When Robin Roots prepares clinical education placements for her physiotherapy students, she has to think creatively. In her job as Coordinator of Clinical Education for UBC’s Northern Cohort in British Columbia, Robin recognizes the region she serves presents unique challenges. For example, many of those needing physiotherapy services are unable to access them due to geographical limitations and/or physical mobility restrictions. Additionally, there are health disparities she must consider, including a higher prevalence of disability and chronic disease. Compounding the situation is the significantly fewer physiotherapists serving the region (2.8 physiotherapists per 10,000 residents versus the provincial average of 6.2 1).
Unique challenges require unique solutions: one distinctive solution Robin looks to is telehealth technology. Working with the well-known B.C. Telehealth expert Dr. John Pawlovich, Robin combines in-person assessments with telehealth follow-up to improve access to physiotherapy services in the remote communities in B.C.
Robin believes there is enormous potential for telehealth to increase access to physiotherapy services in Northern B.C. as well as other low-access regions. Together with her students, she is helping to pioneer physiotherapy telehealth services in the province.
Robin and I met in January 2016 at a health information technology conference at UBC where she was presenting on her work using telehealth. My own interest in this subject developed several years ago, while completing my Masters of Health Administration at UBC. I became very interested in eHealth and the potential it offered to the physiotherapy profession and the patients we treat. My work has since led me to examine the potential for practical physiotherapy delivery models using telehealth technology for areas like Northern B.C.
Through this work and my other research, I am increasingly convinced that in many situations, physiotherapy delivered through a telehealth medium has the potential to achieve the Institute for Healthcare Improvement’s ‘Triple Aim’, achieving improvements in the quality, efficiency and patient experience in health care delivery. For clarity, I will call this ‘telephysiotherapy’ in this article to distinguish it from the broader term, ‘telerehabilitation’.
Despite the potential that Ms. Roots and I can both envision, telephysiotherapy is not available to B.C. residents in any mainstream way.
This appears to be the situation in much of Canada, although pockets of knowledge and application exist. With telehealth use increasing dramatically across Canada in other areas of medicine, I would pose the following question:
Is it time for all residents, especially those in rural and remote regions, to have access to telephysiotherapy?
This article looks at the current telehealth explosion in Canadian health care, what the evidence indicates telephysiotherapy could do for residents in Northern B.C. and similar regions in Canada, the barriers to its mainstream use, and the steps that might be taken to develop this new model.
The telehealth explosion
Telehealth, which literally means providing health care services at a distance, is not a new concept. In fact, it may have been born in the early 1900s when the Reverend John Flynn, an outback missionary in Australia, used a radio powered by bicycle pedals to communicate doctors’ instructions by Morse code 1,500 kilometres away. (2) Now, modern developments are resulting in an explosion of its practical application, primarily through videoconferencing technology.
Canada’s Health Informatics Association, COACH, reported a massive 45.7% jump in telehealth sessions between 2012 and 2014 in its Canadian Telehealth Report. (3) Government, patients, and private industry are all driving this surge as they recognize the benefits telehealth can provide.
Canada Health Infoway confirms that telehealth does indeed provide significant improvements in patient access to health services, the quality of care provided, and the level of spending in providing services. (4)
Some examples of the specific benefits include:
$55 million in health care system annual cost avoidance
A reduction of 47 million kilometres of patient travel
Better chronic disease management
More equitable health care delivery with improved Aboriginal access to specialist services
Improved timeliness of care
Improved patient-centred care with access to services closer to home, and more
Note that these values are from 2010. With the considerably higher telehealth usage since, further benefits would be expected that are commensurate with the increased usage in 2015.
These benefits are common to most telehealth services that reduce the need for patients to travel, including telephysiotherapy.
But… online physiotherapy? Really?
