This text-based course is an edited transcript of the webinar Telehealth (Digital Practice) Implementation: Considerations and Road Map, presented by Edward Dobrzykowski, PT, DPT, MHS, AT,Ret
- Participants will be able to identify at least three component steps required for the implementation of telehealth (digital practice) into existing clinical practice.
- Participants will be able to identify at least two regulatory and insurance considerations each.
- Participants will be able to describe at least two potential clinical scenarios for digital practice.
- Participants will be able to identify at least three evidence-based strategies of telehealth use in patient care.
- Participants will be able to list at least four resources available in the telehealth/digital practice space.
You have most likely been introduced to telehealth over the past several months. The preferred term is now “digital practice” and it has evolved from a gradual implementation into medicine and rehabilitation. We have been thrust into this methodology due to the current pandemic. The pathway from an in-person visit to remote delivery has been daunting due to the rapid response required by the moving parts of the healthcare system. We now know that we can provide healthcare delivery through remote means for most of our patients.
There are a few things you can reflect on during this presentation. Have we completed all the steps to fully and safely implement digital practice? Where do we go from this point in our planning process? Will this be temporary or permanent? Due to rapid changes, what I say today is current to the best of my knowledge. There may be some content changes that will most likely occur depending on when you listen.
History of Telemedicine
Over two decades of telemedicine history have been led by physicians with underlying purposes to expand rural patient access. Even before the year 2000, there were incidences of telemedicine. However, the goal was to expand access to the patients who were not able to see us. Those patients tended to be in rural areas. We wanted to provide them with access to available specialists, who tended to be in urban areas. We also wanted to improve healthcare delivery.
Think about how our technology has progressed over a couple of decades. The earlier years of technology presented many barriers. The pioneers included states with large rural populations and the Veterans Administration Department of Defense, followed by some healthcare systems like the Health Maintenance Organizations. They ventured into telehealth as a result of the same desire to increase patient access, but also lower costs and improve value.
As far as implementation, the utilization was previously moving at a gradual pace of employment. As our world changed a few months ago, utilization in rehabilitation went up about five to 10 percent, then zooming up into the 80 percent level. Implementation was aided by the number of vendors that came along. In the past five to seven years, vendors have allowed people to take advantage of the new technologies, as well as make it easier for us to get into the digital practice space. We have not yet deciphered full deployment of clinical practice because there are still some diagnoses and other patient types where hands-on delivery is deemed essential.
The early years were all about access. How can primary care and specialists be utilized efficiently in rural areas? There were also some smaller hospitals that needed specialist coverages, hospitalists, radiologists, and so on. How can we mitigate the impact of weather events, which impeded in-person visit attendance? A benefit that we will see from more telehealth is still being able to have our visits when in-person visits are hindered. Is there a way to complement our desire to improve health by reducing the impact of social and health disparities? More recently, today's healthcare consumer has demanded the convenience of access to their providers, even when an in-person visit was a viable option. I have struggled with having more designed telehealth for improving access to patients who otherwise would not have it.
Moving to the more convenient side of telehealth, modernization has allowed us to discover email and communication programs connected to our electronic health records. Home programs specific to rehabilitation increased our contact points with our patients, and hopefully their adherence and outcomes.
Today, our need is obvious: provide care without direct patient contact and reduce community infection. Those providers that are unwilling or choosing not to use telehealth in the past were thrust into the need for using visits outside of traditional patient care. We have had to figure that out quickly.
I would like to point out how all of these areas have converged within digital practice:
- Regulatory Changes
- Policy Changes
- Insurance Changes
- Digital Practice Technologies
- Virtual Health Technologies
There has been a convergence of the long-standing need for patients to improve their access with gradual changes in practicing regulations and supporting telehealth. Government policy changes have recently broadened access, particularly with Medicare patients regarding rehabilitation and private insurance coverage. This applies to the passage of payer parity laws, providing that people in certain states would have to pay the same rate for a digital practice visit as they would for an in-person visit.
