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The worldwide burden of musculoskeletal diseases is increasing. The number of newly registered rheumatologists has stagnated. Primary care, which takes up a key role in early detection of rheumatic disease, is working at full capacity. COVID-19 and its containment impede rheumatological treatment. Telemedicine in rheumatology (telerheumatology) could support rheumatologists and general practitioners.
The goal of this study was to investigate acceptance and preferences related to the use of telerheumatology care among German rheumatologists and general practitioners.
A nationwide, cross-sectional, self-completed, paper-based survey on telerheumatology care was conducted among outpatient rheumatologists and general practitioners during the pre-COVID-19 period.
A total of 73.3% (349/476) of survey participants rated their knowledge of telemedicine as unsatisfactory, poor, or very poor. The majority of survey participants (358/480, 74.6%) answered that they do not currently use telemedicine, although 62.3% (291/467) would like to. Barriers to the implementation of telemedicine include the purchase of technology equipment (182/292, 62.3%), administration (181/292, 62.0%), and poor reimbursement (156/292, 53.4%). A total of 69.6% (117/168) of the surveyed physicians reckoned that telemedicine could be used in rheumatology. Surveyed physicians would prefer to use telemedicine to communicate directly with other physicians (370/455, 81.3%) than to communicate with patients (213/455, 46.8%). Among treatment phases, 64.4% (291/452) of participants would choose to use telemedicine during
Before COVID-19 appeared, our results indicated generally low use but high acceptance of the implementation of telerheumatology among physicians. Participants indicated that the lack of a structural framework was a barrier to the effective implementation of telerheumatology. Training courses should be introduced to address the limited knowledge on the part of physicians in the use of telemedicine. More research into telerheumatology is required. This includes large-scale randomized controlled trials, economic analyses, and the exploration of user preferences.
The worldwide burden of musculoskeletal diseases is increasing [
In recent decades, information and communication technologies have entered health care. One field of application is telemedicine, which is defined as follows [
Telemedicine is the practice of medicine over a distance, in which interventions, diagnoses, therapeutic decisions, and subsequent treatment recommendations are based on patient data, documents and other information transmitted through telecommunication systems.
The use of telemedicine in the provision of rheumatology care (telerheumatology) could ease constraints on health care access and the timeliness of care, bridge the workforce gap, and improve access to care for underserved communities [
The aim of this user-centered study was to assess the acceptance by physicians of the implementation of telerheumatology and to identify potential application areas in preparation for the development of telemedical approaches.
This paper reports on findings from the analysis of data collected as part of a cross-sectional, self-completed, paper-based survey of German outpatient rheumatologists and general practitioners from September to November 2018; the survey investigated acceptance, opportunities, and obstacles to the implementation of telemedicine.
The inclusion criteria for participants were that they had to be (1) rheumatologists or general practitioners, (2) practicing in ambulatory health care, (3) based in Germany, and (4) active (ie, not retired and not in training).
Two health care researchers (FM and WM) and one experienced rheumatologist (MW) designed the questionnaire. It was pilot-tested on 5 rheumatologists and 5 general practitioners to gauge the need to refine wording and format, and to check whether predefined response options were exhaustive. Minor revisions were made accordingly.
The questionnaire comprised 25 questions and was divided into three mandatory sections:
Telemedicine: knowledge and use.
Telerheumatology.
Sociodemographic data.
Response categories were nominal or ordinal. The questionnaire also contained several open questions.
The
The
Questions about sociodemographic and occupational characteristics included age, gender, medical specialty, clinical location, type of practice, and number of patients (quarterly).
The survey was sent to all rheumatologists (n=49) and general practitioners (n=1820) in the federal state of Brandenburg, Germany, and rheumatologists (n=39) and general practitioners (n=487) in a nationwide reference group. The contact details of potential participants in Brandenburg were provided by the Brandenburg Association of Statutory Health Insurance Physicians. The nationwide reference group consisted of physicians from RHADAR (RheumaDatenRhePort GbR) and cooperating rheumatologists and general practitioners. RHADAR is an association of more than 25 rheumatologists that share the aim of developing and improving digital technology. The association also collects and analyzes anonymized patient data to identify supply and demand for rheumatology services. In total, 88 rheumatologists and 2307 general practitioners were contacted by mail.
Statistical analyses were performed using SPSS Statistics for Windows, version 22.0 (IBM Corp). Descriptive statistics included quantities, percentages, median scores, and ranges for ordinal variables.
