SINGAPORE—In the first quarter of the 21st Century, the world of medicine has seen an explosion in health technologies, many of which have the potential to greatly impact patients’ lives.
At the 26th Congress of the Asia Pacific League of Associations for Rheumatology (APLAR) in August 2024, Rebecca Grainger, MBChB (Dstn), BMedSci (Dstn) MIsntD, FHiNZ, FRACP, PhD, professor, Department of Medicine, Te Whatu Ora Capital Coast and Hutt Valley, University of Otago, Wellington, New Zealand, gave a lecture titled, Health Technologies and Patient Engagement. She described new technologies and presented the evidence for how such interventions may help improve outcomes in rheumatology and make patients feel more involved in their medical care.
Dr. Grainger began by answering the question: “What is personalized care?” In her words, personalized care is a system in which information, such as a patient’s unique biology, their individual needs, their preferences and social circumstances, can be used to ensure care is tailored specifically to that patient.
The application of personalized care can occur at different time points, including the point of access, when questions of diagnosis and management arise, and when patients are followed over time. Regarding access, Dr. Grainger noted that demand for rheumatologists outstrips supply; thus, getting the right patients in for an evaluation at the right time is key. Delays often occur at four main points:
- After the initial onset of symptoms;
- After the first evaluation by a primary care provider;
- After the first appointment with a rheumatologist; and
- The point at which a diagnosis can be secured, and a treatment plan can be implemented.
Symptom Checkers & Diagnosis
Rheumatology faces a challenging conundrum: Many patients with inflammatory rheumatic diseases encounter obstacles to seeing a rheumatologist in a timely manner, yet up to 60% of patients who see a rheumatologist for rheumatic complaints are not ultimately diagnosed with an inflammatory rheumatic disease.1,2 Thus, room exists for help from online symptom checkers, which are patient-facing, diagnostic, decision-support systems. In some cases, such tools may reduce delays in care and errors in diagnosis, helping triage patients appropriately.
Through the work of The Joint Pain Assessment Scoring Tool (JPAST) project, a European initiative aimed to enable and accelerate precision medicine for early treatment in rheumatology, researchers have developed an online symptom checker named Rheumatic?. To date, Rheumatic? has demonstrated high discriminative performance in identifying patients likely to develop rheumatoid arthritis (RA) in an at-risk population and in differentiating inflammatory rheumatic diseases from other musculoskeletal conditions in people with early joint swelling.3
With respect to the user-perceived experience, more than 12,000 people who had used this tool were surveyed in a study. Of these individuals, 78% found the tool useful, 76% felt the questionnaire allowed them to describe their complaints well and 74% would recommend the tool to friends and other patients.4
Dr. Grainger noted that such results for symptom checkers are encouraging. However, a key question that must be explored is: “How accurate are these tools?”
In a 2022 systematic review, Wallace et al. evaluated the accuracy of symptom checkers in yielding a diagnosis and appropriately guiding patient triage. They identified 10 studies that looked at a range of conditions, including inflammatory arthritis, ophthalmologic diseases and HIV. (Note: 50% of these studies recruited real patients, and the remainder used simulated cases). Among the tools studied, primary diagnostic accuracy (i.e., listing the correct diagnosis first) ranged from 19–38%, top three diagnostic accuracy (i.e., listing the correct diagnosis first, second or third) was 33–58% and overall triage accuracy (i.e., providing the correct triage advice) was 49–90%.5
In Dr. Grainger’s view, this study implies that symptom checkers show promise, but are not yet completely ready for primetime.
With a plethora of potential technological interventions, rheumatologists must not neglect the elements of medicine that have always been important in caring for patients, such as attentive listening, empathy & the nuances of the physical examination.
Virtual Care
Dr. Grainger next discussed telehealth, which can take the form of telemedicine visits conducted by video and/or phone, remote monitoring of patients and online platforms designed to provide patient education and self-support tools.
