Clinical Triaging Considerations for Telehealth: Difference between revisions

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== Introduction ==
== Introduction ==
Telehealth enables individuals to access rehabilitation services in their home environment. However, because health professionals are unable to assess these patients in person, they must first determine if telehealth is a viable option. This page discusses clinical triaging principles that must be considered in order to determine if a patient is a suitable candidate for telehealth.
Telehealth enables individuals to access rehabilitation services in their home environment. However, because health professionals are unable to assess these patients in-person, they must first determine if telehealth is a viable option for healthcare delivery. This page discusses clinical triaging principles that must be considered in order to determine if a patient is a suitable candidate for telehealth.


The American Telemedicine Association states that physical therapists can see patients via telehealth on a case by case basis. Decisions must be based on clinical judgement, the client's informed choice and professional standards of care.<ref>[https://telerehab.pitt.edu/ojs/index.php/Telerehab/article/view/6063/6293 Brennan D, Tindall L, Theodoros D, Brown J, Campbell M, Christiana D, Smith D, Cason J, Lee A. A blueprint for telerehabilitation guidelines. Int J Telerehabil. 2010;2(2):31.]</ref><ref name=":2">Cottrell, M. and Russel, T. Clinical Triaging and Practical Considerations in Telehealth Course. Physioplus. 2020</ref>  
The American Telemedicine Association states that physical therapists can see patients via telehealth on a case by case basis. Decisions must be based on clinical judgement, the client's informed consent and professional standards of care.<ref>[https://telerehab.pitt.edu/ojs/index.php/Telerehab/article/view/6063/6293 Brennan D, Tindall L, Theodoros D, Brown J, Campbell M, Christiana D, Smith D, Cason J, Lee A. A blueprint for telerehabilitation guidelines. Int J Telerehabil. 2010;2(2):31.]</ref><ref name=":2">Cottrell, M. and Russel, T. Clinical Triaging and Practical Considerations in Telehealth Course. Physioplus. 2020</ref>  
== Clinical Triaging Considerations ==
== Clinical Triaging Considerations ==
There are various factors that must be considered in order to appropriately triage telehealth patients.
There are various factors that must be considered in order to appropriately triage telehealth patients.
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=== Presence of Red Flags/Serious Pathology ===
=== Presence of Red Flags/Serious Pathology ===
When assessing any patient, in person or via telehealth, it is essential to consider if there are any potential or actual red flags. Red flags can indicate serious pathology and need to be directly referred to the appropriate medical professional. Red flags are consider in more detail [https://www.physio-pedia.com/An_Introduction_to_Red_Flags_in_Serious_Pathology here], but common red flags include:
When assessing any patient, in-person or via telehealth, it is essential to consider if there are any potential or actual red flags. Red flags can indicate serious pathology and need to be directly referred to the appropriate medical professional. Red flags are discussed in more detail [https://www.physio-pedia.com/An_Introduction_to_Red_Flags_in_Serious_Pathology here], but common red flags include:
* Escalation of pain and progressive worsening of symptoms that do not respond to medications or the usual conservative management.
* Escalation of pain and progressive worsening of symptoms that do not respond to medications or the usual conservative management.
* Fever and weight loss  
* Fever and weight loss  
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* '''Insufficiency fracture:''' Sudden onset pain, most commonly in the thoracolumbar region. This results from low impact trauma.  
* '''Insufficiency fracture:''' Sudden onset pain, most commonly in the thoracolumbar region. This results from low impact trauma.  
* '''Spine related neurological symptoms:''' relatively new onset weakness that progressively worsens with less than grade 4 in one or more myotome.  
* '''Spine related neurological symptoms:''' relatively new onset weakness that progressively worsens with less than grade 4 in one or more myotome.  
* '''Cervical Myelopathy:''' The rare occurrence of myelopathy from cervical spondylosis in which the patient presents with pain and diminished coordination ability, balance impairments, and possibly loss f bowel and bladder control.
* '''Cervical Myelopathy:''' The rare occurrence of myelopathy from cervical spondylosis in which the patient presents with pain and diminished coordination ability, balance impairments, and possibly loss of bowel and bladder control.
* '''Inflammatory arthritis OR rheumatological conditions:'''
* '''Inflammatory arthritis OR rheumatological conditions:'''
** Persistent synovitis (swollen arm joints) particularly of the small joints of the hand, stiffness that lasts for at least 30 mins in the morning. This would indicate rheumatoid or psoriatic arthritis.
** Persistent synovitis (swollen arm joints) particularly of the small joints of the hand, stiffness that lasts for at least 30 mins in the morning. This would indicate rheumatoid or psoriatic arthritis.
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** Any type of myalgia causes due to viral infection or fibromyalgia but showing worse symptoms proximally, ie shoulder or pelvis, associated with 30 mins of stiffness, and an acute raise response (CRP/ESR). This could be polymyalgia rheumatic or Myalgia that require urgent referral to a Rheumatologist.
** Any type of myalgia causes due to viral infection or fibromyalgia but showing worse symptoms proximally, ie shoulder or pelvis, associated with 30 mins of stiffness, and an acute raise response (CRP/ESR). This could be polymyalgia rheumatic or Myalgia that require urgent referral to a Rheumatologist.


