2011/12/03 by Alan Chong W. Lee, Nancy D. Harada · 1 citation
Medicine · #Telemedicine and Telehealth Implementation #Stroke Rehabilitation and Recovery #Cardiac Health and Mental Health
paper · doi:10.2522/ptj.20110100
openalex publication_date 2011/12/03 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/29
Telehealth is defined as the delivery of health-related services and information via telecommunications technologies. According to the American Telemedicine Association (ATA), “telehealth” is a broad term used to describe the use of electronic communications to deliver clinical services as well as other types of health information.1 In rehabilitation, telehealth is defined by the American Physical Therapy Association (APTA) as the use of electronic communications to provide and deliver a host of health-related information and health care services, including, but not limited to, physical therapy–related information and services, over large and small distances.2 Telehealth may be used to provide health education and advice, communicate patient reminders, monitor clinical status, or deliver interventions. Other rehabilitation disciplines, such as occupational therapy and speech therapy, utilize the terms “telerehabilitation”3 and “telepractice”4 as terms to define telehealth in their respective disciplines. The Patient Protection and Affordable Care Act (Public Law 111–148) (PPACA),5 signed into law on March 23, 2010, addresses the use of telehealth as a means of delivering efficient and effective health care in the United States. The national health care reform6 presents a unique opportunity for physical therapists to become identified as clinicians eligible to provide telehealth physical therapy services. However, there are several barriers to overcome if telehealth as a means of health care delivery for physical therapist practice is to become a reality. The objectives of this health policy perspective article are: (1) to describe the development of the telehealth field from a rehabilitation perspective, thereby highlighting some of the potential applications by physical therapists; (2) to discuss current barriers to adoption of telehealth technology by physical therapists; and (3) to identify an overall strategy to achieve long-term adoption of telehealth practices for physical therapists. The earliest applications of telehealth used technology to monitor cardiac function during home exercise.7,8 Generally, evaluations of these programs found them to be safe and feasible. In 2000, Kaiser Permanente evaluated the effectiveness of a remote video system (PTS 100 home video system, American Telecare, Minneapolis, Minnesota) that allowed patients who were chronically ill and nurses to interact in real time. Although no differences were found in quality indicators or patient satisfaction between use of the video system and usual care, the video system had lower mean costs of care compared with usual care.9 According to a conversation with Cathy M. Sox, RN (November 2011), telehealth monitoring programs to manage chronic diseases continue to expand coverage of care at Kaiser Permanente Sacramento and Roseville. The US Department of Veterans Affairs (VA), in 2001, was one of the first health care systems in the United States to implement home telehealth services, and by 2012 the VA aims to have 92,000 patients using telehealth services.10 The VA states that the “value derived from telehealth is not in implementing telehealth technologies alone, but how the VA uses health informatics, disease management and telehealth technologies to target care and case management, thereby facilitating access to care and improving the health of its patients.”11,12 Although the VA developed several early telehealth programs targeted at adults with complex medical conditions such as diabetes, stroke, and congestive heart failure, the one that has the greatest applicability to physical therapists is the Low Activities of Daily Living Monitoring Program (LAMP). In this program, which is administered through a text messaging device, physical therapists and occupational therapists are able to monitor the activities of daily living and safety of frail older adults living in their own homes. The VA also has developed a program to determine the effect of telehealth on physical function, disability, falls-related self-efficacy, and patient satisfaction of patients with stroke after discharge to the home. The preliminary results of an ongoing phase II, 2-arm, 3-site randomized controlled trial by Chumbler et al13 indicate that telehealth is safe and feasible for patients and takes advantage of a novel technology to deliver a focused rehabilitation intervention that complements currently available post–acute rehabilitation resources. These programs have consistently demonstrated high patient and provider satisfaction, as well as improved clinical outcomes. Telehealth services adopted by physical therapists may address one part of the PPACA's mandate for care coordination within the Federal Coordinated Health Care Office established in 2010. Therefore, in our opinion, these programs can serve as examples that may be adapted by physical therapists in non-VA settings for improving care coordination for seniors and expanding coverage of health care. Lee and Harada identified 117 articles related to telerehabilitation and physical therapy in a PubMed