Athletic Training and Sports Health Care

Clinical Roundtable 

Telehealth

Elizabeth Ballard, DPT, PT, LAT, ATC; David F. Gallegos, MA, ATC, Cert. MDT; Lisa Kluchurosky, MEd, AT, ATC; James R. Scifers, DScPT, PT, SCS, LAT, ATC

Abstract

The 2019 novel coronavirus (COVID-19) pandemic has caused changes to numerous aspects of work and life across the United States and the world. One of the changes affecting individuals across the health care spectrum has been the change to working remotely. This change of location regarding where health care providers practice has also affected patients who were receiving health care services at the time of the pandemic shutdown. As a result of the overnight closure of secondary schools, colleges, universities, and outpatient health care locations, patients and clinicians were forced to adapt their practices to include telehealth.

Although this term may be new to many health care systems and providers, telehealth has been practiced in the United States for more than 60 years, with the earliest examples dating back to the late 1950s and the provision of physician services to patients at a distant location via closed-circuit television. Today, a wealth of technological advances makes providing telehealth a viable option for providers across a variety of disciplines, including those in the rehabilitation fields. The sudden transition to telehealth, necessitated by the global pandemic, has allowed clinicians and health care systems to be creative in developing new and exciting methods of reaching both current and future patients, perhaps making telehealth the “new normal” for expanding patients' access to health care services that were not currently available.

Scifers: Telehealth has been on the horizon of the U.S. health care industry for years. How has the COVID-19 pandemic accelerated the use of telehealth in your specific practice?

Gallegos: In our outpatient physical therapy practice, telehealth has been a long-standing alternative for care and education options when patients traveled or for the occasional referral outside of our reach. COVID-19 drastically changed our paradigm; overnight, telehealth represented 20% of our business. It was a means to follow our practice acts and professional responsibility in completing episodes of care. For patients considered “non-essential” and for those opting to refrain from in-person visits, telehealth was a viable option. Because many of those patients have since completed their plans of care and are independent in self-management, telehealth has become an option for physicians who practice telehealth to refer patients digitally and for consumers across the region to access our clinical specialties. I foresee telehealth as an on-going service, education, and consulting option going forward.

Kluchurosky: The pandemic enabled health care providers and organizations to initiate and roll out telehealth services overnight, and that is exactly what many organizations did. I manage two separate clinical departments within my hospital. One department was up and running on telehealth within 4 days of the pandemic hitting, and the other was live on telehealth 10 days later. Our hospital had all outpatient services live on telehealth within 2.5 to 3 weeks. This was truly a remarkable accomplishment on their part to ensure all departments were able to continue providing necessary care to our patients.

Ballard: Prior to the pandemic, my facility did not use telehealth at all. I would occasionally make a follow-up phone call with a patient after discharge, but I had never used video conferencing to treat patients prior to the COVID-19 pandemic.

Scifers: What have been the most surprising benefits and greatest challenges of providing telehealth to patients?

Ballard: The most surprising benefit to providing telehealth services has been that patients have truly progressed and improved without hands-on care. Initially, I was skeptical about the value of telehealth in promoting patient care and even questioned the ethics of billing patients for telehealth services. However, I have found that telehealth has been invaluable for young athletes who were post-surgical patients…

The 2019 novel coronavirus (COVID-19) pandemic has caused changes to numerous aspects of work and life across the United States and the world. One of the changes affecting individuals across the health care spectrum has been the change to working remotely. This change of location regarding where health care providers practice has also affected patients who were receiving health care services at the time of the pandemic shutdown. As a result of the overnight closure of secondary schools, colleges, universities, and outpatient health care locations, patients and clinicians were forced to adapt their practices to include telehealth.

Although this term may be new to many health care systems and providers, telehealth has been practiced in the United States for more than 60 years, with the earliest examples dating back to the late 1950s and the provision of physician services to patients at a distant location via closed-circuit television. Today, a wealth of technological advances makes providing telehealth a viable option for providers across a variety of disciplines, including those in the rehabilitation fields. The sudden transition to telehealth, necessitated by the global pandemic, has allowed clinicians and health care systems to be creative in developing new and exciting methods of reaching both current and future patients, perhaps making telehealth the “new normal” for expanding patients' access to health care services that were not currently available.

