Cover Story

No Going Back: Experts Discuss Telemedicine in O&P

Experts discuss the benefits of telemedicine in O&P and how practices can take advantage of this technology.

The advent of telemedicine has signaled a massive shift in how practitioners interact with patients and each other in O&P practices throughout the United States. Using tablets and video communication apps, practitioners can check in with patients who have questions about their prosthesis. Using online meeting software, they can communicate with colleagues, therapists and fabrication facilities at once, keeping everyone on the same page when it comes to clients. With body sensors, physical therapists can record a variety of measurements related to gait, balance and speed.

In July 2016, the New England Journal of Medicine published a review article that concluded telemedicine is poised to transform health care delivery for millions of patients across the United States. In “The State of Telehealth,” authors from the University of Rochester Medical Center and the Scripps Research Institute wrote that there were three trends shaping telehealth. First, telehealth has the potential to make care more accessible, convenient and less costly. Second, the use of telemedicine is being expanded from its traditional use in acute conditions to facilitating consultations and meetings between patients and practitioners. Lastly, the authors concluded use of telehealth is no longer limited to hospitals and clinics, and is increasingly used in the home via smartphones and other mobile devices.

According to practitioners and other experts, the future of telemedicine, particularly when it concerns O&P, may include the expanded use of wearable devices and virtual consultations. Although it is possible that telemedicine may never replace one-on-one examinations, where a sense of touch and the ability to easily move around the patient is required, it remains clear to many experts that the presence of telemedicine will continue to grow as technology advances and becomes more readily available.

New way to meet people

Ed Lemaire, PhD, first began working in early telemedicine in the late 1990s, connecting with small communities in Canada. Currently a senior investigator at the Ottawa Hospital Research Institute, Centre for Rehabilitation Research and Development, he said the way O&P practitioners use telemedicine has changed from a focus on formal interactions with patients to a more informal, “as needed” meeting schedule.

Image: ©Shutterstock

Image: ©Shutterstock

According to Lemaire, O&P practitioners can use widely available platforms, such as Skype and Google Hangouts, to communicate with patients who are spread out across small, rural communities to answer questions or issues that can be dealt with remotely.

Ed Lemaire, PhD
Ed Lemaire

“If you suddenly eliminated all of telemedicine or the ability to share information effectively, you can lose all connections,” he told O&P News, “and people working in a small communities are back on their own, in a vacuum, doing the best they can or sending patients, ‘back to the big city,’ which is avoided by many people in rural areas.”

According to Lemaire, the ability to be able to establish remote communication with patients also has societal impacts. For example, elderly patients may need their adult children to transport them to office visits. To accomplish this, the adult children may need to take off from work or pay for hotel rooms.

Companies also use the technology. Jonathan Naft, CPO, LPO, owner of Geauga Rehab Engineering (GRE) and vice president and general manager of Myomo Inc., told O&P News his companies also make extensive use of meeting apps to communicate with patients and researchers.

Jonathan Naft, CPO, LPO
Jonathan Naft

“For Myomo, we will use it to collaborate with O&P customers when the patients are coming in and trying the device,” he said. “We can dial in via video conference using a webcam with video and audio to assist and answer questions instead of hopping on a plane to fly to those institutions.”

At GRE, similar communication tools are used to communicate between offices, particularly with the fabrication facility. For example, if a prosthetist is working with a patient who is an amputee with extensive customization requirements, both can “dial in” with video and audio to officials at the fabrication facility during consultations, Naft said.

“It makes a huge impact,” he added. “It makes us much more efficient and it is more cost-effective, but the best aspect has been the improvement in communication. Before using this technology, the whole team is not necessarily present when meeting with patient. Now, when we have those meetings, it is as though the whole team is in the room.”

Patients who are outfitted with Myomo’s Myopro orthosis are also provided with a pre-programmed tablet when they first attend therapy to begin their pre-functional training, Naft said. If therapists have any questions about the orthosis, they can use the tablet to reach the company through its built-in webcam.