* Headache of relatively new onset mainly in the temples which may radiate to the jaw. Also, there will be proximal areas, pelvic and shoulder pain, symptoms of the eye and there will be an acute response with raised ESR and CRP, usually in patients above 50 years. This patient may be a suspect for giant cell arteritis.<ref name=":1">''5.      [https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/urgent-emergency-msk-conditions-requiring-onward-referral-23-march-2020-updated.pdf Urgent and Emergency Musculoskeletal Conditions Requiring Onward Referral.]'' [https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/urgent-emergency-msk-conditions-requiring-onward-referral-23-march-2020-updated.pdf NHS. Report number: 001559, 2020.]</ref><ref name=":0">Magee D. ''Orthopedic Physical Assesment.'' 4<sup>th</sup> edition. Missouri: Saunders Elsevier; 2006</ref>
* '''Headache''' of relatively new onset mainly in the temples which may radiate to the jaw. Also, there will be proximal areas, pelvic and shoulder pain, symptoms of the eye and there will be an acute response with raised ESR and CRP, usually in patients above 50 years. This patient may be a suspect for giant cell arteritis.<ref name=":1">''5.      [https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/urgent-emergency-msk-conditions-requiring-onward-referral-23-march-2020-updated.pdf Urgent and Emergency Musculoskeletal Conditions Requiring Onward Referral.]'' [https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/urgent-emergency-msk-conditions-requiring-onward-referral-23-march-2020-updated.pdf NHS. Report number: 001559, 2020.]</ref><ref name=":0">Magee D. ''Orthopedic Physical Assesment.'' 4<sup>th</sup> edition. Missouri: Saunders Elsevier; 2006</ref>
=== Urgency to Access Care ===
=== Urgency to Access Care ===
As with face-to-fact consultations, it is essential with telehealth to consider the urgency for the patient to access care. For instance, a patient six weeks post-ACL repair will require more rapid review than a patient who has long standing non specific low back pain with no neurological symptoms.<ref name=":2" /> However, each patient needs to be considered on a case by case basis.  
As with face-to-face consultations, it is essential that a health professional considering using telehealth determines how urgently care is required. For instance, a patient six weeks post-ACL repair will need to be reviewed more rapidly than a patient who has long standing non specific low back pain with no neurological symptoms.<ref name=":2" /> However, each patient needs to be considered on a case by case basis.  
=== Individual Patient Factors ===
=== Individual Patient Factors ===
Various patient factors should also be considered when deciding if telehealth is an appropriate method of healthcare delivery.<ref name=":2" />  
Various patient factors should also be considered when deciding if telehealth is an appropriate method of healthcare delivery.<ref name=":2" />  


