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Can eHealth Technology Enhance the Patient-Provider Relationship in Rehabilitation?

  • Sophia Wang
    Affiliations
    Department of Psychiatry, Indiana University, Indianapolis, IN

    Center for Health Innovation and Implementation Science, Indianapolis, IN

    Mental Health Service Line, Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN
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  • Dan Blazer
    Affiliations
    Department of Psychiatry and Behavior Sciences, Durham Veterans Administration Medical Center, Durham, NC

    Center for the Study of Aging, Durham Veterans Administration Medical Center, Durham, NC
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  • Helen Hoenig
    Correspondence
    Corresponding author Helen Hoenig, MD, MPH, Physical Medicine and Rehabilitation, Durham Veterans Administration Medical Center, 508 Fulton St, Durham, NC 27705.
    Affiliations
    Physical Medicine and Rehabilitation Service, Durham Veterans Administration Medical Center, Durham, NC

    Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, NC
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Published:April 21, 2016DOI:https://doi.org/10.1016/j.apmr.2016.04.002

      Keywords

      List of abbreviations:

      CPT (Common Procedural Terminology)
      Technology has a long history of use in rehabilitation, both for therapeutic interventions (eg, to provide various kinds of exercise or modalities such as ultrasound) and for remediating disability (eg, assistive technology and prosthetic limbs). However, the use of electronic technology is increasingly pervasive in the delivery of health care, including rehabilitation. The term eHealth refers to use of electronic technologies in health care, many of which fall under the broad category of Telehealth. The use of the term eHealth is rapidly evolving, but some eHealth technologies with potential relevance to rehabilitation include videoconferencing, store-and-forward imaging, mobile apps, sensor-based and Internet-based systems for data collection/communication, and algorithmic software to help interpret electronic data (eg, data in the electronic health record and sensor-based data).

      Health Resources and Service Administration. Telehealth. Available at: http://www.hrsa.gov/healthit/telehealth/. Accessed December 12, 2015.

      • Dicianno B.E.
      • Parmanto B.
      • Fairman A.D.
      • et al.
      Perspectives on the evolution of mobile (mHealth) technologies and application to rehabilitation.
      Although eHealth offers many benefits, the effects on the patient-provider relationship have been problematic. The constant presence of such technology can consume health care providers, sometimes requiring that they spend more time with electronic health records and software to support medical decision making than seeing patients face to face,
      • Verghese A.
      Culture shock—patient as icon, icon as patient.
      which, in turn, is perceived by patients as less effective.
      • Street R.L.
      • Liu L.
      • Farber N.J.
      • et al.
      Provider interaction with the electronic health record: the effects on patient-centered communication in medical encounters.
      Increasingly, patients themselves are turning to the Internet to find information on their disorders and using algorithmic searches to “e-diagnose” themselves.
      • Street R.L.
      • Liu L.
      • Farber N.J.
      • et al.
      Provider interaction with the electronic health record: the effects on patient-centered communication in medical encounters.

      Fox S, Duggan M. Health online 2013. Available at: http://www.pewInternet.org/∼/media/Files/Reports/PIP_HealthOnline.pdf. Accessed May 1, 2015.

      Like other health care providers, rehabilitation providers face the technologically driven loss of human interaction with their patients.
      • Lee A.C.
      • Harada N.
      Telehealth as a means of health care delivery for physical therapist practice.
      Models for rehabilitation patient-provider communication emphasize the importance of therapeutic connection, and studies
      • Lequerica A.H.
      • Kortte K.
      Therapeutic engagement: a proposed model of engagement in medical rehabilitation.
      • Jesus T.S.
      • Silva I.L.
      Toward an evidence-based patient-provider communication in rehabilitation: linking communication elements to better rehabilitation outcomes.
      • Hall A.M.
      • Ferreira P.H.
      • Maher C.G.
      • Latimer J.
      • Ferreira M.L.
      The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review.
      show that the therapeutic relationship can affect rehabilitation outcomes. It is critical that as a field we are aware of new and developing eHealth technologies that might help to foster patient-provider connection and patient-centered health care in the context of rehabilitation.
      The goal of this Editorial is to raise awareness among rehabilitation providers about a growing body of technology, its diversity, and its potential applications to support and enhance the critical patient-provider relationship in rehabilitation. To critically examine the potential ways eHealth technologies might be used to enhance the rehabilitation patient-provider relationship, we focus on 3 aspects of a model proposed by Jesus and Silva
      • Jesus T.S.
      • Silva I.L.
      Toward an evidence-based patient-provider communication in rehabilitation: linking communication elements to better rehabilitation outcomes.
      for patient-provider communication in rehabilitation: (1) knowing the person and contextual factors; (2) effective information exchange and education; and (3) shared goal setting and action planning.

