Telerehabilitation (TR) refers to the delivery of rehabilitation via a variety of technologies and encompasses a range of services that include “evaluation, assessment, monitoring, prevention, intervention, supervision, education, consultation, and coaching.” The terminology may differ (e.g., teletherapy, teleSCI, telestroke) based on practice settings and business models. The aim of digital technology services that can be offered with TR should be to provide more accessible services and to coordinate and securely transfer knowledge between professionals, care providers, and consumers.
Telecommunication technologies and services are available to provide care for persons with disabilities or in need of rehabilitative services as a part of acute care, subacute care, or long-term follow-up, and TR has been shown to be effective for people with motor and neurological impairments and musculoskeletal conditions. Information and communication technologies that may be used to deliver rehabilitation services include synchronous communication, for example, video and audio conferencing, chat messaging, as well as asynchronous communication, for example, “store and forward” images for consultation, reviewing of data obtained from sensor and wearable technologies at a later time, and nonurgent messaging on patient portals. TR is delivered by a broad range of health care professionals that may include physicians, nurses, occupational therapists, physical therapists, psychologists, respiratory therapists, pharmacists, dieticians, social worker/care managers, and speech-language pathologists. Frequently, family members and caregivers are also involved in TR encounters.
TR services can be performed virtually anywhere rehabilitation services are provided. This can be in the emergency room or at a sporting event, if the local policy includes rehabilitation providers at this stage in a patient’s care. TR can also start prior to patient’s admission to an acute inpatient rehabilitation program. Using telecommunication technologies, such as videoconference meetings to an acute care hospital, a patient at home, or to a local municipality, can make it possible to personalize and customize an upcoming inpatient stay. Virtual care can also make it easier for inpatients to participate in rehabilitation even if they require isolation for infections or if they are immunocompromised. Evaluating a person’s home environment and collaborating with local care providers and thus planning discharge to the patient’s community is also an important part of the rehabilitation process that can be facilitated with TR. This is particularly important for persons with lifelong rehabilitation needs that occur in the individual’s home or local environment and not in a rehabilitation clinic.
The delivery of TR services can occur in many settings such as clinics, hospitals, homes, schools, therapy offices, long-term care facilities, and other community settings such as worksites. Multiple studies have shown that TR can improve adherence to treatment, improve physical and mental function and quality of life, and reduce health care costs, while maintaining patient satisfaction. Home-based TR may also reduce rehospitalizations and visits to the emergency department. For example, TR can decrease the frequency of exacerbation of conditions like chronic obstructive pulmonary disease (COPD). Therefore any patients with disability who are eligible for in-person rehabilitation should ideally be considered for TR.
Implementation of digital monitoring and TR services can improve the safety and quality of care, and simultaneously increase health care providers’ workflow efficiency. Still, the integration of ever-advancing technologies presents challenges to the health care system, and the successful implementation of digital technologies in TR is a complex and time-consuming process. Moreover, as newer digital technologies are deployed, the digital divide may widen and special considerations should be made for vulnerable populations including people with disabilities, migrants, or those that live in rural areas. Participation in TR should especially be encouraged for persons at high risk of complications, those who may have limited access to technology, the elderly, those with low socioeconomic status, and minorities.
Rehabilitation professionals and other stakeholders should be aware of the following key principles when developing and implementing a TR program ( Table 2.1 ).
|Key Principles||Telerehabilitation Program Phases|
|Administrative Principles||Development Phase|
|Clinical Principles||Implementation Phase|
|Technical Principles||Evaluation Phase|
Health care organizations and professionals should be aware of guidelines and standards set forth by their nationally recognized associations and other regulatory, credentialing, privileging, and accrediting requirements for licensing, professional liability, and professional development. Operational and/or contractual requirements should be followed during the implementation of the TR program. Any national and regional laws, professional regulations, and/or organizational policies must be followed with regard to informed consent. The scope of TR services should be established, including types of service being provided, type of technologies, capturing of video, audio, and/or photographic images, record keeping, privacy and security, billing arrangements, and support personnel. Organizations and professionals need to consider policies and/or procedures to determine the client’s location at the time of the encounter and establish a secondary mode of communication in the event of communication disruption. This is crucial for safety planning should a medical or domestic emergency arise. Any research activities that may occur with TR programs need to have the research protocol reviewed and approved by the local research/ethical review committee. On a periodic basis, the organization should review the TR program for risks, quality of service, and viability of the program. More detailed legal considerations are covered in Chapter 28 .
Health care professionals who will be using TR technologies should be trained in the operation and troubleshooting of the equipment they are using and in supporting the patient through troubleshooting their end device. Professionals performing TR services may need to modify educational materials or techniques that can be provided virtually. Having an appropriate facilitator (e.g., caregiver, family member, care manager) and/or interpreter may be necessary to meet the client’s needs and to facilitate TR encounters, and any additional persons accompanying and participating in the TR encounter need to be announced, recognized, and approved by both the client and the provider. Clients’ safety during TR encounters is paramount. If the professional notices that their client may be experiencing any distress, the virtual encounter may need to be terminated and the client directed to seek an appropriate local health care provider or emergency services.