==== Age ====
==== Age ====
Age can have a number of impacts on treatment regardless of the mode of healthcare delivery. Young patients tend to recover faster than older patients in most cases. This is likely due to fast healing rates and the presence of comorbidities among older patients. <ref>Middaugh SJ, Levin RB, Kee WG, Barchiesi FD, Roberts JM. Chronic pain: Its treatment in geriatric and younger patients. Arch Phys Med Rehabil. . 1988 Dec;69(12):1021-6.</ref> However, with telehealth it is important to consider unique factors related to age. Patients have varying levels of familiarity with the technology required to engage in telehealth<ref>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. Available from <nowiki>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4795318/</nowiki></ref> and this can often be influenced by age. Similarly, it is important to consider cognitive status when exploring telehealth as an option.<ref name=":2" /> Is the patient able to follow instructions and fully consent to the assessment and treatment?<ref name=":2" />
The age of a patient should be considered regardless of the mode of healthcare delivery. However, with telehealth it is important to consider unique factors related to age. Patients have varying levels of familiarity with the technology required to engage in telehealth<ref name=":3">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. Available from <nowiki>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4795318/</nowiki></ref> and this can often be influenced by age. Similarly, it is important to consider cognitive status when exploring telehealth as an option.<ref name=":2" /> Is the patient able to follow instructions and fully consent to the assessment and treatment?<ref name=":2" />


==== Presence of Comorbidities ====
==== Presence of Comorbidities ====
While telehealth has been shown to be effective in managing certain long term conditions (eg cardiovascular disease and stroke care), particularly when delivered as part of an overarching MDT programme,<ref>Lee HS, Chumbler N, Brown E, Fonarow GC, Berube D, Nystrom K. et al. Recommendations for the Implementation of Telehealth in Cardiovascular and Stroke Care: A Policy Statement From the American Heart Association. Circulation. 2016; 135(7). </ref> face to face triaging may be more effective when managing these patients.<ref name=":2" /> However, in the context of COVID-19, many regions/countries are encouraging these vulnerable groups to be triaged via telehealth in order to reduce their risk of contracting this virus.  
While telehealth has been shown to be effective in managing certain long term conditions (eg cardiovascular disease and stroke care), particularly when delivered as part of an overarching MDT programme,<ref>Lee HS, Chumbler N, Brown E, Fonarow GC, Berube D, Nystrom K. et al. Recommendations for the Implementation of Telehealth in Cardiovascular and Stroke Care: A Policy Statement From the American Heart Association. Circulation. 2016; 135(7). </ref> face-to-face triaging may be more effective for physiotherapists.<ref name=":2" /> However, in the context of COVID-19, many regions/countries are encouraging these vulnerable groups to be treated via telehealth in order to reduce their risk of contracting this virus.  


==== Mental Health ====
==== Mental Health ====
Psychological factors affect the functioning of an individual<ref>[https://academic.oup.com/ptj/article/91/5/700/2735743 Linton SJ, Shaw WS. Impact of psychological factors in the experience of pain. Phys Ther. 2011 May 1;91(5):700-11.]</ref> and may have an impact on whether or not they can be safely triaged by telehealth.<ref name=":2" />
The presence of psychological issues may have an impact on whether or not a patient can be safely triaged by telehealth.<ref name=":2" />


==== Mobility of the Patient and Other Impairments ====
==== Mobility of the Patient and Other Impairments ====
Subjects who are frail and immobile are considered a high priority when triaging patients as they are at a higher risk of developing complications.<ref>[https://jamanetwork.com/journals/jamasurgery/fullarticle/1867407 Kim SW, Han HS, Jung HW, Kim KI, Hwang DW, Kang SB, Kim CH. Multidimensional frailty score for the prediction of postoperative mortality risk. JAMA surgery. 2014 Jul 1;149(7):633-40.]
Subjects who are frail and immobile are considered a high priority when triaging patients as they have an increased risk of developing complications.<ref>[https://jamanetwork.com/journals/jamasurgery/fullarticle/1867407 Kim SW, Han HS, Jung HW, Kim KI, Hwang DW, Kang SB, Kim CH. Multidimensional frailty score for the prediction of postoperative mortality risk. JAMA surgery. 2014 Jul 1;149(7):633-40.]
</ref> However, it is essential to consider their safety when determining if telehealth is an apporpiate option. Consider if you need to be present or perhaps if a carer/support person can assist when balance or mobility impairments are present.<ref name=":2" /> Similarly, visual or hearing impairments can have a significant impact on a patient's ability to engage in telehealth consultations.  
</ref> However, it is essential to consider their safety when determining if telehealth is an apporpiate option. Consider if you need to be present or perhaps if a carer/support person can assist when balance or mobility impairments are present.<ref name=":2" /> Similarly, visual or hearing impairments can have a significant impact on a patient's ability to engage in telehealth consultations.  


