By: Arden McGregor, MA, CPsych, CBIST, and Dennis Radman, BSc, RRP, CBIST

 

Insurance reform has driven a significant interest in technology as a solution to reduce the cost of rehabilitation services and increase overall system capacity, but this just scratches the surface of its benefits. In fact, as far back as 1997, Telehealth has been touted as the most significant contribution to healthcare delivery systems of the future (Bashshur, 2004). eRehabilitation™, a component of telehealth, is a cutting-edge and bourgeoning means of delivering rehabilitation services. At Brainworks, we have developed and defined eRehabilitation™ as a comprehensive treatment platform that uses interactive audio, video, or data communications to provide rehabilitation services at a distance. Healthcare software and technology development is moving at a near breakneck pace. Advances in computing, wireless and internet technologies, development of smart devices, cloud computing with the incorporation of evidencebased therapies are coming together to propel healthcare to levels only dreamed of. eRehabilitation™ is not designed to replace traditional healthcare; rather augment and improve it. The use of technology to complement face-to-face rehabilitation services has grown by leaps and bounds, particularly in the cognitive, behavioural and psychosocial realms. Time and money constraints, geographical and weather constraints are being smashed through the use of technology.
 
Advantages

There are several practical advantages to providing therapy services online. By harnessing the power of the internet, services can be provided in context, with no commute for client or therapist, resulting in an overall cost savings. Additionally, shorter, more frequent sessions make good clinical sense from a learning theory perspective, but until now have not been realistic. Therapists can now provide abbreviated sessions more frequently to spread out their involvement and contain costs while boosting efficacy. Our clinical experience, confirmed by a growing literature base, indicates that e-based sessions result in fewer cancellations.
 
There are significant benefits seen in rehabilitation outcomes. Clients can be diagnosed and assessed earlier and “wait times” for treatment can be significantly reduced which can contribute to improved outcomes and less costly treatments. Canada has the second longest wait times for seeing a specialist compared with 10 other countries, according to both primary care physicians and their patients (Keely, Liddy, & Afkham, 2013). Keely’s research showed a reduction in wait times when e-technologies were deployed. Fortney and his colleagues (Fortney, Kaboli, & Eisen, 2011) recommended a proactive use of digital communications and technology to reduce wait times. Towards an effort to research interventions to improve veterans’ access to care, Kehle and her colleagues conducted a systematic review of the literature and found veterans who received their consultation via telemedicine reported that their care was significantly more convenient than those who attended inperson appointments. Further, veterans who were provided treatment through telehealth and associated technologies initiated treatment significantly more quickly (73.8 versus 114.3 days) (Kehle, Greer, Rutks, & Wilt, 2011).
 
With reduced costs, a larger proportion of funding can be utilized for treatment. Let’s unpack this a little: A typical Treatment Plan for a home- and community-based service provider can be broken down as shown in Figure 1 where upwards of 45% of the funds are all too often allocated to travel costs. Travel expenses are even higher when clients live in remote areas, with some of the Plans we have reviewed for remote clients allowing for upwards of seven hours of travel for a single session.


Figure 1. Comparison of Cost Breakdown Between Faceto-Face and eRehabilitation™ Treatment Plans 

 

When eRehabilitation™ is used, two things happen. First, all or at least the majority of the previously used “travel funds” can be directed towards treatment. Depending on the nature of the assessment/treatment, some travel may be required for in-person clinical visits; or an initial visit with a rehabilitation technician may be required to ensure that the technology is properly set up and the client can comfortably access it. It behooves us to funnel every available dollar towards client care. Treatment frequency and duration can be increased leading to beneficial rehabilitation outcomes when the funding pool is allocated optimally.
 
