The Telemedicine Challenge
Individuals with rheumatic disease are often evaluated by a rheumatologist every few months. Thus, getting appropriate follow-up care while minimizing exposure to high-risk settings, such as medical centers, and optimizing the effectiveness of stay-at-home orders is a challenge. To address this, telemedicine has been catapulted to the forefront of medical care in the setting of the COVID-19 crisis.
Telemedicine is challenging on many fronts, including billing, medical malpractice coverage, and interstate practice regulations. These issues are rapidly being addressed at the healthcare system and governmental levels.
Perhaps the most immediate challenge of telemedicine, however, is implementing a visit. This can prove difficult for rheumatologists, their office staff, and patients, who may not be familiar with some the technical aspects of a telemedicine visit, such as scheduling and use of a video interface.
Furthermore, there is little specialty-specific experience about when to appropriately use telemedicine, and what the visits should entail in terms of clinical evaluations or the implications of the limits of clinical evaluations. For example, the physical joint examination, a mainstay of rheumatologic care, cannot be accomplished through current telemedicine applications.
Should ancillary staff be trained to be an onsite extension of the remote rheumatologist? These issues, all of which need to be answered in a systematic way, are particularly important for new patients with disease manifestations, such as joint inflammation, which may not have previously been identified by a rheumatologist and may be crucial for diagnosis.
As such, while exposure restrictions are in effect, rheumatologists may have to rely largely on patient-reported symptoms and what can be gleaned through video imaging. However, it is hoped that these issues will spur the development and implementation of new methods to remotely evaluate patients and that these may benefit the field even after the COVID-19 crisis has resolved. Moreover, these new methods may be broadly beneficial, especially in the face of a predicted workforce shortage in rheumatology
A further challenge in clinical care is obtaining the laboratory tests that are critically important for making diagnoses in rheumatic diseases and are needed to evaluate medication efficacy and toxicity. To address this, some medical centers have developed laboratory collection facilities that maintain high levels of protection for healthcare providers and patients and are separate from facilities evaluating individuals with suspected COVID-19. There remain concerns about the impact of asymptomatic carriers on these models, given that the safety of these sites is typically predicated on symptom-based screening when specific testing for the virus is not widely available.