Blueprint for Telerehab Guidelines

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International Journal of Telerehabilitation telerehab.pitt.edu

31International Journal of Telerehabilitation Vol. 2, No. 2 Fall 2010 (10.5195/ijt.2010.6063)

A Blueprint for TelerehabilitationGuidelines

David Brennan, MBE1, Lyn Tindall, PhD2, Deborah Theodoros, PhD3,Janet Brown, MA4, Michael Campbell, MS5, Diana Christiana, MAT6,David Smith7, Jana Cason, DHS 8 Alan Lee, DPT9

1 National Rehabilitation Hospital, Washington, DC, 2 Department of Veterans AffairsMedical Center, Lexington, KY, 3 The University of Queensland, Queensland, Australia,4 American Speech-Language-Hearing Association, Rockville, MD, 5 University of NorthCarolina at Greensboro, Browns Summit, NC, 6 Clinical Communications, Sugar Land, TX,7 Telehealth Resource Center - Marquette General Hospital, Marquette, MI, 8 AuerbachSchool of Occupational Therapy, Spalding University, Louisville, KY, 9 Mount St. MarysCollege, Los Angeles, CA

Abstract

Telerehabilitation refers to the delivery of rehabilitation services via information and communication technologies. Clinically,this term encompasses a range of rehabilitation and habilitation services that include assessment, monitoring, prevention,intervention, supervision, education, consultation, and counseling. Telerehabilitation has the capacity to provide serviceacross the lifespan and across a continuum of care. Just as the services and providers of telerehabilitation are broad, soare the points of service, which may include health care settings, clinics, homes, schools, or community-based worksites.This document was developed collaboratively by members of the Telerehabilitation SIG of the American Telemedicine

Association, with input and guidance from other practitioners in the eld, strategic stakeholders, and ATA staff. Its purposeis to inform and assist practitioners in providing effective and safe services that are based on client needs, current empiricalevidence, and available technologies. Telerehabilitation professionals, in conjunction with professional associations andother organizations are encouraged to use this document as a template for developing discipline-specic standards,guidelines, and practice requirements.

Keywords: Telerehabilitation, telepractice, rehabilitation, American Telemedicine Association

Introduction

The Telerehabilitation Special Interest Group of theAmerican Telemedicine Association is comprisedof practitioners in health and education, andtechnology specialists who are engaged in applyingtelecommunications and health information technologiesto improve access to rehabilitation and educationalservices, and to support independent living. This

document was developed collaboratively by members ofthe Telerehabilitation SIG, with input and guidance fromother practitioners in the eld, strategic stakeholders, andATA staff.

The purpose of this guide is to inform and assistpractitioners in providing effective and safe services thatare based on client needs, current empirical evidence,and available technologies. The material in this guideaddresses general principles and not specic practiceguidelines for telerehabilitation and is not intended to

replace the primary practitioners clinical, educational,or technology decision-making about the appropriatecourse of action/management of any client. Inherent withinthis document is the recognition that safe and effectivetelerehabilitation practice requires specic training, skillsand techniques as documented below. Furthermore, thematerial in this guide should not be interpreted, nor used,as a legal standard of care.

Scope and Definitions

Telerehabilitation refers to the delivery of rehabilitationservices via information and communication technologies.Clinically, this term encompasses a range of rehabilitationand habilitation services that include assessment,monitoring, prevention, intervention, supervision,education, consultation, and counseling. Telerehabilitationservices are delivered to adults and children by a broad


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32 International Journal of Telerehabilitation Vol. 2, No. 2 Fall 2010 (10.5195/ijt.2010.6063)

range of professionals that may include, but is not limitedto, physical therapists, speech-language pathologists,occupational therapists, audiologists, rehabilitationphysicians and nurses, rehabilitation engineers,assistive technologists, teachers, psychologists, and

dieticians. As other personnel such as paraprofessionals,family members, and caregivers may assist duringtelerehabilitation sessions, for the purposes of thisdocument, the term professionals will be used to denoteprofessional providers of telerehabilitation services.The term clients will be used to refer to all recipients oftelerehabilitation services and is intended to include bothpatients in medical settings, and children and adults whoreceive services outside the medical sphere, for example,in schools or at home.

