|Ahead of print publication
Digital technologies in rheumatology: new tools, new skills, and new care
Natasha Ung1, Rebecca Grainger2
1 Department of Rheumatology, Westmead Hospital, Westmead, NSW; University of Sydney, New South Wales, Australia
2 Department of Medicine, University of Otago Wellington; Wellington Regional Rheumatology Unit, Te Whatu Ora - Capital, Coast and Hutt Valley, New Zealand
|Date of Submission||28-Jul-2022|
|Date of Acceptance||10-Aug-2022|
|Date of Web Publication||07-Oct-2022|
Department of Medicine, University of Otago Wellington, P. O. Box: 7343, 23a Mein St., Newtown, Wellington South 6242
Source of Support: None, Conflict of Interest: None
Digital technologies, such as the World Wide Web and mobile computing, have transformed the way we communicate, learn, do business, and spend our leisure time. Similar digital transformations have been slower, or perhaps not yet arrived, in health care. Digital health technologies that might transform health care include electronic health records, virtual visits, wearable devices, and insights from analysis of big data sets artificial intelligence approaches such as machine learning. While many of us now have electronic health records, these are often little more than electronic filing cabinets, not integrating diverse health information, such as patient-generated information, or capable of embedded telehealth. In addition, despite the enormous volume of electronically-held health data, these data are not routinely managed in a way that analysis and insights are easily available. Artificial intelligence, particularly machine learning and neural networks, may provide the means for knowledge to be derived from all the clinical data we now hold., Some progress has been made in developing the evidence base to support the adoption of digital technologies in rheumatology care. In particular, over the past decade, a body of literature examining the utility of remote monitoring and the role, benefits, and risks of telemedicine in rheumatology. The COVID-19 pandemic has then further sharply focused our attention on digital tools for providing rheumatology care, with a steep change in the number of publications addressing digitally supported or delivered care. Two review articles in this special issue of the Indian Rheumatology Journal summarize recent insights. Yeoh and Madenidou have focused on telemedicine adoption during the COVID-19 pandemic: They have highlighted the uncertainties about how teams work in this setting, which rheumatic diseases and presentations might be most suitable for telemedicine, and the impacts of the abrupt change to telemedicine on education and training. MacBrayne et al. focus on the role of remote monitoring in rheumatology. They explore how this could support a fundamental change from the model of regularly booked follow-up appointments to a model that includes patient-reported monitoring through mobile applications or passive monitoring with biosensors. While the field of digital rheumatology care evolves we must not only consider the technology but also keep in mind wider considerations: Where does telemedicine work best in rheumatology care? What types of patients can be remotely monitored? Finally, how do we ensure that changes in care delivery to avoid the increase in health outcomes disparities which already exist for some patient groups.
The benefits and pitfalls of telehealth in rheumatology that were revealed during the rapid change to telehealth in the COVID-19 pandemic should provoke reflection on how to improve systems of rheumatology care, rather than only focusing on replacing in-person visits with virtual consultations. Patient-reported outcome measures (PROMs) have utility in the routine assessment of disease activity, are advocated by the American College of Rheumatology and the European Alliance for Associations of Rheumatology, and most importantly, capture a patient's perception of their own health. Successful utilization of PROMs collected electronically (so-called ePROMs) will require support for people with rheumatic disease to understand PROMs, disease self-assessment, and self-management strategies. A prepandemic study from a center in the Netherlands that introduced an online portal for people with rheumatoid arthritis provides proof of concept for the use of ePROMs. The patients using this system to self-manage had better rheumatoid arthritis control and had fewer in-person visits. This illustrates that changes in a system of care can provide good patient outcomes with lower ongoing direct costs, acknowledging that establishing such a system has high upfront costs. Moreover, such a system does require a well-resourced service for result monitoring, remote management provision, along with identification and follow-up of lack of engagement by patients. This does not always need more rheumatologists: In another prepandemic, real-world example, a “Virtual Monitoring Clinic” was established in a Singapore hospital, in which pharmacists and nurses were trained in teleconsultation to assess and manage people with rheumatic disease in remission or with low disease activity. Unsurprisingly, this service was well prepared to provide coordinated care during the COVID-19 pandemic. While further validation of such approaches, in other settings and in other rheumatic diseases is certainly required, the larger challenge is how to reduce the upfront investment in integrated patient-facing management portals. Defining the minimal effective and useful functionality for patients and health-care staff and required information technology infrastructure, likely staffing, required safety net procedures, and anticipated benefits seem priorities for reducing barriers to widespread development of such systems. After implementation, ongoing evaluation of patient engagement and patient outcomes is an absolute necessity. Such technology implementation will not be easy but since the demand for rheumatology care continues to increase in the face of limited capacity to train rheumatologists, we must collectively invest in such change and learn from each other.
Integral to virtual care models is patient engagement in the measurement of disease activity. People with rheumatic diseases such as rheumatoid arthritis are already adept at identifying disease flares and increasing self-management strategies, well ahead of contacting their rheumatology service. The patient report may be complemented by data from activity sensors, which have been shown to accurately identify flares in people with rheumatoid arthritis and axial spondyloarthropathy. While promising and exciting, it remains unknown if app- and biosensor-derived data will provide additional insights into patient reports, and how to integrate these data into clinical care. Other challenges include rapid drop-off in app or device use, even over short periods. While we anticipate further research into mobile health data collection and its implications for clinical care, we must also remember a very human limitation of technology: A technology could be for anyone but is unlikely to be for everyone. It seems likely that our health-care systems will need to provide a range of options for our patients to interact with us – delivering the care the way a patient wishes to receive it, while also ensuring the best possible health outcomes for all.
While continued advancement in digital health seems desirable and inevitable, we must ensure new technologies do not increase disparities in access to health care, and in turn, health outcomes. While addressing the social determinants of health that so strongly influence health outcomes is outside the direct control of the rheumatology community, any digital health-care tools must be deployed in such a way to avoid exacerbating inequities. Considering the impact and needs of the digitally disadvantaged are non-negotiable. Nevertheless, future rheumatology care seems likely to blend traditional and digitally-supported care. Decisions on which type, and when, should take into account the patient and disease factors and should be a shared decision-making process. Patients who are in remission, have digital skills, access to necessary technology, and accept (or even prefer) this approach, may be well served with remote monitoring and less frequent in-person rheumatology visits. This would free up resources for traditional in-person clinic-based management of people with higher disease activity, or facing more disadvantages. Although implementing digital care models will not be without challenges, we should look forward to a digital health-care transformation in rheumatology. We, as rheumatologists, along with our health-care teams, will need to keep up with technology developments, continually upskill, and show adaptability in our work. Remember these technology developments are just new tools, aimed to benefit our patients. We just need to understand how to use them.
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