The study was conducted in compliance with current data protection regulations and the Helsinki Declaration. All study participants were informed about the research project. Data were anonymized before analysis. The ethics committee of the Theodor Fontane Medical School in Brandenburg stated that no written consent was necessary due to the noninterventional study design.
From September to November 2018, a cross-sectional, self-completed, paper-based survey on telerheumatology was filled in by German outpatient rheumatologists and general practitioners. Of the 2395 questionnaires that were sent out, 497 (20.8%) were returned. Of the 497 responses, 12 (2.4%) were excluded from the analysis because fewer than half the questions were answered. The final response rate for rheumatologists was 55% (48/88) and for general practitioners it was 18.9% (437/2307).
Data for this study were obtained from 485 physicians (437/485, 90.1% general practitioners; 48/485, 9.9% rheumatologists) (see
Participant demographics.
Demographic | Rheumatologists, n (%)a | General practitioners, n (%)a | Total, n (%)a | ||||||
|
|
|
|
|
|||||
|
Total | 47 (100) | 427 (100) | .22 | 474 (100) | ||||
|
<40 | 4 (9) | 36 (8.4) |
|
40 (8.4) | ||||
|
40-50 | 16 (34) | 85 (19.9) |
|
101 (21.3) | ||||
|
51-60 | 20 (43) | 208 (48.7) |
|
228 (48.1) | ||||
|
>60 | 7 (15) | 98 (23.0) |
|
105 (22.2) | ||||
|
|
|
|
|
|||||
|
Total | 46 (100) | 424 (100) | .17 | 470 (100) | ||||
|
Female | 19 (41) | 235 (55.4) |
|
254 (54.0) | ||||
|
Male | 27 (59) | 189 (44.6) |
|
216 (46.0) | ||||
|
|
|
|
|
|||||
|
Total | 47 (100) | 427 (100) | <.001 | 474 (100) | ||||
|
City | 23 (49) | 62 (14.5) |
|
85 (17.9) | ||||
|
Town | 10 (21) | 144 (33.7) |
|
154 (32.5) | ||||
|
Provincial town | 14 (30) | 144 (33.7) |
|
158 (33.3) | ||||
|
Rural area | 0 (0) | 77 (18.0) |
|
77 (16.2) | ||||
|
|
|
|
|
|||||
|
Total | 47 (100) | 424 (100) | <.001 | 471 (100) | ||||
|
Single-handed | 10 (21) | 242 (57.1) |
|
252 (53.5) | ||||
|
Group | 37 (79) | 182 (42.9) |
|
219 (46.5) | ||||
|
|
|
|
|
|||||
|
Total | 45 (100) | 411 (100) | .14 | 456 (100) | ||||
|
<500 | 4 (9) | 15 (3.6) |
|
19 (4.2) | ||||
|
500-1000 | 17 (38) | 130 (31.6) |
|
147 (32.2) | ||||
|
>1000 | 24 (53) | 266 (64.7) |
|
290 (63.6) |
aPercentages may not add up to 100% due to rounding.
A total of 73.3% (349/476) of respondents rated their knowledge of telemedicine as 4 (unsatisfactory), 5 (poor), or 6 (very poor). The minority (127/476, 26.7%) rated their knowledge of telemedicine as 1 (very good), 2 (good), or 3 (satisfactory). The majority (358/480, 74.6%) did not currently use telemedicine, but 62.3% (291/467) answered that they would like to use it (see
Telemedicine: knowledge and use.