== Other Considerations ==
== Other Considerations ==
You may determine that a patient is a suitable candidate for telehealth, but you must also consider at which point in their care you use it. Can you complete the initial assessment via telehealth or will you just use it for reviews? Perhaps a hybrid model is best. This decision will be based on the client's condition and individual patient factors.<ref name=":2" />


== Language Barriers ==
==== What Stage of Treatment is Telehealth Appropriate? ====
When language is a barrier, assessment meets a roadblock. Thus telerehabilitation must involve the use of translation softwares
You may determine that a patient is a suitable candidate for telehealth, but you must also consider at which point in their care you use it. Can you complete the initial assessment via telehealth or will you just use it for follow up appointments? You might decide a hybrid model is best. This decision will be based on the client's condition and individual patient factors.<ref name=":2" />


== Patient’s Physical Location ==
==== Physical Location ====
* ·        In case the patient residing close to a community facility, or the General Practitioners clinic then it would only make sense to schedule appointments with these facilities to unload the system.  
You will need to consider the patient's physical location. Are they at home or at a friend/family member's house? Some patient's will be at GP clinics. Having another person present has both positives and negatives. They can help with the assessment and reduce some safety risks (ie provide balance support), but having an extra person present poses certain privacy and confidentiality issues.<ref name=":2" />
* ·        If there is someone else with the patient, these individuals could assist in the special tests and aid 
* ·        If the geographical location of the residence of a client has architectural barriers that don’t suit his travel needs then telerehabilitation becomes the obvious choice for him.
* ·        Influence of internet connection barriers when present puts these clients on a list of cases to be seen in person.  


== Who Is Present During the Consult ==
==== Geographical Location ====
Specific staff need to be established for this purpose or role
When looking at telehealth for patients in rural or remote areas, it is important to consider if there may be any internet connectivity barriers.<ref name=":2" /> Access to high speed internet is a recognised barrier for many rural telehealth programmes<ref name=":4">Rural Health Information Hub. Connectivity Considerations for Telehealth Programs. Available from https://www.ruralhealthinfo.org/toolkits/telehealth/4/connectivity (accessed 16 May 2020). </ref>. Problems with video calls as a result of slow internet can interrupt consultations and reduce patient satisfaction with telehealth.<ref name=":4" />


The recently retired staff who are at a higher risk of contacting Covid 19
==== Privacy ====
As discussed [https://www.physio-pedia.com/Ethical_and_Professional_Considerations_with_Telehealth here], privacy is a significant consideration when utilising telehealth. It is important to consider what application you are using for the consultation - does it have end-to-end encryption to ensure the patient's security and privacy is maintained?<ref name=":5">Digital Physical Therapy Task Force. Report of the WCPT/INPTRA digital physical therapy practice task force. World Confederation for Physical Therapy. 2019. 24 p. Report No. 7. Available from <nowiki>https://www.wcpt.org/sites/wcpt.org/files/files/wcptnews/REPORT%20OF%20THE%20WCPTINPTRA%20DIGITAL%20PHYSICAL%20THERAPY%20PRACTICE%20TASK%20FORCE.pdf</nowiki></ref> Similarly, the patient needs to have access to a private space in their physical location - especially when dealing with sensitive issues (such as visualisation for pelvic examinations).<ref name=":2" />


Staff who are self-isolating but can support telerehabilitation clinics
==== Therapist Skill Level  ====
As with any clinical encounter, a physiotherapist needs to have the appropriate skills to safely carry out an assessment and intervention for the presenting condition. However, with telehealth, they need to be able to do this without actually being present to perform assessment tests.<ref name=":2" />


Technology support teams and administrative teams to ensure the maintenance of appointments, notifications, and provide technical assistance.
==== Necessary Assessment and Treatment Requirements ====
When considering using telehealth, a physiotherapist needs to be able to select the appropriate tests/interventions and red flag screening questions without being able to physically assist in the examination. Thus, it is important to consider if another person can be present to help with the tests (eg a local GP). Similarly, it may be necessary to refer patients for imaging if you have any concerns about their presentation.<ref name=":2" />


