- Email: [email protected]
Telehealth in Physical Medicine and Rehabilitation: A Narrative Review
PM R 9 (2017) S51-S58
www.pmrjournal.org
Clinical Informatics in Physiatry
Telehealth in Physical Medicine and Rehabilitation: A Narrative Review Adam S. Tenforde, MD, Jaye E. Hefner, MD, Jodi E. Kodish-Wachs, MD, Mary A. Iaccarino, MD, Sabrina Paganoni, MD, PhD
Abstract Telehealth refers to health care interactions that leverage telecommunication devices to provide medical care outside the traditional face-to-face, in-person medical encounter. Technology advances and research have expanded use of telehealth in health care delivery. Physical medicine and rehabilitation providers may use telehealth to deliver care to populations with neurologic and musculoskeletal conditions, commonly treated in both acute care and outpatient settings. Patients with impaired mobility and those living in locations with reduced access to care may particularly benefit. Video-teleconferencing has been shown to be effective for management of burn patients during acute rehabilitation, including reduced health care use expenses and less disruptions to care. Telehealth can facilitate developing interprofessional care plans. Patients with neurologic conditions including stroke, spinal cord injury, traumatic brain injury, and amyotrophic lateral sclerosis may use telehealth to monitor symptoms and response to treatment. Telehealth also may facilitate occupational and physical therapy programs as well as improve weight management and skin care in patients with chronic conditions. Other applications include imaging review in sports medicine, symptom management and counseling in concussion, traumatic brain injury, and pain management programs. Limitations of telehealth include barriers in establishing relationship between medical provider and patient, ability to perform limited physical examination, and differences in payment models and liability coverage. The expansion of telehealth services is expected to grow and has potential to improve patient satisfaction by delivering high quality and value of care.
Introduction Maximizing function and quality of life via a patientcentered team approach are fundamental principles in the practice of physical medicine and rehabilitation (PM&R) [1]. Achieving these goals with our patients is sometimes challenging in practice because a patient’s ability to treat and manage his or her health does not exist solely in the confined location of hospitals and outpatient clinics but also in the schools, homes, markets, pharmacies, and communities. A patient’s interactions with health care today may be limited by a number of factors, including geography, time, finances, and access to technology. Yet, a patient’s success with managing his or her health depends on a combination of social and physical determinants, including transportation access, literacy, and social support [2]. Telehealth (which encompasses telerehabilitation, telecare, teleconsult, telemedicine, and remote nonclinical
services) is a method of care delivery that increases access to health care services and may support and facilitate patient-centered care [3]. Telehealth-enabled care delivery leverages telecommunication devices to provide medical care outside the traditional face-to-face, in-person medical encounter. Health care delivery for a patient using telehealth may include the combination of history, modified physical examination, diagnostic testing, assessment, and management. Patient treatment and longitudinal care using telehealth include behavioral medicine,[4], medications [5], patient education [6], and shared decision making [7]. Medical care and active decision-making may be provided either synchronously (real-time interaction) or asynchronously (communication between a patient and provider is conducted at different times). Research providing the strongest evidence for telehealth, including telerehabilitation, was characterized by the Agency for Healthcare Research and Quality in
1934-1482/$ - see front matter ª 2017 by the American Academy of Physical Medicine and Rehabilitation http://dx.doi.org/10.1016/j.pmrj.2017.02.013
S52
Telehealth in Physical Medicine and Rehabilitation
June 2016 [8]. The authors of this report concluded systematic reviews demonstrate moderate evidence and potential benefit of delivering telerehabilitaion care for cardiovascular disorders and other conditions commonly treated in PM&R. Research providing strongest evidence for telehealth applications was in remote monitoring, communication, and education/counseling for chronic conditions including cardiovascular disease and diabetes. Positive outcomes associated with telehealth included reduction of hospitalization admissions, mortality, and possible cost effectiveness using telerehabilitation [8]. An earlier 2009 report in Canada characterized the effectiveness of telehealth applications for specialties that share patient populations commonly seen by physiatrists including neurology, cancer, pulmonary, mobility, and chronic pain. Of the highest-quality studies, 81% were successful, with 47% having clinically significant outcomes [9]. Other studies have documented use of this technology for both acute and chronic conditions commonly seen by physiatrists, including burn rehabilitation [10], amyotrophic lateral sclerosis (ALS) [11], disorders of consciousness [12], spinal cord injury (SCI) [13], musculoskeletal [14] and spine conditions [15], and chronic pain [16]. The purpose of our narrative review is to characterize the current knowledge of telehealth applications and outcomes in health care delivery for patients seen in the field of PM&R. Our review includes an introduction on health care delivery of telehealth. Subsequently, we outline current evidence based on available literature for treatment of both inpatient and outpatient neurologic and musculoskeletal conditions. We conclude with a summary of the current state of telehealth for health care delivery and future directions of research to optimize patient care and efficiency. Telehealth in Health Care Delivery Telehealth uses technology to deliver medical care outside the traditional in-person patient visit and continues to evolve in capacity over time. There is no formal structure for delivery of telehealth; delivery may use one or more available technologies. Telehealth capacity changes rapidly and is facilitated by the growth of technology; however, the basic mechanism for delivery of telehealth includes a mode of communication between the involved parties by which data are exchanged. The exchange of data may be in numerous forms, including written, audio, visual, or haptic (data obtained from patient contact with technology). Technologies such as e-mail, cellular texting, traditional phone lines, videoconferencing, cameras, 3-dimensional motion sensors, sensors, global positioning systems, robotics, and virtual reality each offer a different type of data exchange. Pramuka and Van Roosmalen describe
[17] how clinical application influences the pairing of technologies for health care delivery. For example, incorporating a physical examination into telehealth encounter may be achieved with both visual and haptic data in addition to audio data. Chronic disease monitoring may use sensor data in addition to audio or text sources. In contrast, provider-to-provider remote team conference may involve teleconferencing. Understanding the clinical need is critical to the technology selection and the data mode being used. The delivery of telehealth is dependent on both the adoption of access to the technology used by the patient. Users also must have the desire to use the telerehabilitation technology, including access to hardware and ability to install software along with support for troubleshooting. Providing a framework to facilitate this technology is important for user adoption. For example, patients may need instructions on how to most effectively use video teleconferencing tools or applications to initiate the conference and to share the screen [17]. Technology usability for people with illness and disability may require additional adaptations and modifications. Passwords may be challenging for someone with cognitive deficits; other forms of security identification such as biometric data, including fingerprints, may be more appropriate. Patients with dysarthric speech may not be able to use voice-recognition solutions and may require augmentative or alternative communication devices to be incorporated into routine telehealth delivery of care. Therefore, the pairing of technology and data delivery must be individualized to patient-specific needs. Acute Care Indications The field of neurology is largely responsible for the introduction of telehealth to health care with the successful implementation of telestroke programs to deliver acute stroke care in remote locations [18]. Telestroke is now an established modality of care with growth in leading neurology departments [19] and allows for delivery of prompt emergency stroke care in geographic regions that have low coverage of neurology providers [20]. A meta-analysis of studies evaluated management of acute ischemic stroke patients with intravenous thrombolysis using tissue plasminogen activator delivered through telestroke networks. This study concluded similar outcomes at 3 months for patients managed by telestroke compared with stroke center-guided thrombolysis of intravenous tissue plasminogen activator delivered in the 3-hour time window [21]. Additional studies suggest that telestroke is costeffective [22-24]. Telehealth also is used increasingly to increase access to specialized care for acute neurologic symptoms. Consultation with remote neurologists for patients admitted to rural hospitals to work-up and manage neurologic symptoms results in shorter hospital
A.S. Tenforde et al. / PM R 9 (2017) S51-S58
stay and no increase in mortality [25]. In addition, the diagnosis of each patient by the neurologist using video link agreed with the follow-up in-person visit [25]. Inpatient Rehabilitation One promising, innovative use of telehealth is in the acute inpatient rehabilitation setting to meet regulations for health care delivery. As the result of economic forces, major changes in health care delivery have resulted in shortened lengths of acute care inpatient stays and a shift of care to lower-cost settings. The Affordable Care Act [26] has directed health care delivery systems to focus on the Triple Aim [27]: improved population health, improved patient experience (including quality and satisfaction), and reduced per capita cost of health care. Postacute care, including acute inpatient rehabilitation, has been of increased interest to policy makers as a result of a 2013 Institute of Medicine report that identified the sector as the source of 73% of the variation in Medicare spending [28]. Towards that end, health care systems have focused on integrating and improving the patient’s experience and services in the continuum of care with an overall reduction in total medical expense. Targeted interventions include reducing preventable readmissions; improving the process of decision-making regarding which patients need postacute hospitalization; improving transitions in care; and enhancing care delivery in the postacute setting. The few studies characterizing telehealth for acute inpatient rehabilitation are limited to select patient populations and primarily use videoconferencing. The populations studied include patients with stroke, burn, and SCI in both acute-care and outpatient settings [29-34]. Telerehabilitation studies have followed traditional telehealth models by focusing on the evaluation of means to facilitate and enable rehabilitation specialists to provide services to patients in rural and/or remote settings [35-37]. Telehealth platforms studied for use in the acute inpatient rehabilitation setting were limited to video-teleconferencing (VTC), commonly referred to as videoconferencing. VTC use interactive and high-quality bidirectional audiovisual systems. Studies also focused on 2 use-cases in the acute inpatient rehabilitation setting: VTC with virtual specialist consultants (patient to provider) and VTC for interprofessional conferences (specialist to rehabilitation team with or without patients). Burn rehabilitation (also referred to as teleburn) is an important model to understand how VTC can be used in postacute care within the inpatient rehabilitation setting. Liu et al [10] studied a total of 29 burn patients participating in 73 VTC visits from March 2013 to March 2014 through a VTC acute-care burn hospital to acute inpatient rehabilitation program and measured improvements in patient’s experience, reduced costs, and
S53