“They like having us on stand-by for that type of coordination,” he said. “It saves us a significant amount of travel time.”

Sensory therapy

In addition to communication, telemedicine also has the potential to assist in therapy, particularly in recording patient progress. Shelia M. Clemens, PT, MPT, a PhD candidate in physical therapy at the University of Miami, told O&P News her most recent research studied the use of body-worn sensors connected wirelessly to a mobile tablet to log and analyze data on how patients walk.

According to Clemens, five sensors were placed on patients’ bodies — two on each leg and one over the sacrum — and as they performed various activities, data on gait symmetry, step length, body sway and other measures were sent to the tablet. Data were then uploaded to a mainframe university server for analysis.

Clemens said patients can use this technology at home to connect to a web portal and follow their progress, as well as analyze how they are moving, without the need for a clinician to be present.

Jeff Quelet, CPO, LPO
Jeff Quelet
Telemedicine Pros and Cons

“Essentially, this has been developed so a patient can have a ‘PT in their pocket,’ enabling them to perform a treatment program and get feedback on their gait pattern at home with fewer actual clinic visits,” she said. “Our system provides details of how an amputee walks, turns and balances using their prosthesis that are unable to be detected with the human eye. In the future, this would provide a means of customizing rehabilitation and prosthetic interventions to an individual.”

Costs vs. savings

According to the “The State of Telehealth,” traditional medical providers and new startup companies can offer virtual patient visits with a physician at relatively short notice at an average cost of less than $50 per visit. By contrast, patients wait an average of 20 days to confirm a 20-minute appointment with a physician, who, with travel and waiting time factored in, can take up 2 hours of an individual’s time.

All the experts and practitioners interviewed for this story agreed telemedicine saves practices money, with relatively little upfront costs. For practices that chiefly use telemedicine to communicate with patients and colleagues, a subscription to a web-based video conferencing platform, such as WebeX or GoToMeeting, or consumer devices like tablets, may be sufficient. However, depending on the size of the practice, those upfront costs could be significant.

Jeff Quelet, CPO, LPO, clinical management officer for Ability P&O, said all clinicians with the group are equipped with a tablet with structure scanners installed, which allow them to examine patients and to communicate with fabrication companies in real-time. The company also employs a clinical outcome director who uses Skype to check in with patients. Twice each month, the company meets with various manufactures all in a single meeting using GoToMeeting. According to Quelet, its costs Ability approximately $3,500 to $5,000 per practitioner per year to maintain and advance these communication tools.

“Obviously, upfront costs are going to be a factor,” he said. “The cost is not super expensive, but capital expeditures dedicated to efficiencies is a line we have to consider in order to advance practitioner care tools.”

Quelet said that information exchange has meant savings for the company down the line.

“It is absolutely a money saver,” he said. “We have been able to effectively translate clinical efficiencies into improved business operations. For example, if the industry standard is 65 days on collecting your money, ours can be 45 [days] to 50 days.”

Naft said telemedicine has saved his companies money by increasing the productivity of practitioners who can now conduct virtual visits with patients easier and without long hours for travel. For the cost of a subscription to WebeX and GoToMeeting, which he described as “affordable,” Naft said GRE and Myomo have enjoyed considerable savings.

“If we have to send a practitioner to multiple visits, that is a lot of time and lost revenue,” he said. “However, with telemedicine meetings, we can increase productivity with staff. Also, it gives us the opportunity to be in front of the patient and the therapists more often than we would otherwise, which translates to higher outcomes for the patients.”

In addition, Clemens said the mobile gait laboratory she and her colleagues used in their study costs “much less than a traditional gait laboratory,” which relies on expensive motion detector equipment. In contrast, Clemens said the system she and her colleagues have devised could provide a less costly way to rehabilitate patients.

