Best Practices for Physical Therapy in the Age of Telehealth
Happy New Year!
While I did not expect to enter 2022 hitting another peak in the COVID pandemic in the US, we are nonetheless here. I find that New Years are a great time to reflect on all of the things you’ve achieved in the last year, celebrate your stellar team, and also reflect on areas of opportunities. In particular, things that surprised you, defied your expectations, and challenged your original understanding of the world are extraordinarily helpful in understanding what we can learn from these new nuggets of truth with the goal of incorporating these into your new understanding of the world in the new year and informing your strategy moving forward.
Reflections on Benefits of Telehealth in PT
Last year, Katy and I embarked on a journey to redefine the $6 Billion Physical Therapy market in the U.S. through Comet Health. We notice that, compared to other disciplines within healthcare, physical therapy lagged in terms of telehealth adoption. For me, it is self-evident that in 20 years, telehealth will be an accepted and routine addition to the arsenal of tools that physical therapists can deploy to improve the lives of their patients and reduced collective human suffering.
However, last year, one typical response I often got when I told people that I was working on telehealth for physical therapy was surprise.
It is physical therapy after all. Doing it remotely without ever touching or seeing a patient?
It seems almost oxymoronic to attempt to do physical therapy, virtually. However, there are so many benefits to being able to see patients remotely today and many enabling technologies that have emerged over the last couple years that not only makes it possible but will make it progressively easier over time as technology continues to advance.
I’d love to share some of our learnings having seen patients via telehealth over the last year to challenge the notion that we do not yet have the technologies and tools we need today to effectively manage patients who require physical therapy remotely. In this article, I also hope to outline some of the challenges we and other providers have faced in switching to telehealth during the pandemic and strategies to mitigating these weaknesses for this care modality and ways of reframing these challenges as opportunities that might actually help bridge patient care in the modern era and make it more accessible for the most vulnerable populations in this country.
Tools and Enabling Technology
The first question I get is: do the tools and technology actually exist today to service patients well over telehealth? The answer for me, as a technologist, is irrefutably yes. I was shocked to see the progress that we had made in computer vision (CV) technology over the last couple years since I graduated with a computer science degree in 2015. The number of off-the-shelf CV algorithms that can be implemented by your average computer science graduate today far exceeds anything that has ever been possible in human history. A new grad today has the power to harness the collective knowledge and research of armies of CV PhDs with a click of a button. They can implement Google Machine Learning algorithms, for example, out of the box that a couple years ago would have been restricted to those with huge computing resources (think rooms and rooms of servers and super computers) and access to hours of dedicated PhD-level talent.
Over the last couple years, these algorithms have been standardized and packaged into deployable packages that can run seamlessly on a mobile device that can be held in the palm of your hands. These algorithms have built-in live video processing and camera capture, pose detection, repetition count, and even form correction. You can easily spin up these algorithms with basic understanding of APIs and computing infrastructure and you can incrementally collect training data that you can feed into these algorithms to create for new use cases and new exercises as quickly as a PT can demonstrate exercises in real life through transfer learning.
Some of the cool pose detection and repetition count functionality you can get off the shelf today with Google ML!
In addition, the cost of the computing to share these tools with patients in the comfort of their homes is so minimal that we are entering into an era in which we can truly scale the capacity of our existing and limited clinical staff by multiple folds.
Cost of computing has gone down considerably over the last couple decades and the amount of computing power in a hand-held mobile device has increased exponentially over the last couple years!
This has many benefits both in the standardization of treatment protocols so all patients are using proven and evidence-based approaches shown to be effective in various operations and conditions.
Secondly, this increases the scale and number of patients an individual clinician can see over the course of their lives and in the same number of working hours by changing the clinician relationship from a one-to-one relationship to a one-to-many relationship.
Lastly, this increases our ability to personalize and adapt treatment length and speed to an individual patient’s progress in their individual recovery journey.
