Rheumatology 2021: Quo Vadis?

In part 1 of this article series, Dr. Concoff dusts off the crystal ball to envision the future of the practice of rheumatology, in particular the role of telemedicine during the COVID-19 pandemic and beyond.

At long last, 2020 has wound down. It has been a dreadful and catastrophic year, lived in the shadow of the coronavirus disease 2019 (COVID-19) pandemic. But even as we begin a New Year with the most excruciating months of COVID-related destruction likely still ahead of us, our hopes are buoyed by the emergency approval of 2 COVID-19 vaccines and the possibilities of the post-pandemic new normal future that widespread vaccination may finally usher in. Yet the new normal of the post-pandemic ecosystem presents opportunities for evolution to better care. Rather than simply looking back at the destruction that the COVID-19 pandemic has wrought, in this series I have dusted off the crystal ball to envision the future of the practice of rheumatology in light of the challenges and advances over the past year.

Part I - Telemedicine:

Short-Term Adaptation to Manage COVID Realities or Long-Term Solution to Challenges in Rheumatology?

The advent of the pandemic mandated the rapid adoption of telemedicine in rheumatology. Prior to the pandemic, rheumatologists had been skeptical of telemedicine as reflected in the limited adoption of remote visits by our practices. Notable challenges to the application of telerheumatology include the inability to completely assess disease activity according to current standards, for instance the inability to perform joint counts or collect other patient-recorded outcomes, reduced the perceived value of such visits. Still, when the pandemic made in-person visits hazardous, telemedicine served as a vital lifeline between Rheumatologists and their patients.

The future role of telemedicine is considerably less certain than has been widely portrayed. Indeed, is not much room on the telemedicine bandwagon as the near unanimity in proclaiming that “telemedicine is here to stay,” with the notable exception a recent, well-reasoned discussion by Richard Allman in The Rheumatolgist,1 has left prognosticators stumbling over one another to extoll its virtues. Yet when we peel back the veneer of the short-term wins, what are our patients, and the system, receiving from telerheumatology visits? When viewed objectively, there is certainly an incremental difference in the completeness of the clinical information extracted from, and therefore the value of, an in-person versus even the most nuanced remote visit from a value perspective. In rheumatoid arthritis (RA) for example, given the proven benefit of treat-to-target strategies with their reliance upon the performance of joint counts, widespread adoption of telemedicine may hamper the adoption of treat to target (T2T) strategies and thereby worsening outcomes. Even when a subjective PRO like a RAPID3 is collected in association with a PRO, the recognized subjectivity of these instruments, including the impact of other painful conditions, comorbid condition, floor and ceiling effects, serve to magnify the challenges in assessing the inflammatory, RA-specific burden among patients seen remotely as opposed to pain- and behavioral health-related distress. This decrease in accurate patient phenotyping moves us further away from what should be the goal of all rheumatologists, the march toward precision medicine in determining the right medication(s), at the right dose, for the individual patient before us. Such determinations will require deep clinical phenotyping coupled with individual-level assessments of meta-omics and companion biomarkers. Though such capability may still seem something from far-flung science fiction, the advances of the Accelerating Medicines Partnership (AMP) consortium in systemic lupus erythematosus (SLE) and RA, and laboratories of applying similar approaches (to be described in greater detail in subsequent articles in this series), have moved us ever closer to this evaluation and treatment paradigm in the clinical setting than we were at the beginning of 2020.

Additional challenges to telerheumatology value are developed because of the limitations of the clinical dataset that can be generated from a remote visit. Many rheumatologists remain uncomfortable with evaluating new patients or making major changes in care including changing medications during telemedicine visits. This scenario may relegate telemedicine to a limited role in cursory, follow-up “check-ins” that do not serve the same comprehensive monitoring purpose that in-person visits have. Similarly, with new patients, telemedicine visits may be terminated prematurely in favor or an in-person visit, if specific physical examination data or case complexity is deemed too challenging for telemedicine. The net result is 2 charges and 2 timeslots allocated to serve the introductory needs of same patient. This latter circumstance may contribute to worsening the already significant access problem that has plagued Rheumatology in the US and worsened long-term outcomes for our patients. What might change these paradigms to address such limitations? The development of scalable, adjunctive, technological tools that augment the remote physical examination, for example to allow us to remotely distinguish painful from tender and/or swollen MCP and PIP joints in RA, would serve particularly well here. In fact, several studies designed to develop and evaluate such tools are underway, the results of which may go a long way toward determining the value proposition for telerheumatology.