Question and responses | Rheumatologists, n (%)a | General practitioners, n (%)a | Total, n (%)a | ||||||
|
|
|
|
|
|||||
|
Total | 47 (100) | 429 (100) | .14 | 476 (100) | ||||
|
1 (very good) | 1 (2) | 19 (4.4) |
|
20 (4.2) | ||||
|
2 (good) | 8 (17) | 34 (7.9) |
|
42 (8.8) | ||||
|
3 (satisfactory) | 9 (19) | 56 (13.1) |
|
65 (13.7) | ||||
|
4 (unsatisfactory) | 9 (19) | 110 (25.6) |
|
119 (25.0) | ||||
|
5 (poor) | 16 (34) | 138 (32.2) |
|
154 (32.4) | ||||
|
6 (very poor) | 4 (9) | 72 (16.8) |
|
76 (16.0) | ||||
|
|
|
|
|
|||||
|
Total | 47 (100) | 433 (100) | .15 | 480 (100) | ||||
|
Yes | 16 (34) | 106 (24.5) |
|
122 (25.4) | ||||
|
No | 31 (66) | 327 (75.5) |
|
358 (74.6) | ||||
|
|
|
|
|
|||||
|
Total | 46 (100) | 421 (100) | .45 | 467 (100) | ||||
|
Yes | 31 (67) | 260 (61.8) |
|
291 (62.3) | ||||
|
No | 15 (33) | 161 (38.2) |
|
176 (37.7) | ||||
|
|
|
|
|
|||||
|
Total | 30 (100) | 260 (100) | .26 | 290 (100) | ||||
|
Yes | 25 (83) | 234 (90.0) |
|
259 (89.3) | ||||
|
No | 5 (17) | 26 (10.0) |
|
31 (10.7) | ||||
|
|
|
|||||||
|
Total | 31 (100) | 261 (100) |
|
292 (100) | ||||
|
Purchase of technology equipment | 16 (52) | 166 (63.6) | .19 | 182 (62.3) | ||||
|
Administration | 21 (68) | 160 (61.3) | .49 | 181 (62.0) | ||||
|
Poor reimbursement | 21 (68) | 135 (51.7) | .09 | 156 (53.4) | ||||
|
Data security | 15 (48) | 120 (46.0) | .80 | 135 (46.2) | ||||
|
Lack of participation by colleagues | 8 (26) | 89 (34.1) | .35 | 97 (33.2) | ||||
|
Technical comprehension of patients | 12 (39) | 84 (32.3) | .47 | 96 (32.9) | ||||
|
Poor internet connection | 5 (16) | 52 (19.9) | .61 | 57 (19.5) |
aPercentages may not add up to 100% due to rounding or where multiple selections were possible.
A total of 69.6% (117/168) of participants considered telemedicine as usable in rheumatology (see
When asked who should interact using telemedicine, 81.3% (370/455) responded
Implementation of telemedicine in rheumatology care.
Question and responses | Rheumatologists, n (%)a | General practitioners, n (%)a | Total, n (%)a | ||||||
|
|
|
|
|
|||||
|
Total | 43 (100) | 125 (100) | .18 | 168 (100) | ||||
|
Yes | 32 (74) | 85 (68.0) |
|
117 (69.6) | ||||
|
No | 11 (26) | 40 (32.0) |
|
51 (30.4) | ||||
|
|
|
|||||||
|
Total | 45 (100) | 410 (100) |
|
455 (100) | ||||
|
Physician-physician | 36 (80) | 334 (81.5) | .88 | 370 (81.3) | ||||
|
Physician-patient | 28 (62) | 185 (45.1) | .03 | 213 (46.8) | ||||
|
Physician-assistant | 14 (31) | 103 (25.1) | .38 | 117 (25.7) | ||||
|
Other participants and combinations | 5 (11) | 13 (3.2) | .009 | 18 (4.0) | ||||
|
No communication | 3 (7) | 54 (13.2) | .21 | 57 (12.6) | ||||
|
|
|
|||||||
|
Total | 45 (100) | 407 (100) |
|
452 (100) | ||||
|
Screening | 23 (51) | 110 (27.0) | .001 | 133 (29.4) | ||||
|
Initial contact | 11 (24) | 142 (34.9) | .16 | 153 (33.8) | ||||
|
Follow-up | 32 (71) | 259 (63.6) | .32 | 291 (64.4) | ||||
|
Other stages | 7 (16) | 38 (9.4) | .19 | 45 (10.0) | ||||
|
At no stage | 8 (18) | 69 (17.0) | .90 | 77 (17.1) | ||||
|
|
|
|||||||
|
Total | 44 (100) | 126 (100) |
|
170 (100) | ||||
|
Telecounseling | 24 (55) | 55 (43.7) | .21 | 79 (45.5) | ||||
|
Telediagnostics | 18 (41) | 58 (46.0) | .56 | 76 (44.7) | ||||
|
Video consultations | 19 (43) | 48 (38.1) | .55 | 67 (39.4) | ||||
|
Online appointment assignments | 20 (45) | 36 (28.6) | .04 | 56 (32.9) | ||||
|
e-Learning | 15 (34) | 40 (31.7) | .78 | 55 (32.4) | ||||
|
Patient apps | 17 (39) | 31 (24.6) | .08 | 48 (28.2) | ||||
|
Digital screening | 15 (34) | 21 (16.7) | .02 | 36 (21.2) | ||||
|
Wearable devices | 9 (20) | 11 (8.7) | .04 | 20 (11.8) | ||||
|
Telesurgery | 3 (7) | 4 (3.2) | .30 | 7 (4.1) | ||||
|
Other tools | 2 (5) | 2 (1.6) | .27 | 4 (2.4) | ||||
|
No tools | 6 (14) | 15 (11.9) | .76 | 21 (12.4) |
aPercentages do not add up to 100% where multiple selections were possible.
