Comment on: Telemedicine in the management of rheumatoid arthritis: maintaining disease control with less health-care utilization

DEAR EDITOR, we read with great interest the manuscript by Müskens et al. In a groundbreaking study in rheumatology, they evaluate the implementation of an eHealth platform and a self-management outpatient clinic in patients with RA. Following the use of the platform, the mean number of outpatient clinic visits decreased, and this was accompanied by a significant decrease in DAS28. As they concluded, real-world implementation of remote monitoring can reduce the number of hospital visits, while maintaining disease control. Their publication provides interesting evidence for assessing new evidence-based digital tools in health care [1]. Currently, decisions on therapeutic strategy are based mainly on compound activity indices [2]. However, a patient’s perception of their disease activity usually differs from that of their physicians [3]. For instance, it has been shown that health-care professionals may underestimate pain in RA, leading to potential divergences between patients and doctors [4]. An added value of the digital solution used in this study is that it includes patient-reported outcomes measures (PROMs) [1]. Evidence about correlation between PROMs and disease activity scores in RA is increasing [5]. Hence, several projects using PROM-based instruments offer the opportunity for custom-made off-hospital monitoring that gets patients more engaged in the self-management of their disease [6]. Regarding PROMs, one type that might be particularly interesting for assessment of patients is ecological momentary assessment (EMA). EMA is based on repeated sampling of a subject’s current behaviour and experience, which enables data collection with high frequency and within the patient’s normal environment [7]. This reduces memory biases and increases the reliability of data, especially for measurement of subjective and changing aspects, such pain. EMA has rarely been used in rheumatic and musculoskeletal diseases (RMDs) studies, but it has recently gained widespread interest for chronic diseases and diseases with recurrent flares [8]. Another type of instrument that can be used to place patients at the centre of research and evaluate clinical care is patient-reported experiences measures (PREMs) [9]. PREMs are tools that report patient satisfaction scores with a health service. They are used to monitor patient feedback regarding overall patient experience of health care. PREMs have shown correlations with patient satisfaction and safety and can be used to assess clinical effectiveness and economic efficiencies in health care [10]. The manuscript by Müskens et al. [1] highlights that the time to understand what happens to the patient outside of the medical appointment is now. The coronavirus disease 2019 pandemic has pushed society towards a dramatic, and often chaotic, adoption of digital health tools. From the implementation of teleconsultations to the embracing of digital solutions in health care, this new paradigm has arrived to stay, following a long-overdue need to embrace digital solutions to improve the care of our patients. Now the question is whether it will be carried out while taking into consideration the unique needs of the rheumatology specialty or, as has happened before, whether we will be forced to use technologies designed by those without an understanding of the particular needs of our complex patients and ourselves as health-care professionals [11]. A relevant finding of this study is that only 37% of the patients are stable users of the digital solution. This fact denotes that multidisciplinary collaboration is crucial in the implementation of digital health in rheumatology; not only are experts in digital health needed, but also professionals in rheumatology and patients, who are the best that may identify patients’ needs. The World Health Organization, in recent guidelines on the use of digital health for strengthening health-care systems [12], strongly highlights the importance of involving healthcare professionals early on, in order to address potential implementation issues, and also to include the need for training and addressing digital health literacy issues. Adoption of eHealth can only happen with trust in such systems, and we cannot trust systems that were designed without strong involvement of clinicians and patients. At this turning point, rheumatologists must seize the challenge to become the leaders of this paradigm shift by becoming involved in the mHealth implementation process. Based on past experience, we do not want to repeat the problems that arose with Electronic Health Records, in which the clerical burden, the lack of interoperability between disparate systems and the non-intuitive interfaces led to significant physician dissatisfaction and a higher risk of professional burnout [13] while failing to facilitate the integrated care that our patients require. In this work, Müskens et al. [1] demonstrate that the efficient implementation of digital tools is possible. It shall be a source of inspiration to continue generating evidence on such a necessary and important field. Now is the moment to go the extra mile towards the L E T T E R