enhanced health care services [10]. VTC visits included a burn consultant and burn patient using this technology for new consults, preoperative evaluations, and postoperative follow-ups. During the study period, total transportation cost savings of $101,110 were achieved by eliminating 146 ambulance transports between the burn hospital and the rehabilitation hospital. The reduced time required to complete virtual visits resulted in estimated savings of 6.8 outpatient burn clinic days. Access to telehealth facilitated earlier discharge of burn patients to the rehabilitation hospital. As a result, 80 inpatient bed days were estimated as saved at the burn hospital. The rehabilitation hospital saved an average of 2.5 patient days by eliminating travel. Notably, no unplanned or preventable readmissions from the rehabilitation hospital to the burn hospital were observed during the study date, and satisfaction surveys demonstrated 100% patient satisfaction primarily related to time saved from travel. The rehabilitation care plan for each patient also had reduced disruptions with resulting improved efficiency at the rehabilitation facility [10]. In addition to direct patient health care delivery, VTC can be used to facilitate developing interprofessional care plans (ICPs) within the acute care setting [38]. The ICP purpose is to develop objectives and intervention to guide rehabilitation and community reintegration. The ICP facilitates communication and can be used to manage patient and family expectations and to guide observations and treatment plan of the interprofessional team. Both geography and schedules can create difficulties in developing an ICP. Careau et al [38] evaluated using VTC (providers to providers with patient) with the goal of developing ICPs. The authors identified several key factors: productive discussion based on common objectives; establishing clear roles and active involvement of the patient and all team members; and the presence of a leader to ensure the meeting is structured and disciplined to facilitate communication among team members [38]. The available literature suggests telehealth in the inpatient rehabilitation setting has the potential to integrate specialty services across the continuum of care. For example, the teleburn study suggests improved patient experience with reduced costs of care [10]. Communication may be enhanced and facilitated within the rehabilitation team, including patients and families, by the use of telehealth VTC [38]. Outpatient Neurorehabilitation On discharge from acute rehabilitation hospitals, a substantial portion of patients who have sustained neurologic injury (including stroke, traumatic brain injury [TBI], and SCI) require long-term outpatient rehabilitation. This patient population often is treated at tertiary centers including acute care and acute inpatient
S54
Telehealth in Physical Medicine and Rehabilitation
rehabilitation hospitals that are located far away from the patients’ residence. Although these centers provide access to specialized acute and postacute rehabilitation for a few weeks, on discharge home patients often have no longer access to the inpatient team as the result of geographic distance compounded by loss of mobility and functional independence that often accompanies neurologic injury. These barriers may have a negative impact on the patient’s rehabilitation program. Telehealth may serve as a method to address these barriers to follow-up care in long-term management of patients with neurologic conditions. Although the impact of telehealth on the chronic management of neurologic disease is less well characterized, a few studies have explored the feasibility of remote medication management in selected neurologic patient populations including Parkinson disease [39-41] and epilepsy [42]. In a small trial of patients with Parkinson disease, videoconferencing was used to provide specialty care at home [41]. On average, each telehealth visit saved participants 100 miles of travel and 3 hours of time [41] compared with an in-person visit. Outcomes were comparable with usual care in terms of quality of life and motor symptoms [39-41]. A study in epilepsy demonstrated substantial patients’ savings in traveling and lost productivity in the telehealth group compared with the usual-care group [42]. In addition, telehealth may be effective for patient populations with neurologic diseases that include dynamic aspects such as community reintegration that require long-term guidance from an expert rehabilitation team, such as patients with SCI [43]. Moreover, neurodegenerative conditions have an increasingly negative impact on multiple functional domains with disease progression, thus requiring continued adjustments to the rehabilitation plan. Several studies have explored the impact of telerehabilitation on neurologic care although most have focused on patient populations with impaired mobility to facilitate multidisciplinary care. Telerehabilitation can be implemented by direct patient-care via VTC. The benefits of this approach include face-to-face time between the clinician and the patient via the web, and reduced burden of time and financial resources by eliminating the need to travel. Pilot studies have suggested that this approach allows the effective delivery of care in neurologic conditions such as ALS [44] and SCI [45]. The U.S. Department of Veterans Affairs has been at the forefront of this approach and has implemented several VTC programs that have enhanced the multidisciplinary care of veterans with TBI [46] and stroke [47]. An important feature of VTC is that it can be used as a method to enhance rehabilitation programs by allowing physical therapists and occupational therapists more frequent contact with patients via “virtual therapy sessions” as shown in a few pilot studies in SCI [48-50]. Similar clinical trials are underway to test the
impact of remote therapy sessions on functional recovery in stroke patients [51]. An emerging modality for telehealth is the use of applications or automated telephone call/messaging programs to provide educational material, instructions, and reminders so that patients can more effectively engage in rehabilitation programs. This modality has been piloted successfully in SCI, where the implementation of automated call programs resulted in reduction of pressure ulcers [52] and improved weight management [53]. Pilot studies also have begun to test the impact of Web-based applications on symptom management in TBI [54,55], skin care in spina bifida [56,57], mobility in stroke [58], and multidisciplinary care in patients with chronic disability [59]. Remote monitoring also can focus on selected physiologic parameters to inform adjustments to the rehabilitation plan. As an example, remote guidance for management of assisted ventilation was shown to be feasible and cost-effective in patients with ALS [11,60,61]. Outpatient Musculoskeletal Care and Sports Medicine In sports medicine, telehealth can be effective for management of musculoskeletal conditions including physical therapy and review of diagnostic imaging studies. Telehealth has been used for delivery of physical therapy services with a recent pilot study assessing telehealth services for rotator cuff injury [62]. Diagnostic imaging review between provider and patient of previous physical examination findings can be readily conducted via telehealth. Telehealth software allows the provider to share images with the patient through the computer interface. This form of visit allows providers to review images and discuss results without the patient coming into the office. Although studies to evaluate the use of telehealth in sports and musculoskeletal clinics are not available, a similar algorithm called teleradiology has been used for multiple decades. Teleradiology has been shown to have similar diagnostic accuracy as imaging studies interpreted by providers within the same health care system [63,64]. Although teleradiology uses a provider-to-provider model (remote radiologists read imaging studies and consult with ordering physicians), a similar provider-topatient interaction in the sports medicine setting is equally feasible and may facilitate timely and convenient follow-up of diagnostic imaging. Telehealth has potential broad application in management of acute sports medicine conditions including sport concussions. For example, increased concussion awareness has lead to local and state mandates for the evaluation of student athletes by specialized concussion provider prior to return to play. Access to specialty care, however, can be limited. A recent case study found that the use of a video telehealth interface was feasible in providing specialty evaluation of a concussed high school
A.S. Tenforde et al. / PM R 9 (2017) S51-S58
athlete residing in a rural community [65]. Research documenting success in neurosurgical triage in TBI [66] has been reported and suggests feasibility in assessing acute neurologic conditions using telehealth. Early assessment by a medical concussion specialist has the potential to improve concussion recognition, remove athletes from play, and triage those injuries that require emergency room transfer verses those that may be observed by athletic training staff or parents. Although outcome-based studies validating the success of this model are lacking, a pilot program is underway to test the use of telehealth for sideline evaluation of concussion [67]. In addition to acute management, a subset of patients with persistent concussion symptoms may be appropriate for use of telehealth for chronic care. The primary focus in the subacute and chronic settings of concussion care is management of symptoms. Telehealth may allow providers to evaluate chronic symptoms, formulate treatment plans, provide patient and family education, guide return to school or work, and prescribe graded exercise for return to play. Chronic headache management via telehealth was found to be as effective as in-office treatment for patients in a rural setting [68]. The use of follow-up phone calls for symptom management in patients diagnosed with mild TBI resulted in decreased symptoms at 3 months [69]. Telehealth also may offer the opportunity for multidisciplinary concussion care. Both cognitive rehabilitation [70,71] and psychotherapy [72,73] services are important adjunctive treatments for concussion and have been delivered via the telehealth platform for patients with more severe TBI; extrapolating these findings to use of telehealth for managing patients with concussions suggests a potential role for treatment. Important barriers to address in the use of telehealth for the management of concussion may be learned from a study by Martinez et al [46], where investigators studied providers who used telehealth to treat veterans with mild TBI. Perceived barriers impeding telehealth success included loss of the physical examination, difficulty scheduling patient appointments, and clinic setup. Although validation models for comprehensive treatment of persistent concussion symptoms has not been reported to date, the individual components of multidisciplinary concussion care have been successfully delivered via telehealth. Pain management evaluation and treatment also may be facilitated through telehealth. In a study of patients with chronic musculoskeletal pain, patient telephone consultation with a specialty pain nurse reduced pain by improving use of nonopioid analgesic medications [74]. Opioid use was not different between treatment groups and median dose of opioids did not increase during the 12-month intervention [74]. In patients with chronic neck pain, the addition of telehealth follow-up to a prescribed home exercise program reduced pain symptoms and disability at 6 months and increased patient
S55
compliance with the home exercise program [15]. A pilot program explored the use of a video telehealth pain clinic between an academic medical center and a rural island community to establish care and provide remote pain consultation [75]. Compared with in-person visits, patients reported a high degree of satisfaction with “telepain,” although ratings were lower both for overall care received and ability to develop a friendly relationship with the provider. Addressing education barriers in pain medicine education for medical providers may be enhanced using technology. For example, using telehealth to provide “telementoring” has been suggested as a method to delivering a pain medicine curriculum [76]. The current available literature for sports, spine, and pain management suggests potential uses in telehealth for patient care that does not require extensive patient contact to perform the physical examination. Telehealth can be used to review diagnostic imaging with patients when the physical examination is not needed. Monitoring symptoms to pain management and treatment of longterm symptoms of concussions are two areas with particular promise. Current Limitations of Telehealth Our narrative review focuses on the most relevant articles pertinent to conditions seen in PM&R practices. Published studies are limited evaluating use of telehealth in the area of PM&R. Gaps in knowledge and research to understand the patients who will have most favorable responses are needed. Additional studies are necessary to evaluate targeted telehealth interventions to reduce preventable readmissions and enhance care delivery in the inpatient rehabilitating setting and to facilitate transfer of care. Telehealth VTC use by physiatrists also may provide valuable specialty services to patients in the long-term acute care, skilled nursing facility, and home care settings. Teleradiology and telehealth use for neurologic conditions including stroke and TBI are suggestive of potential uses in outpatient neurologic, musculoskeletal, and sports medicine practice but require formal studies to determine efficacy. Telehealth itself does not have a standardized definition in the literature, and the use of this technology varies between providers and patient populations; determining clinical outcomes compared with in-person traditional visits is challenging to quantify. Research is needed to determine appropriate use and efficacy for conditions treated by physiatrists. Future research should focus on outcome measures such as cost, quality, value, as well as patient and provider satisfaction In addition to understanding best practice for specific patient populations, we recognize current limitations in adopting telehealth services. Reimbursement is not available in all states and has not been covered by Medicare payment model; however, insurance and other
S56
Telehealth in Physical Medicine and Rehabilitation
payers are expanding payment and framework for delivering telehealth services. There is variability in coverage of telehealth across state lines and whether the physician-patient relationship was previously established during traditional in-person initial visit. Medicolegal factors are important to address to protect the provider and health care system. Despite these challenges, telehealth continues to grow and will alter the health care landscape. We encourage physiatrists to be receptive to adopt use of the technology in practice.
