Virtual rheumatology during COVID-19: ‘A gift in a seemingly ugly package’
Prashant Kaushik MB BS, MNAMS, FACP, FACR, Rh MSUS., Northeastern Health System (NHS).,Oklahoma State University Center for Health Sciences
Adrita Ashraf MB, B.S., TMG/OMECO at Northeastern Health System
Creticus P. Marak MB, B.S.,Northeastern Health System, Tahlequah, OK
Jana Baker, D.O, FACOI., Oklahoma State University Center for Health Sciences
Prashant Kaushik MB, BS
The authors do not have any conflict of interest
Key words: Virtual interviews, Telerheumatology, Cherokee Nation, COVID-19
It is known that 2% of the American population, an estimated 6.9 million individuals, selfidentify
as American Indian and Alaska Native1. While it is also clear that early access to a
rheumatologist is imperative to achieve appropriate outcomes in rheumatologic diseases, a
significant gap and disparity exists in the access to rheumatology care between urban and rural
areas. A current sizable rheumatology workforce shortage exists and is projected to worsen
significantly, thereby posing a significant challenge2. In early 2020, the COVID-19 pandemic
had significantly shifted healthcare to remote delivery methods to protect patients, clinicians, and
hospital staff. This global condition also impacted rheumatology services.
In the pre-COVID months, the use of Telerheumatology for virtual visits increased access to
Rheumatology care in rural America with good patient and provider satisfaction results3. In
relation to the pandemic, Telerheumatology has played a key role in the management of patients
with chronic rheumatic diseases, particularly for those with comorbidities, and/or on
immunosuppressive therapy. Additionally, it has been contributive to maintaining social distance
and ‘flattening the pandemic curve’4.
Telerheumatology came to Tahlequah, Oklahoma, the capital of Cherokee Nation (CN), at the
Northeastern Health System (NHS) in the midst of the COVID-19 pandemic. The Division of
Rheumatology was initiated at the NHS in January 2021, and has been providing full-time
Rheumatology services since then to a large catchment area.
The clinical experience over the recent 11 months has already brought some revelations. A
strikingly high prevalence and a vast spectrum of systemic inflammatory immune-mediated
rheumatic diseases exists in the rural population served, including palindromic rheumatism,
rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and other connective tissue
diseases, psoriatic arthritis, axial and peripheral spondyloarthritides, polymyalgia rheumatica,
vasculitides, microcrystalline arthritides, etc.
A mixed model offering both face-to-face and virtual Rheumatology visits was offered to the
patient population. This has been shown to be the optimal combination, as it can overcome the
barriers to accessing care posed by distance, while also mitigating the limitations of virtual
consultation5. Procedures like arthrocentesis, and injection of/for various joints, carpal tunnel,
bursitis, de Quervain’s and flexor tenosynovitis, etc. are being scheduled as in-person follow up
visits electively. The two-week Telerheumatology service combined with the two-week inperson
Rheumatology service has had a major positive impact on the Rheumatology care of the
patients of this rural community. Initial visits/new patients are being served in a very reasonable
timeframe as are the follow-ups. All necessary musculoskeletal procedures are being done with
Ultrasound-guided point of care technique and the necessary infusions are being performed on a
very regular basis at our Infusion Center. It is very comforting to see that the patients and the
referring providers are very grateful for and appreciative of the service, supporting the previous
observation that Telerheumatology visits are non-inferior to in-person visits and are more time
and cost effective.5
In agreement with the previous revelation in North American/Manitoba Native American
population including Cree, Ojibway, and Metis, with smaller populations of Dakota, Dene,
Sioux, and Chipewyan6, the morphology of RA in the CN population is different. An explosive,
polyarticular onset is quite common clinically with a marked preponderance of strong
seropositivity for rheumatoid factor, cyclic citrullinated peptide antibody and 14.3.3 ETA
conferring a potentially severe nature to the disease and a need for early biologic therapy.
The first population-based lupus registry in the Unites States American Indian and Alaska Native
population demonstrated high rates of incidence and prevalence7. Although this study included
the data from Oklahoma City area via Indian Health System, this case study addresses the
Cherokee Nation population. It has also been observed that the American Indian patients with
SLE have autoantibody profiles different from European American and African American
patients with SLE along with poorer disease outcomes8. SLE is widely prevalent in the CN
population with protean clinical manifestations.
A significantly high prevalence of systemic sclerosis with pulmonary involvement, including
nonspecific interstitial pneumonitis and pulmonary artery hypertension has also been observed in
the CN patients. There has been a paucity of previous information on this disease in this unique
population/setting and more information can be provided with further observation.
In addition to the initiation of patient-care in-person and via Telemedicine, formal Rheumatology
training of the Oklahoma State University (OSU) residents from our own NHS Internal Medicine
residency program as well as the CN Family Medicine residency program was initiated.
Concomitantly, the medical students from the OSU College of Osteopathic Medicine at the CN,
the country’s first tribally affiliated medical school, have started rotating within the
Rheumatology Division. A diagnostic and interventional musculoskeletal point-of-care
ultrasound (POCUS) has been keenly incorporated into both, teaching and clinical service. This
has led to an increased interest in Rheumatology as a discipline.
Despite having some limitations that can be resolved with ongoing refinement, Telemedicine can
become a “virtual” game changer for academic programs including Internal Medicine and
Rheumatology, 10. Outcome measures in future larger studies can quantify improved timely
access and improved educational opportunities for residents & medical students.
The COVID-19 pandemic has led to a transformation in health infrastructures and
medical education/recruitment. This article emphasizes and reinforces the concept that
rheumatology consultation via Telemedicine is non-inferior to in-person clinic visits and very
helpful in diagnosing rheumatologic diseases early and managing them adequately especially
during the time of a pandemic. Although not a novel idea, it is an intriguing and worthwhile
observation in a unique setting and continues to maintain as well as expand patient-access to
rheumatologic services in a rural setting.
The successful use of Telemedicine for managing Rheumatology patients supports greater
exploration of this digital tool for a decentralized approach toward seamless patient care11.
Acknowledgment: Our immense gratitude to Cherokee Nation Health Services for the kind
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