• autoimmune diseases
• lupus erythematosus, systemic
• health services research

We thank Perniola et al for their interest in our paper and the circumstantial details on their outpatient activity.1 Our service is a referral rheumatology department with more than 100 outpatients evaluated every day. Since the first Italian subject has been diagnosed with COVID-19 and transferred to our Hospital on 21 February 2020, a prompt reorganisation of our department and of the entire hospital facilities has been carried out in order to create a COVID-19 hub hospital and deal with the emergency at best.2 Starting 24 February 2020, we have severely restricted the access to our outpatient clinic. Nevertheless, we have maintained the administration of intravenous therapies (biologics, antimetabolites and prostanoids) and the evaluation of patients requiring urgent interventions (eg, patients suffering from organ or life-threatening conditions and/or disease flares). Follow-up visits have been initially taken over by phone contact.3 Subsequently, a proper telemedicine platform has been implemented by our institution, allowing a direct visual interaction with patients and the possibility of sharing test results, pictures and medical records in real-time during the visit. The use of this platform was preferred over a simple phone-consultation and/or unprotected email interaction because it was integrated into the official medical record software in use at our institution and also for data security. In fact, patients had to undergo a three-step authentication in order to access the platform and shared data were stored in protected servers of our institution and automatically destroyed after 45 days.

We initially experimented with the platform on systemic lupus erythematosus (SLE) patients, who were chosen as a good test sample because of their complexity. Telemedicine served us a double aim: (1) to carry out routine evaluation of our outpatients and their clinical conditions and (2) to retrieve information about exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the clinical course and outcome of COVID-19.4 Currently, despite the containment measures having been eased, we are continuing to adopt teleconsultations, after an initial telephonic triage, for patients with stable clinical conditions or with symptoms possibly attributable to COVID-19 who do not require hospitalisation.

In our experience, telemedicine is allowing to guarantee most of the planned visits in safe conditions for chronic patients already in our outpatient circuit. A similar approach has been carried out at our hospital by other specialties, including cardiology. However, a spike in deadly manifestations such as sudden cardiac death has been reported, due to the inaccessibility of routine care or fear to appeal to medical help.5 In the light of these reports, we have still to evaluate the usefulness of telemedicine in new patients requiring prompt diagnosis and very early referral as in the detection and fast tracking of large vessel vasculitides.6 It is likely that we will be able to better balance the consequences of such delays that occurred during the COVID-19 pandemic, in the future and we should get ready to manage them in the best possible way.