Conclusion
Future Directions
Acknowledgments
Telehealth has an opportunity to enhance medical care through a combination of high patient satisfaction, providing quality medical care with reduced costs resulting in high value services. Patients can maintain a provider-patient interaction through communication that is portable, minimizing time of travel and lost productivity in work. One recent study estimated total time for a clinical encounter takes over 2 hours, yet 20 minutes is spent directly with the physician [77]. Telehealth can provide an alternative to maintaining care with adverse weather conditions that would make travel for in-person visits unsafe or impractical or for individuals limited in ability to travel due to geography, resources or impairments in mobility. Infrastructure costs are minimal for the medical provider who uses secure software to conduct the encounter and requires minimal use of ancillary staff to conduct the visit. Although patients and providers often celebrate innovation in medical care, often these services and products are accompanied by greater costs. In contrast, appropriate use of telehealth has the potential to enhance care and may potentially lower overall costs to the medical system. Expansion of telehealth may meet these goals to optimize patient care and outcomes. Telehealth is expected to contribute to the future care physiatrists provide patients. Patients with limited access to physiatrists will benefit from expansion of telehealth to improve access to care. Patient education and delivery of care may be enhanced to improve functional outcomes. The notable increase in publications focused on telehealth for chronic neurologic conditions and high degree of user satisfaction [20,78,79] will likely lead to increasing adoption of telehealth for long-term rehabilitation of patients with neurologic disease. Documented use of telehealth in burn rehabilitation patients at our institution [10] suggests value for use in the acute rehabilitation setting. Communication in family meetings and ICP may be enhanced using VTC [38], including improved ease for providers when this care is delivered off-site. Our experiences in use of telehealth for imaging review in management of sports conditions, providing care to individuals with impaired mobility and guiding symptom management in patients with concussion suggests these may be effective uses for telehealth.
A.S.T., J.E.H., M.A.I., and S.P. would like to acknowledge the efforts at our institution Spaulding Rehabilitation Hospital (SRH), in collaboration with Massachusetts General Hospital Telehealth Division and supported by the Massachusetts General Physician Organization (MGPO), who have implemented the telehealth platform to perform “Virtual Visits.”
There are promising applications for telehealth for PM&R in both inpatient and outpatient settings. Telehealth is a rapidly growing technology that will alter the delivery of health care. Future research is required to evaluate methods to best use telehealth for specific patient populations. Patients and providers are expected to benefit as use of this technology expands.
References 1. American Academic of Physical Medicine and Rehabilitation. FAQs About Physiatry Available at http://www.aapmr.org/aboutphysiatry/about-physical-medicine-rehabilitation/faqs-about-physiatry - 1. Accessed November 22, 2016. 2. Office of Disease Prevention and Health Promotion. Healthy People 2020. Healthy People 2020. Available at https://www.healthypeople. gov/2020/topics-objectives/topic/social-determinants-of-health. Accessed November 22, 2016. 3. HRSA. Telehealth November 2015 [June 17, 2016]. Available at http:// www.hrsa.gov/ruralhealth/telehealth/. Accessed November 22, 2016. 4. Brenes GA, Danhauer SC, Lyles MF, Hogan PE, Miller ME. Telephone-delivered cognitive behavioral therapy and telephonedelivered nondirective supportive therapy for rural older adults with generalized anxiety disorder: A randomized clinical trial. JAMA Psychiatry 2015;72:1012-1020. 5. Dharmar M, Kuppermann N, Romano PS, et al. Telemedicine consultations and medication errors in rural emergency departments. Pediatrics 2013;132:1090-1097. 6. Steffen LE, Boucher KM, Damron BH, et al. Efficacy of a telehealth intervention on colonoscopy uptake when cost is a barrier: The Family CARE Cluster Randomized Controlled Trial. Cancer Epidemiol Biomarkers Prev 2015;24:1311-1318. 7. Veroff D, Marr A, Wennberg DE. Enhanced support for shared decision making reduced costs of care for patients with preferencesensitive conditions. Health Aff (Millwood) 2013;32:285-293. 8. Totten AM, Womack DM, Eden KB, et al. Telehealth: Mapping the Evidence for Patient Outcomes From Systematic Reviews. Technical Brief No. 26. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2015-00009-I.) AHRQ Publication No. 16-EHC034-EF. Rockville, MD: Agency for Healthcare Research and Quality; June 2016. Available at, www.effectivehealthcare.ahrq.gov/ reports/final.cfm. Accessed November 22, 2016. 9. Hailey D, Roine R, Ohinmaa A, et al. Evidence on the effectiveness of telerehabilitation applications Alberta, Canada: Institute of Health Economics; 2010 Available at http://www.ihe.ca/ publications/evidence-on-the-effectiveness-of-telerehabilitationapplications. Accessed November 22, 2016. 10. Liu YM, Mathews K, Vardanian A, et al. Urban telemedicine: The applicability of teleburns in the rehabilitative phase. J Burn Care Res 2017;38:e235-e239.
A.S. Tenforde et al. / PM R 9 (2017) S51-S58 11. Pinto A, Almeida JP, Pinto S, Pereira J, Oliveira AG, de Carvalho M. Home telemonitoring of non-invasive ventilation decreases healthcare utilisation in a prospective controlled trial of patients with amyotrophic lateral sclerosis. J Neurol Neurosurg Psychiatry 2010;81:1238-1242. 12. Zucchella C, Di Santis M, Ciccone B, et al. Is telemonitoring useful for supporting persons with consciousness disorders and caregivers? A preliminary observational study in a real-life population. J Telemed Telecare 2016 Oct 12 [Epub ahead of print]. 13. van de Pol E, Lucas K, Geraghty T, et al. The delivery of specialist spinal cord injury services in Queensland and the potential for telehealth. BMC Health Serv Res 2016;16:29. 14. Cottrell MA, Galea OA, O’Leary SP, Hill AJ, Russell TG. Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: A systematic review and meta-analysis. Clin Rehabil 2016 May 2 [Epub ahead of print]. 15. Gialanella B, Ettori T, Faustini S, et al. Home-based telemedicine in patients with chronic neck pain. Am J Phys Med Rehabil 2016 August 31 [Epub ahead of print]. 16. Choi Yoo SJ, Nyman JA, Cheville AL, Kroenke K. Cost effectiveness of telecare management for pain and depression in patients with cancer: Results from a randomized trial. Gen Hosp Psychiatry 2014;36:599-606. 17. Pramuka M, van Roosmalen L. Telerehabilitation technologies: Accessibility and usability. Int J Telerehabil 2009;1:85-98. 18. Hess DC, Audebert HJ. The history and future of telestroke. Nat Rev Neurol 2013;9:340-350. 19. George BP, Scoglio NJ, Reminick JI, et al. Telemedicine in leading US neurology departments. Neurohospitalist 2012;2:123-128. 20. Davis LE, Coleman J, Harnar J, King MK. Teleneurology: Successful delivery of chronic neurologic care to 354 patients living remotely in a rural state. Telemed J E Health 2014;20:473-477. 21. Kepplinger J, Barlinn K, Deckert S, Scheibe M, Bodechtel U, Schmitt J. Safety and efficacy of thrombolysis in telestroke: A systematic review and meta-analysis. Neurology 2016;87:1344-1351. 22. Nelson RE, Saltzman GM, Skalabrin EJ, Demaerschalk BM, Majersik JJ. The cost-effectiveness of telestroke in the treatment of acute ischemic stroke. Neurology 2011;77:1590-1598. 23. Demaerschalk BM, Switzer JA, Xie J, Fan L, Villa KF, Wu EQ. Cost utility of hub-and-spoke telestroke networks from societal perspective. Am J Manag Care 2013;19:976-985. 24. Nelson RE, Okon N, Lesko AC, Majersik JJ, Bhatt A, Baraban E. The cost-effectiveness of telestroke in the Pacific Northwest region of the USA. J Telemed Telecare 2016;22:413-421. 25. Craig J, Chua R, Russell C, Wootton R, Chant D, Patterson V. A cohort study of early neurological consultation by telemedicine on the care of neurological inpatients. J Neurol Neurosurg Psychiatry 2004;75:1031-1035. 26. Patient Protection and Affordable Care Act of 2010. Available at https://www.hhs.gov/healthcare/about-the-law/read-the-law/. Accessed December 8, 2016. 27. TIHI Triple Aim Initiative. Available at http://www.ihi.org/Engage/ Initiative/TripleAim/Pages/default.asp%. Accessed December 8, 2016. 28. Institute of Medicine. Variation in Health Care Spending: Target Decision Making, Not Geography. Washington, DC: The National Academies Press; 2013. 29. Schwamm LH, Holloway RG, Amarenco P, et al. A review of the evidence for the use of telemedicine within stroke systems of care: A scientific statement from the American Heart Association/ American Stroke Association. Stroke 2009;40:2616-2634. 30. Nguyen LT, Massman NJ, Franzen BJ, et al. Telemedicine follow-up of burns: Lessons learned from the first thousand visits. J Burn Care Rehabil 2004;25:485-490. 31. Saffle JR, Edelman L, Theurer L, Morris SE, Cochran A. Telemedicine evaluation of acute burns is accurate and cost-effective. J Trauma 2009;67:358-365.
