‘It is the future of health care’: New monitoring app gives providers real-time PROM data

A novel remote monitoring app could help patients provide real-time information about their disease — including flares and other health care visits — to their rheumatologist in the long durations between visits.

The Rheumera smartphone app, designed with the input of rheumatologists and their patients, is a digital assessment tool that gathers a broad array of patient-reported outcome measure (PROM) data that rheumatologists can use to manage flares, adjust therapeutic interventions and assess disease progress.

“As you can imagine, it can be difficult at times for the patient to recall or appropriately summarize everything that has been affected by their disease over the past 90 to 120 days since their previous visit, or even how they have done over the past 2 weeks,” Jasen Chi, MD, medical director of specialty care at ARcare and Chi Arthritis and Rheumatology Associates, based in Arkansas, told Healio. “Gathering better clinical response data yields improved shared treatment decisions in clinical practice, and thus improved adherence to treatment plans.

“The development team has taken the physician input and built out a physician app that matches to the provider’s schedule and pulls in the patients PRO scores, comments and outside appointments, and summarizes it for their review on their phone prior to walking into the patient room,” he added.

Healio sat down with Chi, who advised Rheumera Inc. on the company’s app, to discuss the need for PROM data among rheumatology patients, the features of this novel application, and how it may be able to fit into personalized care paradigms moving forward.

Healio: Please discuss the importance of patient-reported outcomes in rheumatology.
Chi: Patient-reported outcomes not only represent the patient voice, but are some of the best indicators of current disease activity. These instruments allow us to assess a variety of symptoms including pain, fatigue and physical and emotional well-being across the cascade of autoimmune diseases we encounter. During a patient’s scheduled clinic visit, we do our best to determine their disease activity and/or the effectiveness of the prescribed medication or treatment regimen based on patient reporting. Rheumatology is especially dependent of the patient expressing the level of their disease state.

The instruments used in rheumatology to measure patient outcomes include tools like MD-HAQ, RAPID3, CDAI and DAS-28. Most of the tools have some component of patient reporting or scoring involved. Today, most physicians and practices are limited by the frequency in which they can gather these valuable metrics. It is mainly collected via clipboard during in-person visits, and discussed during the patient-physician encounter.

Healio: Why could remote patient monitoring be so beneficial for rheumatology patients?

Chi: Our patients have chronic inflammatory autoimmune diseases, and each disease in each patient is a progression. Patients will often respond to treatment in very different ways. With the limited number of trained rheumatologists, we are all limited in the frequency in which we can see our patients. Most practices schedule their return patients at 3- to 4-month intervals. So much can and does happen with patients between office visits.

Using remote monitoring is common in other sub-specialties. There are often first-alerts to trends and urgent patient needs. The future of best-practice medicine will include more and more of the tech-enabled remote monitoring modalities. Between wearables, sleep technology, and smart devices that are becoming exponentially more “intelligent” by the day, we are on the verge of real-world evidence that can be available in real-time. The data that is coming in via remote monitoring is the voice of the patient, and typically cannot be found in the current physician-entry limited EHRs.

Healio: As a physician, how much more useful is this information than traditional patient-reported data?

Chi: Unfortunately, even if a patient were diligent and took 90 to 120 days of detailed notes, scored measures and reported them in a paper notebook, it would be — and often is — very difficult to receive this information and process it in a timely manner. This is where artificial intelligence, programmed into apps like Rheumera, can be efficient tools to take all reported measures, flares and patient comments, and appropriately summarize the data and filter out excess noise. Not only is this giving the patient their voice, but it also allows for a more productive in-office visit at the next direct appointment.

Healio: Why is this an important that Rheumera was developed with rheumatologists?

Chi: There are nuances to all patient encounters. It can be argued that the fine details of the patient reported data in patients with autoimmune diseases could be some of the most nuanced. The Rheumera app was designed by rheumatologists to incorporate into the current workflow of already over-burdened rheumatology providers. The tool was developed to improve efficiency while increasing applicable data points for patients with rheumatic diseases.

Physicians can mark treatment initiation and any other significant dose or therapy changes to evaluate trends. Patient alerts, medication reminders and nudges can be used to reinforce compliance and increase adherence to the shared therapeutic goals. The rheumatologist can then use the collected data to identify early trends. They know what questions to ask based on years and years of experience.

