Remote Monitoring in Rheumatology: What’s Holding It Back?

For patients with rheumatoid arthritis, going to the doctor to discuss any ongoing symptoms or problems can be a hardship, especially if rheumatologists are scarce in their area. A mobile app under development in Switzerland could ease their burden.

DETECTRA is a remote patient monitoring (RPM) system that employs objective digital biomarkers to assess the disease activity of arthritis. The concept is very straightforward. Patients use a mobile app at home to take photos of their hands and respond to basic questionnaires for their specific disease.

Healthcare providers see the photos and monitoring data on a dashboard, as well as biomarkers such as the Finger Fold Index that measures the swelling in the joints as an indicator of disease activity. The dashboard is used to track and manage patient data and schedule patient follow up, either through remote or in-patient visits. A study of eight patients with rheumatoid arthritis reported promising results: Participants said the mobile app was user-friendly and motivated them to work with their provider in managing their disease.

“That very basic model had the ability to discriminate swollen from nonswollen joints. We had a very promising accuracy of 84%, with 88% sensitivity and 75% specificity,” said lead researcher Marc Blanchard, MSc, PhD, project leader in digital health in the rheumatology department at Lausanne University Hospital, Lausanne, Switzerland. Since then, the model has been significantly improved through training on over 1000 hand images.

DETECTRA is part of a large arsenal of RPM tools clinicians are exploring to increase access to care for rheumatology patients. A multidisciplinary task force for the European Alliance of Associations for Rheumatology (EULAR) summarizes remote care as “use of digital technologies — so-called ‘telehealth’ interventions. It is used in all parts of the patient pathway, including communication with patients/caregivers, disease screening, or monitoring of different aspects of the disease.”

Use of RPM in patient care is growing — at least 30 million Americans are using such devices, with the global market reaching an estimated $1.7 billion by 2027.

Digital health solutions have become a necessity to ensure timely, effective, and equitable treatment, as the demand for rheumatologic care outpaces supply, said Johannes Knitza, MD, PhD, MHBA, a rheumatologist and researcher at the University Hospital of Giessen and Marburg, as well as Philipps University of Marburg, both in Marburg, Germany.

“The care gap is widening rapidly, making it increasingly difficult to provide timely and continuous monitoring for patients with rheumatic diseases. Remote monitoring helps bridge this gap by ensuring close disease surveillance while also improving efficiency in healthcare systems,” Knitza said.

RPM enables early interventions and treat-to-target strategies, reducing the need for frequent in-person visits. “Patients benefit from better access to care, more personalized treatment adjustments, and greater engagement in managing their own health,” he added.

As an example, if a patient enrolled in an RPM program is doing well, they might not need to see their rheumatologist for a routine in-person checkup and or even need a telemedicine visit. To give their provider confidence that they are doing well, a patient may need only to provide their electronic patient-reported outcome (ePRO) or other patient data to the RPM monitoring app, said Jeffrey Curtis, MD, MS, MPH, a professor of medicine, in the Division of Clinical Immunology and Rheumatology at the University of Alabama at Birmingham, Alabama.

“Conversely, if something isn’t going well, RPM or remote therapeutic monitoring [RTM] provides a better way to access one’s healthcare provider and provide objective evidence” via imaging, ePROs, or wearable biosensor devices about what’s happening, instead of just sending a message through a patient portal, Curtis noted.

The technology also brings more granularity and objectivity in data input, Blanchard said. A healthcare provider might only get data from in-person visits every 6 months or annually. With remote monitoring, you can get data every week, or every day. “That’s key because in arthritis we want to predict changes, we want to detect the changes and act as early as possible.” More data and granularity lead to greater accuracy and predictive values for potential worsening of conditions or improvements due to a change in treatment, he added. 