S57
32. Syed-Abdul S, Scholl J, Chen CC, et al. Telemedicine utilization to support the management of the burns treatment involving patient pathways in both developed and developing countries: A case study. J Burn Care Res 2012;33:e207-e212. 33. Galea M, Tumminia J, Garback LM. Telerehabilitation in spinal cord injury persons: A novel approach. Telemed J E Health 2006;12: 160-162. 34. Woo C, Guihan M, Frick C, Gill CM, Ho CH. What’s happening now! Telehealth management of spinal cord injury/disorders. J Spinal Cord Med 2011;34:322-331. 35. Brennan DM, Mawson S, Brownsell S. Telerehabilitation: Enabling the remote delivery of healthcare, rehabilitation, and self management. Stud Health Technol Inform 2009;145:231-248. 36. Theodoros D, Russell T. Telerehabilitation: Current perspectives. Stud Health Technol Inform 2008;131:191-209. 37. Schopp LH, Johnstone BR, Merveille OC. Multidimensional telecare strategies for rural residents with brain injury. J Telemed Telecare 2000;6(Suppl 1):S146-S149. 38. Careau E, Vincent C, Noreau L. Assessing interprofessional teamwork in a videoconference-based telerehabilitation setting. J Telemed Telecare 2008;14:427-434. 39. Biglan KM, Voss TS, Deuel LM, et al. Telemedicine for the care of nursing home residents with Parkinson’s disease. Mov Disord 2009; 24:1073-1076. 40. Dorsey ER, Deuel LM, Voss TS, et al. Increasing access to specialty care: A pilot, randomized controlled trial of telemedicine for Parkinson’s disease. Mov Disord 2010;25:1652-1659. 41. Dorsey ER, Venkataraman V, Grana MJ, et al. Randomized controlled clinical trial of “virtual house calls” for Parkinson disease. JAMA Neurol 2013;70:565-570. 42. Ahmed SN, Mann C, Sinclair DB, et al. Feasibility of epilepsy follow-up care through telemedicine: A pilot study on the patient’s perspective. Epilepsia 2008;49:573-585. 43. Soopramanien A, Pain H, Stainthorpe A, Menarini M, Ventura M. Using telemedicine to provide post-discharge support for patients with spinal cord injuries. J Telemed Telecare 2005;11(Suppl 1): 68-70. 44. Nijeweme-d’Hollosy WO, Janssen EP, Huis in ’t Veld RM, Spoelstra J, Vollenbroek-Hutten MM, Hermens HJ. Tele-treatment of patients with amyotrophic lateral sclerosis (ALS). J Telemed Telecare 2006;12(Suppl 1):31-34. 45. Yozbatiran N, Harness ET, Le V, Luu D, Lopes CV, Cramer SC. A tele-assessment system for monitoring treatment effects in subjects with spinal cord injury. J Telemed Telecare 2010;16:152-157. 46. Martinez RN, Hogan TP, Lones K, et al. Evaluation and treatment of mild traumatic brain injury through the implementation of clinical video telehealth: Provider perspectives from the veterans health administration. PM R 2017;9:231-240. 47. Chumbler NR, Li X, Quigley P, et al. A randomized controlled trial on stroke telerehabilitation: The effects on falls self-efficacy and satisfaction with care. J Telemed Telecare 2015;21:139-143. 48. Van Straaten MG, Cloud BA, Morrow MM, Ludewig PM, Zhao KD. Effectiveness of home exercise on pain, function, and strength of manual wheelchair users with spinal cord injury: A high-dose shoulder program with telerehabilitation. Arch Phys Med Rehabil 2014;95:1810-1817.e2. 49. Yuen HK. Effect of a home telecare program on oral health among adults with tetraplegia: A pilot study. Spinal Cord 2013;51:477-481. 50. Dallolio L, Menarini M, China S, et al. Functional and clinical outcomes of telemedicine in patients with spinal cord injury. Arch Phys Med Rehabil 2008;89:2332-2341. 51. Koh GC, Yen SC, Tay A, et al. Singapore Tele-technology Aided Rehabilitation in Stroke (STARS) trial: Protocol of a randomized clinical trial on tele-rehabilitation for stroke patients. BMC Neurol 2015;15:161. 52. Houlihan BV, Jette A, Friedman RH, et al. A pilot study of a telehealth intervention for persons with spinal cord dysfunction. Spinal Cord 2013;51:715-720.
S58
Telehealth in Physical Medicine and Rehabilitation
53. Rimmer JH, Wang E, Pellegrini CA, Lullo C, Gerber BS. Telehealth weight management intervention for adults with physical disabilities: A randomized controlled trial. Am J Phys Med Rehabil 2013; 92:1084-1094. 54. Dexheimer JW, Kurowski BG, Anders SH, McClanahan N, Wade SL, Babcock L. Usability evaluation of the SMART application for youth with mTBI. Int J Med Inform 2017;97:163-170. 55. Pavliscsak H, Little JR, Poropatich RK, et al. Assessment of patient engagement with a mobile application among service members in transition. J Am Med Inform Assoc 2016;23:110-118. 56. Parmanto B, Pramana G, Yu DX, Fairman AD, Dicianno BE. Development of mHealth system for supporting self-management and remote consultation of skincare. BMC Med Inform Decis Mak 2015;15:114. 57. Yu DX, Parmanto B, Dicianno BE, Pramana G. Accessibility of mHealth self-care apps for individuals with spina bifida. Perspect Health Inf Manag 2015;12:1h. 58. Paul L, Wyke S, Brewster S, et al. Increasing physical activity in stroke survivors using STARFISH, an interactive mobile phone application: A pilot study. Top Stroke Rehabil 2016;23:170-177. 59. Fairman AD, Yih ET, McCoy DF, et al. Iterative design and usability testing of the iMHere system for managing chronic conditions and disability. Int J Telerehabil 2016;8:11-20. 60. Vitacca M, Paneroni M, Trainini D, et al. At home and on demand mechanical cough assistance program for patients with amyotrophic lateral sclerosis. Am J Phys Med Rehabil 2010;89:401-406. 61. Vitacca M, Comini L, Tentorio M, et al. A pilot trial of telemedicine-assisted, integrated care for patients with advanced amyotrophic lateral sclerosis and their caregivers. J Telemed Telecare 2010;16:83-88. 62. Macias-Hernandez SI, Vasquez-Sotelo DS, Ferruzca-Navarro MV, et al. Proposal and evaluation of a telerehabilitation platform designed for patients with partial rotator cuff tears: A preliminary study. Ann Rehabil Med 2016;40:710-717. 63. Bashshur RL, Krupinski EA, Thrall JH, Bashshur N. The empirical foundations of teleradiology and related applications: A review of the evidence. Telemed J E Health 2016;22:868-898. 64. Lefere P, Silva C, Gryspeerdt S, et al. Teleradiology based CT colonography to screen a population group of a remote island; at average risk for colorectal cancer. Eur J Radiol 2013;82:e262-e267. 65. Vargas BB, Channer DD, Dodick DW, Demaerschalk BM. Teleconcussion: An innovative approach to screening, diagnosis, and management of mild traumatic brain injury. Telemed J E Health 2012;18:803-806. 66. Yurkiewicz IR, Lappan CM, Neely ET, et al. Outcomes from a US military neurology and traumatic brain injury telemedicine program. Neurology 2012;79:1237-1243.
67. Anne. Available at https://vsee.com/blog/vsee-dell-ummc-telehealthconcussion-evaluation-high-school/. Accessed December 8, 2016. 68. Muller KI, Alstadhaug KB, Bekkelund SI. Telemedicine in the management of non-acute headaches: A prospective, openlabelled non-inferiority, randomised clinical trial. Cephalalgia 2016 June 14 [Epub ahead of print]. 69. Bell KR, Hoffman JM, Temkin NR, et al. The effect of telephone counselling on reducing post-traumatic symptoms after mild traumatic brain injury: A randomised trial. J Neurol Neurosurg Psychiatry 2008;79:1275-1281. 70. Bourgeois MS, Lenius K, Turkstra L, Camp C. The effects of cognitive teletherapy on reported everyday memory behaviours of persons with chronic traumatic brain injury. Brain Inj 2007;21:1245-1257. 71. Topolovec-Vranic J, Cullen N, Michalak A, et al. Evaluation of an online cognitive behavioural therapy program by patients with traumatic brain injury and depression. Brain Inj 2010;24: 762-772. 72. Tsaousides T, D’Antonio E, Varbanova V, Spielman L. Delivering group treatment via videoconference to individuals with traumatic brain injury: A feasibility study. Neuropsychol Rehabil 2014;24: 784-803. 73. Fann JR, Bombardier CH, Vannoy S, et al. Telephone and in-person cognitive behavioral therapy for major depression after traumatic brain injury: A randomized controlled trial. J Neurotrauma 2015; 32:45-57. 74. Kroenke K, Krebs EE, Wu J, Yu Z, Chumbler NR, Bair MJ. Telecare collaborative management of chronic pain in primary care: A randomized clinical trial. JAMA 2014;312:240-248. 75. Hanna GM, Fishman I, Edwards DA, et al. Development and patient satisfaction of a new telemedicine service for pain management at Massachusetts General Hospital to the island of Martha’s Vineyard. Pain Med 2016;17:1658-1663. 76. Katzman JG, Comerci G Jr, Boyle JF, et al. Innovative telementoring for pain management: Project ECHO pain. J Contin Educ Health Prof 2014;34:68-75. 77. Ray KN, Chari AV, Engberg J, Bertolet M, Mehrotra A. Disparities in time spent seeking medical care in the United States. JAMA Intern Med 2015;175:1983-1986. 78. Edgar MC, Monsees S, Rhebergen J, et al. Telerehabilitation in stroke recovery: A survey on access and willingness to use low-cost consumer technologies. Telemed J E Health 2016 October 5 [Epub ahead of print]. 79. Fairman AD, Dicianno BE, Datt N, Garver A, Parmanto B, McCue M. Outcomes of clinicians, caregivers, family members and adults with spina bifida regarding receptivity to use of the iMHere mHealth solution to promote wellness. Int J Telerehabil 2013;5:3-16.
