He explained how, with ballooning wait times across rheumatology practices nationally, an increasing need exists to be more selective about the patients accepted to be seen in clinic. Data for rheumatology clinics at Duke University shows median wait times have increased to 160 days as of 2023 (Figure 1, below).
Figure 1: The median wait time at Duke University rheumatology clinics
Additionally, the longer the wait time, the higher percentage of patients who will no show or not attend the visit. The no-show rate is around 15% for patients scheduled within 90 days, but doubles to 30% for patients waiting nine to 12 months for an appointment.
“Every no show for a new patient is a missed opportunity for a patient who needs our care,” Dr. Doss said.
Referral Triage
To address these challenges, many institutions are using referral triage, a process in which incoming referrals are reviewed, and appointments are preferentially allocated to patients with a higher likelihood of rheumatic disease.
“Many practices are restricting appointments for certain referrals, such as fibromyalgia, osteoarthritis, hypermobility or chronic fatigue,” Dr. Doss said.
Potential challenges for referral review include missing patients with real rheumatic disease, disgruntled patients or referring clinicians, and time necessary for manually reviewing charts.
Benefits of E-Consults
Another modality of providing access to care are e-consults, which are asynchronous, non-patient facing communications between healthcare providers giving diagnostic and/or treatment recommendations to referring clinicians.
The process first involves a referring provider placing an e-consult order—for example—for a patient with a positive antinuclear antibodies (ANA) test. The rheumatologist will then perform a medical record review, provide diagnostic and/or treatment recommendations, and accept or decline an in-person appointment.
“E-consults have many benefits, including screening out low yield referrals, expediting urgent appointments, and educating referring providers,” Dr. Doss said. “Primary care providers have also learned over time from reading e-consult recommendations, and now, they are more likely to complete some of the initial workup on their own.”
Studies conducted after the implementation of e-consult services have shown reduced wait times in other specialties and decreased need for in-person rheumatology referrals.1,2,3
At Duke University, no protected time is provided for this work. The physicians receive compensation of $25 per completed e-consult.
“In 2025, we also started billing insurance for e-consults,” Dr. Doss said. “Surprisingly, two thirds of e-consults we submitted for billing have actually been paid.” He notes that since billing insurance, patients sometime
Figure 2: The total number of e-consults completed at Duke University from 2017–2025
s get a bill with an average patient payment of $7.
Of a total of 7,748 e-consults completed in the past nine years at Duke University, 59% had an in-person appointment recommended by the process (Figure 2, below). Now, they receive approximately 30–40 e-consults per week.
Future directions include the potential role of artificial intelligence assisted screening.
Resources for Primary Care Providers
Next, Pankti Reid, MD, MPH, associate professor of medicine at the University of Chicago, presented on the development and implementation of the Rheumatology for Primary Care website, which can be used to help address gaps created by the rheumatology workforce shortage.
A study published on delay from symptom onset to rheumatology assessment showed only 8–42% of patients are seen within the first 12 weeks of symptoms.4 Dr. Reid explained the challenges of the supply-and-demand imbalance combined with a paucity of guidance for efficient rheumatology evaluation.
“There needs to be a more accessible resource to help evaluate and manage patients who cannot get to a rheumatologist in a timely manner,” Dr. Reid said.
The Rheum for Primary Care website was developed by the ACR, funded by an education grant from Pfizer, as a concise, free tool for primary care providers. Content was created by rheumatologists in collaboration with primary care providers and reviewed by disease experts, including disease-specific information and symptom-directed guidance.
The symptoms section provides information for various chief complaints, such as joint pain, muscle weakness, Raynaud’s or rashes. Dr. Reid said, “There are flowcharts for a provider to follow, review differential diagnoses they should consider, and determine what tests to order for initial evaluation.”
Other sections of the website provide an explanation of rheumatology labs and links to medication information from the ACR.
Dr. Reid noted that from October 2024 to October 2025, the website received more than 63,000 views from more than 52,000 active users.