'''Advantage: assistance with tests, or supervision.''' 
==== Scope of Practice and Reimbursement ====
It is important to check if your registration board or professional body has placed limitations on your scope of practice when utilising telehealth.<ref>Cottrell, M. and Russel, T. Introduction to Telehealth Course. Physioplus. 2020</ref>  You should also find out if you are correctly licensed to treat a patient in a different state/region to you before undertaking a telehealth consultation.<ref name=":5" /> Similarly, you need to check if a patient's insurer covers telehealth - this is not always the case and reimbursement is a key challenge for telehealth.<ref name=":3" />


'''Disadvantage: privacy and confidentiality.'''  
== Summary ==
Once you have considered the above issues, you should be able to determine if a patient is an appropriate candidate for telehealth, in-person or a combination of telehealth and face-to-face care.  


== Privacy of the Patient If You Need to Visualize Areas of the Patient’s Body ==
It is essential that you consider:
* The environment should have only the therapist and the client use a private space
* The client's condition and screen for any red flags/serious pathology
* The communication channel needs to be a safe medium to prevent hacking. Thus an end to end encrypted platform is more apt.
* The urgency of the condition
* Data information needs to retain in the documentation form and not telephonic or video graphic data
* Individual patient factors that will affect the ability of the patient to engage in telehealth
* Also consider individual factors (Some cultures are conservative and are not comfortable exposing certain body parts, especially when being recorded)
* And other issues such as location, privacy, skill level and how well the assessment can be adapted to telehealth, scope of practice and your ability to be reimbursed as a therapist.  
* Clinical consultation of pelvic area pain conditions may be awkward for the client.
* The workforce team (each member must maintain the privacy and security of the client)
* The site that is being used as a platform needs to be continually checked for its policies on communication and information technology  
 
== Therapist Skill to Translate It to Telehealth  ==
An assessment of telerehabilitation shoulder relies mostly on subjective assessment, posture examination, movement examination. When overpressure is necessary it can be given by the patients in case possible. Special tests performed actively can be carried out. Muscle length examination should be included in If required a visit from the local healthcare provider (Village healthcare provider may help to aid the assessment process.
 
== Scope of Practice and Registration Within Your State or Country ==
The telehealth governing rules vary from place to place
* AS stated by the APTA Physical therapists are not yet recognized under the scope of telehealth of medicare, thus an e-visit paid to a therapist cannot be reimbursed under Medicare and most insurance companies. However, Tricare offers coverage in case all the criteria are met  Medicare however is providing coverage for a 7-day consultation which involves clinical decision making.<ref>[http://www.apta.org/PTinMotion/News/2020/03/20/CoronavirusUpdateMarch20/ Tepper D, Ries E, Hilgenberg J. ''Coronavirus Update: March 20, 2020.''<nowiki> Available from: http://www.apta.org/PTinMotion/News/2020/03/20/CoronavirusUpdateMarch20/ [20/03/2020]</nowiki>]
</ref>
 
* The Health Professions Council of South Africa has permitted the practice of telerehabilitation given the COVID 19 situation and applicable to this situation doesn’t resolve. However, this facility is restricted to already established patient-therapistt relationships. New patient consultations are discouraged. Also, Therapists must professionally conduct themselves over these consultations. <ref>''[https://www.hpcsa.co.za/Uploads/Events/Announcements/HPCSA_COVID-19_guidelines_FINAL.pdf Covid-19 Outbreak in South Africa: Guidance to Health Pracisioners.]'' [https://www.hpcsa.co.za/Uploads/Events/Announcements/HPCSA_COVID-19_guidelines_FINAL.pdf <nowiki>Available from: https://www.hpcsa.co.za/Uploads/Events/Announcements/HPCSA_COVID-19_guidelines_FINAL.pdf[26/04/2020]</nowiki>]</ref>
 
* The Australian Physiotherapy Association has permitted the practice of telerehabilitation and the Australian Heath Funds will provide benefits to individuals availing telerehabilitation consultation. <ref>''[https://australian.physio/sites/default/files/APATelehealthGuidelinesCOVID190420FA.pdf Telehealth Guidelines.]'' [https://australian.physio/sites/default/files/APATelehealthGuidelinesCOVID190420FA.pdf ''Covid-19 Emergency Response Telehealth.''<nowiki> Australian Physiotherapy Association. Available from: https://australian.physio/sites/default/files/APATelehealthGuidelinesCOVID190420FA.pdf [03/2020]</nowiki>]</ref>
 
