Three important pathways towards telehealth integration: a closer look
Integration of telehealth services occurs within several notable pathways. These pathways include academia, clinical practice, and mHealth, which included Connected Health Devices (CHDs) or Wearable Digital Devices (WDDs). Virtual pathways interconnect and add value to the healthcare industry in diverse and useful ways. Conversely, they do not work well when intentional integration is not taken seriously. The academic environment is a good place for telehealth instruction, as this exposes future providers to value-based virtual care and expands access to their beneficiaries (Dy Aungst & Patel, 2020; Muntz et al., 2021). There are many health care professions that are purposefully incorporating telehealth instruction within their curricula (Dy Aungst & Patel, 2020; Muntz et al., 2021). This mindful integration was spurred from the need to embed instruction on telehealth within traditional practice models (Muntz et al., 2021). Similarly, occupational therapy (OT) programs were offered to instruct students on telehealth through ACOTE standard B.4.15 which was authorized in the summer of 2020 (Patterson et al., 2021). However, this educational standard does not explicitly outline how telehealth may be leveraged by academicians to enhance greater adoption. (Hui et al., 2021; Patterson et al., 2021). Telehealth’s integration within the academic setting is essential as it exposes occupational therapy students to didactic instruction, hands-on learning, and virtual simulation experiences that foster greater interoperability within the clinical arena (Posey et al., 2020).
Practitioners not afforded instruction in telehealth are disadvantaged from their colleagues that did receive instruction and training. Therefore, it is incumbent for the OT profession to embed telehealth instruction during school, as well as post-graduation. The profession ought not continue to reminisce on missed opportunities, but rather, make the needed adjustment to curricular rajectories now, or risk sliding into practice irrelevancy. There remains many rural communities in pediatrics, adults, and aged adults that are not afforded the same access to quality therapeutic intervention as their urban and suburban counterparts. Rural patients have higher rates of chronic diseases, such as heart failure, diabetes mellitus, chronic obstructive pulmonary disease, mental health disease, as well as higher mortality rates (List et. al., 2019). Populations living in remote regions can be addressed effectively and efficiently through the use of telehealth and virtual care and training up the next cadre of virtual providers may offset this imbalance (List et al., 2019).
Integration of telehealth within the clinical or practice arena equates to choosing a tool, assessment, or treatment approach and intentionally weaving it within traditional treatment milieus. Therefore, if you wish to assess a patient’s fine motor manipulation skills, while using telehealth, you might ask them to don a button down shirt and fasten and unfasten the garment’s buttons, rather than having the patient perform a Nine Hole Peg test or the Minnesota Rate of Manipulation test (Jobbagy et. al., 2018). Assessment activities conducted under the umbrella of telehealth may differ considerably however, the outcomes obtained offer clear guidance and cues to the evaluating practitioner. Providers conducting telehealth evaluations and/or interventions must make a break from the physical clinic setting and map out evaluation approaches that offer timely information (Shea, 2021). Virtual approaches depend heavily on clear and concise communication, as well as deputizing family members to ensure the patient will follow instructions correctly (Raj et al., 2022).
Teletherapists often leverage the assistance of family members in setting up the patient, ensuring instructions were understood, and fostering improved compliance with home exercise programs (Raj et al., 2022). A playbook or simple set of protocols could enhance quality telehealth experiences, as well as minimize the awkwardness of stumbling through virtual sessions (Wicklund, 2021). Integration of telehealth services within the clinical arena could also promote service efficiencies by decoupling practitioners from fixed facilities, i.e. outpatient clinics, inpatient hospitals, schools, physical medicine and rehabilitation units, etc., and opening up greater access to complex patients which are overburdened by accessing traditional healthcare systems (Chudasama et al, 2021; McPhail, 2016). As we peer through this lens of healthcare administrators and advocates for our aging adults, we need to be mindful that many of our complex patients opt to remain in their homes and push back against being medically institutionalized. Concurrent with our adopted ethos of promotion of graying in place, we should also embrace population wellness and primary care (Bolt et. al., 2019). This service delivery pivot towards primary and interdisciplinary case management is occurring slowly and steadily; however, it could be accelerated with the use of telehealth services. Telehealth offers complex patients that are immunocompromised a safe haven by engaging them in the comfort of their homes. It could also minimize the impact of travel, lodging, lost work and wages and the inconvenience of having to see a provider for routine follow up care (Haleem et. al., 2021; Heath, 2017). Having the opportunity to visit their provider through virtual platforms is becoming popular among millennial patients (Mcaskill, 2015). In a survey of 1,700 Americans who fell within the millennial generation it was discovered that 60% of them support using telehealth and 71% reported that they would readily use a mobile application to chat with their doctor it offered (Mcaskill, 2015). This generation fully understands how to leverage secure telehealth links with their providers and will opt for convenience over establishing in-person rapport (Kennedy, 2022). From online searches that evaluate patient feedback about providers to scheduling real-time virtual appointments, millennials are taking advantage of telehealth and they feel comfortable about this form of healthcare interaction (Kennedy, 2022).