Second, the client benefits by enabling them to use their own time more efficiently. For clients involved in clinicbased care, their travel is minimized too. Clients no longer have to invest as much time getting ready and dressed, packing items, finding parking, waiting in lobbies, and getting a babysitter, which are some of the many costs to the client seeking clinic-based treatment. There is also the cost of missing work, which is often quite exaggerated for clients who would otherwise need to commute a fair distance to a more urban location. These intangibles cannot be dismissed as trivial. The intangibles add up to countless hours over the course of a year − and over a lifetime. By providing telehealth options, clients are given further control of their healthcare and their precious time. A parent can spend time with his or her children in their own home rather than in traffic and the waiting room. Those countless hours can be used for other priority activities, which is of value to all.
 
Efficacy

Granted, online therapies are often the most convenient for the tech-savvy professional, but do they actually work? The research is supportive and growing: There are similar efficacy rates to face-to-face therapy; strong efficacy rates for depression, anxiety, and agoraphobia (Andersson, 2009). The World Health Organization in their World Report on Disability reviewed research on the use of telehealth to provide services for mental health, cardiac rehabilitation, remote assessment for home modifications, consultation for prosthetics, orthotics, and wheelchair prescription, and cognitive rehabilitation among other services and concluded: “Growing evidence on the efficacy and effectiveness of telerehabilitation shows that telerehabilitation leads to similar or better clinical outcomes when compared with conventional interventions (p. 119).” Research supports the use of telehealth in occupational therapy (Steel, Cox, & Garry, 2011). A number of efficacy studies concluded that there is no significant difference in clinical outcomes between occupational therapy services provided in-person and services provided through telehealth for wheelchair assessment (Schein et al., 2011), pre-admission orthopedic occupational therapy home visits (Hoffmann & Russell, 2008), assessment of activities of daily living and hand function in individuals with Parkinson’s disease, and ergonomic assessment (Jacobs, Blanchard, & Baker, 2012). These online modalities are not as effective with serious psychotic episodes requiring inpatient treatment. Clearly, the practitioner must always critically analyze how, where and with whom they are used to ensure best practices.
 
One might wonder if the efficacy of online counseling improves if there is a prior face-to-face relationship. According to the literature, there is very little difference (Spek et al., 2007). Online therapies such as eRehabilitation™ therapies work best with clients who are functional and want to do better.
 

Satisfaction Rates

Client satisfaction rates are similar when comparing face-to-face and online therapy, with those who live in rural areas typically reporting higher satisfaction rates. A survey conducted by the Ottawa Hospital showed that patients are overwhelmingly positive about their telemedicine program, with 98.6% of almost 900 patients surveyed saying they were satisfied with the services (Glauser, Nolan, & Remfry, 2015). In one survey, 21% of patients said not having to travel to the doctor’s visit was the top benefit of telemedicine, while 20% said it was the ability to be cared for from their homes. About 74% of patients are comfortable with communicating with their doctors using technology instead of seeing them in person (Iafolla, 2015). About 53% of patients said that telemedicine somewhat or significantly increases their involvement in treatment decisions (Glauser et al., 2015). Veterans reported that telemedicine was more convenient than travelling to wound care team. Almost all (92.8%) participants were satisfied with telemedicine care. Veterans provided telemedicine were significantly more satisfied with convenience of their care. Perceived physician communication was not inferior in telemedicine as compared to in-person consultations (Agha, Schapira, Laud, McNutt, & Roter, 2009).
 

Guidelines

As is the case with all regulated industries, healthcare faces unique challenges when adopting new technology. The healthcare industry cannot embrace advances in technology as quickly as some other industries − the regulatory and operational infrastructure does not support it. Legal and ethical issues, such as privacy and liability, must be carefully addressed in advance. It’s not just a matter of jumping onto the online-therapy bandwagon. There are very popular public network systems that escape federal oversight by remaining completely silent on compliance to privacy legislation. Without any statements about privacy and security in a way that ties them to healthcare requirements, using such networks would potentially put healthcare providers and clients at risk if they were to use these platforms. By using the most advanced encryption protocols, software, and secure web-interfaces, these issues can be appropriately handled.
 