“In the foreseeable future, this type of technology has the potential to decrease health care costs by providing a more efficient means to rehabilitate patients,” Clemens said. “Additionally, it may allow for a prosthetist to better tailor prosthetic design and componentry to a patient based on more detailed movement analysis.”

Limitations

Although telemedicine may be ideal for interviews and quick follow-up questions with patients, it cannot replace one-on-one evaluations with prosthetists and orthotists, which, at least for the time being, are necessary for detailed examinations.

For Brian Waryck, CP/L, and Chris Bollinger, MOT, OTR, a clinical manager and upper limb prosthetic therapy specialist, respectively, both from Advanced Arm Dynamics, telemedicine can only take practitioners and patients so far. At some stage, an in-person visit will be required, they said.

Brian Waryck, CP/L
Brian Waryck

“A large part of what we do is physical evaluation,” Waryck told O&P News. “You can do the preliminary interview and gather goals with patients from a distance, but when you are evaluating strength and range motion, that has to be done in person. Palpating residual limb, getting sense of subsurface structures, anything that goes into consideration of prosthetic design, all has to be done in person.”

Chris Bollinger, MOT, OTR
Chris Bollinger

Bollinger said in-person visits are also required to evaluate patients for potential prostheses.

“Getting a hands-on feel that may contraindicate a certain prosthesis is important,” he said. “You cannot physically touch the patient with telemedicine.”

According to Naft, the most significant drawbacks to telemedicine are reliance on internet service and Wi-Fi and the aversion of some patients and practitioners to new technology.

He added that training patients to use certain apps and technology can take up too much of a practitioner’s time.

“We do not want to be in the tech-support business,” Naft said. “Telemedicine can backfire on you if you have a patient who will require so much information technology training because you spend half the time on that.”

As for the tech-averse, Naft said older patients are no more hesitant to take on new technology than young patients. Instead, it is a matter of familiarity.

“Not an age thing,” Naft said. “It is a break in the routine. What assess with the patient is a willingness to be progressive. It does take time to train the patients, and we do that.”

According to “The State of Telehealth,” the biggest hurdle to using telemedicine faced by patients is the “digital divide,” in which individuals who are older, live in rural areas, have lower incomes and are less educated are less likely to have internet access than their younger, urban, higher-income and more educated counterparts.

As such, those who need telemedicine the most may be the least likely to benefit from it.

“Technology can be a drag on the whole process if it does not communicate, if the portals are limited or the patient does not have resources to gain access to the internet,” Quelet said. “You are out of luck if there is no Wi-Fi signal.”

The future

According to Lemaire, the future of telemedicine in O&P lies in wearable devices, such as smartphones and smartwatches. The technology could expand beyond video and telemedicine itself, and grow into mobile health care, he said.

“It is all about how to take advantage of wearable, mobile technologies, wherever it is appropriate,” Lemaire said. “We wrote an app where you clip a smartphone to the back of your belt and conduct walking tests and a simple clinical evaluation. The sensors that are already in the phone then give [an] assessment of motion quality, side-to-side, front-to-back, stride changes at any angle. You could also connect a smartwatch through Bluetooth to tell what the arms are doing.”

OPN 175 Survey Question

Whatever the future of telemedicine entails, Clemens argued none of the current technology or telemedicine methods are going away anytime soon. The technology will only expand and gain a greater foothold as tablet, smartphone and smartwatch ownership increases among patients.

“There is no turning back from here. This type of technology is here to stay,” Clemens said. “The possibilities are endless, and the systems themselves will continue to become more compact and user friendly.”

Considering this, Clemens stressed the importance of education in O&P. To stay current with the latest telemedicine methods and best practices, those who teach will need to understand the technology, she said.

“I think what will be important is how education of prosthetists and therapists will evolve in teaching new clinicians how to use this type of equipment,” Clemens said. “It needs to be incorporated into programs at O&P and PT schools. Yet, one of the greatest challenges may be getting the professors well-versed enough on it to teach.” – by Jason Laday

Disclosures: Bollinger, Clemens, Lemaire, Naft, Quelet and Waryck report no relevant financial disclosures.

