Telehealth Potential Remains, Trapped by Regulations and Licensure Barriers

Dr. Alan Lee's Perspective article in the December 2011 Physical Therapy journal offers hope tempered with a dose of pragmatic reality - much work still needs to be done if telemedicine techniques can be brought to bear for the benefit of physical therapists' patients.

Some of the barriers on the provider side identified by Dr. Lee include:

• licensing and credentialing - Alaska and Washington state are the only two states to include telemedicine language in their practice acts. New legislation promoting "license portability" is being prepared for the Congress in 2012.

  “Telemedicine is medicine, just practiced virtually”,

  ...said the office of the bill's sponsor, Senator Tom Udall of Utah. 

On the policymakers' side the barriers include:

• billing and reimbursement - payment for physical therapy services is currently dictated by the setting or delivery method, ie: home health, outpatient, hospital, etc,

Telemedicine's biggest benefit is probably its costs savings to both the provider and the patient.

But, new evidence that telemedicine can impact relevant patient outcomes that are "hot topics" among payers and policymakers is increasing.

Geisinger Health Plan, using telemonitoring technology, has demonstrated a 44% reduction in 30-day readmissions compared to a control group.

How Can Outpatient Physical Therapists Use TeleMedicine?

I imagine a scenario similar to the Geisinger program where patients are followed after discharge to monitor their status and identify risk factors before symptoms occurs, or before an adverse event happens.

Can you imagine Skype connection (available for free on newer laptop computers) with your geriatric patients?

What if you could measure the 10-foot Gait Velocity over Skype and predict the need for Skilled Intervention based on slowing gait speed?

What if Medicare would pay - based on this one measure alone?

The Pragmatic Physical Therapist Avoids Models

I recommend the August 2008 Physical Therapy Journal for the Case Report titled

Process for Applying the International Classification of Functioning, Disability and Health Model to a Patient With Patellar Dislocation by Kevin Helgeson and A Russell Smith Jr

(subscription required)

I blogged about this article just two days ago

The patient was an active 23-year old female graduate student who wanted to return to hiking and running.

"She sustained the following... second-degree tear of the medial collateral ligament (MCL) of the right knee, with a lateral dislocation of the patella. She was referred for magnetic resonance imaging (MRI) of her right knee; the MRI was performed the following week. The MRI findings reported by the radiologist were “sprain of the medial collateral ligament with overlying edema and bone bruises of the posterior medial tibial plateau and of the lateral femoral condyle with a small knee joint effusion.”

What I found helpful was Helgeson and Smith's pragmatic approach to decision-making.

"The choice of impaired patellofemoral joint stability as the primary impairment for the patient in this case report was reevaluated through an assessment of the level of improvement of the patient’s primary activity limitation. If she had not been making progress toward resolving the activity limitation in the first weeks of treatment, then reevaluation of the primary and secondary impairments would have been indicated."

By pragmatic I mean the ability to change the plan of care based on the patient's response, measured at the level of the functional ability - in this case walking, hiking and squatting.

This pragmatic approach avoids the use of models - simplifications of human structure and function that are used as aids to decision-making.

The pragmatic approach relies on test data, functional ability, to make decisions.

I would have used the OPTIMAL test to measure functional ability.

The problem, as I see it, is that the use of test data to make decisions 'pigeonholes' physical therapists - that is, it forces them to make decisions that might be contrary to their favorite model or treatment technique.

Full disclosure: My favorite treatment technique for lower back pain is spinal stabilization.

When stabilization doesn't work, as indicated by my OPTIMAL score, I am forced to resort to other means, such as ultrasound or massage to treat the patient.

I don't like it - but I do it.

I wonder if other physical therapists are similarly vexed by using data?

Or, do you just stick with the model?

Physical Therapist uses the ICF model for Decision-Making

This is the first physical therapy article (that I have seen) since the APTA adopted the International Classification of Functioning (ICF) framework in June 2008 that uses the framework for decision-making.

I've used the framework when it was called the International Classification of Disability, Impairments and Handicaps (ICDIH) since late 2007, when I started writing this blog on Physical Therapy Diagnosis.

I've found the process liberating.

I feel more able to help my patients and at the same time I feel less personal responsibility if those patients fail to improve with physical therapy.

I just take the measurements (impairments and abilities).

I find the link - the Physical Therapy Diagnosis.

The treatments are more or less routine.

Back to the article...

This case report by Kevin Helgeson, PT, DHSc describes the treatment of a 23-year old girl with a recurrent patellar dislocation. The measurements and treatments described in the article are pretty routine: exercise, patellar gides, proprioceptive training, etc.

What I found interesting, in the 'Discussion' was the authors' comments on their decision-making process.

"An important aspect of this evaluation process in the ability to reevaluate the interrelationships within the ICF framework and decisions made throughout the course of treatment. The choice of impaired patellofemoral joint stability as the primary impairment for the patient in this case report was re-evaluated through an assessment of the level of improvement of the patient's primary activity limitation. If she had not been making progress toward resolving the activity limitation in the first weeks of treatment, then reevaluation of the primary and secondary impairments would have been indicated."

I can use this in my practice.

We use the OPTIMAL scale. We use the OPTIMAL to write Bulletproof PT Notes for Medicare compliance.

For example, I follow-up with a patient using the OPTIMAL.

They are not making progress with walking long distances. Their goal is 2/5 OPTIMAL. I record their current score, 4/5 (lower scores are better).

Based on their failure to improve, I decide to change their plan of care and try again.

I have just demonstrated skilled physical therapy using my decision-making. The OPTIMAL was my tool and the ICF was my framework.

You can see more examples of skilled physical therapy using the OPTIMAL (and other tests) within the ICF framework. It's all Medicare compliant. It's called Bulletproof Physical Therapy Charts and Notes.