Telemedicine (TM) witnessed a tremendous surge in the field of rheumatology during the COVID-19 pandemic, driven by the need to care for patients safely, as has been evidenced by a number of studies around the world.1–4 TM facilitated both patient care and clinician-clinician relationships, administrative activities, as well as healthcare training/ education.5 TM can significantly reduce both the time and transportation-related costs and is now considered a strategic factor in improving health care in both rural and urban settings.6 TM currently includes aspects as diverse as electronic medical records, remote visits, mobile health, portable technology, digital therapeutics, and artificial intelligence applied to medicine.5 Nevertheless, the World Health Organisation recommends that studies be carried out to determine the benefits, harms, acceptability, feasibility, resource use, and considerations regarding equality as they pertain to TM.5,7

The application of TM to rheumatology has been the focus of many studies in the last decade, and is presently an area that is of great interest and development.8,9 Systematic reviews, including those prior to the pandemic, have demonstrated that TM can be effective in managing inflammatory rheumatic diseases, in addition to being cost-effective.2,10,11 The vast majority of patients are extremely satisfied with TM.12,13 One study revealed that, during the pandemic, those patients who lived furthest away from the rheumatologist’s clinic were the ones who were most likely to use TM.1 Another study has revealed that there are no significant differences in health status between patients with rheumatic illnesses who used TM and those who were seen at hospital visits, which suggests that TM has obvious advantages in the follow-up of these individuals.3 TM can be applied to the management of people suffering from rheumatoid arthritis (RA), who often find it difficult to access specialist care when they are experiencing a flare up, as well as to tailoring treatments to the stage of the disease so as to bring about remission.14

Despite the abundance of studies, the real evidence of the benefits or harm that TM may cause is scarce, and we do not know its impact on healthcare in rheumatology. In Spain, there have been few studies evaluating the use of TM in rheumatology, and they were mainly focused on the effects of the COVID-1915,16 pandemic and on primary care.17,18 The existence of many and varied applications of TM and its great potential for future development make it advisable to evaluate its development and current use in the clinical practice of rheumatology in our country. For all these reasons, this study aims to analyse the use of TM in rheumatology consultations and to evaluate proposals for its implementation by a large group of specialists in the Spanish clinical practice setting.

This qualitative, multi-centre study relied on the Delphi methodology to arrive at a consensus of Recommendations for the Use of Telemedicine in Rheumatology (RESULT, its acronym in Spanish). The Delphi method was chosen as the formal approach to consensus, as it maximises the advantages of expert group-based methods and minimises their disadvantages.19 The Delphi method was applied in two rounds of nationwide consultations. The first round took place in May-June 2022 and the second one in October-November 2022. Three specialists in rheumatology, who acted as scientific coordinators of the study, were in charge of the development of the study protocol (NOR NUL-2021-01) and the questionnaire. In addition, the R + D department of the Saned Group and an expert statistician participated in the study. To conduct this study, a search was carried out in PubMed for recent articles on TM applied to rheumatology (search terms: telemedicine rheumatoid arthritis, telemedicine rheumatology, telehealth rheumatology, remote consultation rheumatology, telerheumatology, virtual rheumatology).

Similarly, an invitation leaflet was sent to specialist rheumatologists at medical centres in Spain included in the Saned database (N = 561), informing them of the nature of the study, as well as the URL where the study was hosted and the password required to access it. On accessing the questionnaire, they were asked for their consent to participate. Those who were not involved in healthcare activities and those who did not treat patients with rheumatic disorders were excluded.

The final questionnaire consisted of 80 items (Supplementary information, Appendix A Table S1) and was divided into nine sections: teleconsultation, diagnosis, treatment, and follow-up (8 items); nursing teleconsultation (2 items); telecare (1 item); telerehabilitation (2 items); teleradiology (1 item); physician and patient telehealth tele-education (1 item); the major barriers to TM (4 items); tele- of telehealth education (8 items), and TM in RA (2 items). Sociodemographic data relating to all participants were likewise collected.

Once admitted and registered for the study, the researchers completed the questionnaire and their responses were automatically entered into a standardised and secure database. Participants were asked to rate their degree of agreement or disagreement with the questionnaire statements on a 5-point Likert scale (“1 = totally disagree,” “2 = strongly disagree,” “3 = indifferent,” “4 = strongly agree,” and “5 = totally agree”). No free-text fields were included in the questionnaire.

