The History of Telerehabilitation

The term telerehabilitation is relatively new, but applications in telemedicine go as far back as the 1880s when some physicians experimented with telecommunication technologies after the invention of the telephone in 1876 (Scalvini'04). The U.S. government first supported telemedicine through services provided by agencies such as the VA. The first recorded use of telemedicine by the VA was in 1957 for a tele-mental health project in Nebraska (Cooper'01). Other projects followed with notable success over the subsequent 20 years, leading the VA to begin a systematic implementation of telemedicine in 1997. The VA adopted the broader, more encompassing term telehealth in lieu of telemedicine in 2003. Telemedicine is now considered a subset of VA telehealth, with VA telehealth incorporated as one part of the wider rubric of VA care coordination. By 2005, many of the Veteran’s Health Administration’s (VHA) twenty-one Veteran’s Integrated Service Networks (VISNs) were using some form of TR technology at VA medical centers and healthcare systems. These facilities use TR to augment services to community-based outpatient clinics (CBOCs) and Veterans Center programs.

In 1998, NIDRR funded the nation’s first RERC on TR to initiate research on TR as a complement to telemedicine and in an effort to address a service delivery gap that emerged when managed-care policies truncated the allowable duration for inpatient rehabilitation. NIDRR also recognized the potential benefits of TR in the areas of primary and secondary prevention across the life span for people with disabilities, cost containment, and vocational rehabilitation.

For the past 15 years, most non-veteran, federally funded telehealth programs have targeted rural populations, often with an emphasis on older adults (U.S. Department of Health and Human Services Health Resources and Services Administration). For example, the Office for the Advancement of Telehealth in the Health Resources and Services Administration supports the Telehealth Network Grant Program’s efforts to develop capacity for telehealth in medically underserved rural areas to improve and coordinate healthcare services. The Office of Rural Health Policy supports Rural Health Care Services through Outreach Grant programs.

Policy issues

Public policy plays an important role in the implementation of telemedicine, and by association, telerehabilitation (Wipf'06; Weinstein'08). Seelman and Hartman conducted a comprehensive review of the literature on TR policy and research tools and concluded that rigorous and comprehensive outcome studies are needed to drive reimbursement policy (Seelman'08b). Government health policy addresses quality, cost, and access to health service resources. The US government and the research community both employ policy analysis and evaluation to determine the efficacy and efficiency of policies as a basis for decisions about resource allocations.

Theodoros and Russell ('08) observed that while it may be technically possible to deliver rehabilitation services across the world, many key policy issues must be addressed. These issues, include: a) licensure across state and national borders; b) equivalence of international clinical standards; c) regulation on privacy issues and the access and protection of patient health information; d) issues on costs and remuneration of services; e) liability and accountability; and f) unification of international rules effecting clinical consultations. Theodorus and Russell also noted that while a number of international organizations, such as the World Health Organization and the World Trade Organization, are entering the debate, there is a lack of leadership on e-health policy.

Seelman’s review of remote home care found that authors expressed the need for policy guidance that addresses function and quality of life factors in clinical assessments. She recommended that technical and clinical systems be held accountable through scrutiny of reports on service delivery and technology performance. Kaplan and Litewka ('08), identified the following policy-related problem areas: a) abridgement of privacy from combining and mining data and the influences of new technology on informed consent; b) inaccurate and obsolete data; c) security breaches; d) usability and user friendliness; e) data standards and integration for linking patient and personal information to achieve interoperability of individual records, personal health management and public health; f) systems design and deployment decisions; and g) tradeoffs between social isolation and enhanced care.

Cost and reimbursement dominate the TR policy literature. Roine, Ohinmas & Hailey ('01) conducted a systematic review of telemedicine literature using economic assessment as one of their inclusion criteria. However, of the 50 articles reviewed, they identified few comprehensive economic analyses, and the quality of the analyses was described as relatively poor. With few exceptions, they reported that studies lacked empirical background about the costs and benefits included in the studies. Because costs varied considerably among studies, the authors concluded that comparison of the cost estimates might not be feasible in many cases (Seelman'08a). The Center for Telemedicine and e-Health Law (CTeL) has studied telehealth reimbursement, and published an independent sourcebook for telemedicine. The CTeL Reimbursement Sourcebook and State Telemedicine Reimbursement Guide address a broad range of legislative and regulatory issues involving telemedicine reimbursement policies at the federal for Medicare, Medicaid, and private insurance -- all of which pay for telehealth to varying degrees.

According to Robert Waters ('07), telemedicine reimbursement in the U.S. may be provided by: a) public payers, Medicare and Medicaid; b) private payers, fee for service; c) managed care, both public and private; and d) special payers such as government and worksite. Medicare reimbursement-related issues include criteria for eligible sites, geographic coverage and services; store and forward technology; facility fees and co-payments and home health durable medical equipment (Waters'07).

