It’s no news that health care is changing, and fast. But as physicians in this rapidly evolving landscape, which changes can actually improve our practice of medicine? One development that holds both significant potential and significant challenges is the rise of telemedicine. At the recent American Academy of Physical Medicine and Rehabilitation (AAPM&R) Annual Assembly in San Antonio, Drs. Rebecca Tapia, Marla Kaufman, Molly Matsumoto, and Joel Scholten presented on the advances made in the area of teleRehab, which is the provision of rehabilitation medicine services using interactive devices over a communication network, and which is an area of growing interest for both patients and rehab specialists.
The speakers noted that virtual care does not replace in-person care, and that the provider must always have the autonomy to determine whether telehealth services are the best setting of care for any given patient. At both the patient site (the “originating site”) and the provider site (the “distant site”), a variety of devices can be used to connect to each other, ranging from something as straightforward as a smartphone to a full telemedicine cart. Simpler equipment is often better than more complex equipment, and handheld devices have the added benefit of having accessibility adaptations (such as increased font size) already built in. A secure encrypted connection is also required in order to maintain HIPAA-level security.
Once the basic system is in place, the speakers noted several compelling benefits in the rehab setting. Therapist home evaluations are measurably easier and more efficient to perform when travel is no longer necessary. While the patient is still in inpatient rehab, the therapist can perform the home evaluation (with the help of a friend or family member of the patient connecting from the home) with the patient present next to them, allowing the patient to provide crucial input about their home routines. (During a normal home evaluation, even if the patient travels to their home with the therapist, they often must wait outside since the home is not yet adapted.)
Patient satisfaction is very high with teleRehab visits, in part because of the unique transportation needs of rehab patients, for whom travel can be complicated. When physically getting to rehab appointments is difficult, they often don’t happen at all. TeleRehab solves this problem and allows much greater frequency of follow-up care. It also allows more education for family members who no longer need to take days off work to travel with their loved ones for appointments and can simply dial in to the visit. It allows specialist rehab care to be available to rural underserved areas that might be many hours from the nearest physical location of a physiatrist.
There are also multiple benefits to the provider, including the need for less physical space (since an exam bed is no longer necessary), a wider geographic reach, insight into the home environment that isn’t possible in a clinic setting, and easier cross-coverage if another physician becomes unavailable. Applications of telecare in the rehab setting are wide and varied, including durable medical equipment evaluations, TENS training, swallow evaluations, aphasia therapy, support groups, prosthetic training, and cognitive rehabilitation.
Challenges do, of course, exist. One such challenge is safety: the potential absence of privacy, patients not taking the telemedicine visit as seriously as an in-person appointment, distracted driving, cybersecurity concerns, and the presence of medical emergencies. Patients need to be educated on these issues and policies need to be in place ahead of time (such as the ready availability of e-911 services so that, should 911 need to be called, dispatched emergency services are local to the patient and not the provider.) Another obvious challenge is the physical exam. How do we perform a physical exam when we can’t lay hands on the patient? The speakers recommended modifying the exam or using an on-site telepresenter (often an RN, PT or OT) who has been trained, can obtain vital signs, and can assist with the hands-on portion of the exam according to the provider’s verbal instructions. Another important issue is that of ethics. The 2008 Ryan Haight Act was passed after a teenager overdosed and died after being prescribed opioids online by a physician who had never seen him in person. The act states that, in general, any controlled substance prescription requires at least one in-person provider visit.
A further challenge is engagement. Telemedicine requires an initial investment for equipment, administrative support, and both provider and patient acceptance. While studies show that telemedicine can lower costs, increase compliance, and decrease the need for additional care, the up-front investment can be a barrier. The speakers advised ongoing review and revision of teleRehab protocols, continuing to establish best practices by consulting literature and colleagues, and avoiding telemedicine-only care for unstable patients.
All four speakers were VA physicians, and acknowledged that many of the barriers to teleRehab present in the wider medical community have been removed in the VA system. One of the major obstacles is reimbursement, but progress in that arena is being made. Already, 37 states have passed parity laws that require insurance companies to pay for telecare if they pay for in-person care. While Medicare still does not cover telemedicine visits that originate in the patient’s home, they recently expanded coverage to include dialysis centers and acute stroke visits, with Medicare Advantage plans projected to include more telemedicine coverage in 2020.
While hurdles are still present and much work is left to be done, these experts noted that teleRehab is part of the future. While hesitancy may exist, the benefits to both patients and providers mean that all physiatrists should be ready to explore how teleRehab can improve the face of rehabilitation care.
Dr. Elizabeth (Lisa) Varghese-Kroll, MD, FAAPMR is a physiatrist and experienced physician advisor with a background in broadcast journalism who is based in the greater Washington, DC area. She is a 2019-2020 Doximity Conference Fellow. Follow her on Twitter at @LisaVKMD.
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