Telehealth and Patient Engagement
October 2020 Issue
"Unprecedented times" and "the new normal" may be the most common phrases used to describe the dramatic changes in our personal and professional lives in response to the COVID-19 pandemic. O&P practices have been forced to adapt their patient care strategies in response to new guidance, recommendations, and regulations from healthcare and government institutions. Avoiding personal contact impacts the provision of any medical service but is particularly disruptive in a profession that relies on intimate shape capture and fitting and adjustment of mechanical components that interface directly with a patient's body. Some strategies for limiting contact involve rotating clinicians' shifts, creative patient appointment scheduling for in-person visits, and the adoption of telehealth technologies and strategies to provide care without requiring face-to-face interaction.
Many different terms and definitions have been used to describe "internet-related technologies to support, enable, promote and enhance health and augment the efficacy and efficiency of the process of healthcare."1 Many healthcare providers have routinely used some form of remote communication technology (e.g., the telephone or text messaging) as part of their care delivery processes, and some incorporated more advanced technologies into their practices for many years prior to the COVID-19 pandemic. In the past 30 years, multiple research reports have described the feasibility of computer and web-based technology in O&P for remote education, orthotic assessment, and to conduct amputee clinics. Almost a decade ago, a mobile phone app was developed to facilitate collaboration between individuals wearing prostheses and their prosthetists. Studies in other medical disciplines have demonstrated the usefulness of these technologies for clinical practices that are common within O&P, such as neurological examination, kinematic gait analysis, goniometric measurement, and orthopedic functional assessment. A number of barriers, including lack of reimbursement, have limited the implementation of these and other telehealth services. It wasn't until 2016 that the US Department of Defense determined that a patient and clinician did not need to be in the same physical location for a medical visit to occur. Prior to March 2020, O&P clinicians may have had similar difficulty imagining how our services could be performed without an in-person visit.
A 2014 article published in The Academy TODAY examined an American Board for Certification in Orthotics, Prosthetics and Pedorthics' Practice Analysis to identify which tasks could be provided without an in-person encounter, and suggested that "telemedicine could significantly improve the efficiency of care during tasks that typically consume one-third of the average practitioner's time."2 The article advised practitioners to "make their own judgments regarding the feasibility of using telemedicine to provide care" by asking, "Can the task be adequately performed and the safety of the patient ensured?" and "Is an in-person follow-up visit required to provide optimal care?"2 An important factor in providing optimal care during any medical encounter is the personal connection between patient and provider. Not only do these connections have a therapeutic benefit, they are essential to ensuring that practitioners address patient needs and concerns in a way that prepares patients to successfully manage their O&P care. As part of determining the feasibility of implementing telemedicine practices, practitioners should consider how these encounters can impact the involvement of patients in their own care.
What Is Engagement?
Like telehealth, patient involvement has been described using many terms and definitions, and "each term is connoted by a peculiar meaning concerning the role that patients enact when called to relate with their own healthcare."1 (See Table 1 for examples.) Patient engagement, also described as patient activation, "refers to the different aspects (not only subjective, but also contextual, relational and organizational) that may foster or hinder patients' ability to truly become positioned at the center of their own care…the concept of patient engagement offers a broader and better systemic conceptualization of patients' role when interacting with their own healthcare…."1 Viewed this way, patient engagement is "the outcome of a patient's actions carried out at different levels of complexity (i.e., individual, relational, organizational, and health policy)."1 Patient engagement also comprises different dimensions, which are described in Table 2. O&P practitioners recognize the importance of patient compliance, or adherence to a treatment plan. However, "patient engagement is a complex and multi-faceted experience which cannot be reduced to the mere consideration of the patient's ability to adhere to medical prescriptions."1 To ensure safe and effective use of the interventions we provide, we must do everything we can to encourage patients to engage in their own care, not just comply with our instructions. How do systems of technology and clinical protocols related to remote patient encounters affect patient engagement?