To the best of our knowledge, we have performed the largest nationwide survey in Germany on the use of telemedicine in adult rheumatology aimed at promoting and guiding the implementation of telerheumatology.
Rheumatologists and general practitioners generally consider the overall application of telerheumatology to be acceptable, and two-thirds of the respondents would like to implement telemedicine in their everyday practice. Rheumatologists expressed an even greater willingness to use telemedicine than general practitioners. Rheumatologists and general practitioners welcomed a wide variety of approaches to telemedicine. However, only a minority of physicians already used telemedicine at the time the survey was conducted. Barriers to its introduction, such as limited knowledge, administrative expenses, the purchase of technology equipment, and inadequate reimbursement, were clearly identified by specialists and generalists. The results provide information on how telemedicine can support rheumatology care from the physician’s perspective. Conservative and familiar communication formats, such as the exchange of information with colleagues, were preferred to the direct exchange of information with patients and assistants. This was demonstrated by the high approval of the item
The average age of our sample is similar to that of German physicians as a whole [
This work adds to the growing body of telerheumatology knowledge [
In contrast to the results of a recent study that identified a negative attitude toward digitization in the health care system among physicians in Germany [
Mobile apps promise to accelerate diagnostic investigations and improve monitoring and the outcomes of patients with RMDs [
Our findings indicate that rheumatologists accept telemedicine to a greater extent than general practitioners. Furthermore, the preferences of rheumatologists differ from those of general practitioners with regard to which specific tools could be implemented into rheumatology care and when. These variations may be related to differences in the two professions as well as the distinct phases of the disease in which rheumatologists and general practitioners encounter RMDs. We also analyzed differences in the acceptance and preferences of telemedicine with regard to the age and gender of the physicians as well as the type and region of their practices. No differences or only small differences were found.
COVID-19 has demonstrated the importance of contactless approaches in medical care. As early as 2018, when we conducted the survey, rheumatologists and general practitioners were willing to use telerheumatology. It is assumed that this readiness has increased due to the pandemic, which is likely to strongly accelerate the use of telemedicine as society adopts new health care standards [
Nevertheless, the great potential of telemedicine is not being fully reached. Further research into the implementation of telerheumatology is desperately needed. This includes large-scale randomized controlled studies on the effects and health economic outcomes, as well as risks and adverse events, of specific interventions.
As our results indicate that there will be no “one-size-fits-all” solution in the realm of telemedicine, further research into the perspectives and preferences of physicians, patients, and other telemedicine users in rheumatology is essential. This may provide the foundation for individual patient- and physician-adapted telemedicine options and triage mechanisms to select patients for either digital or analog consultations, as appropriate [
As physicians reported barriers to the use of telemedicine, it would appear that the structural framework is not yet in place for the effective implementation of telerheumatology. Considerable administrative effort and inadequate reimbursement structures prevented the surveyed physicians from using telemedicine. However, the greatest barrier was the limited knowledge on the part of physicians on the use of telemedicine, which highlights the need for the timely introduction of low-threshold training courses.
Our study showed that rheumatologists and general practitioners support the implementation of telerheumatology, and two-thirds of respondents would like to implement telemedicine into their clinical routine. Rheumatologists expressed an even greater willingness to use telemedicine than general practitioners, with respondents welcoming a variety of telemedicine approaches. However, only a minority of the surveyed physicians currently use telemedicine. Furthermore, most physicians regard their knowledge of telemedicine as rather poor. The provision of high-quality rheumatology care using telemedicine will require urgently needed research as well as a reduction in existing barriers and training for specialists and generalists.
information technology
patient-reported outcome
RheumaDatenRhePort GbR
rheumatic and musculoskeletal disease
telemedicine in rheumatology
The authors would like to thank the participants, their teams, and all other supporters of this study. We also owe special gratitude to KV Consult- und Managementgesellschaft mbH, which initiated the study. We thank Phillip Elliot for editing the manuscript. Financial support was provided by Novartis Pharma GmbH. Novartis had no role in the study design or in the collection, analysis, or interpretation of the data; the writing of the manuscript; or the decision to submit the manuscript for publication. Publication of this article was not contingent upon approval by Novartis.
All authors were involved in drafting the article and critically revising it for important intellectual content, and all authors approved the final version to be submitted for publication. FM had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. FM, WM, and MW were responsible for the study conception and design and for acquisition of the data. FM, JK, WM, JE, AH, and MW were responsible for analysis and interpretation of the data.
None declared.