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11 Articles in Volume 21, Issue #1
Advanced Practice Matters with Theresa & Jeremy: Mentorship
Ask the PharmD: What is a true opioid allergy?
Behavioral Medicine: How Clinicians Can Reduce the Stigma Attached to Chronic Pain
Chronic Headache: How to Conduct a Virtual Neurological Examination
COVID-19 Long Haulers: A Look at Cardiovascular Risk
How COVID Has Changed Pain Practice and Policies
How to Conduct a Pain Evaluation Using Telemedicine
Inside the Potential of Biologics for the Treatment of Rheumatoid Arthritis
Managing Pain in Parkinson’s Disease
Spinal Cord Stimulation Shown to Improve Pain and Movement in Parkinson’s Disease
TeleRheumatology Before and During the COVID-19 Pandemic

TeleRheumatology Before and During the COVID-19 Pandemic

How to effectively deliver remote care to rural patients – a case in telemedicine from the University of Pittsburgh Medical Center.

The COVID-19 pandemic has upended nearly every aspect of daily life, including routine medical care. In early April 2020, in-person medical practice visits were down 69% from pre-pandemic levels and, at the same time, telemedicine visits were at their highest levels in recorded history. By early October 2020, rheumatology was among the top three medical specialties using telemedicine by percent of total visits, tied with endocrinology and surpassed only by behavioral health.1

The risk reduction of conducting home video visits is particularly appealing in rheumatology; this format allows immunosuppressed patients to remain safely at home while providers continue to carefully monitor their disease and medications. However, there are limitations to conducting virtual-only physical exams.  

Herein, we review the workings of a telerheumatology program before and during the COVID pandemic and offer strategies for meeting the needs of patients living in rural areas with limited access to specialty medical care.

 

Rheumatoid Arthritis Care: Why a Physical Exam is Crucial

The treatment of rheumatoid arthritis (RA) in a general sense can be divided into two key phases: diagnosis and maintenance. Diagnosis of the disease draws from the integration of history, physical exam, and supportive laboratory testing. In this phase, joint palpation is crucial for distinguishing arthralgia, or painful joints, from arthritis, or inflamed joints, based on the presence of joint swelling in addition to tenderness. Joint swelling, suggestive of synovitis, must also be distinguished from subcutaneous edema. Both of these key examinations rely on palpation which is not physically possible through telemedicine.

The monitoring phase of care assesses disease activity and medication tolerability. Similar to making a diagnosis, assessing disease activity takes into account the number of tender and swollen joints on palpation and integrates this with the patient’s and physician’s assessment of global disease activity to distinguish controlled disease from uncontrolled disease.

 

In Practice: The UPMC TeleRheumatology Center

How a Tele-Rheumatology Program Works

There is a myriad of approaches to providing care through telemedicine. Our primary approach at The TeleRheumatology program at the University of Pittsburgh Medical Center (UPMC) has been to utilize teleconsult centers to serve patients living in rural communities. There are three such centers and each one is located in or nearby a local community hospital. Each center has an audio-visual connection to a remote rheumatologist, who is located at a centralized academic medical center. The patient visits one of the teleconsult centers (based on their location) and a telepresent RN facilitates the session. After the virtual visit, the patient is able to have lab work and imaging done at the local community hospital.

During the pandemic, we have limited in-person visits to the teleconsult centers and instead adopted a supplementary home-based telemedicine model for appropriate patients.

It is worth noting that, at UPMC, we have been successfully using telemedicine to provide full-spectrum adult rheumatology care to rural Pennsylvania since 2013, years before the pandemic abruptly pushed telemedicine into the spotlight. For the majority of these patients, there are no rheumatologists within a 2-hour drive, and many without this care model would otherwise go without treatment. We, therefore, structured our telerheumatology program with these important considerations in mind. As a result, teleconsult centers have been able to provide RA care without sacrificing quality. In fact, in 2019, a single provider delivered 618 telerheumatology visits to three counties in western Pennsylvania.

Typically, an initial consultation at our telerheumatology program occurs after a primary care doctor suspects possible rheumatoid arthritis (or another rheumatologic condition) and makes a referral to the teleconsult center. Staff contact the patient to review the mechanics of the visit and schedule an appointment time. The patient arrives and checks in at the consult center, the same way they would for any other visit.

The Virtual Rheumatology Exam

In the virtual exam room, the rheumatologist performs a complete history through a video conferencing system (see Figures 1 and 2). When it comes time for the physical exam, a licensed healthcare provider, in our case an experienced RN, assists the patient with positioning and arranges different remote cameras for close inspection of the skin, eyes, and mucus membranes. Additionally, they auscultate the heart and lungs with a Bluetooth-connected stethoscope under the direction of the rheumatologist and perform a specialized joint exam, conveying their findings of tenderness and synovial swelling.

Mirroring an in-person visit, the rheumatologist then provides an assessment and plan based on the findings of the comprehensive history and physical exam. Traditionally, follow up-visits are performed in the same manner as the initial consultations.

Figure 1. Video conferencing system used at the telerheumatology program ((Images courtesy U Pittsburgh).

Figure 1. Mirroring an in-person visit, the rheumatologist provides an assessment and plan based on the findings of the comprehensive history and physical exam. (Images courtesy U Pittsburgh Telerheumatology).

