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An Overview of Telehealth

Jana Cason, DHS, OTR/L, FAOTA

April 2, 2020

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What is Telehealth?

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Telehealth Defined

The World Federation of Occupational Therapists (WFOT) in 2014 published a telehealth position statement, which defined telehealth as “the use of information and communication technologies (ICT) to deliver health-related services when the provider and the client are in different physical locations.” The term telehealth can be used more broadly to describe patient education and general health information. For example, it could take the form of text messages that are delivered to pregnant women at certain milestones in the pregnancy to promote a healthy pregnancy. The term telehealth can be very broad. When it is used generally by associations and in the context of discussing service delivery, the definition of telehealth is that the provider and the client are in different physical locations. If you are interested in looking at the full telehealth position statement by the World Federation of Occupational Therapists, it is available on their website in their resource center.

In 2018, the American Occupational Therapy Association (AOTA) published its most current telehealth position paper. Their first position paper was published back in 2005, and was originally called the “Telerehabilitation Position Paper.” Over time, the terminology changed. It was revised in 2010, 2013, and the most current version is the 2018 revision. In this paper, AOTA defines telehealth as “the application of evaluative, consultative, preventative, and therapeutic services delivered through information and communication technologies.” This paper outlines the different telehealth models of care and applications in occupational therapy. It also touches on the various technologies that are used, including both synchronous and asynchronous. It highlights practitioner qualifications as well as ethical considerations. Finally, it addresses funding and reimbursement and provides some clinical case examples. If you are interested in telehealth, I recommend that you review it thoroughly. We will also discuss many other resources throughout this presentation, recorded in 2016.

Another important document, also published in 2017 by AOTA on the topic of telehealth, is the Ethics Advisory Opinion. Essentially, this document takes the code of ethics and it aligns those principles with the applications of telehealth. Both documents are available through AOTA in the official documents area.  There are additional resources specifically addressing changes to policy (e.g., licensure requirements and reimbursement) as a result of the COVID-19 pandemic available on the AOTA website at https://www.aota.org/Practice/Manage/telehealth/coronavirus.aspx.

Terminology

It is essential that we clarify the definitions of and differences between the following “tele-” terms:  telemedicine, telehealth, telerehabilitation, tele-occupational therapy, telepractice, and telecare.

The term telemedicine is primarily used in relation to delivering medical services online. For example, you might have a scan read by a radiologist or a dermatologist could look at a skin condition. Telemedicine refers to more physician-driven, medically related services.

Telehealth is a broader, more over-arching term. Telehealth is the term that was endorsed by AOTA in 2013 with their updated telehealth paper. This term was identified, chosen and endorsed by AOTA over the previously used term (telerehabilitation) because we recognize the important role of occupational therapy to promote health and wellness. In the literature, telerehabilitation started to be very narrowly defined as and associated with rehabilitation services for individuals with disabilities. Occupational therapy represents such a broad spectrum of services, we wanted to be sure to use the term that best captured the full scope of what OT practitioners provide, especially incorporating the element of health and wellness. Telehealth was a much better fit. At that same time, the policy and the language started to move. It was an optimal time to make that shift because the terminology used in drafting legislation and policy is more reflective of that term telehealth. It positions occupational therapy with more current terminology that is commonly understood and used by stakeholders.

Telerehabilitation, or telerehab, was the original term endorsed by AOTA. In general, when you hear telerehab used, it alludes to rehabilitation services. The term was changed to encompass habilitative, health and wellness, and other aspects of an occupational therapist’s service.

Tele-occupational therapy is a term used by the Canadian Association of Occupational Therapists, although they also incorporate the term telehealth in their position statement.

Telepractice is used primarily by the American Speech-Language-Hearing Association. They have chosen to use that term to describe remote service delivery because many of their practitioners work in educational settings. They feel that term better represents practitioners, many of whom, work in non-medical settings (e.g., schools).

Telecare is a term that describes the remote service delivery model and is a term more predominantly used in the UK. I mentioned this term because it does create challenges when a practitioner is looking online to find research and evidence. In a search engine, you might type in the word “telehealth,” and because the researcher has chosen to use a different term, key articles may not be included in your search result. I wanted to make sure that you get an overview of some of the various terms used so that as you do explore the literature, you can expand your search terms to capture all of the evidence around this topic.

Another term you might hear is e-health or electronic health. That term encompasses apps, blogs, health information, gaming technologies, electronic medical records, etc. When using an app or gaming technologies with your client in the clinic or in the home, and you are in-person with the client, it is not a telehealth application. Telehealth is where we have that remote service delivery, and the client and the practitioner are in different physical locations. We may use apps, or we may use gaming technologies, but those tools do not constitute a telehealth application. Similar to e-health, the term m-health is often used to refer to mobile health, which involves using some type of device or mobile technology to access healthcare information.

You will also notice in the AOTA telehealth position paper, that the term “tele” can be added to the actual service. We might talk about tele-intervention, telemonitoring or tele-evaluation. Essentially, adding the “tele” prefix designates that the application of those different services occurred remotely.

Service Models

When we talk about the use of telehealth, it is important to mention that it does not have to be an “all-or-nothing” approach. There are applications where telehealth could be used exclusively and be very effective. However, as states and licensure boards make policies, it is important to broaden our notion of how telehealth might fit into our current clinical models so that they do not create barriers to the use of telehealth.

For example, occasionally, a state or licensure board might draft policies with language specifying that an in-person evaluation is required first before the use of telehealth. This is problematic because there is solid evidence to demonstrate various OT assessments can be valid and reliable when administered remotely. It is possible to do a very effective evaluation through telehealth technologies. Furthermore, creating a requirement of first meeting in-person could eliminate the opportunity to use telehealth at all because some people have access barriers. It should be at the discretion of the practitioners to determine if it is an appropriate delivery model and if the evaluation and the interventions to be provided are a good fit for telehealth.

Another option to consider is a hybrid delivery model, where some services are performed in person and some remotely. Some services that require physical handling, where we would need to physically touch that patient, we may want to see the patient in person. Then, when appropriate, some services could be done effectively through telehealth.

Lastly, it may be that some clients are not good candidates for telehealth. They may be unable to access the required technology. Or, their support is limited in the home and there is a question of their safety. There might be a variety of different reasons where we might decide that in-person is a better fit for our client. Again, it should be at the clinical discretion of the therapist to make those decisions. We want to be careful about any arbitrary requirements that could hinder the use of telehealth.


jana cason

Jana Cason, DHS, OTR/L, FAOTA

Dr. Jana Cason is an associate professor at Spalding University’s Auerbach School of Occupational Therapy in Louisville, Kentucky.  She serves as Chair of the American Telemedicine Association’s Telerehabilitation Special Interest Group and Chair of the American Occupational Therapy Association’s Technology Special Interest Section.  She is Senior Associate Editor of the International Journal of Telerehabilitation, a peer-reviewed, open-access, PubMed indexed journal.  She has authored numerous refereed articles, book chapters, and standards and guidelines documents related to telehealth.


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