Most importantly, RPM connects patients and healthcare providers. “It might not be a human connection, but it’s another layer, another dimension of the connection. It does not require much time or resource efforts, but it collects data and involves and empowers the patients from home,” Blanchard said.

ePROs Lead the Surge in RPM

The COVID-19 pandemic played a significant role in accelerating digital health adoption, forcing many institutions to rapidly integrate remote care solutions, Knitza said. “These experiences have paved the way for more structured and evidence-based implementations” of remote technology, he added.

ePROs have been among the most accessible and impactful solutions in rheumatology, Knitza said. “Multiple studies have demonstrated their ability to track disease activity and trigger timely in-person assessments,” he noted. In one systematic review and meta-analysis of 4473 patients with inflammatory arthritis, investigators reported that ePRO measures yielded higher rates of remission and lower disease activity among patients than among those in control groups receiving usual care or an active control intervention.

A prime example of a tool by which ePROs could be collected is the PatientSpot app (previously ArthritisPower), which supplies patients with a free mobile app to track chronic disease symptoms and treatments. Through its robust infrastructure, it facilitates symptom tracking, therapy initiation monitoring, and symptom management through ePROs collection, “which can be complemented with curated educational content — aimed at improving awareness about specific diseases and therapeutic options that can ultimately facilitate shared and informed decision [making]. These factors may play a key role in achieving better patient outcomes. This allows users to engage and invest in their own healthcare and decision making around it alongside their healthcare providers,” said Shilpa Venkatachalam, PhD, MPH, director of Patient-Centered Research Operations and Ethical Oversight at the Global Healthy Living Foundation (GHLF) and co-principal investigator for the PatientSpot registry.

The PatientSpot infrastructure also supports a clinical use component, enabling clinicians to monitor therapeutic and physiological progress remotely. A study of patients from 25 rheumatology clinics across the United States found that the app improved physician follow-up (42.4%) and monitoring disease changes over time (24.2%).

Ongoing feasibility initiatives are evaluating the effectiveness and optimal use cases of RTM via the PatientSpot app as part of standard care, said Venkatachalam, a patient who lives with rheumatoid arthritis and osteoarthritis. She and her PatientSpot colleagues define RTM as a method that “connects patients to their healthcare provider using a smartphone app with or without a physiologic biosensor device in an insurance-reimbursable program that compensates physicians each month for their patients’ use of this technology and its associated monitoring by office staff.”

PatientSpot has also been integrated with the electronic health record, data warehouse, and customized monitoring dashboards in many US community rheumatologists’ practice settings. It facilitates giving ePRO information directly to treating providers and their office staff to provide actionable, quantitative patient information when and where it’s needed, noted Curtis, who co-founded the registry with Venkatachalam.

Other RPM methods such as wearables offer a major advantage by passively collecting continuous data, reducing patient burden. They generate objective, high-density insights for early detection of disease progression, Knitza explained. Capillary self-sampling and smartphone-based assessments “further enhance monitoring by providing objective markers, such as inflammation levels and morning stiffness, which help refine treatment decisions,” he said.

In his own work, Knitza and colleagues explored a hybrid telehealth care pathway for patients with axial spondyloarthritis (TeleSpActive). Patients used a medical app to document disease activity on a weekly basis and a capillary self-sampling device at home to measure C-reactive protein levels.

“In interviews, patients reported benefits such as a better overview of their condition, ease of use of telehealth tools, greater autonomy, and, most importantly, travel time savings,” according to study authors.

Knitza in other research used RPM to accurately identify patients who did not progress to rheumatoid arthritis, safely eliminating unnecessary in-person or telephone consultations. “Additionally, we evaluated patient-performed functional tests for myositis, demonstrating excellent reliability. With proper patient education, self-assessments become highly effective, allowing physicians to focus on clinical decision making rather than repetitive measurements,” he said.

Nearly all his own patients now complete ePROs before their in-person visits, allowing for much better preparation and more meaningful consultations.

Gerald Lushington, PhD, a neuroimmunological scientist in Lawrence, Kansas, has been studying the use of natural language processing (NLP) in combination with biometric and PRO data in patients with lupus.

Long before generative AI, NLP methods had acquired solid analyses to infer not just what a person is saying, but also how they’re “feeling” as they say it, explained Lushington, who’s the chief scientific officer and co-founder of Qnapsyn Biosciences and head of data science at Progentec Diagnostics.

How can a clinician determine whether a worrisome remote measurement is an indicator of pathological shift, rather than a patient having a bad day? “NLP might help to mitigate that through, say, a friendly “diary”-type app that a patient could write or speak into,” Lushington said.

