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Telemedicine – modalities that facilitate patient evaluation and treatment remotely – has been used by physicians and patients in various forms for many decades,1 even before the COVID-19 pandemic. However, the pandemic necessitated a rapid expansion in telemedicine strategies, which included the delivery of these services to patients with psoriasis and psoriatic arthritis (PsA).
The COVID-19 pandemic posed challenges in the management of PsA, one of which was balancing the need for disease-modifying antirheumatic drugs (DMARDs) against the potentially increased vulnerability to SARS-CoV-2 infection due to the immunosuppressive nature of therapy.2 In addition, a small number of scientific reports published during the pandemic reported regional delays in medical care for psoriasis3 and PsA,4 which was another concern for patients because of the association between delayed diagnosis of PsA and worse joint pathology and poorer functional outcomes.5
In January 2022, Gottlieb and colleagues6 reviewed the benefits and challenges of providing care for patients with PsA via telemedicine.
Notable benefits included improved patient access to clinicians, especially for those in rural or remote areas; suitability for “high-level” components of examination and outcome assessment procedures, such as visualizing PsA disease domains, including dactylitis and psoriatic nail lesions; and maintaining follow-up and shared medical decision-making, while also ensuring physical distancing during the pandemic.6
Challenges included potential disparities in access to telemedicine visits caused by unequal access to operable videoconferencing equipment and difficulty in visually evaluating less accessible skin areas7 and examining for enthesitis.6
The team of researchers recommended best practices for clinicians including use of screening tools and patient-reported outcome measures; establishing protocols for determine appropriateness of telemedicine visits; patient support and education for engaging with telemedicine; and remaining up-to-date on state- and institution-specific policies and regulations regarding coding, reimbursement, interstate access, and other issues.6
To further understand the benefits, challenges, and considerations of a telemedicine-based approach for PsA, we interviewed 2 experts with a clinical focus in psoriasis and PsA and with research interests in telemedicine.
Steven Vlad, MD, PhD, is a rheumatologist at Tufts Medical Center, Boston, an epidemiologist at the Tufts Clinical and Translational Science Institute, director of study design at New England Baptist Hospital, and assistant professor at Tufts University School of Medicine.
David Rosmarin, MD, is a dermatologist and vice chair of education and research in the Department of Dermatology at Tufts Medical Center and assistant professor at Tufts University School of Medicine.
Reports have suggested that patient satisfaction with telemedicine is high, including for those with rheumatic diseases. What trends have you noticed in the delivery of care via telemedicine for PsA during the course of the COVID-19 pandemic?
Dr Rosmarin drew attention to a recent study8 conducted by his team of researchers that indicated high satisfaction overall with teledermatology visits during the pandemic. Participants who were women vs men expressed significantly greater willingness to attend a teledermatology visit again; younger age and non-Hispanic ethnicity were predictors of preference for teledermatology vs in-person visits.
David Rosmarin, MD: Offering an additional way for patients to receive health care via telemedicine is great. For patients who live far away from a provider or have limited access to a specialist, telemedicine can be beneficial. The best scenario is when patients have access to both in-person and telemedicine visits and can choose what works best for them.
Steven Vlad, MD: Lots of people love it, and I see why. It’s so much more efficient to do a visit from home or a private place at work, and to not have to miss part of a day traveling and sitting. During the heart of the pandemic when we were seeing very few people in person, telemedicine really was a great way to keep in touch and make sure that people got the care they needed. There are times when the doctor still has to see the patient in-person, but a hybrid approach works well, and I think a lot of patients really appreciate the convenience. I can’t think of many, if any, of my patients who weren’t happy with a telemedicine visit.
Delay in diagnosis of PsA is known to be associated with worse disease burden. Have you seen any shifts over time in diagnosis and decision-making in PsA from a telemedicine perspective?
Dr Vlad: I’m not sure that I’ve seen much of a difference. I think the biggest aid to timely diagnosis is physician awareness. Primary care providers, dermatologists, and other doctors who aren’t rheumatologists need to be aware of this disease, know something about the symptoms, and know when to refer. Then we, rheumatologists, have to have the resources to see these people promptly, whether in person or by telemedicine – that means enough [number of] rheumatologists and support staff.
But I think that as long as we are paying attention to what our patients are telling us — whether in person or through a screen — we can still integrate information and make timely changes. I still modify medications, etc, over the same time periods as I would otherwise.
How do your screening, interview, diagnostic, and outcome assessment processes for PsA differ between traditional care and telemedicine services?
Dr Rosmarin: Telemedicine visits are a great option for some patients, particularly those who are doing well and need a check-in. However, in-person visits are still important for developing a connection between provider and patient and performing certain aspects of the physical exam that can’t be done virtually.
