Introduction to Telehealth

Introduction

Telehealth is the delivery of health-related services and information via electronic communication. The terms telehealth and telemedicine can be used interchangeably, but they have different definitions. Telemedicine refers specifically to the remote delivery of healthcare services and clinical information using telecommunications technology, such as internet, wireless, satellite and telephones.[1] Telehealth is defined as the use of electronic communications to share medical information from one place to another with the intention of improving a patient’s health.[2] Telehealth is an expansion of telemedicine, but unlike telemedicine (which focuses on curative aspects of health) it encompasses preventive, promotive and curative aspects of health and many different healthcare professions are involved in its delivery.[3] It is a broad term and can include both patient and healthcare professional education, as well as public health initiatives and health administration.[4]

Telehealth is not a new concept. There are reports of its use since the early 20th century when providers used two-way radios for communication.[2] Then from the 1960s, health professionals used telephones to provide advice and guidance to patients. However, with the introduction of various new technologies, telehealth is now challenging the way healthcare is delivered.[2] Over time, new telehealth terminology has developed based on the field of health care (teleradiology and telepsychology) or the purpose of the intervention (telerehabilitation or telecare).

The term digital practice is also sometimes used. 'Digital practice’ is considered to be more comprehensive than ‘tele’ because it represents the range of different technologies available and their impact on practice and service models, both now and in the future.  The WCPT/INPTRA Digital Physical Therapy Practice Task Force have proposed that the term digital practice be used to refer to healthcare service delivery, as well as support and information that is delivered remotely using digital communication and devices. They concluded that the goal of digital physical therapy/physiotherapy practice is to facilitate the “effective delivery of physical therapy services by improving access to care and information and managing health care resources”.[5] However, as 'telehealth' is a more recognisable term. it will be used here instead of digital practice.

The Purpose of Telehealth

Telehealth aims to overcome barriers and provide equitable access to health care services and interventions.[3] Telehealth also helps to overcome barriers to face-to-face consultations, such as problems with scheduling, adverse weather, and illness.[6]

Different Models of Telehealth

  • Synchronous telehealth is when health information is delivered in real-time[7] through a live telehealth consultation. This is done through interactive video with the patient and health professional present at the same time.[8] It is used to consult with, diagnose and treat patients.[9]
  • Asynchronous telehealth[7] or store and forward, refers to the collection of patient information (diagnostic images, vital signs, video clips) at the patient site. This information is then assessed and analysed by a health practitioner located at another site.[8][9] An example of this is a patient tracking their activity or steps in a day - this information is then sent to the physiotherapist to monitor.
  • Hybrid telehealth is where both in-person and telehealth services are provided to the patient. [6] It can also include a combination of live telehealth (synchronous) and store-and-forward therapy (asynchronous) consultations.[8]
  • Remote patient monitoring (RPM) refers to the use of devices to remotely collect patient information, such as glucose and blood pressure monitoring. This information is then sent to a home health agency or a remote diagnostic testing facility (RDTF) for interpretation.[10] It enables tracking and monitoring of the patient.[9]
  • The newest model of telehealth is Mobile Health or mHealth - this includes online services and mobile phone applications that are marketed directly to consumers.[9] It enables consumers to access health information, as well as online groups which provide peer-to-peer support.[10]

The Benefits of Telehealth

Telehealth has many benefits for patients, physiotherapists and society.[3]

The benefits to the patient include:[5]

  • Access to physiotherapy services otherwise unavailable in remote locations
  • Removal of barriers such as travel time, parking, and waiting rooms
  • Improved safety for patients who are too ill to travel or have mobility restrictions
  • Not location dependent
  • An increase in the patient’s autonomy to manage their health through online self-management and monitoring
  • More flexibility for patients as they can schedule therapy at times that suit them
  • More cost-effective therapy in terms of travel, leaving work early or leaving children or family with a caregiver[5]
  • Reducing medical utilisation in certain patient groups (eg cardiac patients)[11]

The benefits to the physiotherapist/ physical therapist include:[5]

  • Improved efficiency as there is less travel between clinic locations
  • Standardised service user pathways
  • Greater consistency in terms of patient self-management at home and monitoring standards of care and outcome
  • Opportunities for improved creativity in the standard of care with evolving technology

The benefits to society include:[5]

  • Better use of public resources
  • Employer benefit, with less worker absenteeism
  • The patient/community is more autonomous and informed
  • Reduction in dependence on the medical system and increased encouragement for patients to self-manage their health
  • Fulfilment of people’s expectations to be more digitally connected
  • More equitable access to healthcare
  • Decreased environmental footprint due to less travel

A study showed that patients with esophageal cancer who underwent esophagectomy and had postoperative complications or who had an increased hospital stay can improve their functional status by doing practical exercises in their home environment supported by telerehabilitation and tablet use, with an experienced physiotherapist guiding remotely[12].

Nonclinical Uses of Telehealth Technologies

There are various non-clinical uses of telehealth technologies, including:[3]

  • Distance education such as continuing medical education and patient education
  • Administrative uses, including meetings among telehealth networks, supervision, and presentations
  • Research on telehealth
  • Online information and health data management
  • Healthcare system integration
  • Asset identification, listing, and patient to asset matching, and movement
  • Overall healthcare system management
  • Patient movement and remote admission

Clinical Uses of Telehealth Technologies

Clinical uses of telehealth technologies include:[3]

  • Transmission of medical images for diagnosis (often referred to as store and forward telehealth)
  • Groups or individuals exchanging health services or education live via videoconference (real-time telehealth)
  • Transmission of medical data for diagnosis or disease management (sometimes referred to as remote monitoring)
  • Advice on prevention of diseases and promotion of good health by patient monitoring and follow-up
  • Health advice by telephone in emergent cases (referred to as teletriage)

Current Limitations in Telehealth

Telehealth has various limitations, which should be considered before using this form of healthcare delivery. These areas are discussed in more detail on our Ethical and Professional Considerations of Telehealth page.