Disclosure A.S.T. Harvard Medical School, Department of PM&R, Spaulding Rehabilitation Hospital, Charlestown, MA; 1575 Cambridge St, Room 9, Cambridge, MA 02138. Address correspondence to: A.S.T.; e-mail: [email protected] Disclosure: nothing to disclose J.E.H. Harvard Medical School, Department of PM&R, Spaulding Rehabilitation Hospital, Charlestown, MA Disclosure: nothing to disclose J.E.K.-W. Cerner Corporation, Kansas City, MO Disclosures outside of this publication: employment and personal fees, Cerner; patents, shared decision making (pending) and medication management (pending)
M.A.I. Harvard Medical School, Department of PM&R, Spaulding Rehabilitation Hospital, Charlestown, MA Disclosure: nothing to disclose S.P. Harvard Medical School, Department of PM&R, Spaulding Rehabilitation Hospital, Charlestown, MA; VA Boston Healthcare System, Boston, MA Disclosures outside this publication: consultancy, Roche ad hoc advisory board, clinical consultant for Pison Tech (money to author); payment for development of educational presentations, CME course Oakstone Publishing (money to author) Submitted for publication December 29, 2016; accepted February 24, 2017.
www.pmrjournal.org
Clinical Informatics in Physiatry
Telehealth in Physical Medicine and Rehabilitation: A Narrative Review Adam S. Tenforde, MD, Jaye E. Hefner, MD, Jodi E. Kodish-Wachs, MD, Mary A. Iaccarino, MD, Sabrina Paganoni, MD, PhD
Abstract Telehealth refers to health care interactions that leverage telecommunication devices to provide medical care outside the traditional face-to-face, in-person medical encounter. Technology advances and research have expanded use of telehealth in health care delivery. Physical medicine and rehabilitation providers may use telehealth to deliver care to populations with neurologic and musculoskeletal conditions, commonly treated in both acute care and outpatient settings. Patients with impaired mobility and those living in locations with reduced access to care may particularly benefit. Video-teleconferencing has been shown to be effective for management of burn patients during acute rehabilitation, including reduced health care use expenses and less disruptions to care. Telehealth can facilitate developing interprofessional care plans. Patients with neurologic conditions including stroke, spinal cord injury, traumatic brain injury, and amyotrophic lateral sclerosis may use telehealth to monitor symptoms and response to treatment. Telehealth also may facilitate occupational and physical therapy programs as well as improve weight management and skin care in patients with chronic conditions. Other applications include imaging review in sports medicine, symptom management and counseling in concussion, traumatic brain injury, and pain management programs. Limitations of telehealth include barriers in establishing relationship between medical provider and patient, ability to perform limited physical examination, and differences in payment models and liability coverage. The expansion of telehealth services is expected to grow and has potential to improve patient satisfaction by delivering high quality and value of care.
Introduction Maximizing function and quality of life via a patientcentered team approach are fundamental principles in the practice of physical medicine and rehabilitation (PM&R) [1]. Achieving these goals with our patients is sometimes challenging in practice because a patient’s ability to treat and manage his or her health does not exist solely in the confined location of hospitals and outpatient clinics but also in the schools, homes, markets, pharmacies, and communities. A patient’s interactions with health care today may be limited by a number of factors, including geography, time, finances, and access to technology. Yet, a patient’s success with managing his or her health depends on a combination of social and physical determinants, including transportation access, literacy, and social support [2]. Telehealth (which encompasses telerehabilitation, telecare, teleconsult, telemedicine, and remote nonclinical
services) is a method of care delivery that increases access to health care services and may support and facilitate patient-centered care [3]. Telehealth-enabled care delivery leverages telecommunication devices to provide medical care outside the traditional face-to-face, in-person medical encounter. Health care delivery for a patient using telehealth may include the combination of history, modified physical examination, diagnostic testing, assessment, and management. Patient treatment and longitudinal care using telehealth include behavioral medicine,[4], medications [5], patient education [6], and shared decision making [7]. Medical care and active decision-making may be provided either synchronously (real-time interaction) or asynchronously (communication between a patient and provider is conducted at different times). Research providing the strongest evidence for telehealth, including telerehabilitation, was characterized by the Agency for Healthcare Research and Quality in
1934-1482/$ - see front matter ª 2017 by the American Academy of Physical Medicine and Rehabilitation http://dx.doi.org/10.1016/j.pmrj.2017.02.013
S52
Telehealth in Physical Medicine and Rehabilitation
June 2016 [8]. The authors of this report concluded systematic reviews demonstrate moderate evidence and potential benefit of delivering telerehabilitaion care for cardiovascular disorders and other conditions commonly treated in PM&R. Research providing strongest evidence for telehealth applications was in remote monitoring, communication, and education/counseling for chronic conditions including cardiovascular disease and diabetes. Positive outcomes associated with telehealth included reduction of hospitalization admissions, mortality, and possible cost effectiveness using telerehabilitation [8]. An earlier 2009 report in Canada characterized the effectiveness of telehealth applications for specialties that share patient populations commonly seen by physiatrists including neurology, cancer, pulmonary, mobility, and chronic pain. Of the highest-quality studies, 81% were successful, with 47% having clinically significant outcomes [9]. Other studies have documented use of this technology for both acute and chronic conditions commonly seen by physiatrists, including burn rehabilitation [10], amyotrophic lateral sclerosis (ALS) [11], disorders of consciousness [12], spinal cord injury (SCI) [13], musculoskeletal [14] and spine conditions [15], and chronic pain [16]. The purpose of our narrative review is to characterize the current knowledge of telehealth applications and outcomes in health care delivery for patients seen in the field of PM&R. Our review includes an introduction on health care delivery of telehealth. Subsequently, we outline current evidence based on available literature for treatment of both inpatient and outpatient neurologic and musculoskeletal conditions. We conclude with a summary of the current state of telehealth for health care delivery and future directions of research to optimize patient care and efficiency. Telehealth in Health Care Delivery Telehealth uses technology to deliver medical care outside the traditional in-person patient visit and continues to evolve in capacity over time. There is no formal structure for delivery of telehealth; delivery may use one or more available technologies. Telehealth capacity changes rapidly and is facilitated by the growth of technology; however, the basic mechanism for delivery of telehealth includes a mode of communication between the involved parties by which data are exchanged. The exchange of data may be in numerous forms, including written, audio, visual, or haptic (data obtained from patient contact with technology). Technologies such as e-mail, cellular texting, traditional phone lines, videoconferencing, cameras, 3-dimensional motion sensors, sensors, global positioning systems, robotics, and virtual reality each offer a different type of data exchange. Pramuka and Van Roosmalen describe
[17] how clinical application influences the pairing of technologies for health care delivery. For example, incorporating a physical examination into telehealth encounter may be achieved with both visual and haptic data in addition to audio data. Chronic disease monitoring may use sensor data in addition to audio or text sources. In contrast, provider-to-provider remote team conference may involve teleconferencing. Understanding the clinical need is critical to the technology selection and the data mode being used. The delivery of telehealth is dependent on both the adoption of access to the technology used by the patient. Users also must have the desire to use the telerehabilitation technology, including access to hardware and ability to install software along with support for troubleshooting. Providing a framework to facilitate this technology is important for user adoption. For example, patients may need instructions on how to most effectively use video teleconferencing tools or applications to initiate the conference and to share the screen [17]. Technology usability for people with illness and disability may require additional adaptations and modifications. Passwords may be challenging for someone with cognitive deficits; other forms of security identification such as biometric data, including fingerprints, may be more appropriate. Patients with dysarthric speech may not be able to use voice-recognition solutions and may require augmentative or alternative communication devices to be incorporated into routine telehealth delivery of care. Therefore, the pairing of technology and data delivery must be individualized to patient-specific needs. Acute Care Indications The field of neurology is largely responsible for the introduction of telehealth to health care with the successful implementation of telestroke programs to deliver acute stroke care in remote locations [18]. Telestroke is now an established modality of care with growth in leading neurology departments [19] and allows for delivery of prompt emergency stroke care in geographic regions that have low coverage of neurology providers [20]. A meta-analysis of studies evaluated management of acute ischemic stroke patients with intravenous thrombolysis using tissue plasminogen activator delivered through telestroke networks. This study concluded similar outcomes at 3 months for patients managed by telestroke compared with stroke center-guided thrombolysis of intravenous tissue plasminogen activator delivered in the 3-hour time window [21]. Additional studies suggest that telestroke is costeffective [22-24]. Telehealth also is used increasingly to increase access to specialized care for acute neurologic symptoms. Consultation with remote neurologists for patients admitted to rural hospitals to work-up and manage neurologic symptoms results in shorter hospital
A.S. Tenforde et al. / PM R 9 (2017) S51-S58
stay and no increase in mortality [25]. In addition, the diagnosis of each patient by the neurologist using video link agreed with the follow-up in-person visit [25]. Inpatient Rehabilitation One promising, innovative use of telehealth is in the acute inpatient rehabilitation setting to meet regulations for health care delivery. As the result of economic forces, major changes in health care delivery have resulted in shortened lengths of acute care inpatient stays and a shift of care to lower-cost settings. The Affordable Care Act [26] has directed health care delivery systems to focus on the Triple Aim [27]: improved population health, improved patient experience (including quality and satisfaction), and reduced per capita cost of health care. Postacute care, including acute inpatient rehabilitation, has been of increased interest to policy makers as a result of a 2013 Institute of Medicine report that identified the sector as the source of 73% of the variation in Medicare spending [28]. Towards that end, health care systems have focused on integrating and improving the patient’s experience and services in the continuum of care with an overall reduction in total medical expense. Targeted interventions include reducing preventable readmissions; improving the process of decision-making regarding which patients need postacute hospitalization; improving transitions in care; and enhancing care delivery in the postacute setting. The few studies characterizing telehealth for acute inpatient rehabilitation are limited to select patient populations and primarily use videoconferencing. The populations studied include patients with stroke, burn, and SCI in both acute-care and outpatient settings [29-34]. Telerehabilitation studies have followed traditional telehealth models by focusing on the evaluation of means to facilitate and enable rehabilitation specialists to provide services to patients in rural and/or remote settings [35-37]. Telehealth platforms studied for use in the acute inpatient rehabilitation setting were limited to video-teleconferencing (VTC), commonly referred to as videoconferencing. VTC use interactive and high-quality bidirectional audiovisual systems. Studies also focused on 2 use-cases in the acute inpatient rehabilitation setting: VTC with virtual specialist consultants (patient to provider) and VTC for interprofessional conferences (specialist to rehabilitation team with or without patients). Burn rehabilitation (also referred to as teleburn) is an important model to understand how VTC can be used in postacute care within the inpatient rehabilitation setting. Liu et al [10] studied a total of 29 burn patients participating in 73 VTC visits from March 2013 to March 2014 through a VTC acute-care burn hospital to acute inpatient rehabilitation program and measured improvements in patient’s experience, reduced costs, and
S53