database search.14 The majority of articles published in the literature over the past 10 years were conceptual or descriptive, thus identifying numerous potential clinical applications of telehealth in physical therapy. There were fewer studies investigating reliability or validity, and the fewest number of studies were conducted in the financial/resource use or effectiveness categories. The descriptive articles in the literature review highlighted the range of potential telehealth applications for physical therapists addressing the cardiovascular, integumentary, neuromuscular, and musculoskeletal systems. As examples, physical therapists have participated on interdisciplinary teams through telehealth to treat people with bronchopulmonary dysplasia.15 In addition, wound care specialists have provided consultation on wound management through telehealth as an efficient way to provide these services where they otherwise might be unavailable.16 Most recently, Russell et al17 randomly assigned 65 participants to receive a 6-week program of outpatient physical therapy either in the conventional manner or by means of an Internet-based telerehabilitation (IBT) program following total knee arthoplasty. Those patients who received the IBT program achieved outcomes comparable to those of the conventional rehabilitation group with regard to flexion and extension range of motion, muscle strength, limb girth, pain, Timed “Up & Go” Test scores, quality of life, and clinical gait scores. The IBT group had statistically significant and clinically important improvements from baseline on the patient-specific functional scale and the stiffness subscale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). In light of these findings, we recommend that future clinical trials should investigate cost reduction and comparative effectiveness for consumers of telehealth services in physical therapy. In addition, in a systematic review of 28 studies looking at clinical outcomes, clinical process, health care utilization, and costs associated with telehealth, Kairy and colleagues18 recommended more methodologically robust studies that investigate resource allocation and costs with a focus on the patient and on clinical process measurements. In our opinion, telehealth outcomes research generated to support the concept of value-based practice19 is paramount to significantly influence reimbursement and payment policy. Before physical therapists can begin to incorporate telehealth technology into their daily practice, several barriers need to be addressed, including issues related to payment policy and licensure. In order to achieve long-term adoption of telehealth practice within the physical therapy profession, actions must be initiated to begin to address the identified barriers. Prior to January 1, 1999, Medicare coverage for services delivered via a telecommunications system was limited to services that did not require a face-to-face encounter under the traditional model of medical care.20 However, the Balanced Budget Act provided for coverage of, and payment for, consultation services delivered via a telecommunications system to Medicare beneficiaries residing in rural health professional shortage areas (HPSAs) as defined by the Public Health Service Act. On October 1, 2001, section 223 of the Medicare, Medicaid, and State Children's Health Insurance Program (SCHIP) Benefits Improvement Protection Act of 2000 (BIPA) (Public Law 106-554) expanded Medicare telehealth services to include consultations, office visits, office psychiatry services, and any additional service specified by the secretary when delivered via a telecommunications system. As specified in the BIPA, originating sites where the telehealth services are rendered include practitioners' offices, critical access hospitals, rural health clinics, federally qualified health centers, and acute care hospitals. More recently, the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275) expanded the list of telehealth originating sites to include hospital-based renal dialysis centers, skilled nursing facilities, and community mental health centers.20 With the expansion of originating sites for telehealth services beyond HPSAs, access to care has improved over the years. Although these payment policy models have evolved for health care agencies and practitioners, physical therapists are not listed as eligible providers of telehealth services through Medicare.21 A complete list of covered telehealth services and eligible practitioners is available on a fact sheet developed by US Department of Health and Human Services.21 The rules published by the Centers for Medicare and Medicaid Services for 2012 suggest a new definition for category 2 coverage of telehealth services. Currently, category 1 services are defined as having met face-to-face comparability with standard clinical care. Category 2 services would remove the requirement for face-to-face comparability with standard care. Instead, category 2 telehealth services may be covered when the service is accurately described by the corresponding billing code and the use of the telecommunications system delivers a demonstrated clinical benefit to the patient.20 The 2012 Medicare telehealth services physician fee schedule with category 2 examples of clinical benefit is available on the Office of the Federal Register Web site.20 Another barrier to