Before the COVID-19 pandemic, telemedicine was in use, but this use was mostly via asynchronous means (i.e., sending an electronic message to a patient or calling them on the phone could be called telemedicine). Synchronous use was very limited and used primarily in rural and remote areas often with the purpose of extending the workforce—such as in Alaska.6
Dr. Grainger noted that telemedicine has several potential advantages, including improved access, decreased time and travel costs for patients, the ability to expand regional and remote care, and the reduction in infectious exposures for patients. At the same time, telemedicine has certain limitations, including potentially lower reimbursement, technological problems (i.e., hardware and software issues, access to Wi-Fi, ease of use and adoption among patients, etc.) and the inability to perform a full physical exam.
In a 2022 systematic review of telemedicine in rheumatology, Jackson et al. evaluated 36 studies and found patient satisfaction with telemedicine was high in a majority of them. However, the effect of telemedicine on primary outcomes for conditions, including RA, gout and systemic lupus erythematosus, varied. Overall, most studies found telemedicine to be as good as in-person care for disease activity control, patient satisfaction, total societal costs and other patient reported outcomes.7
Some researchers have noted that issues still exist regarding the confidence levels of rheumatology fellows-in-training to deliver virtual care. Thus, initiatives have been undertaken to create education materials to teach fellows and improve confidence levels.8
Clinical Pearls
Dr. Grainger concluded her lecture by summarizing the key priorities that will allow health technology to be helpful in future medical practice.
First, patients must be well educated on the uses and potential misuses of such technologies. They must understand their role in the clinician-patient relationship and should feel encouraged and empowered to successfully use these technologies.
Regarding real-world results, these technologies must demonstrate the ability to improve patient-reported and objective outcome measures, enhance quality of life and support patient well-being and independence.
Finally, with an ever-expanding plethora of potential technological interventions, rheumatologists must not neglect the elements of medicine that have always been important in caring for patients, such as attentive listening, empathy and the nuances of the physical examination. Thus, through her excellent talk, Dr. Grainger reflected the best of rheumatic care across the timespan—in the past, the present and into the future.
Jason Liebowitz, MD, is an assistant professor of medicine in the Division of Rheumatology at Columbia University Vagelos College of Physicians and Surgeons, New York.
References
- Knitza J, Mohn J, Bergmann C, et al. Accuracy, patient-perceived usability, and acceptance of two symptom checkers (Ada and Rheport) in rheumatology: Interim results from a randomized controlled crossover trial. Arthritis Res Ther. 2021 Apr 13;23(1):112.
- Feuchtenberger M, Nigg AP, Kraus MR, et al. Rate of proven rheumatic diseases in a large collective of referrals to an outpatient rheumatology clinic under routine conditions. Clin Med Insights Arthritis Musculoskelet Disord. 2016 Oct 2;9:181–187.
- Knevel R, Knitza J, Hensvold A, et al. Rheumatic?—A digital diagnostic decision support tool for individuals suspecting rheumatic diseases: A multicenter pilot validation study. Front Med (Lausanne). 2022 Apr 25;9:774945.
- Lundberg K, Qin L, Aulin C, et al. Population-based user-perceived experience of Rheumatic?: A novel digital symptom-checker in rheumatology. RMD Open. 2023 Apr;9(2):e002974.
- Wallace W, Chan C, Chidambaram S, et al. The diagnostic and triage accuracy of digital and online symptom checker tools: A systematic review. NPJ Digit Med. 2022 Aug 17;5(1):118.
- Patricoski C. Alaska telemedicine: Growth through collaboration. Int J Circumpolar Health. 2004 Dec;63(4):365–386.
- Jackson LE, Edgil TA, Hill B, et al. Telemedicine in rheumatology care: A systematic review. Semin Arthritis Rheum. 2022 Oct;56:152045.
- Bolster MB, Kolfenbach J, Poeschla A, et al. Incorporating telemedicine in rheumatology fellowship training programs: Needs assessment, curricular intervention and evaluation. Arthritis Care Res (Hoboken). 2023 Dec;75(12):2428–2434.