There is not yet an industry-wide “gold standard” in terms of specific professional guidelines for the provision of online rehabilitation services; however, standards are being developed and updated with increasing rapidity. The American Psychological Association (APA) published guidelines for the practice of telepsychology in 2013. The Ontario Psychological Association published Guidelines for Best Practices in the Provision of Telepsychology in 2015. In 2011, the College of Psychologists of Ontario adopted the Model Standards for Telepsychology Service developed by the Association of Canadian Psychology Regulatory Organizations. The Model Standards have not been incorporated into the CPO Standards of Professional Conduct but are considered an Advisory for Psychological Practice. Similarly, the APA noted that the intent of their guidelines was not to prescribe specific actions, but, rather, to offer the best guidance available when incorporating telecommunication technologies in the provision of psychological services.
 
Technology and its applicability to rehabilitation professionals is a dynamic area, a moving target, with many changes likely ahead. This is an emergent field and our laws and standards have always struggled to keep up with practice. We all need to practice ethically, according to our professional guidelines, and within our professional scope.
 
These are exciting times. Cutting-edge technology, clinical research and practice are converging in ways we never thought possible even 10 years ago, when Brainworks began our foray into eRehabilitation™. The landscape of rehabilitation service delivery is being transformed. Clinical excellence is being redefined as the bar for healthcare delivery rises and barriers are overcome.
 

An Integrated Approach

We suggest incorporating aspects of eRehabilitation™ into virtually every Treatment and Future Care Plan. It is literally the best of both worlds. We have found this to be a way to increase efficacy and keep costs in check. No one is fond of travel costs, for either therapist or client. We have found that, when done correctly, many clients prefer the “e” version of rehabilitation. We had expected this would be the case mainly for those with geographical or physical barriers to access services – but, in reality, it has become far more mainstream with clients throughout major urban centres finding that they can get the service they need in a fraction of the time. From student to senior, eRehabilitation™ is on its way to becoming “the new normal” for service delivery.
 
The option of having both traditional face-to-face and online therapies available clearly benefits both the professional and client alike. When needed, clients and professionals can meet in person for face-to-face sessions. By integrating today’s technologies with long-standing, evidence-based, face-to-face practices, we are able to maximize the excellence and efficacy of treatment delivery.
 

What Does All This Mean for Future Care?

There are good things ahead. Technology is advancing. Guidelines are starting to catch up. The industry is taking off. We are not only able to reach those who were previously unreachable, but we can do it better, faster, less expensively and more effectively.
 
Client demands, but also reimbursement issues, are fueling Brianworks’ growth in eRehabilitation™. In Ontario, community-based service providers are no longer assured of mileage reimbursement on Statutory Accident Benefit files. In fact, if this trend continues, we will be approaching equal cost for services of equal value (i.e., counselling in Toronto should theoretically cost the same as counselling for a client in a remote corner in northern Ontario). Travel reimbursement for therapists and clients alike will likely continue to decline.
 
Could Pokémon be a Precursor of Things to Come?

“Pokémon Go” has been abuzz across the globe in recent weeks, and the rehabilitation industry will benefit from this early example of augmented reality (AR). Many are familiar with virtual reality (VR). Virtual reality creates in immersive computer generated environment which “replaces” the real world. The user of VR is completely cut off from the real world; for example, wearing a VR headset to play a video game. Augmented reality is closer to the real world. Augmented reality adds graphics, visuals and sounds, overlaying these onto the real world. With AR, users can interact with the real world and at the same time see both the real and virtual world co-existing. A review of numerous publications on the use of VR in patients with neurological diseases concluded that strong scientific evidence supports the beneficial effects of VR. However, further studies are needed to fully determine which changes are generated in cortical reorganisation, what type of VR system is the most appropriate, whether benefits are maintained in the long term, and which frequencies and intensities of treatment are the most suitable (Viñas-Diz & Sobrido-Prieto, 2016). Both VR and AR are in their infancy, insofar as their implementation in rehabilitation. We will see applications of these tools and  many other technologies being developed and implemented by pioneers in the rehabilitation industry. Technologies will continue to become more affordable for the masses. The user-friendliness and integration of technologies will advance. The rapid pace of development will advance the rehabilitation industry to heights unseen.
 