enhanced health care services [10]. VTC visits included a burn consultant and burn patient using this technology for new consults, preoperative evaluations, and postoperative follow-ups. During the study period, total transportation cost savings of $101,110 were achieved by eliminating 146 ambulance transports between the burn hospital and the rehabilitation hospital. The reduced time required to complete virtual visits resulted in estimated savings of 6.8 outpatient burn clinic days. Access to telehealth facilitated earlier discharge of burn patients to the rehabilitation hospital. As a result, 80 inpatient bed days were estimated as saved at the burn hospital. The rehabilitation hospital saved an average of 2.5 patient days by eliminating travel. Notably, no unplanned or preventable readmissions from the rehabilitation hospital to the burn hospital were observed during the study date, and satisfaction surveys demonstrated 100% patient satisfaction primarily related to time saved from travel. The rehabilitation care plan for each patient also had reduced disruptions with resulting improved efficiency at the rehabilitation facility [10]. In addition to direct patient health care delivery, VTC can be used to facilitate developing interprofessional care plans (ICPs) within the acute care setting [38]. The ICP purpose is to develop objectives and intervention to guide rehabilitation and community reintegration. The ICP facilitates communication and can be used to manage patient and family expectations and to guide observations and treatment plan of the interprofessional team. Both geography and schedules can create difficulties in developing an ICP. Careau et al [38] evaluated using VTC (providers to providers with patient) with the goal of developing ICPs. The authors identified several key factors: productive discussion based on common objectives; establishing clear roles and active involvement of the patient and all team members; and the presence of a leader to ensure the meeting is structured and disciplined to facilitate communication among team members [38]. The available literature suggests telehealth in the inpatient rehabilitation setting has the potential to integrate specialty services across the continuum of care. For example, the teleburn study suggests improved patient experience with reduced costs of care [10]. Communication may be enhanced and facilitated within the rehabilitation team, including patients and families, by the use of telehealth VTC [38]. Outpatient Neurorehabilitation On discharge from acute rehabilitation hospitals, a substantial portion of patients who have sustained neurologic injury (including stroke, traumatic brain injury [TBI], and SCI) require long-term outpatient rehabilitation. This patient population often is treated at tertiary centers including acute care and acute inpatient
S54
Telehealth in Physical Medicine and Rehabilitation
rehabilitation hospitals that are located far away from the patients’ residence. Although these centers provide access to specialized acute and postacute rehabilitation for a few weeks, on discharge home patients often have no longer access to the inpatient team as the result of geographic distance compounded by loss of mobility and functional independence that often accompanies neurologic injury. These barriers may have a negative impact on the patient’s rehabilitation program. Telehealth may serve as a method to address these barriers to follow-up care in long-term management of patients with neurologic conditions. Although the impact of telehealth on the chronic management of neurologic disease is less well characterized, a few studies have explored the feasibility of remote medication management in selected neurologic patient populations including Parkinson disease [39-41] and epilepsy [42]. In a small trial of patients with Parkinson disease, videoconferencing was used to provide specialty care at home [41]. On average, each telehealth visit saved participants 100 miles of travel and 3 hours of time [41] compared with an in-person visit. Outcomes were comparable with usual care in terms of quality of life and motor symptoms [39-41]. A study in epilepsy demonstrated substantial patients’ savings in traveling and lost productivity in the telehealth group compared with the usual-care group [42]. In addition, telehealth may be effective for patient populations with neurologic diseases that include dynamic aspects such as community reintegration that require long-term guidance from an expert rehabilitation team, such as patients with SCI [43]. Moreover, neurodegenerative conditions have an increasingly negative impact on multiple functional domains with disease progression, thus requiring continued adjustments to the rehabilitation plan. Several studies have explored the impact of telerehabilitation on neurologic care although most have focused on patient populations with impaired mobility to facilitate multidisciplinary care. Telerehabilitation can be implemented by direct patient-care via VTC. The benefits of this approach include face-to-face time between the clinician and the patient via the web, and reduced burden of time and financial resources by eliminating the need to travel. Pilot studies have suggested that this approach allows the effective delivery of care in neurologic conditions such as ALS [44] and SCI [45]. The U.S. Department of Veterans Affairs has been at the forefront of this approach and has implemented several VTC programs that have enhanced the multidisciplinary care of veterans with TBI [46] and stroke [47]. An important feature of VTC is that it can be used as a method to enhance rehabilitation programs by allowing physical therapists and occupational therapists more frequent contact with patients via “virtual therapy sessions” as shown in a few pilot studies in SCI [48-50]. Similar clinical trials are underway to test the
impact of remote therapy sessions on functional recovery in stroke patients [51]. An emerging modality for telehealth is the use of applications or automated telephone call/messaging programs to provide educational material, instructions, and reminders so that patients can more effectively engage in rehabilitation programs. This modality has been piloted successfully in SCI, where the implementation of automated call programs resulted in reduction of pressure ulcers [52] and improved weight management [53]. Pilot studies also have begun to test the impact of Web-based applications on symptom management in TBI [54,55], skin care in spina bifida [56,57], mobility in stroke [58], and multidisciplinary care in patients with chronic disability [59]. Remote monitoring also can focus on selected physiologic parameters to inform adjustments to the rehabilitation plan. As an example, remote guidance for management of assisted ventilation was shown to be feasible and cost-effective in patients with ALS [11,60,61]. Outpatient Musculoskeletal Care and Sports Medicine In sports medicine, telehealth can be effective for management of musculoskeletal conditions including physical therapy and review of diagnostic imaging studies. Telehealth has been used for delivery of physical therapy services with a recent pilot study assessing telehealth services for rotator cuff injury [62]. Diagnostic imaging review between provider and patient of previous physical examination findings can be readily conducted via telehealth. Telehealth software allows the provider to share images with the patient through the computer interface. This form of visit allows providers to review images and discuss results without the patient coming into the office. Although studies to evaluate the use of telehealth in sports and musculoskeletal clinics are not available, a similar algorithm called teleradiology has been used for multiple decades. Teleradiology has been shown to have similar diagnostic accuracy as imaging studies interpreted by providers within the same health care system [63,64]. Although teleradiology uses a provider-to-provider model (remote radiologists read imaging studies and consult with ordering physicians), a similar provider-topatient interaction in the sports medicine setting is equally feasible and may facilitate timely and convenient follow-up of diagnostic imaging. Telehealth has potential broad application in management of acute sports medicine conditions including sport concussions. For example, increased concussion awareness has lead to local and state mandates for the evaluation of student athletes by specialized concussion provider prior to return to play. Access to specialty care, however, can be limited. A recent case study found that the use of a video telehealth interface was feasible in providing specialty evaluation of a concussed high school
A.S. Tenforde et al. / PM R 9 (2017) S51-S58
athlete residing in a rural community [65]. Research documenting success in neurosurgical triage in TBI [66] has been reported and suggests feasibility in assessing acute neurologic conditions using telehealth. Early assessment by a medical concussion specialist has the potential to improve concussion recognition, remove athletes from play, and triage those injuries that require emergency room transfer verses those that may be observed by athletic training staff or parents. Although outcome-based studies validating the success of this model are lacking, a pilot program is underway to test the use of telehealth for sideline evaluation of concussion [67]. In addition to acute management, a subset of patients with persistent concussion symptoms may be appropriate for use of telehealth for chronic care. The primary focus in the subacute and chronic settings of concussion care is management of symptoms. Telehealth may allow providers to evaluate chronic symptoms, formulate treatment plans, provide patient and family education, guide return to school or work, and prescribe graded exercise for return to play. Chronic headache management via telehealth was found to be as effective as in-office treatment for patients in a rural setting [68]. The use of follow-up phone calls for symptom management in patients diagnosed with mild TBI resulted in decreased symptoms at 3 months [69]. Telehealth also may offer the opportunity for multidisciplinary concussion care. Both cognitive rehabilitation [70,71] and psychotherapy [72,73] services are important adjunctive treatments for concussion and have been delivered via the telehealth platform for patients with more severe TBI; extrapolating these findings to use of telehealth for managing patients with concussions suggests a potential role for treatment. Important barriers to address in the use of telehealth for the management of concussion may be learned from a study by Martinez et al [46], where investigators studied providers who used telehealth to treat veterans with mild TBI. Perceived barriers impeding telehealth success included loss of the physical examination, difficulty scheduling patient appointments, and clinic setup. Although validation models for comprehensive treatment of persistent concussion symptoms has not been reported to date, the individual components of multidisciplinary concussion care have been successfully delivered via telehealth. Pain management evaluation and treatment also may be facilitated through telehealth. In a study of patients with chronic musculoskeletal pain, patient telephone consultation with a specialty pain nurse reduced pain by improving use of nonopioid analgesic medications [74]. Opioid use was not different between treatment groups and median dose of opioids did not increase during the 12-month intervention [74]. In patients with chronic neck pain, the addition of telehealth follow-up to a prescribed home exercise program reduced pain symptoms and disability at 6 months and increased patient
S55
compliance with the home exercise program [15]. A pilot program explored the use of a video telehealth pain clinic between an academic medical center and a rural island community to establish care and provide remote pain consultation [75]. Compared with in-person visits, patients reported a high degree of satisfaction with “telepain,” although ratings were lower both for overall care received and ability to develop a friendly relationship with the provider. Addressing education barriers in pain medicine education for medical providers may be enhanced using technology. For example, using telehealth to provide “telementoring” has been suggested as a method to delivering a pain medicine curriculum [76]. The current available literature for sports, spine, and pain management suggests potential uses in telehealth for patient care that does not require extensive patient contact to perform the physical examination. Telehealth can be used to review diagnostic imaging with patients when the physical examination is not needed. Monitoring symptoms to pain management and treatment of longterm symptoms of concussions are two areas with particular promise. Current Limitations of Telehealth Our narrative review focuses on the most relevant articles pertinent to conditions seen in PM&R practices. Published studies are limited evaluating use of telehealth in the area of PM&R. Gaps in knowledge and research to understand the patients who will have most favorable responses are needed. Additional studies are necessary to evaluate targeted telehealth interventions to reduce preventable readmissions and enhance care delivery in the inpatient rehabilitating setting and to facilitate transfer of care. Telehealth VTC use by physiatrists also may provide valuable specialty services to patients in the long-term acute care, skilled nursing facility, and home care settings. Teleradiology and telehealth use for neurologic conditions including stroke and TBI are suggestive of potential uses in outpatient neurologic, musculoskeletal, and sports medicine practice but require formal studies to determine efficacy. Telehealth itself does not have a standardized definition in the literature, and the use of this technology varies between providers and patient populations; determining clinical outcomes compared with in-person traditional visits is challenging to quantify. Research is needed to determine appropriate use and efficacy for conditions treated by physiatrists. Future research should focus on outcome measures such as cost, quality, value, as well as patient and provider satisfaction In addition to understanding best practice for specific patient populations, we recognize current limitations in adopting telehealth services. Reimbursement is not available in all states and has not been covered by Medicare payment model; however, insurance and other
S56
Telehealth in Physical Medicine and Rehabilitation
payers are expanding payment and framework for delivering telehealth services. There is variability in coverage of telehealth across state lines and whether the physician-patient relationship was previously established during traditional in-person initial visit. Medicolegal factors are important to address to protect the provider and health care system. Despite these challenges, telehealth continues to grow and will alter the health care landscape. We encourage physiatrists to be receptive to adopt use of the technology in practice.