effective adoption of telehealth technology by physical therapists relates to license uniformity and portability. Currently, Alaska and Washington are the only states that have adopted standards for licensure of telehealth practice in physical therapy; thus, the profession faces a major hurdle in initiating licensure standards throughout the rest of the United States. The board language in Alaska states that telerehabilitation is provided to patients who are located at distant sites within the state that are not in close proximity of a physical therapist.22 In Washington, telehealth means providing physical therapy via electronic communication where the physical therapist or physical therapist assistant and the patient are not at the same physical location.23 Although novel implementation of telehealth services in Alaska and Washington has demonstrated cost savings in resource-limited rural regions,24 the states have different licensure standards for telehealth services. There are no defined rules for advancing licensure standards for physical therapists utilizing telehealth services on a large scale nationally. In our view, the first step to addressing licensure issues on telehealth is to examine the lack of licensure language on telehealth standards in various states. To illustrate this point, West Virginia's statutes and rules dealing with physical therapy allow consultation between a physical therapist and another physical therapist or health care provider through telecommunications that are delivered via audio, video, or data communication.25 However, West Virginia does not have any statutory language regarding telehealth services. In this regard, the Federation of State Boards of Physical Therapy (FSBPT)'s Model Practice Act language on telehealth26 can serve as a tool for public protection and legislative change. In our opinion, licensure language to regulate the practice of physical therapy with telehealth services must be addressed if physical therapists are to participate in national health reform in the 21st century. Next, licensure portability for interstate physical therapist practice in the United States has not been established to date. However, licensure portability models of other health professions have been increasing. In nursing, as of 2010, 24 states have joined the Nurse Licensure Compact, which clarifies the authority to practice telenursing, provides greater mobility for nurses, and protects the public's health and safety.27 The Nurse Licensure Compact allows a nurse to have one license (in his or her state of residency) and to practice in other states (both physically and electronically), subject to each state's practice laws and regulations. In medicine, some states such as New Mexico allow physicians holding a full and unrestricted license to practice in another state to receive a “telemedicine license” to enter New Mexico remotely to practice telemedicine.28 A model act to regulate the practice of medicine across state lines established in 1996 allows 19 Northeast and West Coast states to participate in a licensure portability grant program through the authorization of the Health Care Safety Net Amendments of 2002 (Public Law 107-251).29 Both nursing and medical professions' state alliances were established with the licensure portability grant program funded by the Health Resources and Service Administration with cooperation of the National Council of State Boards of Nursing (NCSBN) and the Federation of State Medical Boards (FSMB), respectively. Yet, the majority of US states do not participate in medical or nursing licensure portability. Thus, the ATA urges policy makers to adopt changes in the current system of providing health professional licensure and regulating medical practices that free consumers to choose and access health care services and health care providers regardless of location.30 In our view, it is time for our professional and association leaders to collaborate with key stakeholders to advance licensure portability to improve access to physical therapy services nationally. Lastly, the lack of licensure uniformity in various states must be addressed. In 2008, the State Alliance for E-Health issued recommendations in its first annual report, Accelerating Progress: Using Health Information Technology and Electronic Health Information Exchange to Improve Care.31 These recommendations included streamlining the licensure process to enable cross-state e-health.29 Licensure uniformity would enable state medical regulatory agencies to share investigative and complaint information, thus increasing public safety and state boards' ability to make informed decisions concerning a license application. In our view, licensure uniformity for physical therapists can only accelerate interstate e-health and protect the general public with licensure boards' oversight. Payment policy issues have long been a subject of interest in the telehealth community because they remain as a key obstacle. Brown et al4 examined the current payment policy models for telehealth services provided by speech therapy practitioners. Although various models exist, the best option for expansion of government support for a telepractice program is Medicaid, according to Brown and colleagues.4 An opportunity may exist for adopting an alternative means of service delivery that has potential for reducing transportation costs that