As an added benefit, this model improves access for patients who are not within the serviceable radius of a skilled provider. This is particularly helpful for patients who require specialized physical therapy including pelvic floor physical therapy for which there are limited providers (~1,000) nationwide. There may not be a provider within a reasonable distance from a patient’s house or place of work.
Telehealth reduces societal burden in the form of time away from work and reduces the time required on the part of a caretaker to shuttling a patient, who may not be mobile, to and from a physical PT location.
Systematizing exercises and home exercise curriculum into repeatable modules also reduces the price point of this knowledge, opening access to treatment to patients who traditionally would not be able to afford it or who avoid treatment due to cost constraints.
Lastly, virtual treatment changes the paradigm for how we think about treating patients — it enables us to make treatment more bite-sized and more accessible, improving adherence because these exercises can be delivered digitally. Physical therapy no longer has to be episodic and restricted to an artificial environment of a physical therapy practice. Instead, we can deliver exercises that patients can incorporate into their day-to-day lives and in the actual environment that they live in day-to-day — their homes.
There has been significant talk over the last couple years around Social Determinants of Health. These are peripheral factors, healthcare adjacent factors, that previously were not considered in the care of a patient which nonetheless significantly impact their outcomes, ability to adhere to treatment protocols, and the progress that they make in recovery. Telehealth gives providers a glimpse into patients’ lives in their natural habitat. Physical therapist now have valuable insight into how patients perform day-to-day activities such as getting up from a chair, reaching up into a cabinet to grab a glass of water, lift a baby and hold them while they nurse. These factors including more basic and fundamental aspects of a patient’s life such as (1) whether or not the patient has a safe space, (2) whether the patient is part of an abusive or traumatic relationship, (3) how are household responsibilities are shared between a patient and her partner, are valuable insights that can be used to inform care. There is also research that patients may be more open with their providers and willing to share sensitive and vulnerable information with their providers because they’re in a safe space.
Social Determinants of Health is becoming an increasingly important factor in patient care and personalization.
Reflections on Areas of Opportunity and Strategies for a New Modality of Care
All of these benefits that we have learned over the last year of operating Comet are not without concomitant weaknesses. One thing that we have found is that a typical course of treatment via telehealth frequently ends up being a reduced number of sessions compared to a full course in-person.
We hypothesize multiple potential reasons for this. One is that it can sometimes be difficult to establish a positive and supportive working relationship with a patient having never met them in person. Having hands on a patient increases feelings of warmth toward that provider and is something that will for the foreseeable future be a weakness in virtual care. While technology will improve over time to include haptics and remote sensing, we nonetheless continue to see this as a challenge today that must be overcome as technological progress lags telehealth adoption.
For providers who are able to, we recommend a hybrid approach which includes a first session and evaluation done in-person followed by more frequent and potentially shorter telehealth sessions. If this evaluation cannot be done in-person, establishing trust early on between the provider and the patient is of paramount importance to the success of the treatment. Patient buy-in is crucial to adherence and treatment effectiveness.
In order to do that, we recommend establishing credibility up front in the first session. Physical therapists must own their knowledge, experience, and credibility in order for patients to know where they come from. One thing we find that providers tend to struggle with is imposter syndrome. They lack confidence in their ability to service patients purely via telehealth. This is despite overwhelming published and peer review literature that suggests that telehealth-based PT treatments have just as good, if not greater, patient reported satisfaction and quantifiable outcome measures versus in-person care. This is also in spite of the fact that patients are opting into receiving telehealth-based care.
As a provider, you should keep in mind that these patients have made an informed decision based on their life circumstances to engage in this form of care for a multitude of reasons. For example, many patients are an hour drive away from the closest specialist which means that they would have to take two hours out of their day for every single session to go seek care for their condition. For many patients, this is untenable. They are unable to take this much time away from their jobs, families, and other life responsibilities to care for themselves.