Integration of telehealth services is dependent on technology and this virtual delivery model is well ingrained with the Internet of things (IoT), or information and communication technology (ICT) (Marwaa et al., 2020). Aligning ICT with telehealth and virtual visits allows the principal drivers of healthcare to reach out to their beneficiaries that have difficulty obtaining services the usual way. These patients may not receive timely services due to being geographically displaced (Gately et al., 2021). One of the benefits of telehealth is that it fosters lengthier periods of engagement with the patient, caregivers and other consulting providers (Marwaa et al., 2020). Multiple studies have revealed that recipients of telehealth are satisfied with their virtual care and are willing to use it again when called on by their provider (Kennedy, 2022). Rapid technological developments have facilitated a wide array of communication mediums, e.g., video conferencing, EMRs, and peripheral digital devices for evaluation and monitoring purposes, etc. (Gately et. al., 2021). Telehealth promotes closer oversight by the provider and ensures better patient safety and therapeutic outcomes because of this surveillance (Marwaa et. al., 2020). One aspect of telehealth that has been growing rapidly is the use of remote patient monitoring (RPM), as well as the use of peripheral or wearable devices. This technology affords patients the ability to age in place and remain at their homes for a longer period of time (Vaidya, 2022). These devices, such as digital pulse oximeters, glucometers, weight scales, heart monitors, fetal monitors, and motion detectors allow continuous monitoring of the patient’s vital signs and activity levels (Vaidya, 2021). Remote monitoring is possible due to the rapid acceleration of bandwidth, coupled with wireless technology that is more prevalent in rural or remote regions than it was a decade ago (Vaidya, 2022). The aim of remote monitoring is to keep patients well and out of acute care hospitals, and as a result save insurance carriers great sums of money (Wicklund, 2021). However, lack of published competencies and outcomes on clinical use with wearable devices hampers further adoption, as well as integration for both the practitioner and the patient (Gately, et al., 2021).
Integration of the three principal pathways of telehealth service models also fall under the umbrella of the Institute for Health Improvement (IHI)’s quadruple aim which was disseminated to all health care stakeholders for the sake of optimizing the US health system’s performance (Freeley, 2017). These national healthcare objectives revolve around, 1) improving population health, 2) reduction of healthcare cost, 3) enhancing the patient/caregiver experience, and 4) improving healthcare provider satisfaction (Freeley, 2017). All four aims dovetail nicely with telehealth integration. For example, patients that live in remote regions and desperately need medical assessment or care would have a more positive experience if they did not have to leave their rural communities or drive long distances, e.g., aims number 1, 2 and 3. Patients that received virtual care for routine services will offer healthcare savings to third party payers, and over time, reduce the 4.1 Trillion dollars spent on healthcare within the US, e.g. aim number 2 (Hartman et al., 2021).
In summary, the three pathways of telehealth integration revolve around academia, clinical practice and mHealth (Dy Aungst & Patel, 2020). Virtual healthcare models add value to the healthcare industry in many ways. Furthermore, when telehealth integration is promoted, it enhances health care outcomes. Purposeful integration of telehealth within education allows instruction and training to be embedded within the profession’s curricula. ACOTE extended OT programs agency in 2018 by including a telehealth standard within instructional delivery; however, what kind of instruction and how much remains nebulous (Patterson et al., 2021).
Integration of telehealth models within traditional treatment methods is also being asked for by key stakeholders of healthcare services (e.g., administrators, providers, customers, etc.). Instructing providers on how to dovetail the two service models is not always intuitive but can be accomplished with proper training. Telehealth assessments and interventions vary considerably from traditional approaches; therefore, clear communication between patient and provider is paramount (Shea, 2021). Playbooks and standard operating procedures and checklists are helpful in establishing consistency and service predictability. Use of telehealth service models dramatically cut down on travel, lost wages, expenses on lodging and promoted aging in place among aged adults (Vaidya, 2022). Millennials prefer engaging their providers using virtual visits and are quite comfortable navigating healthcare applications online or on their smartphones.
Integration of technology, such as through the use of remote patient monitoring (RPM) allows patients and providers to stay in close contact; thus, averting harmful healthcare emergencies that often led to acute care admissions (Vaidya, 2022). The IHI’s quadruple aim integrates well with telehealth service models and adds further credence to the benefits of virtual care in a time of public health crisis (Freeley, 2017).
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