Telehealth Opportunities in the Digital Age

Abstract

What will acute care physical therapy look like in the future? The vision proposed in the last president's message promoted strategies for repositioning acute care physical therapy within our evolving system of health care so that we use our unique abilities to optimize movement for functioning while reducing reliance on expensive interventions, facilitate transitions among services while promoting optimal resource use, and focus on the management of patients with complex and multiple comorbidities.1 In this issue of the Journal of Acute Care Physical Therapy, I am joined by Dr Alan Lee, a secretary of Telerehabilitation Special Interest Group of American Telemedicine Association (ATA), a member of the Section on Health Policy and Administration's (HPA) Technology Special Interest Group, and a former member of the Acute Care Section's Board of Directors, for a different proposal—the role for telehealth in our future. It was recently proposed that “The days of dismissing telemedicine as a mere technology option are over. Advances and refinements in the delivery of health care through audiovisual connections are powering not just individual ‘visits’ between clinicians, and patients, but entirely different ways to spread specialty expertise around, cover shortages of medical professionals, compete in metropolitan areas and anticipate health reform.”2 Spreading expertise and covering shortages to address needs, we have been enduring in acute care physical therapy and we propose that engaging in telehealth may benefit addressing those and other challenges. We acknowledge that there are significant obstacles to implementing telehealth.3 Opponents of telehealth may assume that the lack of hands-on care is a barrier for the physical therapy profession, and that the inability to interact face-to-face with a client or patient presents insurmountable limitation. An additional concern in recent telemedicine literature was that remote telemonitoring at home, for the management of chronic diseases, did not save health care dollars in rehospitalizations.4 Furthermore, past evidence indicated that if the practitioner at the bedside deemed telehealth technology as cumbersome, the overall outcomes were inferior.5 Our discussions with acute care physical therapists (PTs), PT assistants, and physical therapy students reveal that telehealth is foreign to many, they have misgivings about the potential for telehealth in physical therapy, and there is an expectation that the acute care environment will provide insulation from encountering telehealth. We disagree, and as an example of the value of telehealth in acute care, we point to the success it has had in intensive care units.6–8 Telehealth is succeeding in other ways within some of our acute care institutions. Promising telehealth acute care practices already exist in specialty consultations in emergency medicine and telestroke care.9,10 The ability to provide urgent telestroke care, including tissue plasminogen activator intervention at the right time, has achieved improved patient outcomes.10 In a survey, Silva and colleagues noted that many academic teaching medical centers have an ongoing telemedicine program in place.10 At the Combined Sections Meeting in 2013, the “Just in Time” principles from Kaiser Permanente Northern California program described telehealth opportunities for hospital-based outpatient physical therapy services. Surprisingly, it was the client/patients' preference to connect online with PTs because of time and travel inconvenience that was the main driver to implementation for telehealth physical therapy services. Technology has become ubiquitous in our patients' lives and in our clinics. The next evolution will be the intersection of these in ways we are just beginning to envision, so that telehealth expands the scope of what we are able to manage for our patients, across our clinics and across our communities. As a background, telehealth is defined as the ability to use telecommunication technology (real-time videoconferencing or store-and-forward/remote monitoring) in physical therapy models for care.11 As Russell et al12 noted in Australia, the ability to provide physical therapy services via telehealth is called telerehabilitation whereas the ability to provide clinical services in medicine is called telemedicine.3 In the early development of the technology, both the terms “telemedicine” and “telerehabilitation” were used. In addition, “telepractice” has been the term used by speech therapists.3 However, key government, corporate, and health organizations are promoting common terminology, and the use of telehealth is the preferred nomenclature. We endorse this consistency of language for clarity, optimal coordination of services, and to advance collaboration with other telehealth adopters in our acute care environments. There is capacity to engage in telehealth—it is recognized in the physical therapy practice language in various state practice acts.13,14 For example, Alaska's Physical Therapy Board language supports physical therapy with telerehabilitation (page 14).13 In addition, American Physical Therapy Association (APTA) has recognized that telehealth may be a component of physical therapy practice.11 On the APTA's website (http://www.apta.org/Telehealth/), you will find resources, along with definitions, policies, and podcasts describing telehealth models for services. If these examples are not persuasive, take a look at the CLEAR project (http://www.habiliseurope.eu/) from 4 European Union member states (Italy, the Netherlands, Spain, and Poland) on how telehealth is a resource for providing physical therapy services for stroke and cardiac rehabilitation for people in the European communities.15 In the United States, poststroke rehabilitation for veterans has been