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Inflammatory rheumatic disorders
  1. B Pal1
  1. 1South Manchester University Hospital, UK
  1. Correspondence to:
    Dr B Pal
  1. F Guillemin2,
  2. A Saraux2,
  3. P Guggenbuhl2,
  4. J-M Behier2
  1. 2Ecole de Santé Publique, Faculté de Medécine, BP 184, Nancy, France

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I was interested to read the paper by Guillemin et al, where the authors used a detailed questionnaire for a telephone survey of patients to assess rheumatic problems.1 I have used a similar but somewhat more extensive questionnaire, which was initially designed for doctors such as general practitioners to complete and return through my cyberclinic project.2

In this study we evaluated the feasibility of a rheumatology consultation and advisory service using internet and email. We devised and posted a detailed rheumatology pro forma on our website (; accessed 26 February 2004) for general practitioners to complete and return on the internet. Two trainee doctors interviewed and completed the pro forma for 207 new patients. Based on this information from the questionnaire alone we were then able to provide provisional diagnoses and management plans, which we compared with those drawn up after a face to face assessment of the same patients in the outpatient clinic. Diagnostic concurrence was noted in the majority of patients (86%), no changes in further investigations, such as radiographs and blood tests, in a sizeable proportion of patients (62%) were necessary, and the majority of patients (74%) required no changes in the treatment plans suggested.

Our results show that it is quite feasible to offer an internet based outpatient consultation and advisory service in rheumatology and possibly other disciplines. Perhaps it is more practical in rheumatology because most of the diagnostic clues lie in a detailed history taken from the patients (as in the patient questionnaire we devised), only then aided by clinical examination and laboratory tests.

To our knowledge this was the first and only internet based service available to general practitioners. This, when established, can enable centres to streamline referral processes and provide early diagnosis and management plans for patients, even before their first appointment, which therefore works as a review appointment (as all the results and details of the patients are available when first attending the clinic). As a result we can cut the consultation time in the clinic to half the usual time required, a consequence of which is that we can see more new patients and perhaps also see more review patients.

We noted that general practitioners were finding it difficult to complete the pro forma on the website with the patients. Therefore, subsequently we devised a patient completed questionnaire, available on the same website, so that patients could complete this pro forma at the GP surgery with the help of an assistant such as a nurse. This facilitates referral and reduces demand on general practitioners’ time. We have been able to devise a separate questionnaire,3 again posted on our website, to facilitate referrals relating to osteoporosis services, and reduce our response time to management plans.

We are therefore not surprised that the authors found such a patient questionnaire helpful in telephone surveys. Compared with telephone consultation in this manner, an internet based questionnaire format would appear to be more convenient and less time consuming. Patients can take their own time in a relaxed manner to do the same. Furthermore, two people are not tied down at the same time—that is, patients can complete and return the questionnaire when convenient, and the researchers or the clinicians can assess such questionnaires at leisure or when convenient. Admittedly, more patients have access to telephone than internet and email, and many do not yet know how to use the latter. Hence, in recent years we have provided “hands-on” training and instructions with a number of road shows4 for our patients to keep abreast with new information technology and to increase “equity” and access for our patients in these days of “modernisation” in the health services.


Authors’ reply

We appreciate Dr Pal’s presentation of a rheumatology consultation and advisory service posted on a website for use by general practitioners, further completed with patient’s targeted online questionnaire to facilitate referral processes and care management and reduce demand on general practitioners’ time.

Although this is certainly of interest for the consultation and care of patients, a prevalence survey cannot rely on such technology. This is not only because people have more access to telephone than internet and email but also, above all, because people in the general population, the target of such a survey, including people with and without disease, will not spontaneously answer an unexpected questionnaire without a minimum of information and invitation. There would be a severe risk of underestimating the denominator and thus biasing the prevalence.