“The average engagement time per page was less than a minute—about 54 seconds,” Dr. Reid said. “That told us we need to keep information very succinct and to the point so it can be used in real-time efficiently in the clinics.”
Dr. Reid highlighted the website’s feedback survey, which is accessible on every page, as a key tool for ongoing improvement. “We are still in the first iteration of the site and greatly appreciate the feedback we’ve received from providers and patient groups,” she said.
Dr. Reid noted that future priorities include stronger partnerships with foundations, expanding patient-informed content and collaborating with other organizations to better reach primary care providers.
Screening Strategies for In-Person Visits
Next, Alexis Ogdie, MD, MSCE, professor of medicine and epidemiology at the University of Pennsylvania, Philadelphia, presented on strategies for determining when patients need our care.
“As you practice for many years, the reality is we cannot see all the patients who need to be seen every four to six months,” Dr. Ogdie said. “The goal is to figure out how to identify patients who need to be seen urgently and which patients do not need to see you as often.”
In a pilot study, Dr. Ogdie enrolled patients in a program in which they were sent a RAPID-3 ahead of their clinic visit. For high RAPID-3 scores, patients would be evaluated as usual with in-person visit to determine if inflammatory arthritis or an alternative etiology, such as fibromyalgia, was the cause.5
“Patients in remission or low disease activity, by RAPID-3, with no significant change in the overall RAPID-3 score, had the option to change their visit to telemedicine or see an advanced practice provider instead,” Dr. Ogdie said.
Other ways to triage include holding spots reserved for patients flaring in templates, asking patients to reschedule follow-up appointments for six months later if doing well and using patient-reported outcome (PRO) measures in advance of appointments to shift timing.
“The RAPID3 can be helpful as a PRO for inflammatory arthritis,” Dr. Ogdie said. Other specific PROs for axial spondyloarthritis and psoriatic arthritis, respectively, include Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Psoriatic Arthritis Impact of Disease (PsAID).
Wearables
Finally, wearable technologies are devices that enable continuous, objective disease monitoring beyond the clinic.6 Wearables include activity and mobility trackers (e.g., Fitbit or Garmin), joint-specific devices, such as smart gloves for rheumatoid arthritis, which are still under development, cardiovascular monitors (e.g., WHOOP Strap or Apple watch), and sleep/recovery monitors (e.g., the Oura Ring).
Wearable devices can be used for self-management. Example: A patient with poor sleep can use a device to better understand their sleep patterns, as well as to evaluate their response to interventions in real time, Dr. Ogdie said.
In Summary
In a world of increasing clinical demands and workforce shortages, this engaging session provided novel practical strategies that rheumatology practices can use to triage patients more effectively.
Mithu Maheswaranathan, MD, is an assistant professor of medicine in the Division of Rheumatology at Duke University School of Medicine, Durham, N.C. and can be followed on X/Twitter @MithuRheum.
References
- Abdellatif B, Natarajan V, Leibowitz AJ, et al. Electronic consultations for endocrine conditions: A scoping review. J Endocr Soc. 2024 Oct 1;8(11):bvae170.
- King HL, Benedetti GB, Barisic S, et al. The impact of hematology electronic consultations on the management of iron deficiency. Eur J Haematol. 2024 Nov;113(5):614–622.
- Rostom K, Smith CD, Liddy C, et al. Improving access to rheumatologists: use and benefits of an electronic consultation service. J Rheumatol. 2018 Jan;45(1):137–140.
- Raza K, Stack R, Kumar K, et al. Delays in assessment of patients with rheumatoid arthritis: Variations across Europe. Ann Rheum Dis. 2011 Oct;70(10):1822–1825.
- Ruderman EM, Ogdie A. Addressing the rheumatology workforce shortage: A question of supply and demand. J Rheumatol. 2022 Nov;49(11):1183–1184.
- Papatriantafyllou M. Wearable device for RA management? Nat Rev Rheumatol. 2024 Jul;20(7):396.