Health care organizations and professionals should ensure that the equipment to be used is safe, sufficient, and functioning properly. This may include having ancillary or peripheral devices (e.g., sensor technologies, a blood pressure monitor, digital stethoscopes, etc.) that may be necessary for the encounter. Privacy and security measures should be in place and compliant with organizational, national, and/or local regulatory requirements. Policies and strategies should also be in place to address any need to update or modify the hardware, software, and/or peripheral devices.
Organizational values and ethics should be incorporated into the policies and procedures utilized for TR programs, and organizations and/or professionals should comply with any applicable laws, regulations, and codes of ethics. Clients should be informed of their rights and responsibilities and informed consent should be documented. Health care providers and their organizations should also reduce and eliminate any potential conflicts of interest associated with providing TR services.
Precautions to ensure privacy should be considered as they relate to the provider’s location (e.g., ensuring headsets are used if the provider is not working from a private office) and using platforms with end-to-end encryption. Furthermore, ensuring the patient is in a therapeutic environment is another nuanced issue, where providers may need to direct the caregiver to leave the room to allow the patient time and space to speak openly about their needs and concerns.
Other ethical considerations include patient autonomy and just and equitable distribution of resources. When using TR methods to a private home, the provider must remain cognizant of potential discomfort a patient may have about being seen in their home environment. Additionally, providers should be prepared to address concerns or refer the patient to resources if the home appears to be unsafe or unfit for a patient. Another prominent issue in the field of TR is the concept of the digital divide and how living in remote locations, poor infrastructure, disability, and lower socioeconomic status can impact the availability of patient-owned TR-enabled devices and access to reliable high-speed Internet. As organizations implement TR, they should consider how they might ensure equitable distribution of services for individuals with these particular barriers.
Types of Telerehabilitation
TR services can be categorized as follows:
Synchronous live videoconferencing —real-time virtual delivery of TR using audio-video technologies.
Asynchronous store and forward —consists of sharing of stored data, such as photographs and radiological images, and recorded visits.
eConsult —electronic messages initiated by a referring provider to a specialist with clinical questions.
Remote patient monitoring (RPM) —personal health and medical information collected on a client at a location is transmitted to a provider at another location for use in care and periodic monitoring of chronic conditions.
Mobile health (mHealth) —the practice of medicine, public health, and education supported by mobile devices such as cell phones and tablet computers.
TR support can also be grouped based on technologies that are used:
Voice only (telephone or mechanical voice),
Video plus voice (screen/videoconferencing),
Computer only (laptop/personal computer [PC]/tablets), and
Robotic voice or video (mechanical voice and/or animation).
The receivers and the modes of the TR services can be grouped into
Provider-to-provider (health care workers to health care workers or to other caregivers),
Direct-to-consumer (health care workers to patients),
Store and forward (transmission of information to health care receivers or users, not active live communication),
Web-based treatments (online treatment), and
Interactive home monitoring (patient educational program).
“Provider-to-provider” TR usually occurs between different departments or hospitals and is frequently used when specialty care is not available where the patient is. One of the most cited “provider-to-provider” TR services is telestroke. Despite stroke being the fifth most common cause of death and the leading cause of long-term disability in the world, and despite and significant advancement in stroke treatment, a limited number of specialists, especially in the rural areas, remains a barrier to evidence-based management. Telestroke programs provide services and management recommendations for patients with acute stroke at a remote site where a stroke physician is not onsite. In spinal cord injury (SCI), the “Hub and Spoke” model is sometimes used between local providers caring for persons with SCI directly and SCI specialists at a distant site, and similar models make sense for other populations of persons with uncommon disabilities.
“Direct-to-consumer” TR programs provide health care directly to clients with rehabilitation needs and can be done via synchronous live videoconferencing, telephone, or mHealth if there is the direct management of the clients by health care providers. With the COVID-19 pandemic, “direct-to-consumer” TR programs were implemented urgently in many locations in early 2020, and the number of TR encounters increased exponentially. Many examples of “direct-to-consumer” TR exist, for instance follow-up management of musculoskeletal disorders, SCI, or stroke where consumers are evaluated and treated via live videoconferencing, and the health care provider recommends changes to the individual’s care. Another example is telemental health, in which a psychologist or a counselor provides counseling via videoconferencing technologies. Speech therapy provided by a speech-language pathologist to the consumer via videoconferencing is also a well-researched service.