Further challenges to the widespread and consistent application of telerheumatology in the future include the need for routine laboratory screening. The pre-pandemic recognition of the need for routine laboratory monitoring to inform follow-up visits did not miraculously vanish with our pivot to virtual-only care. It would appear, as we have learned through collecting data from the past several months, that routine screening laboratories at least in stable patients, may be deferred for a time without significant consequences. Yet such testing has functioned as an early warning system that has improved the safety of the medications we use, for instance as in elevated liver enzymes indicating early methotrexate hepatotoxicity. Though such screening laboratory tests may be deferred for a time, and may actually reduce short-term healthcare costs from chronic rheumatic conditions, there is a point after which kicking that can further down the curb will likely result in increased costs from progressive, unrecognized complications of either medications or underlying disease. At that point, the value needle to away from telerheumatology alone. Given this “delta” in value between in-person and remote visits, Payers may or may not continue to reimburse Telemedicine visits at a level that justifies the time spent performing them from the practice perspective. The longer in-person screening visits and laboratories are deferred, the more likely that the delta negatively affects the value proposition. Yet we have no current understanding of when such changes occur. Thus, a sensitivity analysis of the mid-and longer-term value of telemedicine visits must been robustly investigated as an extension of the positive short-term results2 that have been generated to date. Such data is needed before we join the chorus extolling the virtues of telerheumatology as a long-term value solution to the challenges of the ecosystem.

Of late, many Payers have included in the rationale for continuing Telerheumatology the perception that this would improve access and efficiency in the setting of the widely acknowledged workforce deficiency in rheumatology. The limits to the remote physical exam are not the only chink in the armor of the argument. However, it is not at all clear that telemedicine, in the absence of the pandemic, allows providers to provide care in a more timely or more efficient manner than in-person visits. In fact, to the contrary, the inability to virtually reproduce the infrastructure of a busy clinic environment impairs, rather than improves, office efficiency and patient volumes. Recall for example, that with in-person visits, even the most efficient clinic has some temporal overlap among patients seen in the pre-COVID rheumatology clinic. Hence the need for each provider to have available multiple exam rooms. Consider the efficiencies of the numerous, simultaneous activities occurring in parallel across different patient appointments in compartmentalized examination rooms, along with the ability for a provider to rapidly toggle, multi-tasking from one patient to another, even as office staff members work feverishly to resolve, in real-time, the “roadblocks” of missing data so frequently encountered during a visit. These capabilities simply have not been reproduced by current telemedicine platforms which reduce most clinic to seeing patients in series, reducing efficiency by about 20%.

Nevertheless, from a patient perspective, the convenience of telemedicine visits from the comfort of a patient’s own home, without the long commutes required in more rural or congested urban areas, long waits in the waiting room, and exposure to other patients are substantial benefits to the patient experience and may drive demand for continued use of telemedicine for some time to come. This set of patient sentiments may be offset by contrary, humanistic perceptions regarding the ability to connect in a meaningful way with a provider over a video interface rather than face-to-face. Given the recognized primacy of trust in the treating rheumatology provider to adherence to medications, for example, might we see a drop-off in outcomes from nonadherent patients who didn’t feel interpersonal connectedness from the sacred interactions and rituals of a face-to-face meeting? Might not patients feel less confident without the ability to interact face-to-face with their provider the delicate dance of triangulated shared decision-making conversation regarding changing to an alternative targeted immunomodulator?

Current biomarkers of disease activity lack the clinimetric properties to supplant in-person disease activity measure-based, T2T care that requires the physical exam. Further, no at-home blood tests to monitor for drug toxicity or risk of disease progression are available (or likely to gain support until the Theranos debacle is forgotten). This scenario must change before simplistic approaches to improve access to rheumatology providers by leveraging entirely subjective measures of disease status and existing lab test are unlikely to replace the need for the clinician’s skill in monitoring and modifying care. Some hope is on the horizon given recent work in predicting flare based upon finger sticks and PRIME cell activity.3

Thus, although it may seem a minority opinion to doubt the role that telerheumatology will continue in its current widespread level of utilization in care in the US, and no one would claim that telemedicine wasn’t a necessary pivot during the pandemic, I remain unconvinced that telemedicine is “here to stay’ outside of special circumstances. It will certainly continue to be vital in rural environments. However, in the absence of substantial technological innovation to augment it, significant improvements in the user interface on both ends in response to willingness on the part of patients and providers to continue mold its sophistication in minimizing the delta from in-person visits, and payer support for equality in reimbursement with in-person visits, its role will fade considerably. In the future, if we fail to robustly develop the technology, we are more likely to view telerheumatology as a quaint, but adequate, short-term fix for an acute problem that we faced rather than a critical portion of the long-term solution to the larger problems of access and efficiency rheumatologists confront moving forward. Or stated otherwise according to the old axiom, “betting on the status quo is never a bad bet in health care.” The question is do we apply the perspective of the pre- or post-pandemic circumstances as the baseline for prognostication.

Read Part II in the series here.

References:

1. Allman RL. Outpatient medicine in the post-COVID-19 era of telemedicine. The Rheumatologist. 2020. Accessed December 31, 2020. https://www.the-rheumatologist.org/article/outpatient-medicine-in-the-post-covid-19-era-of-telemedicine/?singlepage=1

2. Ferucci ED, Day GM, Choromanski TL, Freeman SL. Outcomes and quality of care in rheumatoid arthritis with or without video telemedicine follow-up visits [published online ahead of print, 2020 Oct 14]. Arthritis Care Res (Hoboken). 2020;10.1002/acr.24485. doi:10.1002/acr.24485

3. Orange DE, Yao V, Sawicka K, et al. RNA Identification of PRIME Cells Predicting Rheumatoid Arthritis Flares. N Engl J Med. 2020;383(3):218-228. doi:10.1056/NEJMoa2004114