Clinical Triaging Considerations for Telehealth

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

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 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.

Clinical Triaging Considerations

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

Patient’s Clinical Condition or Presentation

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.

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 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

Specific Red Flag Conditions:

• 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.

Urgency to Access Care

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. However, each patient needs to be considered on a case by case basis.

Individual Patient Factors

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

Age

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 and this can often be influenced by age. Similarly, it is important to consider cognitive status when exploring telehealth as an option. Is the patient able to follow instructions and fully consent to the assessment and treatment?

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, face-to-face triaging may be more effective for physiotherapists. 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

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

Mobility of the Patient and Other Impairments

Subjects who are frail and immobile are considered a high priority when triaging patients as they have an increased risk of developing complications. 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. Similarly, visual or hearing impairments can have a significant impact on a patient's ability to engage in telehealth consultations.

Other Considerations

What Stage of Treatment is Telehealth Appropriate?

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.

Physical Location

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.

Geographical Location

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

Privacy

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? 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).

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.

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.

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. 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. 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.

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.

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

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