Telemedicine: is the new normal fit for purpose?

Abstract

The COVID-19 pandemic forced health-care providers to pivot to virtual models of care, and this trend seems set to continue. At the start of this year, NHS England recommended that at least 25% of outpatient appointments should be by telephone or video for the foreseeable future. But although the time and cost-saving advantages to both health systems and patients are clear, the suitability of telemedicine to rheumatological services remains uncertain. More worryingly, evidence increasingly suggests this new normal risks deepening existing health disparities already made worse by the pandemic. While telehealth offers a potential solution to a variety of health system pressures, it's not yet fully fit for purpose. Most patients with rheumatic diseases in the UK said they were dissatisfied with telemedicine, rating it worse than face-to-face care in every category (except for convenience) in a recent survey. The respondents were particularly concerned about building trust in the medical relationship and the accuracy of assessments. Although a minority of patients said that telemedicine had sped up communication with their doctor, worryingly, some patients said that they didn't have their usual access to emergency appointments—leading to feelings of insecurity. What's more, evidence suggests that telehealth will mostly benefit those who already enjoy good health care. The UK survey showed that barriers to remote appointments place certain groups at a disadvantage, including those who were early in their disease journey, those from socioeconomically or educationally disadvantaged backgrounds, and patients for whom English is not their first language. Similar barriers exist in in the USA, with additional blocks for patients without health insurance. The COVID-19 pandemic has exposed and exacerbated pre-existing racial and socioeconomic inequalities, some of which are associated with individuals' living conditions. In the USA, at least, large urban centres initially bore the highest burden of COVID-19 but as the pandemic progressed, cases and deaths disproportionately affected rural communities (151 vs 175 deaths per 100 000 residents). With telemedicine, physical distance also plays a key role—further distance from a clinic increased the likelihood of patients using telemedicine, but only to some degree. Patients too far away from a clinic often lack access to high-speed internet, effectively eliminating telemedicine as an option. Clinicians too, have expressed doubt that telemedicine is a panacea for delivering rheumatological services. Indeed, two-thirds of paediatric rheumatology providers surveyed by the Childhood Arthritis and Rheumatology Research Alliance (CARRA) said that telehealth visits did not provide enough information to make a complete clinical assessment. At the same time, just over a third of respondents reported that roll out of telehealth services had increased their feelings of burnout—a sentiment also conveyed by clinicians in the UK survey. It's not that telemedicine doesn't have the potential to work if done well. Patients with inflammatory rheumatic diseases who experience fatigue, for example, fared better with a telephone cognitive behavioural programme than those simply provided educational materials. But it seems that not all patients are equally suited to telemedicine—those with widespread pain, for example might benefit less than others. Whereas telehealth seemed well-suited to the assessment of tender and swollen joints for many patients with rheumatoid arthritis (with patient and clinical assessments largely in agreement), those with widespread pain tended to rate their tender and swollen joints more disparately from their doctor. Some are touting telemedicine as a potential solution for the lack of adequate specialist care—there is less than one rheumatologist to 100 000 people in many high-income countries and none in some low-income countries. Not only can telemedicine help to relieve access constraints for patients, but it can also be used to virtually educate general physicians (GPs). Most GPs were in favour of a piloted care model that provided virtual access to an autoinflammatory specialist, offering them guidance from an expert for complicated cases not routinely seen in their everyday practice. Telemedicine ticks a lot of potential boxes—convenience, reduced costs, and mitigation of the paucity of clinical staff and specialists, to name a few. Nevertheless, as communities continue to suffer from the inequalities widened by the COVID-19 pandemic, it is incumbent on policy makers and health systems to ensure that the solution doesn't exacerbate the problem. For the data on COVID19 mortality in the USA see https://www.cdc.gov/coronavirus/2019-ncov/COVID-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html For the data on COVID19 mortality in the USA see https://www.cdc.gov/coronavirus/2019-ncov/COVID-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html