== Clinical Triaging process in a nutshell ==
<blockquote>Review the charts of all the patients on waiting lists</blockquote><blockquote>Identify the high-risk patients and provide a direct referral, if not able to meet the demand to identify those patients whose treatment can be delayed, without the risk of any further progression or complication </blockquote><blockquote>However, this increases the patients on waiting lists and isn’t advised given the Covid-19 situation</blockquote><blockquote>Offer remote consultation services</blockquote><blockquote>Arrange a face to face consultations in case remote consultations aren’t possible<ref>''[https://www.csp.org.uk/news/coronavirus/remote-service-delivery-options/telephone-guidance-msk-practice Telephone guidance for musculoskeletal practice.]'' [https://www.csp.org.uk/news/coronavirus/remote-service-delivery-options/telephone-guidance-msk-practice <nowiki>Available from: https://www.csp.org.uk/news/coronavirus/remote-service-delivery-options/telephone-guidance-msk-practice [21/03/2020]</nowiki>]</ref></blockquote>Thus as therapists, it is our responsibility to provide the necessary essential musculoskeletal care before there is worsening of symptoms. So let us act early and aid the healthcare system and patients in every way possible.


== References ==
== References ==
[https://telerehab.pitt.edu/ojs/index.php/Telerehab/article/view/6063/6293]<references />
[https://telerehab.pitt.edu/ojs/index.php/Telerehab/article/view/6063/6293]<references />
[[Category:Course Pages]]
[[Category:Course Pages]]

Revision as of 10:55, 16 May 2020

Original Editor - Ashmita Patrao Top Contributors - Ashmita Patrao, Jess Bell, Kim Jackson, Lucinda hampton and Olajumoke Ogunleye

Introduction[edit | edit source]

Telehealth enables individuals to access rehabilitation services in their home environment. However, because health professionals are unable to assess these patients in-person, they must first determine if telehealth is a viable option for healthcare delivery. This page discusses clinical triaging principles that must be considered in order to determine if a patient is a suitable candidate for telehealth.

The American Telemedicine Association states that physical therapists can see patients via telehealth on a case by case basis. Decisions must be based on clinical judgement, the client's informed consent and professional standards of care.[1][2]

Clinical Triaging Considerations[edit | edit source]

There are various factors that must be considered in order to appropriately triage telehealth patients.

Patient’s Clinical Condition or Presentation[edit | edit source]

You will need to consider if the patient has a formal diagnosis (eg spinal stenosis or COPD), as well as symptom severity (eg pain levels, presence of neurological symptoms, severe shortness of breath). Will these symptoms affect your ability to effectively treat a patient via telehealth? It is also important to consider the chronicity of the condition. More severe and acute cases may need to be triaged sooner.[3][4]

Presence of Red Flags/Serious Pathology[edit | edit source]

When assessing any patient, in-person or via telehealth, it is essential to consider if there are any potential or actual red flags. Red flags can indicate serious pathology and need to be directly referred to the appropriate medical professional. Red flags are discussed in more detail here, but common red flags include:

  • Escalation of pain and progressive worsening of symptoms that do not respond to medications or the usual conservative management.
  • Fever and weight loss
  • Being systemically unwell
  • Night pain that disturbs and prevents sleep
  • Changes in bladder/bowel habits[5]

Specific Red Flag Conditions:[edit | edit source]