Telerehabilitation has the capacity to provide serviceacross the lifespan and across a continuum of care.Just as the services and providers of telerehabilitationare broad, so are the points of service, which may

include health care settings, clinics, homes, schools,or community-based worksites. Terminology used todescribe telerehabilitation is similarly broad. Some termsare used specically to refer to individual rehabilitationdisciplines, such as telespeech (speech-languagepathology) or teleOT (occupational therapy). More genericterms, such as teletherapy and telepractice are also used,allowing for a broader focus on populations and activities,such as educational settings and wellness promotionin addition to rehabilitation. It is not the intent of thisdocument to resolve the debate over terminology; ratherthe goal is to provide consistency across applications,regardless of the vocabulary used. For the purposes ofthis document, the term telerehabilitation will be used,

and the reader is reminded that terminology may differaccording to the application and location.

Key Principles

The following information represents key administrative,clinical, technical, and ethical principles that should beconsidered in the course of providing telerehabilitationservices. They are based primarily on the AmericanTelemedicine Associations Core Standards forTelemedicine Operations, and describe additionalconsiderations that are present across applications withintelerehabilitation and its related elds. As educationand advocacy are central to the continued growth oftelerehabilitation, this document can and should beused as a tool to educate members of the medicaland education professions, students, stakeholders,administrators, legislators, and community members.Telerehabilitation professionals, in conjunction withprofessional associations and other organizations, areencouraged to use this document as a template fordeveloping discipline-specic standards, guidelines,and practice requirements. A bibliography of research

in the eld can be found on the webpage for theTelerehabilitation Special Interest Group of the AmericanTelemedicine Association (www.americantelemed.org).

Administrative Principles:

Organizations and/or professionals shall comply withnational, state, local and other credentialing, privileging,and regulatory requirements for licensure, certication,and for the use of telerehabilitation.

Organizations and/or professionals shall be aware oftheir locus of accountability and any requirements(including those for liability insurance) that apply whenpracticing telerehabilitation. This includes credentialingrequirements at the site where the practitioner is locatedand the site where the client is located (which may bedifferent states or jurisdictions), in compliance withregulatory and accrediting agencies.

If required, organizations and/or professionals shalluse billing and coding processes that designate thattelerehabilitation services have been provided (e.g.through the use of a modier) as required per guidelinesof the payer.

Organizations and/or professionals shall have traceabledocumentation that a telerehabilitation session occurredwith a client. This documentation should be available toboth the referring and consulting sites as appropriate.

Organizations and/or professionals shall be aware of theadvanced requirements for privacy and condentialityassociated with provision of services through telehealthtechnology at both the originating site and remote setting.

Organizations and/or professionals shall determinerequirements for documentation, storage, and retrievalof client records to protect the clients personal health

information in accordance with federal and stateregulations (e.g. HIPAA, FERPA, etc.). Specic guidelinesshall be in place to address access to client records soas to ensure that unauthorized users cannot access,alter, tamper with, destroy or otherwise misuse clientinformation.

Organizations and/or professionals shall have amechanism in place for ensuring that clients are aware oftheir rights and responsibilities with respect to accessinghealth care via telehealth technologies, including theprocess for communicating complaints.

Organizations and/or professionals shall ensure that anappropriate facilitator is available when necessary tomeet client and provider needs before, during, and afterthe telerehabilitation encounter.

Organizations and/or professionals engaged in

telerehabilitation research shall ensure the protectionof participants in research protocols. Researchprotocols shall be approved by local Institutional ReviewBoard(s) and be in compliance with relevant legislation,regulations, and other requirements for supportingparticipant decision-making and informed consent aswell as safeguarding of Protected Health Information.

