the phone or for answering emails,” he said. “For too long, when we have been making phone calls or sending emails to patients after hours, we have been taking care of people’s lives for free. Those days are gone.”
To that point, Wells noted that there is a code for chronic care management.
“It is possible to get paid up to 20 or 40 minutes per month to deal with patients with chronic conditions,” he said, noting that this can range from answering emails to updating information on a patient’s chart. “Many doctors do not know that.”
Privacy Please
Another area of uncertainty among rheumatologists regarding telemedicine is the shifting borders of privacy as pandemic restrictions ease.
According to Shachar and colleagues, the Office for Civil Rights at HHS, in response to COVID-19, stipulated that penalties would not be enforced for HIPAA violations that occurred during the “good faith provision of telehealth” while the pandemic was ongoing.
“However, a more nuanced approach to privacy may be needed after the pandemic to support telehealth expansion,” they wrote.
HIPAA regulations may need to be “revisited,” with a balanced look at patient needs and considerations weighed against risks such as hacking and so-called “Zoom bombing,” where uninvited parties can disrupt video calls, they added.
“Guardrails, such as periodic audits, would be needed to ensure security,” Shachar and colleagues suggested. “Perhaps, similar to systems in the financial sectors (ie, personal access to bank accounts and investment accounts), a more user-friendly approach to privacy may be possible for personal health care delivery.”
Understanding the diverse array of platforms used by doctors and patients is critical to ensuring safety, according to Wells.
“Doximity video and certain Zoom platforms are encrypted and HIPAA compliant,” he said. “However, FaceTime is encrypted but not HIPAA compliant. Just being encrypted may not be enough to ensure privacy of the information. Right now, there are concerns anyone can hack into these platforms and essentially hold the information for ransom.”
Wells added that platforms like Zoom have developed specific software for medical visits, and that other companies have similar products in the works. As those technologies reach the market, they may impact how insurance carriers choose to cover various types of telehealth interactions.
‘A Ton of Money at Stake’
Shachar and colleagues were clear that without a fair and comprehensive reimbursement structure, all the technology in the world may not be enough to bring telerheumatology into the mainstream.
“Regulatory change governing payment parity will need to be sustained after the pandemic, and adequate reimbursement for telehealth will be an important factor to maintaining broad adoption,” they wrote.
Without these changes, they added, smaller practices, particularly in rural areas, may find themselves in “financial difficulty” due to fewer patients coming in for in-person visits.
“All things considered, insurance carriers recognized that it was a necessity during the pandemic and have been reasonable about coverage and reimbursement,” Albert said.
He acknowledged, however, that there may be some “pushback” should COVID-19 become endemic.
“It is a mixed picture with that regard,” Albert said. “Telemedicine encounters do save a lot of money for a lot of people.”
Of course, patients save on travel costs, but institutions also may save because they would ultimately require less infrastructure for patient care. However, that may not count as good news for everyone.
“Some institutions may want a higher percentage of patients to come in for evaluations because, when they come in, they also get labs and infusions done near the hospital,” Albert said. “This ancillary income for associated players and partners creates complex issues around reimbursement.”
It is worth noting that Congress is pushing to keep telehealth a standard part of patient care because so many Americans benefited from it, according to Albert. However, the federal government is just one body that can impact the use and uptake of telehealth throughout the country. Individual states also play a significant role in this regard, although there are still significant barriers to practicing across state lines, according to Peoples. “Competitiveness among insurance companies aims to keep care within the state,” she said. “Also, there are financial and other kinds of relationships between officials and insurance companies. There is a ton of money at stake.”
It is with these factors in mind that Peoples suggested that patient and provider advocacy can come into play.
“Policymakers and insurance carriers may not truly understand that there are not enough rheumatologists in certain regions and states,” she said.
However, insurance coverage is not the only problem with telehealth at the state level. The necessity of seeing patients across state lines has also given rise to complicated licensing issues.
Jumping Licensure Hurdles Between States
Many states relaxed or eliminated certain licensure requirements in response to COVID-19, allowing some clinicians from one state to care for patients in another.
“Because these regulations create a more permissive environment, however, mechanisms are required to ensure verification of clinicians,” Shachar and colleagues wrote.
Attempts to get all states on the same page regarding telehealth could be a tall order. “Another approach may involve federal telehealth practitioner licensing, which could reduce the compliance burden for physicians who practice telehealth in more than one state,” Shachar and colleagues added.