The Delphi consultation was conducted in two rounds.19 All statements were evaluated by the participants in the initial round of the Delphi consultation. In the second round, only those questions were included for which no consensus had been reached in the first round, together with the results of the first round for those questions. To evaluate the various items in the questionnaire as to the degree of agreement, the score was aggregated as follows:

• -

  Scores of between 1 and 2: disagree,

• -

  A score of 3: indifferent,

• -

  Scores of between 4 and 5: agree.

Consensus was assumed to have been reached when at least 75% of the panellists agreed (scores of 4–5) or disagreed (scores of 1–2) with the given statement. For those statements that generated consensus in the first round, the results reflect the results obtained in that round; for statements that failed to achieve consensus in the first round, the results of the second round are given.

The aim of the two-round Delphi consultation described in this paper was to explore the application of TM in rheumatology practices, as well as to evaluate and agree on recommendations for its use and development. Overall, this Delphi consultation revealed that rheumatologists believe that the incorporation of TM could be useful in many aspects of patient diagnosis, treatment, and follow-up, as well as to stimulate communication between specialists, nursing staff, and continuing medical education (Table 2), although there are clear impediments to implementing it in Spain.

Rheumatologists reached a high degree of consensus concerning the value of using TM in the follow-up of certain patients. Many healthcare consultations can be resolved remotely, in particular the bureaucratic ones. They also achieved a consensus that first appointments and those of individuals with active inflammation, digital barriers, sensory difficulties, or cognitive impairment could be attended to in person. In this respect, a Canadian study has found that, indeed, difficulty in using a telephone, the need for another person to be present to assist them, or new appointments (versus routine follow-up), were the main issues identified by patients with regard to teleconsultations.13 Another study has indicated that older age and lack of internet access, poor health, and lack of digital literacy decrease trust in and satisfaction with TM.21 In our study, 88% of rheumatologists believed that whether or not a patient requires a face-to-face consultation could be determined by means of teleconsultation. Other studies have suggested implementing a triage system to decide which type of consultation is the most appropriate for each patient.21

Numerous studies have demonstrated the effectiveness of nursing TM when treating rheumatic diseases.22–25 On the whole, the rheumatologists consulted in our study were positive about the potential teleconsultation has in nursing. All participants were of the opinion that teleconsultation improves treatment compliance. This was corroborated by a recent study among rheumatologists in France, which revealed that the use of TM increased adherence.26

While the majority of rheumatologists considered that video-call platforms may be beneficial for rehabilitation, no consensus was reached in this regard. Nevertheless, one study found that, in patients with mild to moderate osteoarthritis of the knee, telerehabilitation via video call was superior to self-treatment.27 A review of studies that have addressed the effectiveness of telerehabilitation supports these results.28

The Delphi consultation showed that rheumatologists view TM education positively for continuing medical education, searching for up-to-date information, or for being in contact with other specialists. Several previous studies have corroborated the utility of TM in medical education, and these results further endorse the integration of digital competencies in medical education, as well as practical training for healthcare professionals. A study carried out in Germany showed that porfessionals' knowledge about TM and the actual use of TM correlate closely, highlighting that TM education must address the multidimensionality of the barriers that still exist to its implementation.29 Some of these obstacles were identified in the Delphi study, such as data security, technical problems, the need to purchase new technological equipment, and connectivity issues. The existence of these barriers was noted with broad consensus by the participants. In this sense, a recent study pointed out that some of the main limitations in the use of TM were specifically administrative/ technical, the lack of suitable equipment, or poor internet connection.30

Data security is a challenge that has been highlighted in a number of previous studies.31 In our study, 95% of the respondents felt that data security systems for TM will need to be put into place. Further studies are needed concerning how factors such as data confidentiality and patient privacy issues might affect the development of TM.7

It is noteworthy that the rheumatologists were not in agreement as to whether TM increases the quality of the service, by establishing closer and more personalised communication, or that it promotes healthcare, regardless of resources or of the pressure of care. In this sense, a recent review has revealed that TM consultations are a significant risk factor that contribute to there being no changes in treatment, which fosters what is known as therapeutic inertia.21