  • Primary and secondary cancers: The common presentations are night pain, escalating pain, systemic illness.
  • Insufficiency fracture: Sudden onset pain, most commonly in the thoracolumbar region. This results from low impact trauma.
  • Spine related neurological symptoms: relatively new onset weakness that progressively worsens with less than grade 4 in one or more myotome.
  • Cervical Myelopathy: The rare occurrence of myelopathy from cervical spondylosis in which the patient presents with pain and diminished coordination ability, balance impairments, and possibly loss of bowel and bladder control.
  • Inflammatory arthritis OR rheumatological conditions:
    • Persistent synovitis (swollen arm joints) particularly of the small joints of the hand, stiffness that lasts for at least 30 mins in the morning. This would indicate rheumatoid or psoriatic arthritis.
    • Autoimmune disorders of recent onset like Lupus or scleroderma or vasculitis with non-articular manifestations of rashes, Raynauds disease with bluish/ red discoloration of hand or feet, inflammatory arthritis which presents with mouth ulcers or sicca related symptoms (drying of mouth and eyes)
    • Any type of myalgia causes due to viral infection or fibromyalgia but showing worse symptoms proximally, ie shoulder or pelvis, associated with 30 mins of stiffness, and an acute raise response (CRP/ESR). This could be polymyalgia rheumatic or Myalgia that require urgent referral to a Rheumatologist.
  • Headache of relatively new onset mainly in the temples which may radiate to the jaw. Also, there will be proximal areas, pelvic and shoulder pain, symptoms of the eye and there will be an acute response with raised ESR and CRP, usually in patients above 50 years. This patient may be a suspect for giant cell arteritis.[6][7]

Urgency to Access Care[edit | edit source]

As with face-to-face consultations, it is essential that a health professional considering using telehealth determines how urgently care is required. For instance, a patient six weeks post-ACL repair will need to be reviewed more rapidly than a patient who has long standing non specific low back pain with no neurological symptoms.[2] However, each patient needs to be considered on a case by case basis.

Individual Patient Factors[edit | edit source]

Various patient factors should also be considered when deciding if telehealth is an appropriate method of healthcare delivery.[2]

Age[edit | edit source]

The age of a patient should be considered regardless of the mode of healthcare delivery. However, with telehealth it is important to consider unique factors related to age. Patients have varying levels of familiarity with the technology required to engage in telehealth[8] and this can often be influenced by age. Similarly, it is important to consider cognitive status when exploring telehealth as an option.[2] Is the patient able to follow instructions and fully consent to the assessment and treatment?[2]

Presence of Comorbidities[edit | edit source]

While telehealth has been shown to be effective in managing certain long term conditions (eg cardiovascular disease and stroke care), particularly when delivered as part of an overarching MDT programme,[9] face-to-face triaging may be more effective for physiotherapists.[2] However, in the context of COVID-19, many regions/countries are encouraging these vulnerable groups to be treated via telehealth in order to reduce their risk of contracting this virus.

Mental Health[edit | edit source]

The presence of psychological issues may have an impact on whether or not a patient can be safely triaged by telehealth.[2]

Mobility of the Patient and Other Impairments[edit | edit source]

Subjects who are frail and immobile are considered a high priority when triaging patients as they have an increased risk of developing complications.[10] However, it is essential to consider their safety when determining if telehealth is an apporpiate option. Consider if you need to be present or perhaps if a carer/support person can assist when balance or mobility impairments are present.[2] Similarly, visual or hearing impairments can have a significant impact on a patient's ability to engage in telehealth consultations.

Other Considerations[edit | edit source]

What Stage of Treatment is Telehealth Appropriate?[edit | edit source]

You may determine that a patient is a suitable candidate for telehealth, but you must also consider at which point in their care you use it. Can you complete the initial assessment via telehealth or will you just use it for follow up appointments? You might decide a hybrid model is best. This decision will be based on the client's condition and individual patient factors.[2]

Physical Location[edit | edit source]

You will need to consider the patient's physical location. Are they at home or at a friend/family member's house? Some patient's will be at GP clinics. Having another person present has both positives and negatives. They can help with the assessment and reduce some safety risks (ie provide balance support), but having an extra person present poses certain privacy and confidentiality issues.[2]

Geographical Location[edit | edit source]

When looking at telehealth for patients in rural or remote areas, it is important to consider if there may be any internet connectivity barriers.[2] Access to high speed internet is a recognised barrier for many rural telehealth programmes[11]. Problems with video calls as a result of slow internet can interrupt consultations and reduce patient satisfaction with telehealth.[11]

Privacy[edit | edit source]

As discussed here, privacy is a significant consideration when utilising telehealth. It is important to consider what application you are using for the consultation - does it have end-to-end encryption to ensure the patient's security and privacy is maintained?[12] Similarly, the patient needs to have access to a private space in their physical location - especially when dealing with sensitive issues (such as visualisation for pelvic examinations).[2]

Therapist Skill Level [edit | edit source]