While his research is ongoing, Lushington believes that using NLP to process short text segments to characterize a patient’s general mood “could really help to sharpen the sensitivity and specificity of RPM data.”

Technology Faces Financial, Buy-in Roadblocks

RPM continues to expand and develop, but this growth area in medical technology faces some important barriers. “There are lots of interesting ideas appearing in papers, business plans, and new clinical studies. But real-world practitioners are a long way from adopting many of these innovations. This includes a fair number of concepts that have tested well,” Lushington noted.

Much of the hesitancy is driven by logistics. Practices intrigued by the possible benefits of RPM technology are grappling with strict privacy and data security policies and how to align those policies with the strengths and vulnerabilities of digital communication, Lushington said.

Healthcare experts in Europe report similar obstacles with buy-in. “It’s just easy to practice the way you do,” said Rachel Knevel, MD, PhD, a rheumatologist at Leiden University Medical Center in Leiden, the Netherlands. Knevel, who leads the data science group on rheumatology at her university, often sees reluctance among her colleagues to accept novel risks. The fear is that new, remote devices could lead to error in treatment.

“People would rather maintain the current status quo, even though it’s not perfect. And even if you propose something that might do better, they worry too much about the novel risks, and they have difficulties in weighting that,” Knevel said.

The US Food and Drug Administration (FDA) and the European Medicines Agency both have regulatory processes for approving digital technologies as medical devices, including RPM, Lushington said. The FDA during the pandemic issued a number of emergency use authorizations for remote or wearable patient monitoring devices that remain in effect under section 564 of the Federal Food, Drug, and Cosmetic Act.

Assuming that medical communities in the United States and Europe have similar interests in empowering RPM for rheumatology, “I would say that forecasting the prospects for RPM rollout will depend a lot on how these regulatory bodies adapt in concert with the technologies themselves to find the right balances between security and functionality and between patient benefit and commercial viability,” Lushington said.

Interpreting medical device regulation and getting certified to use remote technology present additional challenges. In the European Union, medical apps or computer software must have a Conformité Européene (CE) certification. “In Europe, what I notice is a lot of the implementation people are struggling a little bit with the rules. You get different legal advice, and if you really want to get it certified under the medical device regulation, it costs quite a bit of money,” Knevel said.

Knitza, who mainly uses RPM in the research space at the moment, said all his RPM software needs to be CE-certified medical products.

Software companies can also make it difficult for novel tools to be linked to the healthcare system. “Ideally, if you have a tool that works, it’s integrated in your clinical healthcare, in your software.” Achieving this is a recurrent struggle, Knevel said.

Many healthcare professionals who need tools to translate large datasets into actionable insights worry about data overload, Knitza said. Patients, on the other hand, may fear that remote monitoring could reduce their access to in-person care, highlighting the need for clear communication and reassurance.

“Educating patients on the necessity and value of remote monitoring is crucial for ensuring its long-term sustainability,” Knitza said.

Security and data breaches also drive user hesitancy.

Laptops and smartphones have already been stress-tested by years of global cyberattacks attempts. While no device is entirely risk free, risk analysts can give actionable estimates for how safe a given protocol is for these long-tested devices and what additional steps can make them tangibly safer, Lushington said. “Those parameters aren’t nearly so obvious yet for all these new smart devices.”

Reimbursement Inconsistent Across Continents

Lack of financial incentives continues to be the primary barrier to remote monitoring adoption. Reimbursement models for using RPM vary by country, Knitza said.

In the United States, Medicare establishes payment for RPM services for the monitoring of acute and chronic conditions. If the rheumatic condition is acute or chronic, it meets this requirement.

Medicare will reimburse for both remote physiologic monitoring (such as oxygen saturation and blood pressure) and RTM. Remote physiologic monitoring data, however, must be collected for at least 16 out of 30 days. This method also requires an established patient relationship, monitoring an acute or chronic condition. Many private payers follow Medicare’s lead and pay clinicians for this practice, including Humana, Aetna, Cigna, UnitedHealthcare, and some BlueCross BlueShield plans.

