I have been working with Vigilias, LLC (FreeState Health Care) as a rheumatology consultant on their Telehealth platform for a year now providing outreach in remote towns in rural Kansas. I have been able to help many, which is the sole purpose of my participation. The more I have explored this landscape, the more I have uncovered limitations as a rheumatologist. Rheumatology is not a binary disease. There are shades of grey that muggy the water and make things complex.
So What are the Good and the Bad?
The premise is simple. Patients access my rheumatology clinic by visiting contracted local satellite hospitals (https://freestatehealthcare.com/connect/partners/).
The setup is simple. Screen with camera and microphone allowing for face to face discussions. Nurse at bedside who assists with input data and examination.
The encounter is simple. I review records - if available. I gather the history.
The exam is not as simple. Rheumatology is a specialty that heavily depends on the physical examination, especially when the condition is rheumatoid arthritis. This would be the pitfall.
I therefore depend on crude methods:
I have the patient raise their arms to assess for range of movement
I have the patient show me their hands on the camera and make a fist to show me their knuckles
This allows me to assess for:
Nodules, such as osteoarthritis
Swollen joints or digits, such as inflammatory arthritis and dactylitis
Nail pathologies, such as psoriasis
Skin changes, such as Raynaud's phenomenon or scleroderma
I have the nurse or patient squeeze the wrist, metacarpals, proximal phalanges, ankles, and feet (en mass or individually)
There are rumors of technologies that may calculate joint diameter or circumference via a camera, such as a phone camera. The utility of this would be in tracking inflammatory joint diseases, such as rheumatoid arthritis, longitudinally as an objective measure of treatment response in the place of performing a joint examination in the telemedicine encounter.
Fortunately, there are tricks to the trade that may be useful in patients that I suspect have an underlying inflammatory arthritis when they have a chronic pain syndrome, such as fibromyalgia, that may bias the exam to reflect joint tenderness when the cause of the tenderness is not inflammation. Another scenario is if I suspect an inflammatory arthritis based on history but the exam is equivocal or not good enough due to aforementioned limitations to examine the patient. I call it a prednisone litmus test. In these patients, I prescribe a prednisone taper and reassess them in two weeks. If their symptoms improve or resolve, then the suspicion for an underlying inflammatory process increases tremendously. If they that little or no response, then the likelihood that their condition is inflammatory becomes very low to null. This is an imperfect method and patient's comorbidities and weight need to be taken into consideration. Also, some patients do not respond to prednisone or methylprednisolone even when I sure the cause of their condition is an inflammatory joint pain.
The ability to provide care for a patient is something I strive for. I do this on a daily basis during my clinic where I have hands-on patient care.
In my telemedicine clinic, things tend to be more grey and I have to rely on crude strategies. The landscape of technology and physical examinations are in the pipeline that will hopefully provide precise and quality data for the examiner and the patient, with the sole purpose of better quality of care.
Until then, the show must go on.