Asynchronous “store and forward” TR is frequently used for dermatological conditions like pressure injury (PI) or a rash where photographic images are transmitted to the provider either from the clients themselves or from another provider. Radiological images such as computed tomography images of persons with an acute stroke can be transmitted to a provider at a distant location in a “store and forward” manner. With the advancement of telecommunication technologies, clients can also send video recordings to providers for their review. In TR, and in areas where individuals live far from providers, this may be ideal when assessing clients’ mobility and equipment needs at their own residences.
Interactive home monitoring or RPM is a TR service in which a client transmits medical information such as blood pressure recordings, weight, glucose levels, catheterization volumes, or nutrition intake to a provider at another location for periodic monitoring to receive timely guidance. Often, this information is submitted to a third-party service that uses nurses or other health care professionals to preliminarily review the data and the physician is only notified in the case of an outlier. A specific example of RPM is the SAPHIRE system for cardiac rehabilitation in which patients exercise using a bicycle with a touch screen and wireless wearable sensors that monitor the patients’ blood pressure, oxygen saturation, and electrocardiogram in real-time. RPM is ideal for issues such as blood pressure management for poststroke patients, and for persons with SCI who have orthostatic hypotension and/or autonomic dysreflexia.
Web-based treatments can provide online monitoring and treatment based on the program used. Many online self-help type programs, smartphone apps, and web-based physical therapy exercise interventions have been developed. Particularly in cardiac and pulmonary rehabilitation, wearable sensors along with a web app enable patients to monitor pulse oximetry and other vital signs and facilitate self-management. In fact, some patients may prefer web or phone-based applications over information provided via computer, and even SMS text messaging has been found to be helpful.
Phases in Implementing a TR Program
There are three phases that should occur with developing and implementing a TR program: development phase, implementation phase, and evaluation phase (see Table 2.1 ).
Program Development Phase
Organizational Support and Funding of the Service
Rehabilitation services should be available for all individuals with disabilities. The organization of health care services should aim to have rehabilitation services available, no matter the geographical location of the consumers or caregivers. Leadership at health care systems including health information management, information technology, credentialing, therapy services, compliance, and billing should be involved early during the integration of telecommunication technologies into all clinical settings in the hospital. Moreover, all members of the multidisciplinary team should ideally be involved in the process of implementation of a TR program. Strong support from the health care organization’s leadership, especially financial support, is needed to establish a new TR program. This support ensures sufficient and adequate capacity, reasonable structure, and appropriate expertise in a way that will ensure that quality and patient safety are protected in the health care service. Thus far, around the world, funding to facilitate increased use of TR seems to have been insufficient, but there will undoubtedly continue to be a substantial increase in the use of TR in the future. The need for more TR visits in 2020 has led to an increase in the funding; however, there may still be a problem with the technological solutions between specialized health care services and regional services, including those provided by general health care providers.
Lack of framework and reimbursement had been a significant barrier to widespread adoption of all telemedicine services (including TR services) prior to the COVID-19 pandemic in many countries. Nevertheless, telemedicine expanded quickly in many countries around the world as many changes were made in privacy rulings and reimbursement structures. In the United States, pursuant to authority granted in the Coronavirus Aid, Relief and Economic Security (CARES) Act, the Centers for Medicare and Medicaid Services (CMS) waived the geographic and site of service originating site restrictions for Medicare telehealth services. These flexibilities allowed patients with Medicare to receive treatments from their homes. Additional flexibilities allowing teaching physicians to use synchronous telehealth (audio and video) technology to supervise residents during the pandemic further boosted adoption in academic medical centers and assisted in jump-starting the process of ensuring graduate medical education on this important topic. Similarly, changes in the reimbursement and regulations in countries such as the United Kingdom, Canada, France, and Italy have helped expand telemedicine to reduce patient hospital and clinic visits, allowing health care to be provided expediently via interactive telecommunications around the world (see Chapter 16 for information regarding Italy).
Telerehabilitation Needs Assessment
Worldwide, TR programs have been successfully implemented in many countries but some countries have challenges they may still need to overcome. As noted earlier, there are many different types of TR that can be implemented, which should be reviewed and considered. The needs of patients and the interest of providers for TR programs should be assessed including possible barriers such as regulatory framework, physical capability, regional broadband infrastructure, and level of technologic proficiency/acceptance of the patient population. In addition, providers should have an awareness of the prevalence of their patients who have telecommunication means and equipment. Performing a needs assessment is appropriate, and some of the more common barriers to implementation of TR are security and privacy issues, concern for the quality of services delivered, lack of evidence to support the effectiveness of TR, reimbursement and billing processes, and technological infrastructure challenges.