Payment varies by insurance plan and the specific use case, Venkatachalam said. “Several CPT [Current Procedural Terminology] codes are available for both RTM and RPM services, covering billing for the initial setup of remote monitoring services, staff time monthly to review monitored data, and follow-up with patients based on the ePRO and other patient data being monitored,” she said.

New billing codes introduced in the United States in 2022 freed patients from having to wear a physiologic biosensor. Instead, the codes permit reimbursement for software as a medical device, allowing for data capture of ePROs and other patient data without the additional expense of a wearable device, Curtis said. “Even newer reimbursement codes are being added that permit monitoring for as few as 2-15 days per month, providing greater flexibility for the first month of initial monitoring that may not satisfy the 16+ day requirement, or when patients may not need monitoring that frequently. Existing reimbursement codes are also being revised that lessen the burden on office staff for monitoring,” he said. 

Forty-two state Medicaid programs currently reimburse for RPM, although coverage varies by state.

In Europe, expansion of digital communication channels such as 24/7 messaging options for rheumatologists has strained physician capacity without adequate reimbursement, said Knitza, whose home country Germany does not currently reimburse for using RPM in rheumatology.

Healthcare insurers in the Netherlands have been exploring the market in remote technology, “but they’re not necessarily very proactive,” Knevel said. Physicians generally get paid by seeing the patient in person, although phone consultations are reimbursed similarly as a patient interaction.

Knevel has been working on a novel symptom checker tool that reduces the need for in-person care. However, there’s no clear reimbursement structure for such a tool at this time, she said.

The Potential to Save Money

RPM’s ability to cut down on healthcare costs is another area of exploration. Conceptually, the argument would be that effective RPM implementations in rheumatology would reduce the time-to-diagnosis, shorten therapeutic adjustment latency, and reduce reliance on institutional resources due to shorter hospital stays and fewer readmissions, Lushington said.

With RPM, healthcare teams can monitor patients in real time gathering real-world data and evidence, allowing them to spot problems and intervene before they escalate. This means they can adjust treatments earlier, preventing more serious and costly issues from developing, Venkatachalam said.

It may also reduce phone calls and office visits. There is the potential to keep track of patients remotely, and by doing so, providers can address concerns without requiring patients to come in or call the office as often. “This not only saves time but may also help reduce administrative costs and strain on office staff, and for the patient living with the chronic disease, it may help address issues related to mobility, taking time-off from work, transportation-related challenges, and so on,” said Angela Degrassi, senior manager for patient-centered research operations at GHLF, where she oversees many of its RTM initiatives.

Tools like the PatientSpot RTM interface offer educational content that helps patients understand their treatment plans better. “When patients feel more equipped and informed, they may also feel more invested in the management of their own health and that then may make them more likely to stick to their treatment plans, leading to better outcomes and fewer complications that might otherwise drive costs,” Venkatachalam noted.

RPM also allows healthcare teams to focus their time and resources on patients who need the most attention. “Routine check-ins can be handled remotely, freeing up in-person visits for those who really need them, making the system more efficient overall and reducing overall burden,” Venkatachalam said.

The potential for savings is clear, but more research and data are needed to fully understand how much money RPM actually saves, Venkatachalam said. “We need more data to show exactly how it impacts healthcare costs in the long run, especially across different patient populations and care settings and across different diseases.”

In 2022, the Mayo Clinic released a promising study about RPM’s ability to lower costs and improve outcomes among patients with COVID-19 who were at risk for severe disease. A total of 80% of the 5796 patients enrolled in Mayo’s RPM program engaged with its cellular and Bluetooth-enabled devices. Investigators then matched 1128 pairs of RPM-engaged and nonengaged patients to do their analysis.

Those who engaged with RPM had lower rates of hospitalization and lengths of stay, resulting in an average savings of $1259 during a 30-day follow-up period and a total cost savings of $1.4 million.

Looking Toward the Future

At least in Europe, remote technology is an underappreciated subject, particularly in the Netherlands, Knevel said.

“We think our healthcare system is so easily accessible, but we tend to forget that people are not coming to our clinics if they’re in low-paying jobs” and can’t take a day off work to see a doctor. People who aren’t literate in Dutch might also have more difficulties in communicating with the healthcare system. In developing these digital tools, healthcare professionals should focus more on these underserved groups who would benefit from remote technology, she advised.

