“It’s important to remember that the alternative to telehealth for many is not in-person care, it is no care because of barriers.”
—Marla Kaufman, MD
Dr. Marla Kaufman, Medical Director & Clinical Associate Professor, Puget Sound VA Hub Site, Telerehabilitation Enterprise Wide Initiative (TREWI), picked up the AAPMR session on teleRehab where Dr. Tapia left off, emphasizing some of the nuts and bolts of an actual teleRehab visit.
The most obvious question is how the physical exam can be completed. In such a hands-on specialty, it can be hard to imagine how video medical visits can work.
Some physiatrists have found ways to modify the exam, while others use a telepresenter—a medical professional such as a nurse or physical therapist who can conduct the physical tests on video. But when patients require frequent visits, particularly with mental health or pain issues in play, these visits can improve patient experience and compliance.
She also emphasized the importance of having procedures in place before initiating teleRehab in your practice. For example, how will you handle medical emergencies? A simple 911 call isn’t an option when the patient is remote from you. What about suicidality? How will you intervene when the patient is in a distant setting? Knowing how you will handle such situations ahead of time is the key to maintaining control of the circumstances, even when your patient is far away.
Other issues that may arise that you should have processes established before initiating teleRehab might include:
- Privacy concerns: Is the patient using a public computer or are family members around?
- Distracted patients: Is your patient able to give full attention to the appointment when not in a typical exam room?
- Abnormal medical findings: How will you further investigate when the exam doesn’t proceed as expected?
- Patient not treating it like a real visit: Do you have patient buy-in for this method of care?
There are also ethical considerations to keep in mind as you consider how teleRehab fits into your doctor bag.
The Ryan Haight Online Pharmacy Consumer Protection Act of 2008 was created after a young man used controlled substances prescribed via telemedicine to commit suicide. According to the act, the physician must conduct an initial in-person medical visit before prescribing controlled substances, and they must follow-up with in-person visits at least every 24 months, even if telemedicine visits happen regularly. In addition, a wise physician will have their own policies in place and heed those of their institution when it comes to how controlled substances will be prescribed and their use monitored.
Another ethical issue is how to share difficult news with patients. One doctor chose to share upsetting news with a patient via video chat and made the New York Times. The use of telemedicine shouldn’t be allowed to remove the human touch from medicine.
These issues should prompt careful consideration about the ethical best practices you will follow if you incorporate teleRehab into your practice
With that in mind, Mary Matsumoto, MD, Assistant Professor at the University of Minnesota, and Joel Scholten, MD Director, Physical Medicine & Rehabilitation for the Department of Veterans Affairs in Washington, D.C., outlined the many opportunities that teleRehab has to add value to the care that the physiatrist provides. In addition to basic follow-up care for things such as medication titration and imaging review, it can also be used to facilitate collaboration between interdisciplinary teams and to improve access to specialists. It can also help improve attendance at family team meetings when key members might not otherwise be able to attend due to other obligations such as work.
No one can predict every issue that may arise with the use of technology in a new setting. So, Kaufman recommends reviewing, revising, and being flexible while continuing to establish best practices. Use the literature and the experience of other providers to best understand the evidence that does exist.
With care and planning, teleRehab can improve quality and access to care while maintaining the safety of patients and protecting their best interests.
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