The advent of telemedicine has signaled a massive shift in how practitioners interact with patients and each other in O&P practices throughout the United States. Using tablets and video communication apps, practitioners can check in with patients who have questions about their prosthesis. Using online meeting software, they can communicate with colleagues, therapists and fabrication facilities at once, keeping everyone on the same page when it comes to clients. With body sensors, physical therapists can record a variety of measurements related to gait, balance and speed.

In July 2016, the New England Journal of Medicine published a review article that concluded telemedicine is poised to transform health care delivery for millions of patients across the United States. In “The State of Telehealth,” authors from the University of Rochester Medical Center and the Scripps Research Institute wrote that there were three trends shaping telehealth. First, telehealth has the potential to make care more accessible, convenient and less costly. Second, the use of telemedicine is being expanded from its traditional use in acute conditions to facilitating consultations and meetings between patients and practitioners. Lastly, the authors concluded use of telehealth is no longer limited to hospitals and clinics, and is increasingly used in the home via smartphones and other mobile devices.

According to practitioners and other experts, the future of telemedicine, particularly when it concerns O&P, may include the expanded use of wearable devices and virtual consultations. Although it is possible that telemedicine may never replace one-on-one examinations, where a sense of touch and the ability to easily move around the patient is required, it remains clear to many experts that the presence of telemedicine will continue to grow as technology advances and becomes more readily available.

New way to meet people

Ed Lemaire, PhD, first began working in early telemedicine in the late 1990s, connecting with small communities in Canada. Currently a senior investigator at the Ottawa Hospital Research Institute, Centre for Rehabilitation Research and Development, he said the way O&P practitioners use telemedicine has changed from a focus on formal interactions with patients to a more informal, “as needed” meeting schedule.

Image: ©Shutterstock

Image: ©Shutterstock

According to Lemaire, O&P practitioners can use widely available platforms, such as Skype and Google Hangouts, to communicate with patients who are spread out across small, rural communities to answer questions or issues that can be dealt with remotely.

Ed Lemaire, PhD
Ed Lemaire

“If you suddenly eliminated all of telemedicine or the ability to share information effectively, you can lose all connections,” he told O&P News, “and people working in a small communities are back on their own, in a vacuum, doing the best they can or sending patients, ‘back to the big city,’ which is avoided by many people in rural areas.”

According to Lemaire, the ability to be able to establish remote communication with patients also has societal impacts. For example, elderly patients may need their adult children to transport them to office visits. To accomplish this, the adult children may need to take off from work or pay for hotel rooms.

Companies also use the technology. Jonathan Naft, CPO, LPO, owner of Geauga Rehab Engineering (GRE) and vice president and general manager of Myomo Inc., told O&P News his companies also make extensive use of meeting apps to communicate with patients and researchers.

Jonathan Naft, CPO, LPO
Jonathan Naft

“For Myomo, we will use it to collaborate with O&P customers when the patients are coming in and trying the device,” he said. “We can dial in via video conference using a webcam with video and audio to assist and answer questions instead of hopping on a plane to fly to those institutions.”

At GRE, similar communication tools are used to communicate between offices, particularly with the fabrication facility. For example, if a prosthetist is working with a patient who is an amputee with extensive customization requirements, both can “dial in” with video and audio to officials at the fabrication facility during consultations, Naft said.

“It makes a huge impact,” he added. “It makes us much more efficient and it is more cost-effective, but the best aspect has been the improvement in communication. Before using this technology, the whole team is not necessarily present when meeting with patient. Now, when we have those meetings, it is as though the whole team is in the room.”

Patients who are outfitted with Myomo’s Myopro orthosis are also provided with a pre-programmed tablet when they first attend therapy to begin their pre-functional training, Naft said. If therapists have any questions about the orthosis, they can use the tablet to reach the company through its built-in webcam.

“They like having us on stand-by for that type of coordination,” he said. “It saves us a significant amount of travel time.”