We see physical therapists who are not confident in their ability to help patients over telehealth. I would urge any physical therapists who feel this way to not dictate how their patients should or should not seek care unless there is a real medical reason for which patients should see a clinician in person. Trust the patient to be the best person to make the decision of how they would like to seek and receive treatment.
The other thing that goes hand-in-hand with this lack of confidence among physical therapists is not being a big enough advocate in pushing patients to continue and adhere to treatment by scheduling follow-up appointments. In a typical in-person physical therapy appointment, front office staff will frequently book all of a patient’s series of appointments up front. This is because they know that patients often need an extra nudge to stay adherent to their course of treatment. The benefits of physical therapy, while clinically proven, do not typically occur after one or two sessions. Progress occurs through continued commitment to the course of treatment and consistent adherence to treatment.
When providers shift to telehealth, we see many physical therapists shrink away from this responsibility. At the end of a session, they will not set aside the time to schedule a patient’s next session. This is not only doing an injustice to your private practice but also doing an injustice to the patient who is expecting you to be an advocate for their recovery journey. If you are not willing to advocate on your patient’s behalf for continued treatment when it is medically necessary and appropriate, you are failing your patient. Have faith and confidence in your ability to make a difference in your patients’ lives. Always schedule a follow up appointment and make time at the end of an appointment to do so.
The first appointment with a patient is one of the most crucial points in building a foundation for a strong patient provider relationship. It is your first impression with a patient and your opportunity to come into your own power as a clinician.
Your goal with this session should be to establish your credibility for both yourself and for the patient so that the patient has confidence in your ability to help them and you have confidence in yourself and the impact you want to make on the world.
After establishing this credibility, the second most important thing you can do in this first session is to listen.
One thing that we have found with our pelvic floor patients in particular is that, oftentimes, this is the first time they are talking with a professional about a longstanding health issue that has impacted their lives on a day-to-day basis for months, perhaps years. They have been potentially shunned by other health care professionals and specialists who have on average ten minutes to spend with them. Physical therapist are often the first providers that patients have seen and interacted with in a healthcare context that are there to truly listen.
Provide the space for patients to tell you about their often complicated medical histories, to tell you about all of the approaches they have tried, what has worked and what has not, and respect that individual’s unique patient journey and story.
Take the time to explore with them their unique functional goals with treatment and what recovery would mean for their lives and their interactions with their family, friends, and coworkers. It often takes a while for patients to feel comfortable enough with their providers to share these details and be vulnerable with their providers because, frankly, a lot of these are very intimate conversations.
One approach that we have noticed is highly effective in encouraging patients to be open in this first session is to send them a very detailed medical history questionnaire to fill out prior to the first session.
This not only puts them in a reflective mindset where they are thinking back on all of their previous interactions, experiences, and challenges that they have had with their health but also helps them be more honest and open with you about their story without having to feel like they have to hide something due to fear of judgment. It can be challenging for all people to open up to someone they don’t know and we find that a thorough questionnaire prepares them well. It also provides you with a set of prompts that you can ask the patient to clarify during your session and helps reduce some of those inherent barriers to connection that can be particularly challenging over this format.
In person, you are able to communicate your warmth and your concern. You are able to read a person’s body language and facial cues. Some of these subtle data points are not available over the telehealth format today. Therefore, you need to be proactive in supplementing your understanding of a patient’s story and intentional in building the trust and empathy that you need in a successful patient provider relationship.
We’re Building a Community of Forward-Thinking PTs — Join Us!
I hope that some of these strategies and insights were helpful and informative as you think about how to incorporate telehealth into your practice in the new year. Telehealth is challenging but a worthy modality to invest in to reach patients where they are.
If you are a PT interested in expanding your supplemental income by seeing patients over telehealth or if you are a PT interested in setting your own hours and being your own boss through an independent telehealth practice, please fill out the form below!
At Comet, we’ve been building a set of software tools to support independent physical therapists looking at setting up their own private practices. Our mission is to bring PT into the 21st century and increase modalities with which patients can seek and receive care.
