Notes for Physios on the use of Tele-Rehab
Susan Coote, PhD
16th March 2020.
These notes aim to give you the key bits of information you need to consider if you are embarking on a tele-health/tele-rehab approach in the coming weeks and months. By tele I mean, telephone, internet based, app based – any technology that allows you to communicate with the patient remotely. These notes are prepared to give physios a sense of “what I do” and are not intended as a “how to” and should of course be considered in the context of your local professional standards and clinical guidelines. This is written in the Irish context as we react to the COVID-19 outbreak with a call to #stay at home and # act like you have it.
For the last 9 months I have been working with Salaso.ie and Novartis to design and deliver tele-rehab for people with MS and have had cause to read multiple studies and guidelines. The useful ones are referenced at the bottom and are incorporated in to the information below. If you are reading this and have other useful information to add please do so by contacting me on Twitter @susancoote or Facebook @susancooteresearch
My key message is that the actual consult can look very like the one that you have in a face to face session, the most obvious one being that you can’t be “hands on” for the assessment and treatment, but as much of my neurology assessment can be movement analysis based I haven’t found barriers to date.
The main difference is safety – safety of the patient as you are remote to them and safety of data.
Data considerations - What systems can I use?
I’ve been using Salaso.ie and understand that they are going to make their tele-health platform available to those who have their exercise prescription app/system already. They meet EU and US data standards. The key is that the data you exchange needs to be secure in transit and in situ – so during the call and afterwards. Data exchanges of confidential information may be less during a follow up call than during an initial assessment – so following up patients already known to you may have different needs than “seeing” a patient for the first time on tele-health.
The UK NHS has guidance on systems here and suggest that mobile messaging and video conferencing are ok
The HSE has some information here on data standards policy which may apply to those working within the HSE https://www.hse.ie/eng/services/publications/pp/ict/
The best advice on “standard” systems like phone, skype etc was from Prof Ita Richardson at UL’s LERO institute – “Better if you have Vidyo - a secure option. But given current circumstances may not be possible. Think about what you need to know - is there a secure way for patient to impart data. Possible to send to you beforehand? Think that others can tap into the session”. I have interpreted that to say that if you are not using a system that has integrated data standards into their platform (like Salaso has) then you need to presume that everything that is said/seen can be seen by others. Maybe you could send a subjective assessment questionnaire by e-mail first so that essential identifiers aren’t transmitted over the wider internet?
I have heard of some physios using Zoom to run classes and it seems to work well – remember that you need the consent of all participants to do that and remind them that any others in the room/house can be seen by everyone on the call if they walk past the camera. I think you should also let the participants know about the lack of data security so they can decide what to share (or not to) during the call.
Patient safety considerations
Generally, the guidelines recommend that you verify the patients’ identity – I do this by asking them to show a photo ID to the camera and note the ID type and DOB on it (or other identifier). For patients that you know from clinical practice this may not be as important. Like any other treatment you need consent, and specifically consent to treat using tele-rehab. The patient needs to explicitly know what is different between in face and tele-health encounters.
The two key safety considerations are that 1) you know where they are so that if they fall or hurt themselves that you could direct the appropriate help to them 2) that you have a way of contacting them if the call drops to check that they are ok. I routinely collect their Eircode, GP & consultant details and also the patients phone number so I can phone them if the call drops. I also encourage them to have a “buddy” at the venue if I am working on balance activities. That way I can bring in the buddy to stand by if needed, or could phone the buddy if the patient was to fall.
Below is an initial assessment script that I use:
Firstly there are some safety issues I need to go through with you before I do the initial assessment;
Verify ID – The first thing I need to is to confirm that I am talking to the right person, can you show me some photo ID with your date of birth on it please?
Type of ID _____________
Date of birth on ID ____________
ID confirmed __________________
Alternative contact method – In case we lose contact during a call, or in case something happens during the call I need a different way of contacting you – what would your preference be?
Contact information _______________________________________
Clarify buddy ID– As I’m not there with you and as there is a small risk of injury or falling I need to know who is in the house with you and how I can contact them, there will need to be someone there for the first exercise session, who will that be and how do I get in touch? ________________________________________________________________________________________________________________________________
I also need to know the exact location you will be exercising at for safety reasons in case of an emergency, what is the address and Eircode of where you will be exercising?
Great we are ready to get started, firstly I’d like your consent to do an initial assessment through a series of questions and then some tests that involve you moving around – is that ok?
There are studies out there that have compared in person and remote assessment in an MSK setting but I didn’t find any for a neuro setting. They found that remote assessment by and large gave similar results (or sufficient detail to allow treatment) to in person objective assessment.
The subjective history is essentially the same as if they were in the clinic and I use a similar method than I would if I was in private practice in the clinic.
The objective assessment is where the differences lie and for my neuro patients the main concern is safety due to balance issues. In my patient information leaflet and during a screening phone call (to assess eligibility for the specific programme and to run through a PAR-Q) I ask them to think where they can position the tablet/phone/laptop so that I can see their whole body and so that they have something to hold on to. The end of the kitchen counter has proven useful as has the kitchen table so the screen can be angled so they can walk towards the camera with the counter beside them if needed, or walk past it to get a side view. Think about what you need to “see” during the assessment.
Like my treatments in the clinic I encourage that balance exercises are done in the corner of a room to reduce falls risk, and that any standing exercises are done at a stable surface such as the kitchen sink or sturdy chair.
Similar to the assessment the key consideration during intervention is safety – think about who you are treating, what physical support they have where you can see them and what person support you might need if your treatment is about balance. If you are an MSK therapist then likely that won’t be as big of an issue for you.
I hope that these notes are of use to you and I welcome any feedback that you have on these and your tele-rehab experiences.
This is the most useful article that I found as it pulls tougher key papers and reviews
Clinical Guidelines and Guidance on E-Health and Tele-health/rehab
Irish Society of Chartered Physiotherapists https://mcusercontent.com/e85d2ee9781c179cbeb40fcde/files/7a3896b3-7908-4118-a886-7395cdf956c4/ISCP_E_Health_Guidelines_March_2020.pdf
European Region of WCPT
Federation of State Boards of Physical Therapy US
American Telemedicine Association guidelines
Telerehab resource guide Alberta, CA