Overview of Physical Therapy in Telehealth

Telehealth is a form of healthcare delivery that utilizes technology as a mechanism to connect patient and provider for delivery of services, communication, sharing of information and both clinical and non-clinical training (“What is telehealth? How is telehealth different from telemedicine?”, n.d.). While more people in the United States have health care coverage, many do not have access to health care services (Sommers, Gunja, Finegold, and Musco, 2015). This growing form of health care delivery is evident in the Department of Veterans Affairs, where 12% of their members used some form of telehealth in 2016 (“VA Telehealth Services Fact Sheet”, 2019). Physical therapy is a profession that should participate in telehealth to deliver physical therapy (PT) services to patients in remote locations.

Background

A major issue facing the United States today is access to health care. Many people in underserved and rural populations do not have proper access to health care services or services in their area are limited which can be a barrier to receiving the health care they need ('Rural Health Information Hub', n.d.). Some of the struggles to access health care include but are not limited to lack of transportation, poor health literacy, some services are located long distances from their home or there is a shortage of providers ('Rural Health Information Hub', n.d.; Lee and Harada, 2012).   For many, health concerns and preventative services are not addressed properly. Telehealth is a way to manage this health disparity (Grona, Bath, Bustamante and Mendez, 2017; Levy, Silverman, Jia, Geiss and Omura, 2015).  This mode of health care delivery promotes access to health care services to patients that otherwise may not have that option. Like other professions, physical therapy could expand services to underserved and remote populations that currently have difficulty accessing such services.

Because physical therapy has traditionally been a “hands on” service, entering into the telehealth market has been controversial.  Physical therapy faces current risks in providing telehealth services in today’s market. The existing structure of reimbursement in the United States does not provide reimbursement for telehealth physical therapy (Cason and Brannon, 2011; Lee, Davenport and Randall, 2018; Shaw, 2009). In the current structure, any services provided by physical therapists would be done strictly to provide the patient the benefit of such services and would go uncompensated. If organizations do not have the funding to promote such a practice, there is no incentive to provide such an option for patients. Currently, Medicare does not recognize physical therapists as telehealth providers (Cason and Brannon, 2011). Medicare tends to set the standard for reimbursement and most private insurance companies follow Medicare guidelines (Clemens and Gottlieb, 2017). Private payer sources will not recognize physical therapy as a telehealth provider until they are recognized by Medicare as a telehealth provider. This is a barrier that will restrict the growth of physical therapy in this market.

State practice acts do not all include telehealth in their scope of practice for the physical therapy license which is also restricting to physical therapists (Lee et al., 2018; Lee and Harada, 2012). The state practice act provides the guidelines in which physical therapists can practice under their state license. If clinicians practice outside of their state’s practice act, they risk liability and their actions may be considered unethical (APTA, 2019; Lee et al., 2018; Shaw, 2009). Licensure may also be at risk when clinicians use telehealth to provide services across state lines. Currently, several states are working to create compacts between states to allow treatment across borders (Lee et al., 2018). Until this issue is resolved, the only real solution for clinicians is to hold current licensure in multiple states. This can be costly and time consuming due to the different requirements for each state (APTA, 2019, Lee et al., 2018).

There are some patient populations that are not appropriate for physical therapy services via telehealth. The issues with providing care to these patient populations create barriers to effective entry into the telehealth market. Telehealth is not the standard of care for physical therapy, so the profession lacks evidence in the efficacy of this type of care. Currently, this type of service is not a primary aspect of physical therapy education so students are not prepared to treat in this manner upon graduating from a CAPTE accredited program (CAPTE, 2017).

Patients that require hands on treatment or evaluation where the physical therapist must use close supervision or guarding, are not good candidates for physical therapy telehealth services (Lee et al., 2018; Shaw, 2009). Patient evaluations typically consist of a patient interview, systems screening, tests and measures. The physical therapist then synthesizes that information to provide the patient with an assessment of their problem and then devises and discusses the plan of care. Most of the evaluation process requires visual inspection, palpation of body structures as well as manual contact to perform joint assessments, muscle strength, provide stabilization and to assess tone. Specific patient populations identified in recent studies includes patients with musculoskeletal dysfunctions (Lee et al., 2018) and patients with cardiopulmonary dysfunctions (Shaw, 2009), both which require significant hands on treatment to meet most patients’ needs. Patients with neuromuscular disorders often require contact assistance to perform functional activities to improve strength, balance and coordination (Fruth, 2017) which are not reasonable to perform at this point with telehealth. Family members or other health care professionals could carry out these hands-on tasks, but at the risk of patient falls or injury, increasing liability on the clinician as well as decreasing patient safety (APTA, 2019; Shaw, 2009).