Scifers: Telehealth has been on the horizon of the U.S. health care industry for years. How has the COVID-19 pandemic accelerated the use of telehealth in your specific practice?

Gallegos: In our outpatient physical therapy practice, telehealth has been a long-standing alternative for care and education options when patients traveled or for the occasional referral outside of our reach. COVID-19 drastically changed our paradigm; overnight, telehealth represented 20% of our business. It was a means to follow our practice acts and professional responsibility in completing episodes of care. For patients considered “non-essential” and for those opting to refrain from in-person visits, telehealth was a viable option. Because many of those patients have since completed their plans of care and are independent in self-management, telehealth has become an option for physicians who practice telehealth to refer patients digitally and for consumers across the region to access our clinical specialties. I foresee telehealth as an on-going service, education, and consulting option going forward.

Kluchurosky: The pandemic enabled health care providers and organizations to initiate and roll out telehealth services overnight, and that is exactly what many organizations did. I manage two separate clinical departments within my hospital. One department was up and running on telehealth within 4 days of the pandemic hitting, and the other was live on telehealth 10 days later. Our hospital had all outpatient services live on telehealth within 2.5 to 3 weeks. This was truly a remarkable accomplishment on their part to ensure all departments were able to continue providing necessary care to our patients.

Ballard: Prior to the pandemic, my facility did not use telehealth at all. I would occasionally make a follow-up phone call with a patient after discharge, but I had never used video conferencing to treat patients prior to the COVID-19 pandemic.

Scifers: What have been the most surprising benefits and greatest challenges of providing telehealth to patients?

Ballard: The most surprising benefit to providing telehealth services has been that patients have truly progressed and improved without hands-on care. Initially, I was skeptical about the value of telehealth in promoting patient care and even questioned the ethics of billing patients for telehealth services. However, I have found that telehealth has been invaluable for young athletes who were post-surgical patients and needed someone to hold them accountable to continue a high-level rehabilitation program that would allow them to return to sport participation without a lapse in care.In addition, telehealth allowed patients who were immunocompromised to continue to receive high-quality care without risking their health status further by coming to the clinic for treatment. The ability to “go into someone's home” virtually also allowed clinicians to provide onsite ergonomic assessments and make adjustments to the patient's home environment in ways we had not previously been able to do.Initially, the greatest challenge included navigating insurance reimbursement for telehealth, because policies seem to be changing daily. This often made it difficult to determine whether telehealth was a covered service for my patients and, if so, what services could be performed to be in compliance with the patient's insurance provider.

Kluchurosky: Patients were initially relieved to be able to keep their appointment but be seen in a safe way that kept them from having to travel to our facilities. We have seen a significant decrease in our no-show rates, which is a reflection of how removing barriers for families will improve their compliance with attending appointments. My providers have been challenged in figuring out how to provide care to their patients virtually, which was completely new for them. Many have found they are still able to provide the same level of care for our patients, whether face-to-face or virtually.Our greatest challenges have revolved around the availability of technology for some of our patients, as well as some behind-the-scenes processing of appointments and financial workflows that we had to figure out as they arose.

Gallegos: The most surprising benefit is that we now have referrals from across the nation and have been identified as experienced clinicians, although only a subset of our providers practiced telemedicine prior to COVID-19. The biggest challenge identified in the process of implementing telehealth was the hesitancy of some clinicians to demonstrate value and feel comfortable providing care when touch is not an option. What is normally a 60-minute onsite visit did often turn into a 15-minute patient encounter because the staff felt their value was defined through exercise. For those clinicians who were able to educate on self-care and tie therapy goals into the life of the patient, 60 minutes was not enough time. I do think the provider of the future will be an educator.

Scifers: How have patients responded to telehealth thus far?