Knitza has seen physician skepticism slowly decline as more high-quality evidence and official recommendations from professional associations emerge. Dedicated training and peer-to-peer knowledge exchange play a crucial role in accelerating adoption, he added.

Professional societies like EULAR and other national organizations are continuously updating their guidelines to incorporate digital medicine, Knitza said. In 2022, EULAR issued guidelines on points to consider for implementing telehealth in the routine care of people with rheumatic diseases, including its specific uses in disease monitoring, the equipment and training healthcare teams will need, and potential barriers.

Organizations such as the Digital Rheumatology Network also try to foster the implementation of RPM.

“Digital therapeutics for mental health are now recommended in various guidelines due to strong evidence and improved patient access. Similarly, AI-driven decision support tools and hybrid care models are expected to be increasingly included in future guidelines,” Knitza said.

Rheumatology as a discipline often faces medical ambiguities. But it also values answers and enhancements. For these reasons, Lushington is optimistic that rheumatologists will embrace RPM as more tools develop and progress. Despite the general reluctance among some physicians to embrace technology, “I’ve met very few rheumatologists who were innately resistant to new protocols offering the chance to shorten the time-to-diagnosis profile and sharpen their sense of when and how to adjust medications. Effective RPM could really impact both of those ever-present concerns,” he said.

The DETECTRA technology still needs fine tuning, especially with respect to the standardization in the images that the patients are taking. Lighting, type of phone, and angle of the photo can all affect the analysis. Blanchard and his colleagues are using computer vision and machine learning to better train the app as more data comes in on skin colors and other variables.

For now, the app is being used for research purposes only. “We are running preclinical studies and are about to launch two multicentric clinical studies in Europe,” Blanchard said. One of the studies will evaluate DETECTRA’s ability to improve early detection in patients at risk of rheumatoid arthritis. The other trial will assess the superiority of the system, compared with standard of care, for the follow-up and management of patients diagnosed with rheumatoid or psoriatic arthritis.

Training patients and healthcare providers in the effective use of RPM tools is not difficult, Lushington said, drawing from his own experiences with digital research. “We’ve primarily looked at cellphone apps and wearable biometric devices, and neither of those pose major barriers.” The more complex an RPM device is, the greater the risk of faulty feedback and regulatory barriers.

“RPM, I believe, is inherently going to self-select a subset of technologies that maximize robustness and minimize burden,” he concluded.

Blanchard is CEO at Atreon SA. Knitza is member of the scientific advisory board for the Digital Rheumatology Network; has received grant or research support from AbbVie, Deutsche Rheumastiftung, GSK, Vila Health; and has served as a speaker for, consultant to, or received honoraria payments from AbbVie, AstraZeneca, BMS, Boehringer Ingelheim, Chugai, Fraunhofer Society, Fachverband Rheumatologische Fachassistenz, GAIA, Galapagos, GSK, Janssen, Lilly, Medac, Novartis, Pfizer, Rheumaakademie, Sanofi, Sobi, UCB, and Vila Health.

Venkatachalam served as a voting member on the 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis and will serve in a similar capacity in 2025. For this story, she and Degrassi had no personal conflicts of interest to disclose. As a GHLF employee, Venkatachalam noted that GHLF receives grants and sponsorships from pharmaceutical manufacturers and other private foundations. A full list of GHLF funders is publicly available here.

Curtis has consulted for and/or received honoraria payments from AbbVie, Amgen, Aqtual, BMS, GSK, Janssen, Lilly, Novartis, Pfizer, Sanofi, Scipher, Sensimetrics, Setpoint, TNacity Blue Ocean, and UCB; received research grants from AbbVie, Amgen, Aqtual, BMS, GSK, Janssen, Lilly, Novartis, Pfizer, Sanofi, Scipher, Setpoint, and UCB. Curtis also leads several data coordinating centers, including the American College of Rheumatology RISE Registry, PatientSpot patient registry (formerly ArthritisPower), and the Excellence Network in Rheumatology to Innovate Care and High-Impact research. 

Lushington and Knevel had no disclosures.

Jennifer Lubell is a freelance medical writer in the Greater Washington Area.