Establish Vision, Mission, Policies, Procedures, Implementation Strategies
A TR program that involves both originating and distant clinical sites should have a clear and shared vision of the TR program being implemented, and the scope of practice determined. The use of TR program leaders (frequently referred to as “champions”) has been recommended and these individuals should be identified, developed, and supported. Dedicated rehabilitation clinicians who are passionate about using remote technology and eager to improve health care services by virtual means should be frontliners. Detailed policies and procedures should be written and approved by the health care organization. Moreover, there is an abundance of resources that can be used to establish policies and procedures, such as guidelines from the American Telemedicine Association and the National Consortium of Telehealth Resource Centers in the United States and the World Health Organization.
Technology, for example videoconferencing, is a useful adjunct in coordination of the rehabilitation process. It can be used to optimize cooperation with local providers, consumer organizations, and other relevant stakeholders. Technology used should provide safe, effective, and predictable interactions that allow specialized health clinicians to share their expertise with providers at a local level. The implementation process should include consumers and other service recipients as active participants and allow the health care system to coordinate follow-up at local and regional levels.
Implementation, however, is not without challenges. Remedying the lack of organizational or facility infrastructure and required videoconferencing software, as well as installation and maintenance of new equipment, take both time and financial support. The coordination of TR can be time-consuming, not only in the initial implementation phase, but also during the maintenance of service delivery. There should be no doubt regarding legal responsibility for service and support, both in hospitals and in the local communities where consumers reside. Privacy, confidentiality, and ethical aspects must also be thoroughly safeguarded before a TR service is initiated. Health care organizations may require providers to obtain additional training and/or be approved for privileges specific to TR. In countries like the United States and Canada, providers must be licensed both in the state/jurisdiction they are practicing and in the state in which the care is being delivered (e.g., when care is provided across state lines) unless within the US Veterans Affairs system that is nationally based and has a legislative exception to this rule. In other countries, providers must also be licensed and the issue of performing health care services across international borders must be evaluated in each possible country-to-country communication. A risk assessment of medicolegal concerns before the initiation of any services is warranted. A prerequisite at the originating sites where the consumers are is a clear understanding of the responsibility of the local providers and for the technologies being used. TR guidelines should be developed and be updated and be continuously available on the organization’s web page.
Exploration and Implementation of Technology
Depending on the types of TR to be offered, equipment needs may vary. For example, common telecommunication equipment used includes PCs, tablet devices, smartphones, or laptops, and both PCs and laptops may require purchasing of webcams and/or a headset. Multiple platforms, such as Zoom, FaceTime, Microsoft Teams, Doximity, and systems that have patient privacy protection, are available for synchronous visits and there are telehealth systems that are embedded with common electronic medical record systems and their patient portals. If at all feasible, videoconferencing equipment should be provided to all rehabilitation providers including physicians, therapists, nurses, and care coordinators, and training for all participants who will provide services must be completed prior to their participation in a TR program.
A wired connection is preferred over WiFi, and the following minimum bandwidth speeds are recommended for different practice settings by the US Office of Health Information Communication and Technology. Factors to consider are number of users, user locations, real-time transactions, hardware, and storage technology.
Single physician practice: 4 megabits per second (Mbps)
Small physician practice (two to three physicians): 10 Mbps
Nursing home and rural health clinic (approximately five physicians): 10 Mbps
Clinic/large physician practice (5–25 physicians): 25 Mbps
Hospital: 100 Mbps
Academic/large medical center: 1000 Mbps
The American Telemedicine Association guidelines also recommend a minimum of 640 × 360 resolution and 30 frames per second for videoconferencing.
Instructions and checklists with a focus on ethical issues, professional quality, and safety for the participants should be prepared. Devices being used should have up-to-date security software, and the providers should have a back-up plan in place for an alternate method of communication in case video communication fails. A telemedicine team (TMT) should be available, and staff members on the TR team should be familiar with the TMT services. The TMT members should have specialized technological expertise, be readily available, and be included in all new clinical projects and feasibility studies. Potential errors and complexities regarding new solutions should be addressed promptly. Participating TR members should be included in all parts of the development of the service, and they should continue in maintaining the services after the technology has been implemented.
One challenge is finding ways to organize a seamless workflow and handoffs between disciplines, especially during the first visit for a provider new to TR. That is, a clerk/receptionist may arrive and register the patient first, then a nurse or medical assistant will usually interact with the patient. In an academic setting, a resident physician may see the patient next followed by the attending physician. In a multidisciplinary clinic, physical or occupational therapists may also engage with the patient in real-time, as needed. At the end, the patient usually needs to interact again with the nursing staff to close out the clinic visit and to schedule future appointments. Streamlined coordination between the members of the care team is preferred. When there are challenges with a seamless handoff, it is prudent to provide very direct communication to the consumers so they will know what to expect during these handoffs.
Program Implementation Phase
The following section will describe the implementation phase of general routine “direct-to-consumer” TR encounters ( Box 2.1 ). For those interested in establishing a telestroke program with its unique needs for stroke management, the reader is referred to ATA’s Practice Guidelines for Telestroke and to Chapter 4.9