PAGE BREAK

Sensory therapy

In addition to communication, telemedicine also has the potential to assist in therapy, particularly in recording patient progress. Shelia M. Clemens, PT, MPT, a PhD candidate in physical therapy at the University of Miami, told O&P News her most recent research studied the use of body-worn sensors connected wirelessly to a mobile tablet to log and analyze data on how patients walk.

According to Clemens, five sensors were placed on patients’ bodies — two on each leg and one over the sacrum — and as they performed various activities, data on gait symmetry, step length, body sway and other measures were sent to the tablet. Data were then uploaded to a mainframe university server for analysis.

Clemens said patients can use this technology at home to connect to a web portal and follow their progress, as well as analyze how they are moving, without the need for a clinician to be present.

Jeff Quelet, CPO, LPO
Jeff Quelet
Telemedicine Pros and Cons

“Essentially, this has been developed so a patient can have a ‘PT in their pocket,’ enabling them to perform a treatment program and get feedback on their gait pattern at home with fewer actual clinic visits,” she said. “Our system provides details of how an amputee walks, turns and balances using their prosthesis that are unable to be detected with the human eye. In the future, this would provide a means of customizing rehabilitation and prosthetic interventions to an individual.”

Costs vs. savings

According to the “The State of Telehealth,” traditional medical providers and new startup companies can offer virtual patient visits with a physician at relatively short notice at an average cost of less than $50 per visit. By contrast, patients wait an average of 20 days to confirm a 20-minute appointment with a physician, who, with travel and waiting time factored in, can take up 2 hours of an individual’s time.

All the experts and practitioners interviewed for this story agreed telemedicine saves practices money, with relatively little upfront costs. For practices that chiefly use telemedicine to communicate with patients and colleagues, a subscription to a web-based video conferencing platform, such as WebeX or GoToMeeting, or consumer devices like tablets, may be sufficient. However, depending on the size of the practice, those upfront costs could be significant.

Jeff Quelet, CPO, LPO, clinical management officer for Ability P&O, said all clinicians with the group are equipped with a tablet with structure scanners installed, which allow them to examine patients and to communicate with fabrication companies in real-time. The company also employs a clinical outcome director who uses Skype to check in with patients. Twice each month, the company meets with various manufactures all in a single meeting using GoToMeeting. According to Quelet, its costs Ability approximately $3,500 to $5,000 per practitioner per year to maintain and advance these communication tools.

“Obviously, upfront costs are going to be a factor,” he said. “The cost is not super expensive, but capital expeditures dedicated to efficiencies is a line we have to consider in order to advance practitioner care tools.”

Quelet said that information exchange has meant savings for the company down the line.

“It is absolutely a money saver,” he said. “We have been able to effectively translate clinical efficiencies into improved business operations. For example, if the industry standard is 65 days on collecting your money, ours can be 45 [days] to 50 days.”

Naft said telemedicine has saved his companies money by increasing the productivity of practitioners who can now conduct virtual visits with patients easier and without long hours for travel. For the cost of a subscription to WebeX and GoToMeeting, which he described as “affordable,” Naft said GRE and Myomo have enjoyed considerable savings.

“If we have to send a practitioner to multiple visits, that is a lot of time and lost revenue,” he said. “However, with telemedicine meetings, we can increase productivity with staff. Also, it gives us the opportunity to be in front of the patient and the therapists more often than we would otherwise, which translates to higher outcomes for the patients.”

In addition, Clemens said the mobile gait laboratory she and her colleagues used in their study costs “much less than a traditional gait laboratory,” which relies on expensive motion detector equipment. In contrast, Clemens said the system she and her colleagues have devised could provide a less costly way to rehabilitate patients.

“In the foreseeable future, this type of technology has the potential to decrease health care costs by providing a more efficient means to rehabilitate patients,” Clemens said. “Additionally, it may allow for a prosthetist to better tailor prosthetic design and componentry to a patient based on more detailed movement analysis.”