The development team has taken the physician input and built out a physician app that matches to the provider’s schedule and pulls in the patients PRO scores, comments and outside appointments, and summarizes it for their review on their phone prior to walking into the patient room. This, and many other features, are built out in collaboration with rheumatologists that are knowledgeable and willing to share their feedback to improve the product and their even their own productivity.

Healio: How can the physician act on the information they receive from the app?

Chi: After reviewing the AI summary of the patient-reported data, the physician can hit a “Copy to Note” button that allows for the reviewed summary to be added into the patient encounter chart. We are now generating data from patient reports that lead to more specific diagnostic criteria for our patients.

Healio: What has been the response from rheumatologists and patients?

Chi: Patients have embraced the technology and feel more connected to the practice. It is enjoyable to share with the patient that we have been monitoring their reports and keeping tabs of how they are doing. The patient now knows that we are closely monitoring their progress and are mutually engaged to improve their baseline disease activity.

As a physician, it has been rewarding when the patient tells me that they have been doing as I asked and are indeed updating the app frequently. I reiterate to them how important it is to create this record of your disease activity. We have used the reports generated from the app many times to send to the insurance company to facilitate biologic initiations or validation of drug change or increase.

Healio: Can the technology help manage patients with more severe or flaring disease?

Chi: One of the patient workflows includes a “Report a Flare” feature. When pushing this button on the app, the patient is first led to a series of important filtering questions, such as, “Are you experiencing more than normal joint swelling or tenderness? If so, where?” as well as, “Are you currently spiking a fever above 100.3 degrees?” or, “Have you taken any additional medicines?”

Another interesting question that we have added asks, “Would you like to notify the provider of your flare today?” The patients are often not asking the office to be directly notified, or requesting a call on the flare alert, but rather are using it to self-journal and document severity, trend or number of flare episodes.

Healio: What diseases/conditions are optimal candidates for this platform?

Chi: Patients with rheumatoid arthritis and psoriatic arthritis are optimal candidates. With a built-in self-reported homunculus called “Manny Quinn,” patients are able to label any effected joints. They identify the area and mark the joint as tender or swollen, and the joint then changes color to make it easy to identify the painful joints. They are also asked to rate tenderness or swelling on a 1-to-5 scale for self-evaluation. There is also a button for taking pictures to add to their profile by date. This is especially helpful for patients with psoriasis and can serve as a baseline or be added to the flare report as an update.

Healio: How about conditions beyond RA and PsA?

Chi: Many symptoms and problems cross over between several rheumatic diseases. All autoimmune diseases eventually will be incorporated into the Rheumera app, as well as other non-autoimmune diseases we may follow. Hyperuricemia gout is a good disease that also benefits from consistent remote monitoring. An individual may participate by reporting lifestyle or diet trends that are key to triggering their gout attack. This will lead to self-monitoring and reporting, and hopefully help change behaviors that may avoid the attack.

Healio: What is your hope for the future of this app?

Chi: We know that we are in the early stages of utilization of this type of technology. CMS and most private-payer insurance companies have embraced the concept of remote monitoring of patients between office visits. CMS has a Connected Care program that consists of many aspects that are designed to encourage physicians and health care providers to remote monitor their patients to improve management and outcomes. There are several approved codes, to date, that make it beneficial to both the patient and the office to use technology to take better care of our patients outside of our traditional in-office visit.

Patient adherence to therapies and medications will be much simpler to evaluate. Intolerance or issues with medications will be quickly reported, and thus opportunities to fix those issues can be provided quicker, vs. finding out 3-4 months later that they have not had their meds in months.

Healio: What are the implications for this type of technology beyond rheumatology?

Chi: Overall, it is the future of health care. Real-time data and easier communication will only lead to faster interventions and more compliance to the plan of care. AI will be learning and looking for trends and future recommendations. These intelligent recommendations are only available with date inputs. Although EHR is the source of truth for patient data, there is a gap in data coverage, and it lacks direct patient voice.

Applications like Rheumera aim to prioritize the patient voice, their reported outcomes and disease state. Autoimmune patient management, while complex, could be the ideal place to hone the technology and make it a part of everyday rheumatology practice. Better technology will yield better outcomes and improve the practice of medicine.

For more information:

Jasen Chi, MD, can be reached at 6 Shackleford Drive, Little Rock, AR 72211; email: Navneet Gosal nav@rheumera.com; jcchi@chiarthritis.com.