How Critical is Tele‐Medicine to the Rheumatology Workforce?

Over the last 20 years, the introduction of biologic agents has led to successful treatment of once debilitating and lifethreatening rheumatologic conditions. Patient outcomes have improved with aggressive, early initiation of therapy and treat-to-target goals to guide therapy. To achieve good outcomes and increase the likelihood of achieving disease remission, patients need aggressive therapy early in their clinical course (1). A barrier to this goal is hesitancy of primary care providers to start treatment in patients with rheumatologic diseases. Surveyed physician medical directors reported their community health center physicians would not initiate medications to treat rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE); only half would even refill RA or SLE medications, underscoring the need for a rheumatologist to treat these patients (2). An unequal geographic distribution of the workforce and a rheumatology manpower shortage exist, further hindering access to care and the implementation of treat-to-target strategies. A 2005 American College of Rheumatology (ACR) workforce study predicted there would be a deficit of up to 2,500 rheumatologists by 2025 (3). Furthermore, a recent ACR workforce analysis highlighted the lack of rheumatology care in rural areas with practicing rheumatologists favoring the coasts, large metropolitan areas, and academic centers, leaving many patients more than 200 miles from the nearest rheumatologist (4). There are many barriers to rheumatology care access, and several solutions have been proposed. Increasing the number of rheumatology fellows in training over the last 10 years has been helpful, but may be inadequate to sustain the rheumatology workforce needs, with more than half of practicing rheumatologists older than age 55 years. Financial incentives and loan repayment programs to attract rheumatology providers to under-served and rural locations have been under-utilized despite successful endeavors for primary care recruitment (5). Recruiting and training midlevel practitioners such as nurse practitioners and physician assistants is another option to improve access to care, but currently there are no midlevel rheumatology training programs. However, nurse practitioners and physician assistants trained in private practices report a significant amount of independence in their practice and are very comfortable with treat-to-target algorithms (6). Leveraging technology through tele-medicine can bridge patient and physician distances and provide an opportunity for more efficient patient encounters. The US Army’s successful utilization of a tele-medicine program demonstrates a potential model for rheumatology care in underserved areas. In 2004, the US Army Medical Department approved and implemented an electronic consultation service, termed e-Consult. Using a secure electronic e-mail system, e-Consults could be initiated from any setting worldwide, affording deployed providers a system to receive timely and concise recommendations from specialists at academic medical centers. From May 2006 to May 2014, the rheumatology telemedicine service provided expert consultation on nearly 200 e-Consults originating from 13 foreign countries and US Naval ships in international waters. More than half of the consults pertained to inflammatory arthritides. The e-Consult service provided rapid responses within 6 hours of receipt and enabled the electronic integration of other subspecialties in select cases. With the help of the e-Consult service, dispositions for more than one-third of the patients were changed, leading to evacuation of only 25 patients to a tertiary care center, thereby altering the course of their illness (7). Under this Army tele-medicine process, there were not any barriers to facilitate consultation. The success of tele-medicine is not unique to the US Army and has been utilized in other health care systems. The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the US Army Medical Department, the US Army Office of the Surgeon General, the Department of the Army or the Department of Defense or the US Government. The authors are employees of the US government. This work was prepared as part of their official duties and, as such, there is no copyright to be transferred. Ian M. Ward, MD, Thomas W. Schmidt, MD, Daniel F. Battafarano, DO: San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, Texas; Charles Lappan, MS: Telehealth, Regional Health Command, Central (Provisional), Fort Sam Houston, Texas. Address correspondence to Ian M. Ward, MD, Rheumatology Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive, San Antonio, TX, 78234-6272. E-mail: ian.m. ward.mil@mail.mil. Submitted for publication January 19, 2016; accepted in revised form January 26, 2016.