Limitations

Although telemedicine may be ideal for interviews and quick follow-up questions with patients, it cannot replace one-on-one evaluations with prosthetists and orthotists, which, at least for the time being, are necessary for detailed examinations.

For Brian Waryck, CP/L, and Chris Bollinger, MOT, OTR, a clinical manager and upper limb prosthetic therapy specialist, respectively, both from Advanced Arm Dynamics, telemedicine can only take practitioners and patients so far. At some stage, an in-person visit will be required, they said.

PAGE BREAK
Brian Waryck, CP/L
Brian Waryck

“A large part of what we do is physical evaluation,” Waryck told O&P News. “You can do the preliminary interview and gather goals with patients from a distance, but when you are evaluating strength and range motion, that has to be done in person. Palpating residual limb, getting sense of subsurface structures, anything that goes into consideration of prosthetic design, all has to be done in person.”

Chris Bollinger, MOT, OTR
Chris Bollinger

Bollinger said in-person visits are also required to evaluate patients for potential prostheses.

“Getting a hands-on feel that may contraindicate a certain prosthesis is important,” he said. “You cannot physically touch the patient with telemedicine.”

According to Naft, the most significant drawbacks to telemedicine are reliance on internet service and Wi-Fi and the aversion of some patients and practitioners to new technology.

He added that training patients to use certain apps and technology can take up too much of a practitioner’s time.

“We do not want to be in the tech-support business,” Naft said. “Telemedicine can backfire on you if you have a patient who will require so much information technology training because you spend half the time on that.”

As for the tech-averse, Naft said older patients are no more hesitant to take on new technology than young patients. Instead, it is a matter of familiarity.

“Not an age thing,” Naft said. “It is a break in the routine. What assess with the patient is a willingness to be progressive. It does take time to train the patients, and we do that.”

According to “The State of Telehealth,” the biggest hurdle to using telemedicine faced by patients is the “digital divide,” in which individuals who are older, live in rural areas, have lower incomes and are less educated are less likely to have internet access than their younger, urban, higher-income and more educated counterparts.

As such, those who need telemedicine the most may be the least likely to benefit from it.

“Technology can be a drag on the whole process if it does not communicate, if the portals are limited or the patient does not have resources to gain access to the internet,” Quelet said. “You are out of luck if there is no Wi-Fi signal.”

The future

According to Lemaire, the future of telemedicine in O&P lies in wearable devices, such as smartphones and smartwatches. The technology could expand beyond video and telemedicine itself, and grow into mobile health care, he said.

“It is all about how to take advantage of wearable, mobile technologies, wherever it is appropriate,” Lemaire said. “We wrote an app where you clip a smartphone to the back of your belt and conduct walking tests and a simple clinical evaluation. The sensors that are already in the phone then give [an] assessment of motion quality, side-to-side, front-to-back, stride changes at any angle. You could also connect a smartwatch through Bluetooth to tell what the arms are doing.”

OPN 175 Survey Question

Whatever the future of telemedicine entails, Clemens argued none of the current technology or telemedicine methods are going away anytime soon. The technology will only expand and gain a greater foothold as tablet, smartphone and smartwatch ownership increases among patients.

“There is no turning back from here. This type of technology is here to stay,” Clemens said. “The possibilities are endless, and the systems themselves will continue to become more compact and user friendly.”

Considering this, Clemens stressed the importance of education in O&P. To stay current with the latest telemedicine methods and best practices, those who teach will need to understand the technology, she said.

“I think what will be important is how education of prosthetists and therapists will evolve in teaching new clinicians how to use this type of equipment,” Clemens said. “It needs to be incorporated into programs at O&P and PT schools. Yet, one of the greatest challenges may be getting the professors well-versed enough on it to teach.” – by Jason Laday

Disclosures: Bollinger, Clemens, Lemaire, Naft, Quelet and Waryck report no relevant financial disclosures.