A mobile app that patients use to track symptoms of rheumatoid arthritis can be “transformative” to the treatment decision-making process, according to a researcher who tested the app with his patients.
Data from the app uploaded daily directly into a patient’s electronic health record are more reliable than memory, Will Dixon, MD, from the Arthritis Research UK Centre for Epidemiology, said at the American College of Rheumatology 2018 Annual Meeting in Chicago.
The app — Remote Monitoring in Rheumatoid Arthritis (REMORA) — prompts patients to answer questions about their rheumatoid arthritis symptoms on a daily, weekly, and monthly basis.
After a small pilot in which eight patients tracked their daily symptoms for 1 month, Dixon and his colleagues recruited 20 patients to track their daily symptoms for 3 months.
Most patients tracked their symptoms through the app “most days” (median, 91% of days); only four of the 20 patients submitted data on 60% of the days or less.
“I was amazed at what a great difference it made when we looked at data together with patients,” Dixon reported. “We saw that several patients didn’t remember perfectly what happened between appointments.”
The recorded data jolted patients’ memories — in a striking way — during monthly consults with the doctor.
“Memory fails,” said Dixon, who described an interaction with a study participant who had been using the app for 1 month.
When she arrived for an office visit, she said she was “absolutely fine.”
“No pain?” Dixon asked.
“Nothing,” she replied.
But when he looked at the data in her health record, Dixon noticed that there was a spike on the graph 2 weeks earlier.
“The pain was at 0 and 1 for the first 7 to 10 days, and then you did have a couple of days when the pain was worse,” he pointed out.
“I’d forgotten that,” she told him.
He described another study participant who wanted to discontinue a biologic after only 1 month. However, a graph of her symptoms showed that disease severity was less pronounced as the month progressed.
The change in symptoms was gradual, “but over the month there was a trend toward improvement,” Dixon explained.
Without the graph of daily data in her electronic health record, neither he nor the patient would have known there was incremental improvement, Dixon said.
“That changed our treatment decision,” he told Medscape Medical News. “We decided to continue on the biologic for a bit longer to see if she improved further.”
In interviews with 16 of the study participants, two clinician researchers analyzed 17 clinical consults. They reported that the REMORA data provided three key positive outcomes:
Better information about the “big picture,” with specific information about short-lived flares that would have otherwise been missed.
Better self-awareness on the part of the patient and better understanding of the disease.
Better conversations and more personalized care.
The potential of an app like REMORA is great, said Dixon. Of course, there’s always a concern that physicians will become overwhelmed if they have information coming in too often, but the potential for research is tremendous, he noted.
“In RA, symptoms go up and down over time. If we have access to daily data, could we automatically identify a potential flare? Could we identify the preflare period? If we can do that, we can start intervening with patients beforehand, when they need help,” he said.
He suggested that a telephone consult with a nurse or advice about medication or coping strategies could be offered in such cases.
Dixon is a technology enthusiast. He and his team just completed a feasibility study in which a smart watch was used to identify the relation between patient activity and pain.
“We’re excited about that one,” he said. “It’s the world’s first research study using a cellular smart watch.”
Results should be in print soon, he told Medscape Medical News.
Not for Everyone
But wearable technology is not for everyone, said Jenny Leese, a PhD candidate at the University of British Columbia in Vancouver, who presented data from several studies that assessed for self-management of activity by patients with arthritis.
“I’ve spoken to some patients who find that having a record of their physical activity that they can share with their health professional really promotes a trust between them and the professional,” she said. They feel like they now have evidence of what they’re sharing.
But other patients are concerned that the tracking will elicit a hostile response from healthcare professionals if they do not attain certain goals, she told Medscape Medical News.
Leese is currently interviewing patients about their experiences with Fitbits and other wearable technology. The wearables can help patients set goals but they can also undermine or delegitimize a patient’s subjective account of a day’s activity.
For example, she explained, the gold standard for steps per day for most people might be 10,000, but for a patient with rheumatoid arthritis patient, a bad day could result in much fewer steps.
“For some that may be a motivation. For others it may cause a jolt of guilt and be demoralizing,” she said.
There is a risk of not fulfilling the potential benefit of the tools if each patient is not evaluated individually, she added. We need to make sure that the patient’s experience with the technology is positive.
A lot of the literature on technology and wearables only lauds the benefits, said Leese. “My research is showing that there may be potential downsides that are not supported in the literature.”
Dixon has consulted for Bayer and Google. Leese has disclosed no relevant financial relationships.
American College of Rheumatologists Annual Meeting: Presented October 22, 2018.