Gallegos: Patients have really enjoyed the option and felt security in continuing care while following social distancing. Our satisfaction scores indicate telehealth is very appreciated by patients. For those patients living locally, care is often preferred in person, whereas screening and triage are preferred virtually and on-demand.

Ballard: Patients have been overwhelmingly positive about receiving telehealth services. Much like health care services provided in the clinic, when using telehealth, I assess the patient, provide treatment, and then reassess the patient. The feedback provided by patients regarding tele-health services is that the care provided has been valuable in aiding their functional recovery.

Kluchurosky: Patients love the telehealth experience. For many patients who may have barriers to accessing necessary health care services (eg, unreliable transportation, work conflicts, or rural location), tele-health has removed these barriers.

Scifers: What communication platforms are you currently using when providing telehealth and how are patient privacy requirements being met?

Ballard: My facility uses Microsoft Teams (Microsoft Corporation) to provide telehealth services. I provide services only while physically in the clinic, never from another location, and services are provided within a closed treatment room with no other patients or providers present. My experience using tele-health has been that this procedure protects patient privacy more than a traditional clinical setting where multiple patients are being treated in the same physical space and discussions between clinician and patient could be overheard by others in the vicinity.

Kluchurosky: Our hospital uses Zoom (Zoom Video Communications, Inc) in conjunction with EPIC as our electronic medical record. Patients join their Zoom appointment through the MyChart patient portal in EPIC, which is secure.

Gallegos: We are currently using Secure Video when recordings are needed, such as in asynchronous care and for staff education playback. For on-demand telemedicine, we focus on simplicity and use Doxy (Doxy.me, LLC). We have opted not to use platforms if they are not compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). We did implement a patient portal on our website to make ongoing tele-health a fully digital experience. We have used paid versions of the platforms with signed Business Associate Agreements that bind HIPAA compliant practices from both the platform and our clinics.

Scifers: How do state licensure acts affect the provision of telehealth across state lines?

Gallegos: State licensure acts do affect our provision of telehealth for patients outside our state. For physical therapy services, we rely on the PT Compact, which recognizes reciprocity across certain state lines when specific regulations are followed. When service is provided by athletic trainers, we follow state-specific restrictions because a compact equivalent is not an option. Some states have recognized the need to assist patient populations as they travel home from school, which has been nice for the care continuum. At the time of this article, New Mexico and Texas have not clarified state line language. Occupational therapy services have not been leveraged for out-of-state services yet, so state policy guides the care provided by our occupational therapists.

Kluchurosky: Because the pandemic has been declared a state of emergency, many states have relaxed licensure requirements for many providers. This has enabled patients to continue to receive the care they need from the provider whom they have chosen. However, the expectation is that the loosening of state restrictions will end, either universally or in some states, once we are no longer in a state of emergency.

Scifers: There is a limited amount of peer-reviewed research regarding telehealth. How would you like to see telehealth investigated in the future?

Ballard: I believe there are opportunities to assess patient outcomes comparing traditional face-to-face care to telehealth services in patients with the same diagnosis. The validity of using instruments such as goniometers in assessing patients or performing movement assessments and gait assessments virtually should also be investigated.

Kluchurosky: As Dr. Ballard stated, I think it will be important for providers and hospitals to be able to demonstrate positive outcomes for services provided to patients via telehealth that are equivalent to in-person services to make a case for the continuation of telehealth services beyond the pandemic.

Gallegos: There will be a few basic litmus measures for telehealth. As mentioned previously, comparative outcomes for services provided onsite and by telehealth should be investigated. Additionally, holistic outcomes encompass the patient experience, clinical efficiency, clinical effectiveness, and cost. I also think the provider experience should be measured. Administrative, clinical, and patient expectations should be clarified because they may not align given current health care payment policy. Finally, there is a difference between telehealth and pandemic-forced digital care. We will likely only focus on the latter if we are not aware of the difference.

Scifers: How do you think tele-health will continue to be used after the COVID-19 pandemic ends?