There are several areas where physical therapists are appropriately positioned to participate in telehealth activities. The spectrum of patients referred to physical therapy is broad. Some patients require a significant amount of time with a physical therapist in a one-on-one manner to provide a safe and effective encounter. Some patients have conditions that require less frequent encounters or minimal hands on treatment. Many patients benefit from education and simple check-ins so the physical therapist can periodically check exercise accuracy and assess function using functional outcome tools (Lee and Harada, 2012; Levy, Silverman, Jia, Geiss and Omura, 2015). Many rural areas have infrequent access to a physical therapist where visits are so limited, they are reserved for initial evaluations (Rural health information hub, n.d.). Patient that are assessed in this format would benefit from subsequent visits that could be done via phone or video conferencing (APTA, 2019; Lee and Harada, 2012). This would allow those in underserved or rural areas to have improved access to physical therapy services and potentially earlier intervention. Patients that have access to physical therapy have shown to improve function, have decreased falls risk and are satisfied with the experience (Grona et al., 2017; Levy et al., 2015).

Telehealth also provides a means for interprofessional practice to occur. In underserved and rural populations, health care providers often have to serve the role of many provider types due to the lack of medical professionals available (Patient Engagement HIT, 2017). Using videoconferencing allows better communication between professionals, whether it is to coordinate care or to provide care by one professional through the education of another (Grona et al., 2017). The use of robot technology can be effectively used to provide physical therapy assessments, provided there is another health care provider that can follow the physical therapists lead, assisting the patient through the exam process (Grona et al., 2017; Levy et al., 2015). This provides the patient with both improved access to care, interprofessional care and a safe environment to receive such care. This type of intervention has shown to improve patient outcomes, decreases readmission rates, and ultimately decreases health care costs (Grona et al., 2017; Lee and Harada, 2012; Levy et al., 2015).

Telehealth can be used for follow-up appointments in many situations where the physical therapist simply needs to check in with the patient to assess progress, or to provide support, tips for continued success, emotional encouragement or extra education (Ben-Arieh, Vimarlund and Boissy, 2015; Lee and Harada, 2012). This type of service eliminates the need for patients to make unnecessary trips into a clinic, which helps reduce the transportation barrier and increases access to care. After two decades in practice, it is not uncommon to see patients cancel visits when they no longer need hands on care, only to have them return a couple months later due to a flare-up. This results in extra visits and increased costs.

Healthcare agencies that oversee research in the area of telehealth provide guidelines for telehealth practices. The American Physical Therapy Association (APTA) promotes the delivery of telehealth but provides counsel on “best practices” for their members (APTA, 2019). The areas that are of greatest concern revolve around the Health Insurance Portability and Accountability Act (HIPAA) requirements, patient consent, types of technology used, storage of records and what to do in the event of a data breach. When clinicians engage in telehealth practices, they are held to the same HIPAA regulations and record storage as those in other settings.

Another area that falls under best practices is the behavior of the physical therapist. One of the major ways that physical therapists connect with their patient is to develop a patient rapport during the initial interview portion of the exam (Fruth, 2017). Telehealth can be perceived by patients as lacking in that personal interaction (Henry, Block, Ciesla, McGowan and Vozenilek, 2016). Clinicians must work to overcome this challenge by promoting communication that portrays empathy and compassion through voice, tone and verbiage used throughout the interaction (APTA, 2019; Henry et al., 2016; Levy et al., 2015).

Conclusion

Telehealth will continue to gain acceptance as the country strives to achieve improved access to health care for those in underserved and rural communities. Physical therapy should continue to move into this delivery mode of health care to deliver physical therapy services in the areas that are recognized as beneficial. While not all patient populations are appropriate for care delivered in this manner, many patients would benefit from physical therapy via telehealth. The areas where physical therapy are likely to make the greatest impact are in follow-up care, early intervention, patient education and through interprofessional practice. There are reimbursement and regulation issues that need to be addressed to make telehealth a standard as the profession makes progress. These issues are currently problematic but as the professional association continues to advocate, the future could be bright for physical therapy telehealth. Future collaborations and research are needed to provide evidence that physical therapists should be considered valuable telehealth providers. Physical therapy should participate in telehealth to deliver services to those in underserved and rural populations using multiple forms of technology to reach those that are currently unable to access such services.

References

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