To many of us, it may come as a surprise that a physiotherapy session can be delivered through telehealth. Indeed, as I discuss this topic with colleagues, I often encounter skepticism about any valuable service being delivered in this way. Although this is understandable on the basis of the apparent incongruity between information technology and a traditionally hands-on profession, providing value to the patient through telephysiotherapy
is not nearly as far a stretch as some believe. With creativity and problem solving, a great variety of patients can be assessed, educated, instructed
in exercise, advised in home therapy measures, monitored, and more—all from a distance. Telephysiotherapy also offers great potential for caregiver involvement and interprofessional collaboration in treatment, in some cases even more so than in-clinic care.
Skeptics are also often surprised by the extent of research on the topic. Concentrated hubs of study have included Australia’s Telerehabilitation Research Unit at the University of Queensland (Dr. Trevor Russell), and Quebec, Canada (Dr. Dahlia Kairy and Dr. Michel Tousignant). The literature that examines telephysiotherapy can generally be divided into the categories of (1) assessment validity and reliability (2) treatment effectiveness, and (3) patient satisfaction. There is persuading evidence in all three of these categories tow suggest that telephysiotherapy should be incorporated into Canadian health care in some form, particularly when
in-person treatment is not available. An especially interesting study published earlier this year found that total knee arthroplasty telerehabilitation was non-inferior to in-clinic visits .5 While a full literature review is beyond the scope of this article, readers are invited to do their own investigation through a search of the authors mentioned above or under the search term “telerehabilitation”.
With the current evidence base, the question to be answered now is not so much can telephysiotherapy provide value, but how can we appropriately and expediently join the rest of the medical system to use telehealth technology to address physiotherapy-related gaps in Canadian health care systems?
So why is it not widely available already?
If telephysiotherapy has a reasonable research base and a significant need exists, why is is it not widely available? The reason for this is partially the lack professional awareness of the benefits, but there are also structural and system barriers that make implementation difficult.
At the top of the barrier list is funding. In B.C., and to my knowledge the rest
of Canada, insurance companies are unfamiliar with telephysiotherapy and will not reimburse for a visit of this type. The same is true for other third-party payers, including worker’s compensation and auto injury insurance. There seems to be understandable hesitation to open the door to telephysiotherapy visits without a guiding framework for its use. Even the B.C. government, despite its push for expanded telehealth service, does not yet have a billing code for telephysiotherapy. As a result, the only remuneration available is by patient private payment or unique special arrangements. With this being the case, it is difficult for telephysiotherapy to become anything more than a niche service. It may be that private enterprise takes the risk
on providing these services, but a truly successful model will likely need further funding sources.
Other barriers include a lack of a recent regulatory framework, concerns about privacy and security, limited knowledge and promotion within our professional associations, and concerns about jurisdictional boundaries. At the Physiotherapy Association of British Columbia, we are taking steps to address these barriers, but the process takes time, partially because much of this work is done on a volunteer basis.
Where do we go from here?
The need for improved physiotherapy access in Canada demonstrated by the Northern British Columbia example, the current telehealth explosion, and the evidence base for telephysiotherapy all point to the conclusion that it is indeed time for telephysiotherapy to become available in a more mainstream way in Canada. But for physiotherapy to join the telehealth wave, it is likely that a coordinated strategy will be needed at the association and regulatory level, both provincially and nationally.
To start, we may be wise to follow the lead of other nations. For example, the American Physical Therapy Association now advocates for telehealth and has produced a position statement in its support and outlined recommendations for its use .6 The Australian Physiotherapy Association has done the same .7 In Canada, I have not found any recent efforts related to the subject at either an association or regulatory level. A 2006 document produced by the Canadian Alliance of Physiotherapy Regulators titled “Considerations for Telepractice
in Physical Therapy in Canada” needs updating, but it could be used as a framework to start a reinvigoration
for telephysiotherapy in Canada. With
a coordinated strategy in place, work with stakeholders to improve funding mechanisms and establish policies for the appropriate use of telephysiotherapy could commence.
While clearly telephysiotherapy will not be for every physiotherapist, there seems to be enough need, interest, and potential to begin to move in this direction. I look forward to a future where well thought-out, mainstream telephysiotherapy becomes reality and contributes to a more accessible and equitable Canadian health care system.
Jeremy McAllister, BScPT, Masters of Health Administration, CPA Member since 1996