In the RA section of the questionnaire, 88% of the panelists believe that TM could be beneficial for certain patients, and a large majority (99%) are of the opinion that this option should be offered, especially for patients with scant active disease or in remission. Future studies will have to determine more precisely which patients may benefit most from TM. Nonetheless, most respondents expressed the opinion that a patient identification system and a patient data platform must be included. No agreement was achieved regarding how to assess disease activity by self-examination. That being said, some recent studies have demonstrated that there is no statistically significant difference between RA patients receiving care via TM and those visiting the hospital.21 Importantly, one study found that the RA patients with the highest degree of disease activity were more likely to use TM.14 In fact, another study identified patient-reported RA flare ups as a red flag in teleconsultation, independently associated with treatment modification or the need for prompt face-to-face consultation.32

The importance of PROs in routine clinical follow-up is increasingly acknowledged. Over the past two decades, rheumatology practice has benefited from the widespread and increasing use of a wide range of PROs (e.g., measures of disease activity, functional status, mental health, and quality of life) to manage chronic rheumatic disease. In this study, most of the rheumatologists (83%) indicated that it would be beneficial to have a platform for PROs. In this regard, a systematic review has documented the effectiveness of TM for PRO communication, improving disease remission, functional impairment, and progression of radiographic joint damage.11 Another recent review of the literature reported that most RA patients held a positive perception of the use of TM in PROs.21 It has also been suggested that electronic PROs could facilitate epidemiology research, which would contribute to the development of future therapies.33

Ninety-one percent (91%) of the rheumatologists considered that RA patients should undergo pre-testing prior to teleconsultation. A similar idea was advanced by the British Rheumatology Society following the COVID-19 pandemic, launching an online PRO questionnaire platform that proved effective in collecting important data prior to (rather than during) the teleconsultation, which contributes to the teleconsultation itself, as well as saving time.34

This Delphi study has some limitations that need to be taken into account in order to properly interpret the results. The sample of rheumatologists selected may not be fully representative of the medical population being studied. Still, all the panelists treated patients with rheumatic conditions (>10 years of experience), and almost all were members of one or more medical societies. Moreover, the results should be interpreted considering the observational and exploratory nature of all questionnaires, reflecting the participants' subjective perceptions. Another possible limitation was the use of a structured questionnaire without free-text fields that could elicit qualitative insights from the participants. To this end, all of the wording was intended to be clear and not open to interpretation. Finally, it is possible that the recent experience from the COVID-19 pandemic may have affected the respondents' opinions and may not be a reflection of their opinion of TM in another situation.

In Spain, recent studies have evaluated TM for the treatment and management of type 1 diabetes,35 inflammatory bowel disease,36 lymphoma,37 haematological disorders,38 headache,39 and infectious diseases,40 among many others. However, more research is needed in the field of rheumatology to better understand the effectiveness of different TM interventions in the treatment of RA and other rheumatic diseases.15–18 Furthermore, studies are needed to identify the most promising TM interventions for patients with rheumatoid arthritis and other rheumatic diseases. Recently, the European Alliance of Associations for Rheumatology (EULAR) published a manifesto containing four principles to be considered when implementing TM in the field of rheumatology:41 1, The use of TM should be tailored to the patient's needs and preferences; 2, The healthcare team should have the appropriate equipment and training and be skilled in telecommunication; 3, TM can be used for screening for rheumatic and musculoskeletal diseases as a pre-assessment in the referral process, for disease management and medication dose regulation, and in some non-pharmacological interventions, and 4, people with rheumatic and musculoskeletal diseases should be offered training in the use of telehealth and barriers should be resolved whenever possible. The Delphi study reported here addresses all these points in an attempt to reach a consensus on recommendations to improve TM in Spain. In conclusion, we believe that TM can be a valuable tool for monitoring patients with rheumatic diseases, as well as alleviating the burden of face-to-face care in rheumatology. Likewise, we regard it as necessary for scientific societies and healthcare providers to coordinate initiatives and interests through working groups on telematic medicine to design secure interactive platforms with the content and solutions to the problems discussed in this article.

This research has been funded by, Madrid, Spain.

Jenaro Graña, María José Moreno, and María del Carmen Carrasco have received fees from Nordic Pharma related to this project.

None of the afore-mentioned authors have received fees related to drafting this manuscript.

The authors’ contribution has consisted of:

• 1

  Participating in the conception/conceptualisation and design of this study, or data acquisition, or analysis and interpretation of the data.

• 2

  Participating in the draft of this article or the critical review of its intellectual content.

• 3

  Final approval of the submitted version.