Across the State or Around the World: Telerehabilitation Technologies Cover the Distance
Advances in telecommuni-
cation technologies such as videoconferencing, smartphones, tablets, Wi-Fi, and broadband, along with e-mail and POTS (plain old telephone service), are propelling the use of telemedicine in the United States and internationally.
Many experts regard telemedicine, or telehealth-these terms are often used interchangeably, with telerehabilitation being a subset-as a highly effective complement, not a replacement, for personal, hands-on patient care in a clinical setting. Telemedicine is generally integrated into healthcare information services and care delivery rather than offered as a stand-alone service. Although occupational, physical, and speech/cognitive therapy have been a longstanding part of telerehabilitation, O&P is now beginning to consider its potential.
Telemedicine's Advantages and Barriers
Several recent studies about the use of telemedicine reveal lower costs and equal or better outcomes in various medical areas, along with high patient satisfaction. Other advantages include the following:
- Reduced travel time and costs for patients and caregivers-especially advantageous for patients with medical conditions that make travel difficult
- Less time off work for patients and caregivers
- Ready access to specialty care and multidisciplinary team care in remote areas
- Access for clinicians to specialists through professional-to-professional consultations
- Remote monitoring of vital signs
- Fast transmission of images and diagnostic test results
- More convenient access to continuing education for health professionals
According to an article in the International Journal of Environmental Research and Public Health, December 2013 ("Crossing the Telemedicine Chasm: Have the U.S. Barriers to Widespread Adoption of Telemedicine Been Significantly Reduced?" by Cynthia LeRouge and Monica J. Garfield), there are also barriers to adoption, although there have been some advances that reduce these difficulties. The barriers include the following considerations:
- Difficulties involved in licensure and credentialing requirements in multiple states or internationally for telemedicine providers
- Vague, inconsistent legalities involving telemedicine that increase providers' liability concerns
- Reimbursement issues
- Unclear return on investment for healthcare organizations
- Lack of broadband infrastructure in many areas, specifically high-demand video and store-and-forward services
- Technology security issues to protect patient information
- Shortage of telemedicine specialty providers and provider reluctance to use telemedicine technologies
Telerehabilitation in O&P
This feature looks at how some U.S. organizations are using telerehabilitation in O&P, which clinicians and practices may be able to incorporate for the benefit of their own patient care.
VA Telerehabilitation Care Forges Ahead
The U.S. Department of Veterans Affairs (VA) operates one of the largest and most comprehensive healthcare systems in the world. Among its facilities are 150 large medical centers and about 800 community-based outpatient clinics (CBOCs) nationwide where veterans can receive primary care closer to home.
VA Telehealth Services Acting Deputy Chief Consultant John Peters notes that more than 677,000 veterans accessed VA care through telehealth in fiscal year 2015. Of these, 282,000 used videoconferencing for live interaction with their VA healthcare specialists. About 98 percent of these videoconferences were between a veteran at a CBOC and a specialist at the medical center; about 6,300 videoconferences were from the veteran's own home to the medical center. "For video telehealth, the VA is just now dipping its toe in the water in going beyond brick-and-mortar VA facilities to veterans at home," Peters says.
Tele-amputation Care Covers the Bases
Three types of telehealth clinics operate under the umbrella of the VA Amputation System of Care (ASoC), according to Rehabilitation Planning Specialist Cindy Poorman, MSPT: an interdisciplinary team with the telehealth amputation clinic, a prosthetist support clinic, and a telehealth support group for veterans with amputations.
The interdisciplinary teams within the VA telehealth amputation clinics include a physician, an amputation rehabilitation coordinator, a prosthetist, and an occupational or physical therapist (OT or PT) depending on need. A telepresenter, usually a nurse or PT, accompanies the veteran at the veteran's site. The clinic provides initial evaluations for a prosthesis and follow-up prosthetic checkouts. Facilities providing tele-amputation clinics have increased from two facilities in 2008 to 36, Poorman says. "In the last four years, episodes of care have increased on average by 50 percent each year-it's growing very quickly."
The prosthetist support clinic provides prosthetic support from the main VA center when the amputation team at the veteran's local VA clinic doesn't have an in-house prosthetist. Services include developing prosthetic prescriptions and new prosthesis checkouts.
The telehealth support group for veterans with amputations involves multiple sites connected through videoconferencing where veterans with amputations can interact and receive support and education from one another-an opportunity they might not have otherwise. Currently this program is running at the James J. Peters VA Medical Center, Bronx, New York; the VA Palo Alto Health Care System, Palo Alto, California; and the James A. Haley Veterans' Hospital, Tampa, Florida. "This program has been really successful, and we anticipate expanding it even further," Poorman says.