Most healthcare consumers now have to own a computer or other device that provides the platform to complete visits. The required broadband coverage was a barrier where I reside in Kentucky. We could have all the telehealth we wanted and use the new technology, but there would be no broadband coverage. However, that barrier has now been reduced extensively.
The emerging virtual health technologies will likely provide a method to facilitate a hands-on approach in rehabilitation and bridge the gaps that exist in digital practice. Recognize that physical therapy, occupational therapy, and speech-language pathology have been active in rehabilitation throughout the last decade. If any occupational therapists would like to dive in further, Dr. Jana Cason has written in the International Journal of Telerehabilitation. In 2013, the American Occupational Therapy Association (AOTA) came out with their position paper and ethical considerations, as well as with the World Confederation of Occupational Therapy in 2014. Additionally, there is a telehealth position statement by Dr. Karen Jacobs from 2015.
In the physical therapy area, Dr. Alan Lee has been an international leader in our profession with telehealth and its applications in a variety of healthcare practices. Our literature is continuing to grow. There is not only the need to educate an existing workforce but our students as well, and digital practice will become more normal. With speech, Dr. Elizabeth Grillo has had some papers talking about speech-language pathology and telepractice methods. Dr. Wales has some resources and the American Speech-Language-Hearing Association (ASHA) has had some position papers on this as well. Additionally, Dr. Janine Bowman at the University of Kentucky has done tremendous work in bringing speech pathology forward in the telehealth space.
What Is Telehealth?
What is telehealth? One definition says that we use it with electronic communication and technology to support long-distance clinical healthcare, as well as patient and professional education. The technologies include video conferencing, store-and-forward imaging, streaming, and wireless and terrestrial communications.
What Is Digital Health/Practice?
Digital health practice is a convergence of technologies, healthcare, living, and society. The point of this new term is to be more encompassing beyond the clinical practice of delivering care and billing insurance. It provides us with a space to communicate as consumers and learn more about our health. It connects us with devices that allow us to track our healthcare needs.
Along with self-management, adherence provides us with the potential for connecting more closely and appropriately with our healthcare providers, particularly when we might have a problem. Digital health connects and empowers people to manage their own health and wellness. This is augmented by accessible and supportive provider teams working within flexible and digitally-enabled care environments. This is where the term “artificial intelligence” comes in. How is that intelligence going to aid us in recognizing where we have a deviation in our healthcare?
Types of Digital Practice
What are the different types of digital practice? I want to review some terms and discuss mobile health, which is sometimes called mHealth. Synchronous means real-time, on-demand healthcare delivery with a patient and a client. This is the method that we will probably be doing most of the time and it is most similar to an in-person visit. You will likely have a camera so you can view the patient during the visit time.
Asynchronous is not real-time healthcare delivery. An example of this is radiologists being able to pick up views of a patient's scans and provide feedback. You can review your patients’ assessments prior to the visit or not. Your dialogue may be post-synchronous with a patient in order to clarify exercises in e-visits.
Remote patient monitoring is the desire to improve the quality of chronic disease management. This means using an assistive device or technology outside of the conventional clinic settings in order to monitor a patient. Wearable devices can track your blood pressure, oxygen saturation, pulse rate, and so on. A home compliance monitor can be used as well, which is common in home care today. There are also device-measuring exercise completions, which are becoming more prevalent. In this case, there would be a device that is either worn or stationary. That device can then measure you from the standpoint of your completion, as well as the types and quality of the exercise. It could also be a trigger to cause someone to intervene from the data provided by the device. For example, a nurse or therapist would monitor a patient’s completion of exercises that target the total joint area. That nurse or therapist would then check their adherence to the quality and quantity of exercises needed. That may cause us to intervene if we see that the exercise is not happening.