Gallegos: Telehealth will likely be part of any health care system where providers participate in primary care services. Telehealth will bridge the distance gap for consumers, allowing them to access primary care services that were not previously available. Telehealth will also promote interprofessional collaboration and interprofessional education. Because digital space is currently a neutral environment, the politics and economics of brick and mortar business will have less of a restrictive impact. This should allow for collaboration not previously realized.

Ballard: I believe that, after the pandemic, telehealth services will continue to be used by my facility in a limited capacity. Ideally, telehealth services will become the norm when providing patient follow-up after discharge or in cases where patients have extended breaks from treatment, such as when college students return home during school breaks. I also believe that telehealth provides an excellent opportunity to assess patients in their home environment and make ergonomic changes that would otherwise require the clinician to travel to the patient's home.

Kluchurosky: Within my organization and in conversations with administrators in other hospitals, it seems most of us are hopeful there will be a place for provision of some telehealth services to patients, as appropriate, moving forward. There is a lot of state and federal advocacy occurring now, so the future of telehealth will be interesting. My opinion is that all providers and specialties have found telehealth to be beneficial in caring for at least some of their patients. Any patient who does not need a hands-on physical examination may be a good candidate for a telehealth visit. The other point that cannot be stated strongly enough is that for some patients who have barriers to receiving quality and necessary care, telehealth enables them to receive appropriate care. This is beneficial to many patients who are living with chronic medical conditions.

Scifers: For clinicians who have not used telehealth previously, what advice would you offer for getting started?

Ballard: I would recommend that clinicians not be afraid to try to incorporate the use of technology into their practice. In my experience, the largest impediment to tele-health was fear of the modality and the technology required when providing such care. However, I quickly found the system was easy to use and the experience of treating patients “virtually” was just as rewarding and beneficial as providing traditional, onsite health care.

Kluchurosky: It is not as difficult to figure out as you might think. If you are billing for your services, you obviously need a strong technical team to help navigate the build and launch. But as far as evaluating or treating patients goes, there really is a lot more you can do that is effective and helpful to patients in their recovery.

Gallegos: Telehealth should be a long-term vision for a provider or a company. The experience must be inviting, a natural progression of brick and mortar care, and valuable. We must recognize convenience is given to both the provider and patient, making them both consumers. The consumer-driven experience should be evident in the policies and procedures and formal telehealth education, both internal and external to the system must be valued. Most associations provide implementation guidance and educational content specific to their members. Broad perspectives must also be developed to understand the new paradigm in the greater health care system and how it will look as we continue the shift to a value-based payment model.

This clinical roundtable was conducted in June 2020.

Suggested Reading

  1. Dinesen, B, Nonnecke, B & Lindeman, D et al. Personalized telehealth in the future: a global research agenda. J Med Internet Res. 2016;18(3):e53. doi:10.2196/jmir.5257 [CrossRef]
  2. Hollander, JE & Carr, BG. Virtually perfect? Tele-medicine for COVID-19. N Engl J Med. 2020;382(18):1679–1681. doi:10.1056/NEJMp2003539 [CrossRef]
  3. Tuckson, RV, Edmunds, M & Hodgkins, ML. Tele-health. N Engl J Med. 2017;377(16):1585–1592. doi:10.1056/NEJMsr1503323 [CrossRef]
Authors

Elizabeth Ballard, DPT, PT, LAT, ATC, is a Physical Therapist and Athletic Trainer at St. Luke's University Health Network, Bethlehem, Pennsylvania.

David F. Gallegos, MA, ATC, Cert. MDT, is Deputy CEO at Southwest Sport & Spine Center, Las Cruces, New Mexico.

Lisa Kluchurosky, MEd, AT, ATC, is Service Line Administrator, Sports Medicine & Developmental Behavioral Pediatrics Nationwide Children's Hospital, Westerville, Ohio.

Moderator: James R. Scifers, DScPT, PT, SCS, LAT, ATC

The authors have no financial or proprietary interest in the materials presented herein.

10.3928/19425864-20200617-01

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