Closing Note

eRehabilitation™ is no longer a thing of the future – it is alive and well and active in the here and now. Careful and creative use of technology gives clients choices and access to quality services that were simply not possible even just a few years ago. Disability, pain, geography, lack of funding for exorbitant travel costs need not be barriers to treatment in many cases moving forward. Medicine developed anesthetics which enabled doctors to operate on the inoperable. Researchers developed antibiotics which led healthcare providers to cure the incurable. eRehabilitation™ lets us reach the unreachable.
 

References

Agha, Z., Schapira, R. M., Laud, P. W., McNutt, G., & Roter, D. L. (2009). Patient satisfaction with physician-patient communication during telemedicine. Telemedicine and e- Health, 15(9), 830-839.
 
American Psychological Association. (2013). Guidelines for the practice of telepsychology. The American Psychologist, 68(9), 791-800.
 
Andersson, G. (2009). Using the Internet to provide cognitive behaviour therapy. Behaviour Research and Therapy, 47(3), 175-180.
 
Bashshur, R., L. (2004). Telemedicine and health care. Telemedicine Journal and e-Health, 8(1), 5-12.
 
Fortney, J., Kaboli, P., & Eisen, S. (2011). Improving access to VA care. Journal of General Internal Medicine, 26, Suppl 2, 621-622.
 
Glauser, W., Nolan, M., & Remfry, A. (2015). Telemedicine on the rise across Canada. Healthy Debate. Retrieved from http://healthydebate.ca/2015/06/topic/telemedicineacross- canada.
 
Hoffmann, T., & Russell, T. (2008). Pre-admission orthopaedic occupational therapy home visits conducted using the Internet. Journal of Telemedicine and Telecare, 14(2), 83-87.
 
Iafolla, T. (2015). 36 Telemedicine Statistics You Should Know. eVisit. Retrieved from https://evisit.com/36- telemedicine-statistics-know
 
Jacobs, K., Blanchard, B., & Baker, N. (2012). Telehealth and ergonomics: a pilot study. Technology and Health Care, 20(5), 445-458.
 
Keely, E., Liddy, C., & Afkham, A. (2013). Utilization, benefits, and impact of an e-consultation service across diverse specialties and primary care providers. Telemedicine and e-Health, 19(10), 733-738.
 
Kehle, S. M., Greer, N., Rutks, I., & Wilt, T. (2011). Interventions to improve veterans’ access to care: a systematic review of the literature. Journal of general internal medicine, 26(2), 689-696.
 
Schein, R. M., Schmeler, M. R., Holm, M. B., Pramuka, M., Saptono, A., & Brienza, D. M. (2010). Telerehabilitation assessment using the Functioning Everyday with a Wheelchair-Capacity instrument. Journal of rehabilitation research and development, 48(2), 115-124.
 
Spek, V., Nyklıcek, I., Smits, N., Cuijpers, P., Riper, H., Keyzer, J., et al. (2007). Internet-based cognitive behavioural therapy for subthreshold depression in people over 50 years old: a randomized controlled clinical trial. Psychological Medicine, 37(12), 1797-1806.
 
Steel, K., Cox, D., & Garry, H. (2011). Therapeutic videoconferencing interventions for the treatment of longterm conditions. Journal of Telemedicine and Telecare, 17(3), 109-117.
 
Viñas-Diz, S., & Sobrido-Prieto, M. (2016). Virtual reality for therapeutic purposes in stroke: A systematic review. Neurología (English Edition), 31(4), 255-277.
 
World Health Organization. (2011). World report on disability.