Practical Considerations in Telehealth
Introduction to Telehealth
The ubiquitous nature of technology in our daily lives has paved the way for the development of alternative methods of healthcare delivery.
- Telehealth is an effective "next-gen" solution that helps clients receive equivalent if not better care than traditional practices.
- To ensure the most effective, safe, and responsible delivery of physiotherapy services through the means of telehealth, some prerequisites need to be met.
Overview of Practical Considerations in Telehealth
There are four domains that need to be considered to ensure the appropriate delivery and consumption of telehealth services.
The patient and therapist would both need access to the appropriate technology to enable telehealth. They must include all components mentioned below. These need to be tested each time before commencement to ensure no disruption during the session. The assistance of IT professionals may be required in some cases.
Internet connectivity: The download speed determines the quality of the video stream, hence, a minimum connection of 50Mbps will enable real-time viewing with minimum to no buffering at 720p. A wired broadband connection will ensure the lowest latency and highest connection speed. Mobile internet and WiFi are inherently slower and may suffer due to environmental barriers such as walls. Keeping a phone nearby is a good idea to enable communication in case of any interruptions during the session.
Camera: Laptops usually have poor-quality inbuilt webcams. A dedicated HD webcam or any hand-held device with a high-resolution front-facing camera can be used instead. It must ideally have a minimum resolution of 720p and a wide field of view enabling better visibility of a larger area that will facilitate detailed assessments. Ensure that the subject is centered and the camera is at eye-level. The face and upper body should be clearly visible. Adjust focus in case the video is not sharp. Mounting the camera on a tripod may improve image stability and sharpness. Position the camera at least 5 feet away from the subject for maximum coverage, or as per the specifications of the camera. Some cases may necessitate the movement of the camera which would require adjusting the focus again. Lastly, the camera must be facing the direction opposite to that of the light source ( for example, the camera must not face a window, but away from it). Additional lighting may be needed to adjust the exposure.
Microphone: A headset or dedicated microphone may considerably enhance audio-quality over inbuilt audio solutions in consumer electronic devices. Wired headsets have no latency and must be used over Bluetooth audio. Do not speak too close or too far from the microphone as it would cause the volume to vary. During movement, audio may not be captured clearly and a lavalier or body mic would be more appropriate over a stationary microphone. A pop filter and foam windscreen will further enhance audio by removing ambient noise.
Software: There are multiple applications available on various platforms for all categories of devices that can be used to assist the practice of telehealth. Each application must be reviewed and assessed for applicability with respect to each client's unique needs. It must be stressed that the software chosen must be user-friendly and intuitive in addition to other clinical considerations. These applications must be downloaded prior to the session and regularly updated for newer features and security patches. Reference files and other relevant data should be sent to the client in advance as well.
Additional hardware: Based on the unique needs of the telehealth setting, additional peripherals may be required. These could include input devices such as touchscreen display units, styli, or assessment tools such as electronic stethoscopes. Gaming units such as Xbox Kinect can be used if applicable.
Location: The therapist can choose between the workplace or their home, based on convenience and other factors mentioned below. The client must choose a room that is private and usually unoccupied by other family members. In case, a special task needs to be assessed in a specific environment, the location can be changed accordingly. External locations may not be preferred since there are many variables that are difficult to control and maintaining consistency in video quality is not possible.
Space: The room must be large enough to allow the evaluation of gait and the utilization of assistive devices such as wheelchairs or walkers. It may be wise to move out all non-essential furniture to declutter and maximize available space. Older clients may benefit from the use of contrast tape as visual landmarks.
Decor: The background must be stationary and of neutral coloring (blue is preferable). Additionally, opting to wear clothing of neutral coloring may improve visibility too. A screen can be used if a neutral background is unavailable. Furniture must be moved out of the way to prevent accidents and clear the line of view.
Equipment: Tools necessary for assessment must be kept close-by and must be arranged in an organized fashion for ease of use and preventing undue delays. They can be placed over a trolley to enable ease of transportation.
Lighting: A well-lit room, between 300-500 lux, is a basic requirement to ensure ideal video capture. Depending on the time of day and the number of windows available, additional lighting sources may be required. A light source must also face the subject since overhead lights alone will cast shadows obscuring visibility. Artificial light sources employing fluorescent bulbs are preferred over incandescent bulbs due to their proximity to white light which will ensure that all subjects in the image maintain their natural colors. This is essential if the client is older since they would suffer from poor color perception.
Noise level: Ambient noise can be controlled by timing the session at the appropriate time. In case levels are still too high, noise reduction techniques may need to be employed. Keeping the door and windows closed may dampen noise but also considerably increase echo. Other methods include the installation of sound-absorbing ceiling tiles, acoustic panels, and carpets.
Communication and Procedures
It is important to create step-by-step procedures for telehealth. Some aspect might be the same as for in-person but it is important that everyone in the clinic follow the same steps. Consider the following questions when developing your process: 
- How do patients book for telehealth?
- What is the cancellation or no-show policy for telehealth?