A clinical video telehealth pilot project allowing the amputation care team at the VA Eastern Colorado Health Care System, Denver, to videoconference with a private prosthetic facility in Colorado Springs, Colorado, to do prosthetic checkouts is under way, Poorman says. "This eliminates the need for veterans to return to the large VA facility; they can be seen closer to home at their private prosthetist's facility," she explains.
Occupational Therapy via Telehealth
"We have been providing occupational therapy telehealth services since 2010," says VA Occupational Therapy Discipline Lead Deborah Voydetich, OTR/L, SCLV. "Last year we had more than 1,200 telehealth patient visits, mostly in the community-based outpatient clinics." For instance, a veteran with impairments who is receiving care at a CBOC may participate in a telehealth visit with a physician and an OT at the main medical facility. The therapist may educate the veteran about how to compensate for some of his or her impairments. "For instance, the therapist might suggest a different way of dressing, how to use different adaptive devices, such as a shoehorn, sock aid, or a dressing stick, or how to modify the home to make it safer."
Home visits via telehealth are an emerging area, Voydetich says. "We want to expand in this area because it definitely makes sense to provide services in the veteran's home and help them maximize their independence in their own environment."
"We're also looking into videoconferencing into the home for veterans with amputations," Poorman adds. "We're thinking about follow-up for wound care, home assessment, safety assessment, and how well the prosthesis is fitting."
Veteran, Provider Satisfaction
Patient satisfaction with videoconferencing in general is 94 percent, although in-home videoconferencing is a small percentage, Peters says. Setting up the video connection between the care team at the facility and the veteran at home is the hardest part, since besides requiring a username and password, the video has to be encrypted to protect privacy. "But once we're connected, the providers, the veterans, and the caregivers are all enthusiastic about it," he adds.
"One of the things we hear from our veterans is that they appreciate not having to travel as far-decreased travel is really important to them," Poorman says.
"Besides veteran satisfaction, there is also provider satisfaction, because many of our providers are learning new techniques and new skills through the telehealth visits," Poorman continues. For instance, a smaller facility may only have one PT on staff. "So, that physical therapist is learning a great deal through the specialty team at the medical center."
International Manufacturers: Using Telerehab for Better Outcomes
Össur utilizes several telecommunication technologies, such as FaceTime, Skype, and other Internet features, for a variety of needs involving its more complex products, generally the RHEO KNEE™ and POWER KNEE™, according to Justin Pratt, CP, director of Össur Academy, prosthetics. Össur Americas is based in Foothill Ranch, California; the parent company is headquartered in Reykjavik, Iceland.
"Situations vary from patient-specific challenges, gait anomalies, provider experience with the device technology, etc.," Pratt notes. "We have used a variety of methods in an effort to see and understand the situation so we can recommend the appropriate adjustments and provide education and support."
When they are with patients in the field, Össur's clinical specialists use interconnectivity with the research and development (R&D) team to help with diagnostics and troubleshooting via the Internet, Pratt explains. For instance, with the POWER KNEE, engineers can tap into the clinical specialist's computer remotely by using Össur's proprietary software and observe the device's behavior. These situations most often involve a patient with a hip disarticulation or bilateral transfemoral amputations and often are related to the range of motion (ROM) the user can accomplish. "Their amputation level, experience, and any training they may have would all influence the changes in parameters within the bionic knee programming." Össur's clinical specialists may also assist by sharing a FaceTime video from their home office with the remote local prosthetist.
"One of our greatest assets at Össur is that everyone desires to push the envelope and find new ways to service our clinical customers and end users," Pratt says. "We often exchange these ideas and methods with our counterparts in Össur offices around the globe so we can all improve our clinical and technical support."
Although Ottobock's Cooperative Care consulting service, headquartered in Austin, Texas, usually involves an in-person meeting with a prosthetist and patient, FaceTime or WebEx videoconferencing technology is used to follow up with the practitioner and patient, explains Byron Backus, CP, senior lower limb clinical specialist for prosthetics.
Telerehabilitation via mobile devices has been indispensable for Backus. "I have assisted practitioners with aligning a prosthesis, programming one of our MPKs [microprocessor knees], adjusting the hydraulics on a hip joint, or all of the above together, as well as programming a DynamicArm or Michelangelo hand. I have used WebEx and FaceTime while sitting at my desk at the office, sitting in a hotel, and even while sitting in an airport." Once, when traveling, he says he had several text messages and phone calls from a practitioner seeking help with a Helix hip fitting. As Backus left the plane, he noticed a sign for free Wi-Fi at the airport. "So...I sent the practitioner an e-mail with a WebEx invitation and within five minutes I was virtually in his office seeing his patient walking. I was able to check the alignment of the prosthesis, suggest some minor alignment changes, and walk the practitioner through the programming of the knee and adjustments to the hip joint. The patient did very well." Backus also has used these technologies to coach practitioners and patients in gait training.