Organizations and/or professionals shall ensure theyhave appropriate technology expertise during planningand start-up phases of a telerehabilitation program.Reasonable care and diligence shall be used when


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33International Journal of Telerehabilitation Vol. 2, No. 2 Fall 2010 (10.5195/ijt.2010.6063)

selecting equipment for evaluating or treating a client.Practitioners need to take appropriate measures tofamiliarize themselves with equipment and safety issueswith client use. To help ensure success, it is essential thatall telerehabilitation providers use appropriate planning

prior to delivering services and are fully aware of thecapabilities and limitations of the equipment they intendto use, and the impact it may have on service delivery.

Organizations and/or professionals shall have in placea systematic quality improvement and performancemanagement process that complies with anyorganizational, regulatory, or accrediting, requirementsfor outcomes management.

Organizations and/or professionals that engage incollaborative partnerships shall be aware of applicablelegal and regulatory requirements for appropriatewritten agreements, memorandum of understanding, orcontracts. Those contracts, agreements, etc., shall bebased on the scope and application of the telerehabilitationservices offered and shall address the administrative,clinical, technical, and ethical requirements outlined in

this document, as relevant, for all parties named.

Clinical Principles:

Professionals shall be guided by existing discipline andnational clinical practice guidelines when practicing viatelehealth. Where guidelines, position statements, orstandards for telerehabilitation exist from a professionalorganization or society (e.g. American Speech-Language Hearing Association (ASHA), AmericanPhysical Therapy Association (APTA), and AmericanOccupational Therapy Association (AOTA)), these shallbe reviewed and appropriately incorporated into practice.Given the variability of rehabilitation clients, candidacyand appropriateness for telerehabilitation should bedetermined on a case-bycase basis with selectionsrmly based on clinical judgment, clients informedchoice, and professional standards of care.

As in all settings, professionals shall have theappropriate education, training/orientation, and ongoingcontinuing education/professional development toinsure they possess the necessary competencies forthe safe provision of quality health services. Providers oftelerehabilitation should have competence in the use ofequipment, as well as considerations related to clientswith cognitive, physical, or perceptual impairments.

Delivery of services via telerehabilitation, whetherinteractive or store-and-forward, may requiremodications to treatment material, techniques,equipment, and setting. Regardless of any modicationsmade, professionals shall deliver services in accordancewith professional standards of care and the principlesof evidence-based practice (i.e., current best evidence,clinical expertise, and client values and goals). Intelerehabilitation encounters, these modications mayinclude: using additional support staff at the remote siteto assist the client with a physical activity or perform ahands-on assessment, digitally reproducing treatmentmaterials for delivery via data sharing or presentationtools, or temporary modication of client environment.

Professionals shall ensure that all persons in the therapyroom at both sites are identied to all participants prior

to initiation of the telerehabilitation session. Disclosure ofindividuals attending the session may be accomplishedby announcing their presence.

Technical Principles:

Organizations and/or professionals shall ensure thatequipment sufcient to support diagnostic and/ortreatment needs is available and functioning properly atthe time of clinical encounters. Beyond basic telehealthtechnology, additional equipment is often required toprovide telerehabilitation services. This equipmentwill vary based on application and may include, forexample, a sound level meter to measure intensity ofspeech, an audiometer for hearing assessment, or onlinemeasurement tools and sensors to measure force orposition during a physical therapy assessment.

Organizations and/or professionals shall comply with all

relevant laws, regulations, and codes for technology andtechnical safety. Organizations and/or professionals shall comply with

federal and state regulations for protection of clienthealth information and to ensure the physical securityof telehealth equipment and the electronic securityof data storage, retrieval, and transmission. Methodsfor protection of health information include the use ofauthentication and/or encryption technology, and limitingaccess to need-to-know (availability for those people whodo require access).

Organizations and/or professionals shall ensure thatall personnel who use telehealth equipment to deliverinformation or services are trained in equipment operationand troubleshooting. Procedures shall also be in place toensure the safety and effectiveness of equipment throughon-going maintenance. Providers of telerehabilitat ionmust know how to operate videoconferencing peripherals,such as document cameras and data sharing tools, toincorporate other treatment materials into a session andcongure audio/video signals so they are appropriate forclients with visual or hearing impairments.