- Should the current intake forms be updated to give consent for telehealth? When and how do patients fill them out?
- How is insurance information collected? How is payment collected?
- What is the patient follow up procedure? Who does it?
- Where should telehealth consent be documented?
- What should the therapist do if the patient only wants in-person sessions?
- Should patients who feel uncomfortable with technology receive a courtesy phone call or test run ahead of time?
- What is the procedure if a patient gets injured while in a telehealth consultation? Does the therapist have the patient's location to call emergency services
- What is the procedure when the internet stops working? Should the therapist phone the patient? Do they have the patient's number?
- How will I advertise this service to current and new patients? Should current patients be emailed? Should a live webinar on telehealth be offered to patients or the general public to introduce them to telehealth?
- How should the referral sources like doctors be updated about the telehealth consultations and what it entails?
For more specific guidance you can register on this link to receive the WebPT. The Rehab Therapist’s Guide to Practicing Telehealth.
Technodexterity: It goes without saying that familiarity with basic communication technology is a skillset that would greatly streamline the process of telehealth. It would be wise to practice with a colleague or partner before starting sessions with a client. The therapist must be able to assist the client during the session and guide them in troubleshooting any snags along the way.
Assessment skills: In order to be able to effectively evaluate the client over the video, the therapist must be highly experienced in traditional settings. A certain ingenuity might be required to overcome the limitations of telehealth. Communicate clearly with the client using simple instructions. Use patient-reported outcome measures (PROM) as much as possible.
Client selection & safety: The nature of the client's clinical condition dictates the applicability of telehealth. Risks and hazards must be identified before enrolling the client. Pre-existing disabilities, such as a visual impairment, can negatively impact the client's participation. This would require the presence of a caregiver during every session. Confidentiality needs to be upheld and data privacy laws need to be followed, always. Clients must be made aware of the limitations of telehealth.
Bedside/"webside" manner: Maintaining eye contact is crucial. Body language is exaggerated on video and is, therefore, a crucial method of "virtual" communication. Professional etiquettes such as grooming and dressing appropriately are essential. The therapist must be mindful of the ethnic and sociocultural beliefs of the client at all times.
Legal requirements: Many countries mandate the registration of telehealth practitioners in order to protect their citizens. Therapists must seek advice from their professional bodies regarding their eligibility for practice.
The client must fully understand the telehealth model and decide for themself whether it is the appropriate healthcare delivery method for them. The following are some important areas that the client must familiarise themselves with, prior to enrollment.
Consent: It is mandatory that the client or someone with legal authority consents to participate in telehealth. Consent must ideally be given in person whenever possible, else consent must be given verbally in a video recording. The client must be free to withdraw from the session whenever possible.
Data privacy: Data cannot be collected without explicit, informed consent and is a punishable offense. Hence, the client and therapist must communicate about the terms of the session regularly to ensure there is no breach of trust. All communication must be performed using platforms that support end-to-end encryption.
Role of caregivers: The participation of caregivers must be encouraged since it may be mutually beneficial for the client and their caregivers. This is especially important for clients with a pre-existing disability or the elderly.
Finance: There must be transparency in terms of billing and the process of claiming subsidies and insurance for the services availed. These must be displayed on the website of the professional body to which the therapist belongs and the local government.
- Cottrell MA, Galea OA, O’Leary SP, Hill AJ, Russell TG. Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: a systematic review and meta-analysis. Clinical rehabilitation. 2017 May;31(5):625-38.
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- Cottrell, M. Clinical Triaging and Practical Considerations in Telehealth. Course. Physioplus. 2020
- Australian Physiotherapy Association. Telehealth Guidelines. Available from: https://australian.physio/sites/default/files/APATelehealthGuidelinesCOVID190420FA.pdf (Accessed 10 May 2020)
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- Tele-Rehabilitation in the Home - iPad set up in the patient’s home. Flinders University. Available from: https://www.youtube.com/watch?v=Sl8WQmTH1LU (Accessed 10 May 2020)
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- Telemedicine Room Setup. CaliforniaTRC. Available from: https://www.youtube.com/watch?v=s6M1yc3FTAM (Accessed 10 May 2020)
- WebPT. The Rehab Therapist’s Guide to Practicing Telehealth
- How to Conduct a Professional Telemedicine Visit Using Good Webside Manner. 4AI4YOU. Available from: https://www.youtube.com/watch?v=8bMFL56Zflc (Accessed 10 May 2020)
- How to Conduct a Physical Exam Via Telemedicine. 4AI4YOU. Available from: https://www.youtube.com/watch?v=4hRObfNyDvc (Accessed 10 May 2020)
- How to get started with online consultations. Running Physio. Available from: https://www.youtube.com/watch?v=XRlrxg0O_gI (Accessed 10 May 2020)
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- Tele-Rehabilitation in the Home - Clinical examples. Flinders University. Available from: https://www.youtube.com/watch?v=h4EbzgcPO1M (Accessed 10 May 2020)
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