Conclusion
Future Directions
Acknowledgments
Telehealth has an opportunity to enhance medical care through a combination of high patient satisfaction, providing quality medical care with reduced costs resulting in high value services. Patients can maintain a provider-patient interaction through communication that is portable, minimizing time of travel and lost productivity in work. One recent study estimated total time for a clinical encounter takes over 2 hours, yet 20 minutes is spent directly with the physician [77]. Telehealth can provide an alternative to maintaining care with adverse weather conditions that would make travel for in-person visits unsafe or impractical or for individuals limited in ability to travel due to geography, resources or impairments in mobility. Infrastructure costs are minimal for the medical provider who uses secure software to conduct the encounter and requires minimal use of ancillary staff to conduct the visit. Although patients and providers often celebrate innovation in medical care, often these services and products are accompanied by greater costs. In contrast, appropriate use of telehealth has the potential to enhance care and may potentially lower overall costs to the medical system. Expansion of telehealth may meet these goals to optimize patient care and outcomes. Telehealth is expected to contribute to the future care physiatrists provide patients. Patients with limited access to physiatrists will benefit from expansion of telehealth to improve access to care. Patient education and delivery of care may be enhanced to improve functional outcomes. The notable increase in publications focused on telehealth for chronic neurologic conditions and high degree of user satisfaction [20,78,79] will likely lead to increasing adoption of telehealth for long-term rehabilitation of patients with neurologic disease. Documented use of telehealth in burn rehabilitation patients at our institution [10] suggests value for use in the acute rehabilitation setting. Communication in family meetings and ICP may be enhanced using VTC [38], including improved ease for providers when this care is delivered off-site. Our experiences in use of telehealth for imaging review in management of sports conditions, providing care to individuals with impaired mobility and guiding symptom management in patients with concussion suggests these may be effective uses for telehealth.
A.S.T., J.E.H., M.A.I., and S.P. would like to acknowledge the efforts at our institution Spaulding Rehabilitation Hospital (SRH), in collaboration with Massachusetts General Hospital Telehealth Division and supported by the Massachusetts General Physician Organization (MGPO), who have implemented the telehealth platform to perform “Virtual Visits.”
There are promising applications for telehealth for PM&R in both inpatient and outpatient settings. Telehealth is a rapidly growing technology that will alter the delivery of health care. Future research is required to evaluate methods to best use telehealth for specific patient populations. Patients and providers are expected to benefit as use of this technology expands.
References 1. American Academic of Physical Medicine and Rehabilitation. FAQs About Physiatry Available at http://www.aapmr.org/aboutphysiatry/about-physical-medicine-rehabilitation/faqs-about-physiatry - 1. Accessed November 22, 2016. 2. Office of Disease Prevention and Health Promotion. Healthy People 2020. Healthy People 2020. Available at https://www.healthypeople. gov/2020/topics-objectives/topic/social-determinants-of-health. Accessed November 22, 2016. 3. HRSA. Telehealth November 2015 [June 17, 2016]. Available at http:// www.hrsa.gov/ruralhealth/telehealth/. Accessed November 22, 2016. 4. Brenes GA, Danhauer SC, Lyles MF, Hogan PE, Miller ME. Telephone-delivered cognitive behavioral therapy and telephonedelivered nondirective supportive therapy for rural older adults with generalized anxiety disorder: A randomized clinical trial. JAMA Psychiatry 2015;72:1012-1020. 5. Dharmar M, Kuppermann N, Romano PS, et al. Telemedicine consultations and medication errors in rural emergency departments. Pediatrics 2013;132:1090-1097. 6. Steffen LE, Boucher KM, Damron BH, et al. Efficacy of a telehealth intervention on colonoscopy uptake when cost is a barrier: The Family CARE Cluster Randomized Controlled Trial. Cancer Epidemiol Biomarkers Prev 2015;24:1311-1318. 7. Veroff D, Marr A, Wennberg DE. Enhanced support for shared decision making reduced costs of care for patients with preferencesensitive conditions. Health Aff (Millwood) 2013;32:285-293. 8. Totten AM, Womack DM, Eden KB, et al. Telehealth: Mapping the Evidence for Patient Outcomes From Systematic Reviews. Technical Brief No. 26. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2015-00009-I.) AHRQ Publication No. 16-EHC034-EF. Rockville, MD: Agency for Healthcare Research and Quality; June 2016. Available at, www.effectivehealthcare.ahrq.gov/ reports/final.cfm. Accessed November 22, 2016. 9. Hailey D, Roine R, Ohinmaa A, et al. Evidence on the effectiveness of telerehabilitation applications Alberta, Canada: Institute of Health Economics; 2010 Available at http://www.ihe.ca/ publications/evidence-on-the-effectiveness-of-telerehabilitationapplications. Accessed November 22, 2016. 10. Liu YM, Mathews K, Vardanian A, et al. Urban telemedicine: The applicability of teleburns in the rehabilitative phase. J Burn Care Res 2017;38:e235-e239.
A.S. Tenforde et al. / PM R 9 (2017) S51-S58 11. Pinto A, Almeida JP, Pinto S, Pereira J, Oliveira AG, de Carvalho M. Home telemonitoring of non-invasive ventilation decreases healthcare utilisation in a prospective controlled trial of patients with amyotrophic lateral sclerosis. J Neurol Neurosurg Psychiatry 2010;81:1238-1242. 12. Zucchella C, Di Santis M, Ciccone B, et al. Is telemonitoring useful for supporting persons with consciousness disorders and caregivers? A preliminary observational study in a real-life population. J Telemed Telecare 2016 Oct 12 [Epub ahead of print]. 13. van de Pol E, Lucas K, Geraghty T, et al. The delivery of specialist spinal cord injury services in Queensland and the potential for telehealth. BMC Health Serv Res 2016;16:29. 14. Cottrell MA, Galea OA, O’Leary SP, Hill AJ, Russell TG. Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: A systematic review and meta-analysis. Clin Rehabil 2016 May 2 [Epub ahead of print]. 15. Gialanella B, Ettori T, Faustini S, et al. Home-based telemedicine in patients with chronic neck pain. Am J Phys Med Rehabil 2016 August 31 [Epub ahead of print]. 16. Choi Yoo SJ, Nyman JA, Cheville AL, Kroenke K. Cost effectiveness of telecare management for pain and depression in patients with cancer: Results from a randomized trial. Gen Hosp Psychiatry 2014;36:599-606. 17. Pramuka M, van Roosmalen L. Telerehabilitation technologies: Accessibility and usability. Int J Telerehabil 2009;1:85-98. 18. Hess DC, Audebert HJ. The history and future of telestroke. Nat Rev Neurol 2013;9:340-350. 19. George BP, Scoglio NJ, Reminick JI, et al. Telemedicine in leading US neurology departments. Neurohospitalist 2012;2:123-128. 20. Davis LE, Coleman J, Harnar J, King MK. Teleneurology: Successful delivery of chronic neurologic care to 354 patients living remotely in a rural state. Telemed J E Health 2014;20:473-477. 21. Kepplinger J, Barlinn K, Deckert S, Scheibe M, Bodechtel U, Schmitt J. Safety and efficacy of thrombolysis in telestroke: A systematic review and meta-analysis. Neurology 2016;87:1344-1351. 22. Nelson RE, Saltzman GM, Skalabrin EJ, Demaerschalk BM, Majersik JJ. The cost-effectiveness of telestroke in the treatment of acute ischemic stroke. Neurology 2011;77:1590-1598. 23. Demaerschalk BM, Switzer JA, Xie J, Fan L, Villa KF, Wu EQ. Cost utility of hub-and-spoke telestroke networks from societal perspective. Am J Manag Care 2013;19:976-985. 24. Nelson RE, Okon N, Lesko AC, Majersik JJ, Bhatt A, Baraban E. The cost-effectiveness of telestroke in the Pacific Northwest region of the USA. J Telemed Telecare 2016;22:413-421. 25. Craig J, Chua R, Russell C, Wootton R, Chant D, Patterson V. A cohort study of early neurological consultation by telemedicine on the care of neurological inpatients. J Neurol Neurosurg Psychiatry 2004;75:1031-1035. 26. Patient Protection and Affordable Care Act of 2010. Available at https://www.hhs.gov/healthcare/about-the-law/read-the-law/. Accessed December 8, 2016. 27. TIHI Triple Aim Initiative. Available at http://www.ihi.org/Engage/ Initiative/TripleAim/Pages/default.asp%. Accessed December 8, 2016. 28. Institute of Medicine. Variation in Health Care Spending: Target Decision Making, Not Geography. Washington, DC: The National Academies Press; 2013. 29. Schwamm LH, Holloway RG, Amarenco P, et al. A review of the evidence for the use of telemedicine within stroke systems of care: A scientific statement from the American Heart Association/ American Stroke Association. Stroke 2009;40:2616-2634. 30. Nguyen LT, Massman NJ, Franzen BJ, et al. Telemedicine follow-up of burns: Lessons learned from the first thousand visits. J Burn Care Rehabil 2004;25:485-490. 31. Saffle JR, Edelman L, Theurer L, Morris SE, Cochran A. Telemedicine evaluation of acute burns is accurate and cost-effective. J Trauma 2009;67:358-365.