Organizations and/or professionals shall have strategiesin place to address the environmental elements of care,including the physical accessibility of the treatmentspace as well as usability of equipment. This is essentialin telerehabilitation applications as considerations mustbe made for clients who have a variety of impairments inareas such as ne/gross motor skill, cognition, speech,language, vision, or hearing.

Organizations and/or professionals shall have infectioncontrol policies and procedures in place for the use oftelehealth equipment and client peripherals that complywith organizational, legal, and regulatory requirements. Inparticular, mechanisms shall be in place for the cleaning/sterilization of equipment for re-use by multiple clients.


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34 International Journal of Telerehabilitation Vol. 2, No. 2 Fall 2010 (10.5195/ijt.2010.6063)

Ethical Principles:

The use of telehealth technology to deliver rehabilitationservices requires consideration of professional ethicalprinciples. Organizations and professionals that adhere

to ethical principles of telerehabilitation shall: Incorporate organizational values and ethics into policy

and procedures documents for telerehabilitation Comply with professional codes of ethics Inform clients of their rights and responsibilities when

receiving rehabilitation through telehealth technology,including their right to refuse

Have in place a formal process for resolving ethical issuesas well as policies that identify, eliminate, and reduceconicts of interests associated with the provision oftelerehabilitation services

Acknowledgements

This document was developed by a committeechaired by David Brennan, MBE and Lyn Tindall, PhDas part of the Telerehabilitation Special Interest Groupof the American Telemedicine Association. The authorsgratefully acknowledge the contributions of the followingWorking Group Members [WG], Consultants [C],Reviewers [R], Telerehabilitation Special Interest Group

Chair [TR], ATA Standards and Guidelines CommitteeMember [SG], and ATA Staff [S]; Nina Antoniotti,RN, MBA, PhD, [Chair, SG], Director of Telehealth,Marsheld Clinic, Marsheld, WI; Jordana Bernard,MBA, [S], Senior Director, Program Services, American

Telemedicine Association, Washington DC; Anne Burdick,MD, MPH, [SG], Associate Dean for Telemedicine andClinical Outreach, Professor of Dermatology, Director,Leprosy Program, University of Miami Miller Schoolof Medicine, Miami, FL; Jerry Cavallerano, PhD, OD,[SG], Staff Optometrist, Assistant to the Director, JoslinDiabetes Center, Beetham Eye Institute, Boston, MA;Ellen Cohn, PhD, CCC-SLP, [Chair, TR, WG], AssociateDean for Instructional Development, School of Healthand Rehabilitation Sciences, University of Pittsburgh,Pittsburgh, PA; Paul Cox, MSEE, [WG], President, PERLResearch, Huntsville, AL; Mary Fran Delaune, PT, MPT,[R], Director, Practice Department, American PhysicalTherapy Association, Alexandria, VA; Matt Elrod, PT, DPT,

MEd, NSC, [R], Associate Director, Practice Department,American Physical Therapy Association, Alexandria,VA; Brian Grady, MD, [SG], VISN5 TMH Lead & Director,TeleMental Health, School of Medicine, Universityof Maryland, Baltimore, MD; Elizabeth Krupinski,PhD, [Vice Chair, SG], Associate Director, ProgramEvaluation, University of Arizona, Arizona TelemedicineProgram, Department of Radiology, Research Professor,Department of Radiology Research, Tucson, AZ;Jonathan D. Linkous, MPA, [S], Chief Executive Director,American Telemedicine Association, Washington, DC;Michael Pramuka, PhD, CRC, [WG], RehabilitationCounselor, Walter Reed Medical Center, Washington,DC; Richard Schein, PhD, [WG], Postdoctoral Associate,

School of Health and Rehabilitation Sciences, Universityof Pittsburgh, Pittsburgh, PA; Lou Theurer, [SG], GrantAdministrator, Burn Telemedicine Program, Universityof Utah Health Sciences Center, Salt Lake City, UT; andJill Winters, PhD, RN, [WG, SG], Dean and Professor,Columbia College of Nursing, Milwaukee, WI.

A Blueprint forTelerehabilitation Guidelines October 2010

Quality Healthcar e ThroughTelecommunicationsTechnology

Blueprint for Telerehab Guidelines

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