For example, we can’t utilize our physical exam as much over telemedicine, so history becomes more important. In particular, it is challenging to assess joints over Zoom; and it can be challenging to assess skin [lesions] if no high-quality images are available. Pictures are often of better quality than Zoom when making a visual diagnosis or performing a skin assessment.
There are some screening tools that can be used for PsA such as [Psoriasis Epidemiology Screening Tool] (PEST); however, what is most important is that all patients with psoriasis are asked about joint symptoms in some way.
Dr Vlad: Luckily, there is no huge difference. We get most of the medical history by listening to the patient and asking them follow-up questions. The big difference is that examination is harder. While we sometimes can see a swollen joint on video, we are much more likely to detect swelling or tenderness when we can both look at and touch each joint. So, I don’t consider a telemedicine visit as a complete replacement for an in-person visit. I still want to see the patient at some point in-person.
What do you think needs to happen for telemedicine to reach its fullest potential in the management of PsA? What needs to be addressed by clinical teams at a practice/hospital level and a broader systemic level? Secondly, how can equity in the distribution of care be ensured?
Dr Vlad: I think that there is a real opportunity here to drag health care into the 21st century. I think this is an opportunity to lessen disparities in access. We need to make sure that we can get relevant lab [tests] and imaging done. But that’s not that hard these days. We have to be able to get data to and from other labs, imaging facilities, and other sources easily to provide good care. Exchanging faxes and phone calls is not going to be good enough. We also need to develop a method to do a joint exam by video and it all has to be integrated into clinical practice. That’s starting to happen. Some medical record systems now make it much easier to do a video visit right from the patient’s electronic “chart.” It can be scheduled easily and run efficiently.
Dr Rosmarin: The ability to take standardized high-quality photographs would be helpful when assessing psoriatic lesions. Video platforms often do not offer high-quality streaming that is as accurate as in-person visits. Also, patients need to be comfortable with the technology and be able to sign on [for a visit] with good internet coverage.
Dr Vlad: If people can’t afford a smart phone or computer, telemedicine is going to be useless. Those who don’t have access to transportation and those who can’t afford to miss work, etc, are going to continue to be vulnerable.
We also have to have buy-in from insurers to pay for this kind of service. During the state of emergency [in the pandemic], at least in Massachusetts, the law required them to pay for telemedicine visits at the same rate that they paid for in-person visits. They are no longer required to do that. As long as that’s the case, providers and hospitals/clinics are deincentivized to provide this type of care.
Dr Rosmarin: If reimbursements for telemedicine go down, physicians and health care systems may be less willing to offer that option. Another difficult aspect of telemedicine is regulations that make it harder for patients. For example, a patient in New Hampshire has to physically be in Massachusetts for a telemedicine visit.
References
1. Lustig TA. The role of telehealth in an evolving health care environment: workshop summary. Board on Health Care Services: Institute of Medicine. National Academies Press (US); November 20, 2012.
2. Gupta L, Misra DP, Agarwal V, Balan S, Agarwal V. Management of rheumatic diseases in the time of COVID-19 pandemic: perspectives of rheumatology practitioners from India. Ann Rheum Dis. 2021;80(1):e1. doi:10.1136/annrheumdis-2020-217509
3. El-Komy MHM, Abdelnaby A, El-Kalioby M. How does COVID-19 impact psoriasis practice, prescription patterns, and healthcare delivery for psoriasis patients? A cross-sectional survey study. J Cosmet Dermatol. 2021;20(6):1573-1579. doi:10.1111/jocd.14104
4. Ninosu N, Roehrich F, Diehl K, Peitsch WK, Schaarschmidt ML. Psoriasis care during the time of COVID-19: real-world data on changes in treatments and appointments from a German university hospital. Eur J Dermatol. 2021;31(2):183-191. doi:10.1684/ejd.2021.4016
5. Haroon M, Gallagher P, FitzGerald O. Diagnostic delay of more than 6 months contributes to poor radiographic and functional outcome in psoriatic arthritis. Ann Rheum Dis. 2015;74(6):1045. doi:10.1136/annrheumdis-2013-204858
6. Gottlieb AB, Wells AF, Merola JF. Telemedicine and psoriatic arthritis: best practices and considerations for dermatologists and rheumatologists. Clin Rheumatol. Published online January 26, 2022. doi:10.1007/s10067-022-06077-3
7. Han G. Psoriatic arthritis diagnosis and management in the era of telehealth. Cutis. 2021;108(2S):5-6. doi:12788/cutis.0313
8. Pannu S, Nguyen BM, Yang FSC, Rosmarin D. Predictors of patient experience with teledermatology in setting of COVID‐19 pandemic in a single medical center. Int J Dermatol. 2021;60(5):626-627. doi:10.1111/ijd.15394