As with any clinical encounter, a physiotherapist needs to have the appropriate skills to safely carry out an assessment and intervention for the presenting condition. However, with telehealth, they need to be able to do this without actually being present to perform assessment tests.[2]

Necessary Assessment and Treatment Requirements[edit | edit source]

When considering using telehealth, a physiotherapist needs to be able to select the appropriate tests/interventions and red flag screening questions without being able to physically assist in the examination. Thus, it is important to consider if another person can be present to help with the tests (eg a local GP). Similarly, it may be necessary to refer patients for imaging if you have any concerns about their presentation.[2]

Scope of Practice and Reimbursement[edit | edit source]

It is important to check if your registration board or professional body has placed limitations on your scope of practice when utilising telehealth.[13] You should also find out if you are correctly licensed to treat a patient in a different state/region to you before undertaking a telehealth consultation.[12] Similarly, you need to check if a patient's insurer covers telehealth - this is not always the case and reimbursement is a key challenge for telehealth.[8]

Summary[edit | edit source]

Once you have considered the above issues, you should be able to determine if a patient is an appropriate candidate for telehealth, in-person or a combination of telehealth and face-to-face care.

It is essential that you consider:

  • The client's condition and screen for any red flags/serious pathology
  • The urgency of the condition
  • Individual patient factors that will affect the ability of the patient to engage in telehealth
  • And other issues such as location, privacy, skill level and how well the assessment can be adapted to telehealth, scope of practice and your ability to be reimbursed as a therapist.

References[edit | edit source]

[1]

  1. ↑ Brennan D, Tindall L, Theodoros D, Brown J, Campbell M, Christiana D, Smith D, Cason J, Lee A. A blueprint for telerehabilitation guidelines. Int J Telerehabil. 2010;2(2):31.
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 Cottrell, M. and Russel, T. Clinical Triaging and Practical Considerations in Telehealth Course. Physioplus. 2020
  3. ↑ Wand BM, Parkitny L, O’Connell NE, Luomajoki H, McAuley JH, Thacker M, Moseley GL. Cortical changes in chronic low back pain: current state of the art and implications for clinical practice. Man Ther. 2011 Feb 1;16(1):15-20.
  4. ↑ Apkarian AV, Sosa Y, Krauss BR, Thomas PS, Fredrickson BE, Levy RE, Harden RN, Chialvo DR. Chronic pain patients are impaired on an emotional decision-making task. Pain. 2004 Mar 1;108(1-2):129-36.
  5. ↑ Finucane L. An Introduction to Red Flags in Serious Pathology. Physioplus 2020.
  6. ↑ 5.      Urgent and Emergency Musculoskeletal Conditions Requiring Onward Referral. NHS. Report number: 001559, 2020.
  7. ↑ Magee D. Orthopedic Physical Assesment. 4th edition. Missouri: Saunders Elsevier; 2006
  8. ↑ 8.0 8.1 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. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4795318/
  9. ↑ Lee HS, Chumbler N, Brown E, Fonarow GC, Berube D, Nystrom K. et al. Recommendations for the Implementation of Telehealth in Cardiovascular and Stroke Care: A Policy Statement From the American Heart Association. Circulation. 2016; 135(7).
  10. ↑ Kim SW, Han HS, Jung HW, Kim KI, Hwang DW, Kang SB, Kim CH. Multidimensional frailty score for the prediction of postoperative mortality risk. JAMA surgery. 2014 Jul 1;149(7):633-40.
  11. ↑ 11.0 11.1 Rural Health Information Hub. Connectivity Considerations for Telehealth Programs. Available from https://www.ruralhealthinfo.org/toolkits/telehealth/4/connectivity (accessed 16 May 2020).
  12. ↑ 12.0 12.1 Digital Physical Therapy Task Force. Report of the WCPT/INPTRA digital physical therapy practice task force. World Confederation for Physical Therapy. 2019. 24 p. Report No. 7. Available from https://www.wcpt.org/sites/wcpt.org/files/files/wcptnews/REPORT%20OF%20THE%20WCPTINPTRA%20DIGITAL%20PHYSICAL%20THERAPY%20PRACTICE%20TASK%20FORCE.pdf
  13. ↑ Cottrell, M. and Russel, T. Introduction to Telehealth Course. Physioplus. 2020
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