Why It Works

The success of our approach to providing rheumatologic care to patients that would otherwise go without depends on three essential components:

  1. Expert teleconsult center staff
  2. Systemwide technology investments
  3. Relationships with local primary care providers

The first of these, the staff at the teleconsult centers, are specially trained in providing care through telemedicine. In our system, the utilization of experienced RNs in this role facilitates reliable and reproducible physical exams, which helps to overcome a key hurdle in the use of telemedicine in rheumatology care. Additionally, the staff are members of the local community, providing important insight into the unique challenges of the three counties the program serves.

The second component, technology investment, allows us to deliver high-quality care with a solid telecommunication infrastructure, advanced audiovisual equipment, and an integrated electronic medical record across the three teleconsult centers. The telecommunication investment in particular has been crucial for us to provide care in regions with limited widespread broadband access.2 High throughput broadband connections coupled with specialized camera systems delivers clear images and conveys confidence to both patients and providers.

The third element, our long-term relationships with local primary care practitioners, has enabled us to provide an integrated care model. The program also promotes professional education whereby medical knowledge gained from one consult can often be applied to other patients with similar medical issues.

However, as described below, the pandemic has presented unique challenges to providing telerheumatology to our rural communities that are not always easily overcome by new technologies.

 

COVID and the Challenges of Home-Based Telemedicine

Prior to the start of the pandemic, a major benefit of the teleconsult center system was keeping patients in their communities without diluting the quality of the care provided. This pandemic has significantly affected this model by limiting in-person visits by the patients to the teleconsult centers, thereby requiring a much higher number of home-based, as opposed to consult-center-based, televisits.

In shifting to this home-based model, disparities in broadband access, in particular, became prominent. A 2019 study of broadband access commissioned by the Pennsylvania Legislature demonstrated that rural counties had substantially slower speeds compared with more urban counties.2 Slow broadband internet connection degrades the quality of the audio and video connection, leading to interrupted conversations, while absent broadband connectivity precludes the use of a video-based interview and visual joint inspection. (Editor’s Note: More on access to care disparities during COVID in our conversation with Dr. Jonathan Goree.)

Further compounding this, a 2018 survey found that 26.3% of surveyed Medicare beneficiaries lacked home digital access (eg, computer, webcam, or smartphone) to health services3 and in a separate but related survey, 13% reported unreadiness for a home-based video telemedicine visit.4 The self-assessed unreadiness was inversely associated with self-assessed health status, with 77% of those describing their health as poor also reporting feeling unready for home telemedicine.4

These challenges, which are not unique to rheumatology, have led to a higher number of telephone-based home-visits as a temporizing measure in the midst of this pandemic until we are able to fully restart in-person visits to the teleconsult centers.

On the other hand, these complexities highlight some of the potentially overlooked strengths of UPMC’s approach to telemedicine. For instance, limited broadband access in rural communities can be addressed by utilizing local teleconsult centers that are linked to high bandwidth broadband as part of the community hospital. During a visit, teleconsult staff are able to manage technology while the patient and physician focus on the medical issues at hand, thereby negating the need for patient digital access or familiarity with telecommunication systems.

 

Tips for a Good Televisit in Rheumatology

Along the way, UPMC’s TeleRheumatology Center has developed a few strategies for providing a good telerheumatology visit that may be applied to any specialty using telemedicine.

For starters, a “computer-side” manner must be developed. While virtual care may seem to be impersonal, clinicians can still cultivate a meaningful provider-patient relationship. Fostering a therapeutic alliance with the patient is a skill that can be learned and developed over time, lending itself to a chronic care model of disease that is extremely relevant to rheumatology. Many of the key aspects of making this virtual connection with patients are straightforward.

The first thing to consider is your onscreen presence, which depends on the position of your monitor and the camera. The camera should be arranged so that when you are looking at the screen it does not look like you are looking down or off to the side. Even if you are making eye contact with the patient on the video, your camera may convey a completely different message.

Second, most patients like to know where you are located when you are conducting the virtual visit, either in a clinical/hospital setting, or a home office. Maintaining a professional appearance on-screen, making appropriate eye contact, and taking the time to carefully listen to the patient’s concerns greatly impacts the virtual visit.

You can include various teaching devices, just as you would during an in-person visit. For example, when I recommend an injectable medication to a patient for the treatment of rheumatoid arthritis, I have an example pen/cartridge/device to show them on the screen and demonstrate how it works. It is important to be inventive and think outside the box when using the remote platform. Despite being many miles away from where the patient is located, it is possible to achieve the all-important human connection.

More from Dr. Peoples with the American College of Rheumatology on why telerheumatology is important.

 

Conclusion: The Difference Delivered to Patients

We will close with the brief story of a 42-year-old patient with psoriatic arthritis. She also has epilepsy and is unable to drive; thus, she relies on her elderly parents, who have chronic health issues of their own, to take her to appointments. Through our telerheumatology program, she has been able to receive specialty care close to home before and throughout the COVID-19 pandemic. At our most recent televisit, she expressed that being able to see her provider in this manner made such a positive difference in her life and her parents’ lives. This difference is independent of any medication prescribed or treatment protocol recommended.

At the end of the day, the goal of any rheumatologist or specialist is to provide the best care for the patient at the right time in the most effective way possible. Treating patients with chronic diseases that cause pain on a regular basis is challenging enough; in many ways, telemedicine allows for a method of care that improves our patients’ daily lives.

 

Additional Telemedicine Resources and Examples

Also in this special telemedicine issue of PPM:

Last updated on: January 5, 2021
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