S57
32. Syed-Abdul S, Scholl J, Chen CC, et al. Telemedicine utilization to support the management of the burns treatment involving patient pathways in both developed and developing countries: A case study. J Burn Care Res 2012;33:e207-e212. 33. Galea M, Tumminia J, Garback LM. Telerehabilitation in spinal cord injury persons: A novel approach. Telemed J E Health 2006;12: 160-162. 34. Woo C, Guihan M, Frick C, Gill CM, Ho CH. What’s happening now! Telehealth management of spinal cord injury/disorders. J Spinal Cord Med 2011;34:322-331. 35. Brennan DM, Mawson S, Brownsell S. Telerehabilitation: Enabling the remote delivery of healthcare, rehabilitation, and self management. Stud Health Technol Inform 2009;145:231-248. 36. Theodoros D, Russell T. Telerehabilitation: Current perspectives. Stud Health Technol Inform 2008;131:191-209. 37. Schopp LH, Johnstone BR, Merveille OC. Multidimensional telecare strategies for rural residents with brain injury. J Telemed Telecare 2000;6(Suppl 1):S146-S149. 38. Careau E, Vincent C, Noreau L. Assessing interprofessional teamwork in a videoconference-based telerehabilitation setting. J Telemed Telecare 2008;14:427-434. 39. Biglan KM, Voss TS, Deuel LM, et al. Telemedicine for the care of nursing home residents with Parkinson’s disease. Mov Disord 2009; 24:1073-1076. 40. Dorsey ER, Deuel LM, Voss TS, et al. Increasing access to specialty care: A pilot, randomized controlled trial of telemedicine for Parkinson’s disease. Mov Disord 2010;25:1652-1659. 41. Dorsey ER, Venkataraman V, Grana MJ, et al. Randomized controlled clinical trial of “virtual house calls” for Parkinson disease. JAMA Neurol 2013;70:565-570. 42. Ahmed SN, Mann C, Sinclair DB, et al. Feasibility of epilepsy follow-up care through telemedicine: A pilot study on the patient’s perspective. Epilepsia 2008;49:573-585. 43. Soopramanien A, Pain H, Stainthorpe A, Menarini M, Ventura M. Using telemedicine to provide post-discharge support for patients with spinal cord injuries. J Telemed Telecare 2005;11(Suppl 1): 68-70. 44. Nijeweme-d’Hollosy WO, Janssen EP, Huis in ’t Veld RM, Spoelstra J, Vollenbroek-Hutten MM, Hermens HJ. Tele-treatment of patients with amyotrophic lateral sclerosis (ALS). J Telemed Telecare 2006;12(Suppl 1):31-34. 45. Yozbatiran N, Harness ET, Le V, Luu D, Lopes CV, Cramer SC. A tele-assessment system for monitoring treatment effects in subjects with spinal cord injury. J Telemed Telecare 2010;16:152-157. 46. Martinez RN, Hogan TP, Lones K, et al. Evaluation and treatment of mild traumatic brain injury through the implementation of clinical video telehealth: Provider perspectives from the veterans health administration. PM R 2017;9:231-240. 47. Chumbler NR, Li X, Quigley P, et al. A randomized controlled trial on stroke telerehabilitation: The effects on falls self-efficacy and satisfaction with care. J Telemed Telecare 2015;21:139-143. 48. Van Straaten MG, Cloud BA, Morrow MM, Ludewig PM, Zhao KD. Effectiveness of home exercise on pain, function, and strength of manual wheelchair users with spinal cord injury: A high-dose shoulder program with telerehabilitation. Arch Phys Med Rehabil 2014;95:1810-1817.e2. 49. Yuen HK. Effect of a home telecare program on oral health among adults with tetraplegia: A pilot study. Spinal Cord 2013;51:477-481. 50. Dallolio L, Menarini M, China S, et al. Functional and clinical outcomes of telemedicine in patients with spinal cord injury. Arch Phys Med Rehabil 2008;89:2332-2341. 51. Koh GC, Yen SC, Tay A, et al. Singapore Tele-technology Aided Rehabilitation in Stroke (STARS) trial: Protocol of a randomized clinical trial on tele-rehabilitation for stroke patients. BMC Neurol 2015;15:161. 52. Houlihan BV, Jette A, Friedman RH, et al. A pilot study of a telehealth intervention for persons with spinal cord dysfunction. Spinal Cord 2013;51:715-720.
S58
Telehealth in Physical Medicine and Rehabilitation
53. Rimmer JH, Wang E, Pellegrini CA, Lullo C, Gerber BS. Telehealth weight management intervention for adults with physical disabilities: A randomized controlled trial. Am J Phys Med Rehabil 2013; 92:1084-1094. 54. Dexheimer JW, Kurowski BG, Anders SH, McClanahan N, Wade SL, Babcock L. Usability evaluation of the SMART application for youth with mTBI. Int J Med Inform 2017;97:163-170. 55. Pavliscsak H, Little JR, Poropatich RK, et al. Assessment of patient engagement with a mobile application among service members in transition. J Am Med Inform Assoc 2016;23:110-118. 56. Parmanto B, Pramana G, Yu DX, Fairman AD, Dicianno BE. Development of mHealth system for supporting self-management and remote consultation of skincare. BMC Med Inform Decis Mak 2015;15:114. 57. Yu DX, Parmanto B, Dicianno BE, Pramana G. Accessibility of mHealth self-care apps for individuals with spina bifida. Perspect Health Inf Manag 2015;12:1h. 58. Paul L, Wyke S, Brewster S, et al. Increasing physical activity in stroke survivors using STARFISH, an interactive mobile phone application: A pilot study. Top Stroke Rehabil 2016;23:170-177. 59. Fairman AD, Yih ET, McCoy DF, et al. Iterative design and usability testing of the iMHere system for managing chronic conditions and disability. Int J Telerehabil 2016;8:11-20. 60. Vitacca M, Paneroni M, Trainini D, et al. At home and on demand mechanical cough assistance program for patients with amyotrophic lateral sclerosis. Am J Phys Med Rehabil 2010;89:401-406. 61. Vitacca M, Comini L, Tentorio M, et al. A pilot trial of telemedicine-assisted, integrated care for patients with advanced amyotrophic lateral sclerosis and their caregivers. J Telemed Telecare 2010;16:83-88. 62. Macias-Hernandez SI, Vasquez-Sotelo DS, Ferruzca-Navarro MV, et al. Proposal and evaluation of a telerehabilitation platform designed for patients with partial rotator cuff tears: A preliminary study. Ann Rehabil Med 2016;40:710-717. 63. Bashshur RL, Krupinski EA, Thrall JH, Bashshur N. The empirical foundations of teleradiology and related applications: A review of the evidence. Telemed J E Health 2016;22:868-898. 64. Lefere P, Silva C, Gryspeerdt S, et al. Teleradiology based CT colonography to screen a population group of a remote island; at average risk for colorectal cancer. Eur J Radiol 2013;82:e262-e267. 65. Vargas BB, Channer DD, Dodick DW, Demaerschalk BM. Teleconcussion: An innovative approach to screening, diagnosis, and management of mild traumatic brain injury. Telemed J E Health 2012;18:803-806. 66. Yurkiewicz IR, Lappan CM, Neely ET, et al. Outcomes from a US military neurology and traumatic brain injury telemedicine program. Neurology 2012;79:1237-1243.
67. Anne. Available at https://vsee.com/blog/vsee-dell-ummc-telehealthconcussion-evaluation-high-school/. Accessed December 8, 2016. 68. Muller KI, Alstadhaug KB, Bekkelund SI. Telemedicine in the management of non-acute headaches: A prospective, openlabelled non-inferiority, randomised clinical trial. Cephalalgia 2016 June 14 [Epub ahead of print]. 69. Bell KR, Hoffman JM, Temkin NR, et al. The effect of telephone counselling on reducing post-traumatic symptoms after mild traumatic brain injury: A randomised trial. J Neurol Neurosurg Psychiatry 2008;79:1275-1281. 70. Bourgeois MS, Lenius K, Turkstra L, Camp C. The effects of cognitive teletherapy on reported everyday memory behaviours of persons with chronic traumatic brain injury. Brain Inj 2007;21:1245-1257. 71. Topolovec-Vranic J, Cullen N, Michalak A, et al. Evaluation of an online cognitive behavioural therapy program by patients with traumatic brain injury and depression. Brain Inj 2010;24: 762-772. 72. Tsaousides T, D’Antonio E, Varbanova V, Spielman L. Delivering group treatment via videoconference to individuals with traumatic brain injury: A feasibility study. Neuropsychol Rehabil 2014;24: 784-803. 73. Fann JR, Bombardier CH, Vannoy S, et al. Telephone and in-person cognitive behavioral therapy for major depression after traumatic brain injury: A randomized controlled trial. J Neurotrauma 2015; 32:45-57. 74. Kroenke K, Krebs EE, Wu J, Yu Z, Chumbler NR, Bair MJ. Telecare collaborative management of chronic pain in primary care: A randomized clinical trial. JAMA 2014;312:240-248. 75. Hanna GM, Fishman I, Edwards DA, et al. Development and patient satisfaction of a new telemedicine service for pain management at Massachusetts General Hospital to the island of Martha’s Vineyard. Pain Med 2016;17:1658-1663. 76. Katzman JG, Comerci G Jr, Boyle JF, et al. Innovative telementoring for pain management: Project ECHO pain. J Contin Educ Health Prof 2014;34:68-75. 77. Ray KN, Chari AV, Engberg J, Bertolet M, Mehrotra A. Disparities in time spent seeking medical care in the United States. JAMA Intern Med 2015;175:1983-1986. 78. Edgar MC, Monsees S, Rhebergen J, et al. Telerehabilitation in stroke recovery: A survey on access and willingness to use low-cost consumer technologies. Telemed J E Health 2016 October 5 [Epub ahead of print]. 79. Fairman AD, Dicianno BE, Datt N, Garver A, Parmanto B, McCue M. Outcomes of clinicians, caregivers, family members and adults with spina bifida regarding receptivity to use of the iMHere mHealth solution to promote wellness. Int J Telerehabil 2013;5:3-16.
Disclosure A.S.T. Harvard Medical School, Department of PM&R, Spaulding Rehabilitation Hospital, Charlestown, MA; 1575 Cambridge St, Room 9, Cambridge, MA 02138. Address correspondence to: A.S.T.; e-mail: [email protected] Disclosure: nothing to disclose J.E.H. Harvard Medical School, Department of PM&R, Spaulding Rehabilitation Hospital, Charlestown, MA Disclosure: nothing to disclose J.E.K.-W. Cerner Corporation, Kansas City, MO Disclosures outside of this publication: employment and personal fees, Cerner; patents, shared decision making (pending) and medication management (pending)
M.A.I. Harvard Medical School, Department of PM&R, Spaulding Rehabilitation Hospital, Charlestown, MA Disclosure: nothing to disclose S.P. Harvard Medical School, Department of PM&R, Spaulding Rehabilitation Hospital, Charlestown, MA; VA Boston Healthcare System, Boston, MA Disclosures outside this publication: consultancy, Roche ad hoc advisory board, clinical consultant for Pison Tech (money to author); payment for development of educational presentations, CME course Oakstone Publishing (money to author) Submitted for publication December 29, 2016; accepted February 24, 2017.