DEAR EDITOR, we read with great interest the manuscript by Mü skens et al. In a groundbreaking study in rheumatology, they evaluate the implementation of an eHealth platform and a self-management outpatient clinic in patients with RA. Following the use of the platform, the mean number of outpatient clinic visits decreased, and this was accompanied by a significant decrease in DAS28. As they concluded, real-world implementation of remote monitoring can reduce the number of hospital visits, while maintaining disease control. Their publication provides interesting evidence for assessing new evidence-based digital tools in health care [1].
Currently, decisions on therapeutic strategy are based mainly on compound activity indices [2]. However, a patient's perception of their disease activity usually differs from that of their physicians [3]. For instance, it has been shown that health-care professionals may underestimate pain in RA, leading to potential divergences between patients and doctors [4]. An added value of the digital solution used in this study is that it includes patient-reported outcomes measures (PROMs) [1]. Evidence about correlation between PROMs and disease activity scores in RA is increasing [5]. Hence, several projects using PROM-based instruments offer the opportunity for custom-made off-hospital monitoring that gets patients more engaged in the self-management of their disease [6].
Regarding PROMs, one type that might be particularly interesting for assessment of patients is ecological momentary assessment (EMA). EMA is based on repeated sampling of a subject's current behaviour and experience, which enables data collection with high frequency and within the patient's normal environment [7]. This reduces memory biases and increases the reliability of data, especially for measurement of subjective and changing aspects, such pain. EMA has rarely been used in rheumatic and musculoskeletal diseases (RMDs) studies, but it has recently gained widespread interest for chronic diseases and diseases with recurrent flares [8].
Another type of instrument that can be used to place patients at the centre of research and evaluate clinical care is patient-reported experiences measures (PREMs) [9]. PREMs are tools that report patient satisfaction scores with a health service. They are used to monitor patient feedback regarding overall patient experience of health care. PREMs have shown correlations with patient satisfaction and safety and can be used to assess clinical effectiveness and economic efficiencies in health care [10].
The manuscript by Mü skens et al. [1] highlights that the time to understand what happens to the patient outside of the medical appointment is now. The coronavirus disease 2019 pandemic has pushed society towards a dramatic, and often chaotic, adoption of digital health tools. From the implementation of teleconsultations to the embracing of digital solutions in health care, this new paradigm has arrived to stay, following a long-overdue need to embrace digital solutions to improve the care of our patients. Now the question is whether it will be carried out while taking into consideration the unique needs of the rheumatology specialty or, as has happened before, whether we will be forced to use technologies designed by those without an understanding of the particular needs of our complex patients and ourselves as health-care professionals [11]. A relevant finding of this study is that only 37% of the patients are stable users of the digital solution. This fact denotes that multidisciplinary collaboration is crucial in the implementation of digital health in rheumatology; not only are experts in digital health needed, but also professionals in rheumatology and patients, who are the best that may identify patients' needs. The World Health Organization, in recent guidelines on the use of digital health for strengthening health-care systems [12], strongly highlights the importance of involving healthcare professionals early on, in order to address potential implementation issues, and also to include the need for training and addressing digital health literacy issues. Adoption of eHealth can only happen with trust in such systems, and we cannot trust systems that were designed without strong involvement of clinicians and patients.
At this turning point, rheumatologists must seize the challenge to become the leaders of this paradigm shift by becoming involved in the mHealth implementation process. Based on past experience, we do not want to repeat the problems that arose with Electronic Health Records, in which the clerical burden, the lack of interoperability between disparate systems and the non-intuitive interfaces led to significant physician dissatisfaction and a higher risk of professional burnout [13] while failing to facilitate the integrated care that our patients require. In this work, Mü skens et al. [1] demonstrate that the efficient implementation of digital tools is possible. It shall be a source of inspiration to continue generating evidence on such a necessary and important field. Now is the moment to go the extra mile towards the LETTER V C The Author(s) 2021. Published by Oxford University Press on behalf of the British Society for Rheumatology. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

Rheumatology Advances in Practice
homogeneous and orchestrated creation of a new paradigm that integrates the digital world and the real world.