Patient-related limitations:

  • As the telehealth market grows, it may be easier for patients to “shop around” and gain the opinions of different service providers - this can cause confusion and discontinuity in the service/care provided[5]
  • As in any interaction, a provider has to consider cultural specific issues, particularly around the recording of images, but also eye contact, the gender of the therapist
  • Language barriers - if an interpreter is necessary, is this person familiar with telehealth?[5]
  • Decision making regarding vulnerable individuals or groups i.e. older people and children - does a caregiver or parent need to be present for the consultation?[5]
  • There is a need for strong communication skills on the part of the therapist, as there is a shortage of the usual visual cues present in face-to-face consultations.[13]

Technological limitations

  • Internet connectivity - if poor or unreliable another communication pathway needs to be utilised[5]
  • Both parties (therapist and patient) need to be familiar with the technology used and to be able to use it easily[5]
  • The integrity of the software implemented plays a role in the success of the consultation as well as the “safeguard” of the consultation[5]
  • The physical set up (proper lighting, camera set-up, audio, background) contributes to the quality of the telehealth consultation[5]
  • Virtual behaviour is different from in-person care. For example, to make eye contact participants (patient and therapist) need to look into the camera and not only at the video/on-screen material[5]
  • Not all individuals (patients and therapists) will have access to the necessary technology to engage in telehealth.[13]

Insurance and funding (medical aids) limitations

  • Therapists and patients need to be aware if telehealth is recognised by healthcare insurers/medical aids. Reimbursement remains a key challenge in rolling out telehealth services.[5][14]

Education limitations

  • Staff members need to be knowledgeable about telehealth and properly trained in the skills required to successfully conduct telehealthcare[5].

Research limitations

  • An evidence-based approach should be adapted to providing telehealth[5]
  • Clinicians/therapists should always apply clinical reasoning and follow the correct standards of practice and relevant codes of conduct.[5]
  • Clinicians/therapists should assess the delivery of telehealth and determine if the relevant outcomes are reached/achieved.[5]

Regulations

  • Different countries have different regulations about telehealth. These regulations and any future changes made may affect the progress of the adoption of telehealth.[5]
  • It is the responsibility of each health care professional to make sure they are not violating privacy and HIPAA laws and to abide by all local, state and government laws concerning telehealth.[7]

References

  1. Achenbach SJ. Telemedicine: Benefits, Challenges, and its Great Potential.  Health Law and Policy Brief. 2020; 14(1). Available at: https://digitalcommons.wcl.american.edu/hlp/vol14/iss1/2
  2. 2.0 2.1 2.2 Neville CW. Telehealth: A Balanced Look at Incorporating This Technology Into Practice. SAGE Open Nursing. 2018; 4.
  3. 3.0 3.1 3.2 3.3 3.4 Cottrell, M. and Russel, T. Introduction to Telehealth Course. Physioplus. 2020
  4. Richmond T, Peterson C, Cason J, Billings M, Terrell EA, Lee AC, Towey M, Parmanto B, Saptono A, Cohn ER, Brennan D. American Telemedicine Association’s principles for delivering telerehabilitation services. International journal of telerehabilitation. 2017;9(2):63.
  5. 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 5.12 5.13 5.14 5.15 5.16 5.17 5.18 Report of the WCPT/INPTRA Digital Physical Therapy Task Force. May 2019.
  6. 6.0 6.1 Cole B, Pickard K, Stredler-Brown A. Report on the Use of Telehealth in Early Intervention in Colorado: Strengths and Challenges with Telehealth as a Service Delivery Method. International journal of telerehabilitation. 2019;11(1):33.
  7. 7.0 7.1 7.2 Mechanic OJ, Kimball AB. Telehealth Systems. [Updated 2019 Dec 27]. In: StatPearls. Treasure Island (FL): StatPearls Publishing; Jan 2020
  8. 8.0 8.1 8.2 What types of telehealth services can I offer? HealthIT.gov. last reviewed on April 15, 2019
  9. 9.0 9.1 9.2 9.3 Marcoux RM, Vogenberg FR. Telehealth: Applications from a legal and regulatory perspective. P&T. 2016; 41(9): 567–570.
  10. 10.0 10.1 ATA. Telehealth Basics. Available from https://www.americantelemed.org/resource/why-telemedicine/ (last accessed 10 May 2020).
  11. Pande RL, Morris M, Peters A, Spettell CM, Feifer R, Gillis W. Leveraging remote behavioral health interventions to improve medical outcomes and reduce costs. Am J Manag Care. 2015; 21(2): e141-51.
  12. van Egmond MA, Engelbert RH, Klinkenbijl JH, van Berge Henegouwen MI, van der Schaaf M. Physiotherapy With Telerehabilitation in Patients With Complicated Postoperative Recovery After Esophageal Cancer Surgery: Feasibility Study. Journal of Medical Internet Research. 2020;22(6):e16056.
  13. 13.0 13.1 Pirtle CJ, Payne KL, Drolet BC. Telehealth: legal and ethical considerations for success. Telehealth and Medicine Today. Available from https://telehealthandmedicinetoday.com/index.php/journal/article/view/144/173 (accessed 1 May 2020).
  14. Dinesen B, Nonnecke B, Lindeman D, Toft E, Kidholm K, Jethwani K. Personalised telehealth in the future: a global research agenda. J Med Internet Res. 2016; 18(3): e53.