Telerehabilitation informatics review

Telerehabilitation is experiencing rapid growth and is fast becoming a significant segment of telemedicine and e-health (Parmanto'08a). The field of TR existed under the assumption that the barriers imposed by distance could be minimized, thus enhancing access and introducing new possibilities for delivering intervention strategies across the continuum of care. The distance barriers are overcome by applying a variety of telecommunications, including voice, video, and virtual reality. Previously, TR was viewed as a field that focused heavily on real-time interactivity (synchronous interaction) rather than a store-and-forward approach (asynchronous interaction) (Winters'02). As a result, most studies and developments presented in the literature focus on devices that can mimic face-to-face interactivity in a tele-setting. The categories of services found in the literature include tele-consultation, tele-monitoring, tele-homecare and tele-therapy. Winters ('02) defined tele-consultation as a standard "face-to-face" telemedicine model using interactive videoconferencing between a local provider (and client) and a remote rehabilitation expert to gain access to specialized expertise. Tele-homecare service delivery occurs when a clinician (usually a nurse or technician) coordinates a rehabilitation service delivery from various providers to the client's home. For example, Hoenig et al. ('06) described a protocol to deliver in-home tele-training to adults with mobility impairments. Tele-monitoring is a clinical application wherein the rehabilitation provider sets up unobtrusive monitoring or assessment technology for the client. Tele-therapy is defined as a model of TR service delivery wherein the client conducts therapeutic activities in the home setting using a therapy protocol that is remotely managed by the therapist. There are numerous examples of applications in this area including tele-neuro and tele-orthopedic rehabilitation, tele-audiology and speech language pathology, and postsurgical tele-training (Hill'06; Feng'07; Heuser'07; Placidi'07).
Map of telemedicine and telerehabilitation services in the intensity-duration space
Figure 1 - Map of telemedicine and telerehabilitation services in the intensity-duration space

Telerehabilitation service is generally characterized by repetitive encounters over a long time period. This is in contrast to other telehealth applications such as in tele-surgery, tele-pathology and tele-dermatology that require short duration, high intensity interactions. The nature of the informatics infrastructure must take into account the nature of the interactions. Parmanto ('08a) has mapped the various types of telehealth on a relative intensity and duration space as shown in Figure 1. The mapping shows the relative differences between representative telemedicine and TR applications. This figure shows the four quadrants of telemedicine applications. These range from a short duration process with low intensity to a long duration process with high intensity. Most TR services are of long duration with a relatively low intensity (Parmanto'08a).
As an example of how these differences impact the requirements of the informatics infrastructure, consider that the many repeated TR encounters over long periods of time result in an accumulation of information that needs to be stored and organized for use by therapists. Managing a wealth of information in complex forms (e.g. video, sound, text, and still images) poses a challenge in TR. However, the reward for doing so in an efficient manner may be the creation of opportunities that do not exist for traditional face-to-face encounters. For example clinical outcomes may be extracted from the data or recorded videos of the interactions between therapists and patients can be used to educate future therapists. Data mining may be employed to learn and characterize the wealth of information that was previously not available.

Tele-technologies allow for remote access to professional expertise(Bashshur'02; Winters'02). However, unlike telemedicine where interventions require one or two types of technologies and single populations, the TR environment requires the integration of multiple specialists, technologies and delivery settings with a highly variable population. Numerous professional considerations shape the use of technology in rehabilitation services requiring a review of current TR technologies, including their strengths and limitations as they relate to accessibility and usability.

Telerehabilitation technology accessibility and usability

Unique challenges arise when rehabilitation services are provided remotely instead of in traditional face-to-face contexts. Potential barriers to TR implementation include licensure, certification and other professional issues, reimbursement, and characteristics of disability (Theodoros'08). Additional challenges relate directly to using video conferencing technology -cameras, computers, microphones, etc. (Pramuka'08). Principles of universal design (UD) can be used to address these potential barriers (Story'98).

Technologies used in TR include text (email, data), audio (telephone, VOIP), visual (cameras, webcams), virtual reality, web-based (chat rooms, websites), wireless (PDA, GPS, cell phone), and integrated systems that combine many of these other technologies. Potential users of the technologies include consumers, caregivers, physicians, therapists, engineers and others. All need to access and use the TR technologies (Winters'02; Brennan'08). The technologies must be tailored to the specific clinical activities, which can range from tele-education, tele-consultation and tele-support, to tele-assessment and tele-evaluation (Winters'02). High levels of technology complexity may be needed for specific TR applications, yet may also require outside support such as a helpdesk (Pramuka'08). Technology installation can also be complex requiring technical support both at the expert center and at the remote site – a potential barrier to adoption by clients (Rosen'01; Bashshur'02). Cost has the potential to be a technology adoption barrier, although lower cost alternatives (Skype, MSN messenger, Google video chat, AOL IM, etc.) may be usable for some applications, especially when the end-user already has a computer, webcam, microphone and speakers.

Technologies that are poorly matched to consumer needs have high rates of abandonment (Batavia'99). Likewise, TR technologies must be matched to clinical applications and user needs and abilities (Winters'02). For example, some applications require real-time data exchange with direct client-therapist interactions. Other applications such as tele-education do not need real-time access; the therapist can make materials available and the client can access them at a convenient time. Appropriate paring of technologies to applications is essential for successful implementation.




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