This is the lay version of the EULAR points to consider for remote care in people with rheumatic and musculoskeletal diseases. The original publication can be downloaded from the EULAR website: www.eular.org.
De Thurah A, Bosch P, Marques A, et al2022 EULAR points to consider for remote care in rheumatic and musculoskeletal diseases Annals of the Rheumatic Diseases 2022;81:1065-1071.
Introduction
EULAR gives advice to doctors, health professionals in rheumatology (HPR) and people with rheumatic and musculoskeletal diseases (shortened to RMD)about the best way to treat and manage diseases. All relevant stakeholders, worked together to develop these points to consider on remote care in people with RMD. The four patients in the team ensured that the patient point of view was included.
What do we already know?
RMDs are a diverse group of diseases that commonly affect the joints, but can also affect your muscles, other tissues and internal organs. People with RMDs are typically looked after in rheumatology outpatient clinics. These clinics are often oversubscribed, and so remote care is being looked at as a possible answer.
Remote care or ‘telehealth’ makes use of digital technologies to help people keep in touch with their healthcare team, and for certain aspects of disease screening and monitoring. Remote care can include live video links with the health provider, as well as apps that can record and store data.
Remote care can improve healthcare access and outcomes, particularly for people living with chronic diseases. During the COVID-19 pandemic, use of telehealth became more common, with remote care services put into place quickly in many clinics. But guidance is now needed on how remote care and telehealth should be developed and integrated into long-term care.
Definitions
Remote care: provision of care using virtual technology that allows people to be evaluated, monitored and possibly treated while the patient and health professional are physically remote from each other.
Telehealth: the use of telecommunications and virtual technology to deliver care outside of traditional clinics and facilities. This could include a telephone helpline, a chat function, or a secure email service.
What do the points say?
In total, there are four overarching principles (OP) and nine points to consider (PtC). The OP say that remote care for people with RMD can be delivered by all members of the healthcare team using a variety of telehealth techniques, but this should be tailored based on shared decision-making as well as the needs and preferences of the individual with RMD. Where new telehealth interventions are developed this should be done in collaboration with the healthcare team, caregivers, and people with RMD. Finally, in order for remote care to be effective, members of the team involved should have adequate equipment and training, as well as good telecommunication skills.
Each PtC is based on the best current knowledge from studies of scientific evidence or expert opinion. The more stars a point has the stronger the evidence is. However, points to consider with limited scientific evidence may be important, because the experts can have a strong opinion even when the published evidence may be lacking.
One star (*) means it is a point with limited scientific evidence.
Two stars (**) means it is a point with some scientific evidence.
Three stars (***) means it is a point with quite a lot of scientific evidence.
Four stars (****) means it is a point supported with a lot of scientific evidence.
Points to consider
- A telehealth pre-assessment may be considered to improve referral to rheumatology and help prioritize people with suspected RMD.***
Rheumatology waiting lists are long, so being able to prioritize people is important. Using telehealth to do a short pre-assessment may help you receive advice more quickly than waiting for a face-to-face appointment. This will also help the health team decide on any tests or referrals that are needed. - If you have a suspected RMD, telehealth may be used for some initial investigations; however, diagnosis should be confirmed in a face-to-face visit.***
Face-to-face appointments are useful for collecting additional information and allowing a physical examination. But if you have a risk factor for developing an RMD, screening by telehealth may be used for initial investigations. This saves you from making an unnecessary trip to the clinic, and thereby saves both time and resources. - The decision to start disease-modifying drugs should be made in a face-to-face visit. But telehealth may be used for education, monitoring, and support.***
If you need to start taking a disease-modifying antirheumatic drug (often shortened to DMARD), it is recommended that the decision is taken face-to-face in the clinic. However, telehealth appointments can be useful to advise and educate you about the treatment effect, potential side effects and so on. Telehealth is also suitable for monitoring how you are getting on with treatment, and can be used to support you to take your medicine properly. - Dose modifications or suspension of disease-modifying drugs, or the addition of other treatments can be discussed using telehealth.***
If you have an RMD, the dose and timing of your DMARDs can be important. This information can be discussed via telehealth. Telehealth is also useful for people who need pain killers, non-steroidal anti-inflammatory drugs (NSAIDs), or steroids. These agents can all be prescribed remotely. - If you have an RMD, telehealth can be used to monitor your symptoms, disease activity and other outcomes.***
EULAR recommendations state that disease activity should be measured at least once every 6 months in people with inflammatory arthritis. How often this happens for you will depend on your specific RMD, and your disease activity and severity. Telehealth is an appropriate way to carry out this monitoring, especially if you have low or stable disease activity. - Telehealth may be used to discuss the need for a face-to-face appointment or other interventions.***
If you think you need a face-to-face appointment, getting in touch via telehealth can be a good starting point. This will allow your healthcare team to arrange any tests or referrals you might need. - Telehealth should be considered for non-pharmacological interventions.***
Telehealth is a good way to promote non-pharmacological interventions. These include disease education, advice on physical activity and exercise, self-management strategies and psychological treatment. - Barriers to remote care should be evaluated and resolved wherever possible.*
There are four areas that might affect people’s ability to access remote care. Some of these are down to each individual patient, and you may be reluctant to try remote care, or have a problem accessing or using the equipment needed. Other barriers are related to the clinic or healthcare team, who may not have the right training or organization in place. Working out what the barriers are and how to address them will make it easier for people to use remote care. - People with RMD using remote care should be offered training in using telehealth.*
Not all people can use digital technologies. If needed, you might be offered training to help you use telehealth services. Other tips for making the most out of a remote consultation include
having your questions prepared ahead of time, and sitting in a quiet place away from distractions.
Summary
Overall, this project has identified areas where remote care and telehealth could improve quality of care and increase healthcare access for people with RMDs. The paper gives guidance to health professionals and people with RMDs about how telehealth should be developed and implemented. The points may be used to guide the development of national and local strategies to support best clinical practice in rheumatology. PtCs with just one or two stars are based mainly on expert opinion and not backed up by studies, but these may be as important as those with three or four stars.
If you have any questions or concerns about your disease or your medication, you should speak to a health professional involved in your care.
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