Mobile health, or mHealth, refers to the concept of mobile self-care. This includes consumer technologies such as smartphones, tablet apps, and programs that enable consumers to capture their own health data. It is likely that most of us are doing that today with our step counts, heart rates, and so on. You can also use it to seek out valid information on specific health questionnaires. For example, there is the use of digital practice in the behavioral health space. This is where patients can fill out screening assessments in order to check in with their healthcare providers and give indications about how they are feeling. There are a number of ways that are emerging which allow patients to do that. I believe that we are going to learn more about this over the next several years.
Patient Satisfaction with Telehealth
What is the patient satisfaction with telehealth? As you go through your digital practice experience, it will be important to track patient satisfaction. The questions may need to be tweaked. The American Physical Therapy Association (APTA) has some suggested questions from Dr. Alan Lee and other committees that have come up with a standard platform. There is nothing surprising in regards to their clinical outcomes and satisfaction, but there are some questions about their use of technology and how that is going.
There is a study by CVS in which patients were satisfied with their telehealth experience. One out of three patients preferred a telehealth visit to an in-person visit. If any of us have had the time to do a telehealth visit, there are some advantages to it. This would include the technology working well and having more confidentiality with your provider that you might not normally have. According to the research, the early experience suggests that patients are accepting of their telehealth experience in many different types of care.
COVID-19 and the Advancement of Digital Physical Therapist Practice and Telehealth
The last couple of months have changed everyone's practice. I want to cite a survey that we did in Kentucky in February of 2019. We had 163 physical therapy respondents and 93 percent of them had not used any form of digital practice. Even that other 7 percent of people were most likely just doing telephone calls. Dr. Alan Lee has provided a paper that I hope you get the chance to look at. He talks about COVID-19 and some of the advantages that have come with it in terms of therapy. It provides the guiding principles of the report from the digital practice task force. One point is that we lack telehealth competencies when it is thrust upon us. We need to work on that independently or with our colleagues.
However, we do not have all the competencies. We were not trained in school for this and we are all still learning what those competencies are. Another good point that he made is that we can preserve scarce resources such as personal protective equipment (PPE), as well as make a case for the advancement of digital physical therapy practice. It provides us with a unique opportunity.
Why do you want to be in digital practice? Today, it may be out of necessity because of the pandemic. Regardless, we all need to step back and think about it as any new business or operational strategy that we might have. The implementation of that requires us to think about why we do it and how it fits with our current practice. In the midst of the pandemic, many practices had not considered it and were required to implement a methodology for telehealth. My goal is to give you that template and make sure that you have all of your bases covered.
Would you be in this space were it not for the pandemic? Was it something that was on your radar for further development? Many of us had thought about it, but it was not an essential need because we already had a way of doing our traditional care. Present data suggest that it will stay in our practice and evolve further. Additionally, its utilization will likely drop a little from today’s rate, depending on the length of this time that we are working through. However, we will most likely settle in a 30 to 50 percent utilization rate of telehealth in many practices.
What is your strategy? You will have to look at the return on investment. Are we going to get paid for this? Are we going to have codes that we can use? Does our implementation extend beyond the return on investment? Does it enhance our quality of connections with our patients and improve those relationships? Does it bring new patients that we might not otherwise have?
Does deployment add value to your practice? Step back and think about that further if you have not already. Get into the mindset of how this fits with other new methods and practice ideas that you have had over the years. Make it an established option where you convert most or all of your practice to digital practice. There are therapists who are already doing this.
How were you positioned in your pre-COVID-19 implementation of telehealth? What types of patients did you see? What populations are now aided by digital practice? This becomes a thought process where you think about the kinds of patients that you can see, no matter what kind of clinical care you deliver. How can that be done when we are so used to being hands-on in our practice, and how do we translate that to healthcare delivery? Will the fast expansion mean positive regulations permit deployment? Is this temporary emergency the reason that we have made these regulations supportive of digital practice? Will they become permanent? Those are questions that we still have.