WebEx has been useful for remote education, such as providing more in-depth information through sharing a presentation or other documentation. Some technical support staff use remote access software to log into a practitioner's computer to troubleshoot software issues or help install Ottobock software, he adds.
High-tech upper-limb prostheses such as the i-limb from Touch Bionics, headquartered in Livingston, Scotland, with a U.S. office in Hilliard, Ohio, require intense user training. After the fitting and initial training, users often require additional education, therapy, and support. Due to the relatively small number of people with upper-limb loss, many prosthetists and OTs are not highly experienced in treating this population. For Touch Bionics' staff prosthetists and OTs, obtaining licenses in multiple states to interact directly with users is impractical.
Given these two situations, Touch Bionics is using telehealth technologies to provide education, training, troubleshooting, and support to the patient's local prosthetist and OT.
Through GoToMeeting or other videoconferencing software, Touch Bionics prosthetist Nathan Wagner, CPO/L, OTR/L, and Lynsay Whelan, OTR/L, director, remote training and occupational therapy, can interact with local clinicians and patients in real time. Through the company's biosim™ software, Wagner and Whelan can remotely access the i-limb.
"The hand itself connects to the local clinician's computer via Bluetooth and can be connected to our program and transmitted to GoToMeeting so everyone can see what the muscles are doing," Wagner explains. The i-limb has two electrode sites for control, although there is a version with one-site control strategy. With two electrode sites, "sometimes the user may think their system isn't working when in reality they may be having trouble firing the muscles and separating out signals. If both muscles are firing at the same time, the hand doesn't know whether to open or close. So, often just by cueing the local occupational therapist and the user, we can help them get better signals for better function."
"We also work with the occupational therapist and the patient on what they want the hand to do, for instance, handling eating utensils, dressing, and other activities," Whelan says. "We can share what we've learned over time to help them figure out how to best do these activities, since the prosthesis user may have to do them differently.
"From the local prosthetists' perspective, we are assisting them to create a better outcome for the i-limb wearer," Whelan adds. "Even though we don't charge for the service, the local prosthetist and therapist are excited when there is a good outcome, and are more apt to use our products again."
Marmaduke Loke, CPO, owner of DynamicBracingSolutions™ (DBS), Carlsbad, California, and Jean-Paul Nielsen (since retired), developed a unique triplanar bracing concept to improve function of patients with neuromuscular disorders such as post-polio syndrome, Charcot-Marie- Tooth disease, and muscular dystrophy. Telecommunication technologies that include FaceTime, Skype, and videos transmitted via e-mail have helped DBS clinicians successfully assess, train, and follow up with international patients, Loke says.
International patients generally send a video to help clinicians assess gait and other factors. Candidates for the bracing solutions follow specific instructions to create their videos and are asked to provide any pertinent medical documentation they have. "We may ask them to see their doctor, PT, or orthotist to provide information regarding manual muscle testing, contractures, ROM, etc.," Loke says.
Loke looks for as many details as possible in the videos. "For improving balance and efficiency, all structural and functional deficits must be recognized and a strategy developed to realign each bone with triplanar management. We need to fully understand the cause and effect of each compensatory movement pattern and how to solve them."
After being fit with and trained on the use of the orthosis and the accompanying exercise program, Loke encourages international patients to send follow-up videos; he also uses Skype and direct phone calls when needed.
"I often give the remote international clients a kit of extra screws, bushings, SACH heels, [and] pads, and will provide instructions," Loke adds. He encourages return visits when possible to check and improve alignment and fit.
Remote troubleshooting often involves helping the patient utilize more efficient movement and more natural walking patterns, which must be practiced repeatedly to fully optimize the functional improvement potential of the orthosis. "Our bracing solution enables clients to move the pelvis in the correct pattern to stop the trunk and head from moving side to side when they compensate."
It's Come a Long Way
Telemedicine has come a long way since a visionary cover appeared on Radio News magazine in 1924. Radio was just beginning to become part of American life, and the first experimental television broadcast was still a few years away. The cover portrayed a "radio doctor" linked to a patient via sound and a live picture, anticipating modern videoconferencing. As the complexities of the technology have caught up with the vision, several experts affirm that telemedicine, including telerehabilitation, will continue to grow, unlocking its potential for better patient care.
Miki Fairley is a freelance writer based in southwest Colorado. She can be contacted via e-mail at .