Medicaid is required to provide while the US deals with its current government debt crisis. Furthermore, some states claim that any provider of a covered Medicaid service that is within their scope of practice can bill for telehealth services. For example, the Telehealth Advancement Act of 2011 in California, which was signed into law on October 7, 2011, will provide Medi-Cal coverage for various healing arts professions, including physical therapists providing telehealth services, starting on January 1, 2012.32 By 2014, the PPACA's time line will create a major expansion of Medicaid coverage in the United States.6 To this end, APTA's public policy priorities to improve coverage under Medicaid fit well with this payment model opportunity. Historically, 21 state Medicaid programs paid for at least one telehealth service in 2002.33 Nine of these states had specific statutes enacted by the state legislature authorizing and defining scope of telehealth activities. The states that provided Medicaid reimbursement for telerehabilitation included Hawaii, Louisiana, Minnesota, and Nebraska, with the justification for reimbursement being shortages of practitioners within rural areas. As for private health insurance coverage, Maine and New Hampshire recently passed legislation requiring private payers to reimburse covered services regardless of whether they are delivered face-to-face or via telehealth.4 Even though some payment policies may exist, Medicare poses the ultimate barrier to widespread telehealth implementation in the United States because physical therapists are not listed as eligible practitioners.21 To address this issue, the ATA's federal telehealth policy priorities for 2011 include removing Medicare coverage barriers to providers whose services are otherwise covered for Medicare, such as physical therapists.34 It is our view that physical therapy leaders should partner with constituents, legislators, and professional organizations to advocate for Medicare eligibility as practitioners of choice who can provide telehealth physical therapy services. As mentioned earlier, only Alaska and Washington have adopted standards for telehealth practice in physical therapy. In this regard, the physical therapy profession may glean ideas from other health professions' licensure model regulation to develop future intrastate and interstate regulations. For example, medical licensure portability recommendations30 with federal, in-state, preemption, and mutual can serve as potential for physical therapy licensure uniformity and portability. In addition, the Health Resources and Service Health to identified key for licensure portability in health licensure or license and Therefore, licensure uniformity must not be in order to address licensure portability for physical therapist In our view, the may serve as a in of licensure for physical therapy practitioners, but they the was by its to investigate licensure to address Licensure uniformity and portability can be one part of the to address the PPACA's mandate of the The from the licensure models of and may provide to on how to and and to address and professional with telehealth services across the will require cooperation from its states and practitioners in order to advance model licensure regulation on telehealth physical therapist The National Act for 2012 is an of legislation to expand licensure in this case for health care An may expand the US Department of state licensure to qualified and health care including and and the requirement to access to and efficient health care. 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Lastly, a focus on value-based practice with the as the key will the adoption of telehealth services in physical therapy. A key step in the of telehealth must include health services research to support policy and in the areas of telehealth services in physical therapy. The For Physical is the opportunity for telehealth to address clinical to the To this end, telehealth services well with the research which medical applications for physical therapy and their on clinical In that to telehealth into clinical practice as the would a to of physical therapy. In our view, physical therapy should collaborate with providers in medicine, nursing, rehabilitation and other health care professions to telehealth practice, and as adoption of technology is to in health care. As in the physical therapists must the opportunity to advocate for telehealth payment policy and licensure for therapy services. our will be by our in payment policy and licensure barriers as a profession, which will be if telehealth as a means of health care delivery for physical therapist practice is to become a reality. delivery of health-related services and information via telecommunications as one way to improve quality and access to health care. Lee and in their Health in article as a of Health Care for Physical examine some of the barriers to the implementation of telehealth in the physical therapy and identify to overcome In this and discuss the opportunity that telehealth provides to the physical therapy will if the profession this opportunity. patients and clinicians with is the of the private in addressing can the profession the of physical therapists for can physical therapists do at the to implement The by in this are her and do not the of the Department of or United States with Lee and by