successfully provided by telehealth home monitoring with physical therapy services.16 In light of the opportunities and the evolving resources available, acute care PTs and PT assistants should consider how participation in telehealth services may benefit our patients and our institutions. We encourage you to start by attending to key best practice concepts for telehealth. As a component of telehealth, clinicians should ensure the use of Health Insurance Portability and Accountability Act (HIPAA)-compliant secure broadband connections. Informed consent is necessary and should be established either face-to-face or remotely. With this informed consent, a patient or client has the right to refuse telehealth services and be given the opportunity for usual face-to-face care if preferred, as that is the best way to ensure the practitioner and patient/client relationship built on trust and preference. In addition, professional standards are the same for telehealth and must be followed for documentation, supervision, and reimbursement. End-user (practitioners and patients) acceptance is the key to success. This area is evolving as the technology becomes sufficiently refined and reliable to meet workflow and other demands within the complex acute care practice environment. In the future, the interoperable electronic medical record should promote efficiencies by interfacing with telehealth technologies. The profession should not neglect developing opportunities that health information technology and telehealth provides to coordinate and advance our services within innovative models of care (eg, medical homes and accountable care organizations). As we envision the future, another promising area for telehealth in acute care could be educating and training future PTs and PT assistants remotely, while a patient is interacting with students, residents, and other clinicians at the bedside. This ability to bring the clinic to the classroom with secure web portals has the ability to be a powerful tool for clinical education in acute care physical therapy. It will also behoove us to investigate the role and effectiveness of telehealth within our acute care services because no evidence has been established to endorse a specific innovative model of care.9 Relevant clinical questions to investigate include—how can telehealth expand our presence and contributions in evolving systems, such as accountable care organizations? How can PTs and PT assistants provide better services in these models? How can telehealth be applied to expand prevention and wellness services? What is the role for telehealth to coordinate health care delivery, and the management of rehabilitation needs, across the continuum of care? Is there a difference in outcomes when a patient receives real-time videoconferencing, remote monitoring, and usual face-to-face physical therapy care? Is there a cost saving or greater value for the dollar spent with technology? How does telehealth physical therapy service provide direct and indirect cost savings in acute care practice? As these questions are answered, we will expand and elevate the provision of acute care physical therapy services. But first we need innovators (clinicians, researchers, and educators) to trial telehealth with our patients and begin to realize the opportunities, within and outside of our practice arena, where we can all achieve improvements in outcomes for individual patients and clients, and eventually for society. There is support to advance telehealth with innovative models of care. In a recent Medicare and Medicaid Research Review, telehealth reimbursement had increased for telemedicine providers in 2009.9 Stakeholders such as APTA, HPA's Technology Special Interest Group, and ATA's Telerehabilitation Special Interest Group provide leadership and information about additional telehealth resources.11,17,18 For example, APTA has developed a toolkit on telehealth. In addition, a telerehabilitation work group consisting of PTs, occupational therapists, and speech therapists is developing telehealth competencies. Lastly, a Frontiers in Rehabilitation Science and Technology (FiRST) group is working to advance telehealth, robotics, regenerative rehabilitation, and genomics as key pillars for clinicians, researchers, educators, and students to read, learn, and apply into best practice in physical therapy. Concurrently, we must be ready to advocate for eligibility in telehealth legislation at federal and state levels as telemedicine bills are introduced.19 In fact, the Medicare Telehealth Enhancement Act of 2009 (H.R. 2068) proposed by Congressman Mike Thompson was one example APTA supported in the past.3 We should continue this effort to become Medicare eligible providers of telehealth. In our minds, this is an extension of the Congressional battles won by past APTA leaders such as Charles M. Magistro and Robert (Bob) C. Bartlett when they advocated for PTs as Medicare-eligible providers in the 1970s. In 2013, the Center for Connected Health Policy survey of 50 Medicaid programs noted PTs as eligible Medicaid telehealth providers in Arizona, Kentucky, Minnesota, Nebraska, New Mexico, and Washington although Indiana does not reimburse for Medicaid PT telehealth services.20 In conclusion, acute care PTs and PT assistants are positioned well to engage in collaboration with telehealth programs and practitioners. There are challenges and there are opportunities accompanying the use of telehealth in physical therapy.3 As the technology becomes an essential part of our society, our patients will profit from our embracing of the telehealth opportunities to adapt the practice of physical therapy to take advantage of the benefits available in this digital age. Alan Lee, PT, PhD, DPT, CWS, GCS Secretary, Telerehabilitation Special Interest Group—ATA Jim Smith, PT, DPT President, Acute Care Section—APTA