eHealth and Patient Engagement
Barello et al. performed a review of 11 studies "to detect, categorize and synthesize findings from the literature about the application of eHealth in engaging people in their own care process."1 They report that the cognitive and behavioral dimensions of engagement have been assessed more systematically than the emotional dimension. The eHealth interventions in the reviewed studies included web portals and mobile applications for managing chronic health conditions, not just communication technology designed for patient/provider interaction. Many of these other interventions are not available or not used commonly by O&P practices. However, several of the studies reported results that are applicable to O&P encounters. For example, the results of one study demonstrated a positive impact on each of the domains of patient engagement in reporting that the "eHealth intervention ‘leads to more disclosure' (behavioral), ‘improves health education' (cognitive), ‘increases patient comfort'(emotional)."1 Another study reported that "the technology-mediated session was considered less intimidating than the in-person visit and adequate for self-disclosure…."1 Rather than create therapeutic distance between patients and providers, certain eHealth interventions may result in patients sharing important information that they would be uncomfortable sharing during a face-to-face encounter. Long-term management of O&P care is analogous to managing a chronic health condition and requires that patients learn and perform self-care behaviors (e.g., socket management, care and cleaning, and wear schedule). Based on findings in this review, protocols that incorporate eHealth interventions to teach self-management skills may positively impact patients' ability to manage their care. Development of these interventions must go beyond simply communicating remotely with patients, but this review demonstrates that patient education and the development of self-care skills can be performed using telemedicine technologies and strategies. Practitioners must be aware of "barriers limiting the effectiveness of the technology-based intervention," including low technology literacy, how illness can impact participation, technical problems, and access to high-speed internet connections.1 The dramatic increase in reliance on telemedicine interventions during the current health crisis has drawn attention to the "diminished accessibility to technology based on various societal and social factors, sometimes referred to as the digital gap or digital divide…."3 This divide must be considered when implementing interventions and protocols, since the required technology and services may be less accessible to populations that are already among the most vulnerable.
Skills for Practitioners
A group of researchers at Northern Illinois University interviewed healthcare providers experienced in providing telehealth services "to describe interpersonal skills important for quality telehealth delivery."4 Participants were asked how they prepared for their first telehealth sessions, the differences between telehealth and face-to-face encounters, problems they had experienced while providing telehealth services, and skills and competencies important for this model of care. The focus of this research was on interpersonal skills and other non-technical aspects of care. Participants discussed the importance of having to "work to bring out more responses" by asking questions, behaving "as if you are in the same room," "making eye contact with the camera," and being prepared and comfortable with the equipment. (See Table 3 for additional insights.) Participants identified verbal and non-verbal factors required to build report, communicate empathy, and develop the relationship with the patient. As in the review by Barello et al., participants in this study reported that "distance between clinician and patient may at times enhance patient disclosure."4 However, they also cautioned that the absence of physical touch represented a barrier and may require additional training.
Precedented Times and Looking Forward
While the challenges created by the COVID-19 health crisis and the telehealth solutions that have been adopted represent a significant change in the way medical care is provided, they are not without precedent. The rapid expansion of telehealth services has been possible precisely because these technologies were already highly developed and had been successfully implemented in many healthcare systems prior to the pandemic. Many of these care strategies have been adopted within O&P, and these new practices are likely to continue in some form after the current pandemic has passed. One researcher observed: "The key transformation of telehealth systems is to shift from crisis mode (where the use of stopgap or unproven technologies has been permitted) to sustainable, secure systems that properly preserve data security and patient privacy and that offer sustained technical support for postcrisis care."5 All healthcare providers will need to face the demands of the "care debt" created by delayed or missed medical care. We can expect to see increased complications for serious conditions and routine O&P follow-up as a result of care being deferred during the crisis.5
Telemedicine technologies and practices have been available and demonstrated as feasible within O&P for many years, but due to the lack of a compelling reason for their adoption, they were not implemented on a wide scale prior to the current crisis. Perhaps investing in the difficult work of changing practices to replace in-person time with remote appointments did not appear to provide sufficient benefit. "Necessity," the saying goes, "is the mother of invention." What we're seeing is that necessity also contributes to the adoption of technology and modification of common practices. As telehealth is adopted on a broader scale within our profession, we may see increased efficiency and effectiveness of care, without compromising quality or engagement.
John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center. He has over 30 years of experience in patient care and education.
1. Barello, S., S. Triberti, and G. Graffigna et al. 2016. eHealth for patient engagement: A systematic review. Frontiers in Psychology 6:2013.
2. Brinkmann, J. 2014. Telemedicine and the ABC Practice Analysis. The Academy TODAY 10(2):5-7.
3. Ramsetty, A., and C. Adams. 2020. Impact of the digital divide in the age of COVID-19. Journal of the American Medical Informatics Association 27(7):1147-8.
4. Henry, B.W., L .J. Ames, D. E. Block, and J. A. Vozenilek. 2018. Experienced practitioners' views on interpersonal skills in telehealth delivery. Internet Journal of Allied Health Sciences and Practice 16(2):2.
5. Wosik, J., M. Fudim, and B. Cameron et al. 2020. Telehealth transformation: COVID-19 and the rise of virtual care. Journal of the American Medical Informatics Association 27(6):957-62.