Wells is licensed in five states, but he acknowledges that he is the exception and not the rule. Still, he believes the workforce shortage will help to drive not only the ongoing use of telerheumatology but the relaxation of licensure rules to ensure that care is delivered.
“There are only a handful of rheumatologists in all of South Dakota, which is one of the states where I am licensed,” he said. “Insurance companies do not want to see their patients die of a chronic but manageable disease, so they will pay for their patients to see me virtually.”
According to Peoples, there are several states where there are too few rheumatologists, or even no pediatric rheumatologists.
“There are patients with rare systemic rheumatic diseases and there is no specialist for that disease in their state,” she said. “Telemedicine modalities can improve these access issues, but we need to see significant improvements in state-to-state licensure agreements and regulations.”
Some legwork is required for physicians to achieve such comprehensive licensure, Wells acknowledged. He noted, however, that it is possible to obtain licensure in as many as 28 states using one specific application.
For Peoples, the fact that so many of the licensing issues were waived during the pandemic is evidence that it can be done safely. Like other experts, she believes that advocacy from patients and practitioners at the policymaker level can make these changes permanent and ensure that these patients receive the care they need.
The Choice of Three Out of Five Patients
In a paper published in Rheumatology (Oxford), Cavagna and colleagues surveyed 175 patients with connective tissue diseases to determine attitudes about telemedicine after the pandemic subsides. The cohort was predominantly women, with a median age just over 62 years.
Results showed that 80% of patients owned a device allowing for video calls, while 86% would have the ability to participate in a telehealth visit. Half of the cohort reported that they would be able to conduct such a visit alone, while 36% said they could do so with the help of a relative.
In all, 78% of respondents said telehealth was an acceptable way to see a doctor. In fact, 61% said they would prefer it.
Understanding which patients prefer telehealth — and, specifically, which telehealth approach — is essential to optimizing care, according to Peoples.
“Patients and I use shared decision-making to determine if a telerheumatology visit at the rural telehealth center is preferable versus a home audiovisual visit in any given situation,” she said. “We need to concentrate on how we can provide the right care for each patient at the right time in the best way.”
However, the issue of telehealth is bigger than just the individual doctor-patient relationship, according to Ferucci.
“Most importantly, we need to consider inequities in access and whether increased use of telemedicine could exacerbate health disparities in populations who are unable to access it,” she said.
For Wells, the issue comes down to advocacy and education, not just for patients but for physicians in other specialties as well.
“I do a TikTok series to help primary care providers and other non-rheumatologists learn how to do a physical exam, and I post it to all my social media sites,” he said.
Meanwhile, Singh said a key component of telehealth is convenience for both doctors and patients.
“If it is 10:30 and I have a cancellation at 11, I can still see a patient, because they can be ready to see me in their home in a few minutes,” he said. “I have seen a number of non-serious patients this way, and it keeps their management on track.”
That said, Singh acknowledged that the process is not always so smooth.
“Sometimes the duration of a visit ends up being longer than an in-person visit because of technological glitches, or even because the patient does not pick up their phone because they do not recognize your number,” he said. “Other patients are unable to hear well, so I end up repeating myself twice or thrice.”
Like Wells, Singh called on the private sector to solve these problems.
“Innovative companies need to work on these things,” he said.
However, these slight technical difficulties are no reason to put off the inevitable, according to Singh, who directed his comments to rheumatology colleagues who may use these obstacles to justify their reluctance about telehealth.
“It is an unavoidable reality that you can no longer run away from,” he said.
- References:
- Cavagna L, et al. Rheumatology (Oxford). 2021;doi: 10.1093/rheumatology/keaa554.
- Shachar C, et al. JAMA. 2020;doi:10.1001/jama.2020.7943.
- The Interstate Medical Licensure Compact. https://www.imlcc.org.
- For more information:
- Daniel Albert, MD, can be reached at 1 Medical Center Dr., Lebanon, NH 03756; email: daniel.a.albert@hitchcock.org.
- Elizabeth Ferucci, MD, can be reached at 4315 Diplomacy Dr., Anchorage, AK 99508; email: edferucci@anthc.org.
- Christine Peoples, MD, can be reached at 3601 Fifth Ave. Suite 2B, Pittsburgh PA 15213; email: peoplesc2@upmc.edu.
- Jasvinder A. Singh, MBBS, MPH, can be reached at 2000 6th Ave. South, Floor 3, Birmingham, AL 35233; email: jsingh@uabmc.edu.
- Alvin F. Wells, MD, PhD, can be reached at 4225 W Oakwood Park Ct., Franklin, WI, 53132; email: a.f.wells@att.net.
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