      Knowing the person and contextual factors

      Given the importance of contextual factors in disability outcomes,

      World Health Organization. International classification of functioning, disability, and health. Available at: http://www3.who.int/icf/icftemplate.cfm. Accessed December 15, 2015.

      it is critical for rehabilitation providers to understand the patient's contextual factors. Lack of information on contextual factors may render useless otherwise effective interventions, particularly those whose effectiveness depends on environmental context and contextually relevant training (eg, assistive technology). Home visits are a helpful solution
      • Clemson L.
      • Mackenzie L.
      • Ballinger C.
      • Close J.C.
      • Cumming R.G.
      Environmental interventions to prevent falls in community-dwelling older people a meta-analysis of randomized trials.
      • Mann W.C.
      • Ottenbacher K.J.
      • Fraas L.
      • Tomita M.
      • Granger C.V.
      Effectiveness of assistive technology and environmental interventions in maintaining independence and reducing home care costs for the frail elderly: a randomized controlled trial.
      • Gitlin L.N.
      • Winter L.
      • Dennis M.P.
      • Corcoran M.
      • Schinfeld S.
      • Hauck W.W.
      A randomized trial of a multicomponent home intervention to reduce functional difficulties in older adults.
      • Gitlin L.N.
      • Levine R.
      • Geiger C.
      Adaptive device use by older adults with mixed disabilities.
      ; however, home visits are expensive and inefficient and challenging to coordinate, and health providers with the relevant expertise may not be available.
      • Fairchild D.G.
      • Hogan J.
      • Smith R.
      • Portnow M.
      • Bates D.W.
      Survey of primary care physicians and home care clinicians.
      • Parker E.
      • Zimmerman S.
      • Rodriguez S.
      • Lee T.
      Exploring best practices in home health care: a review of available evidence on select innovations.

      Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC. Health professions per 10,000 population: maps. Available at: http://www.shepscenter.unc.edu/workforce_product/2012-health-professionals-per-10000-population-maps/. Accessed July 1, 2016.

      In fact, most rehabilitation providers see their patients out of context in the hospital or a clinic, with its inherent limitations. Providers compensate through intensive discharge planning; nonetheless, that disconnect can affect the patient-provider relationship either during treatment, when the patient does not feel fully understood, or on return home, when disparities between the hospital-/clinic-based therapeutic plans and reality become apparent. Teletechnology offers a potential solution.
      Photos and videos can enable patients to provide real-time information on their particular challenges, enabling “ecological momentary assessment.”
      • Dicianno B.E.
      • Parmanto B.
      • Fairman A.D.
      • et al.
      Perspectives on the evolution of mobile (mHealth) technologies and application to rehabilitation.
      Real-time televideo has been used to remotely deliver in-home therapy services with improved outcomes over usual care.
      • Sanford J.A.
      • Griffiths P.C.
      • Richardson P.
      • Hargraves K.
      • Butterfield T.
      • Hoenig H.
      The effects of in-home rehabilitation on task self-efficacy in mobility impaired older adults: a randomized clinical trial.
      • Jackson J.
      • Ely E.W.
      • Morey M.C.
      • et al.
      Cognitive and physical rehabilitation of intensive care unit survivors: results of the RETURN randomized controlled pilot investigation.
      • Chumbler N.R.
      • Quigley P.
      • Li X.
      • et al.
      The effects of tele-rehabilitation on physical function and disability for stroke patients: a randomized, controlled trial.
      It also has been used to support in-home rehabilitation of severely impaired veterans
      • Bendixen R.M.
      • Levy C.E.
      • Olive E.S.
      • Kobb R.F.
      • Mann W.C.
      Cost effectiveness of a telerehabilitation program to support chronically ill and disabled elders in their homes.
      and for rehabilitation after orthopedic surgery.
      • Moffet H.
      • Tousignant M.
      • Nadeau S.
      • et al.
      In-home telerehabilitation compared with face-to-face rehabilitation after total knee arthroplasty.
      • Tousignant M.
      • Giguère A.M.
      • Morin M.
      • Pelletier J.
      • Sheehy A.
      • Cabana F.
      In-home telerehabilitation for proximal humerus fractures: a pilot study.
      Photovoice is a technique wherein photo/video images are used to depict one's life and share it with others—the richer subjective fostering improved understanding.
      • Baker T.A.
      • Wang C.C.
      Photovoice: use of a participatory action research method to explore the chronic pain experience in older adults.
      To provide a concrete example: in commenting about a photovoice documentary of daily experiences of 3 patients who lived in wheelchairs, a physician wrote, “None of which [the patient's fears] were apparent during the conversation with his doctor.”
      • Berland G.
      The view from the other side—patients, doctors, and the power of a camera.
      The efficacy of photo/video images across these diverse populations and modes of use is striking, lending truth to the aphorism a picture speaks a thousand words.

      Effective information exchange and education

      In-person health care delivery is constrained by time. Electronic technology has the potential to increase opportunities for communication and education, with technology ranging from simple home messaging devices that query patients periodically (eg, about particular problems
      • Galea M.
      • Tumminia J.
      • Garback L.M.
      Telerehabilitation in spinal cord injury persons: a novel approach.
      or therapeutic goals
      • Harada N.D.
      • Dhanani S.
      • Elrod M.
      • Hahn T.
      • Kleinman L.
      • Fang M.
      Feasibility study of home telerehabilitation for physically inactive veterans.
      ) to sensor-based systems to sophisticated interactive systems. Data on the direct effects of sensor-based technologies on patient-provider communication are limited, but there are some studies showing beneficial effects on rehabilitation outcomes. For example, a number of studies have examined use of accelerometers to guide treatment, with several studies showing improvements in physical activity and gait, albeit with limited long-range health outcomes.
      • Geirish J.M.
      • Goode A.P.
      • Batch B.C.
      • et al.
      The impact of wearable motion sensing technologies on physical activity: a systematic review.
      Interactive patient educational systems are another example, having been shown to improve outcomes for diverse medical populations,
      • Kao D.P.
      • Lindenfeld J.
      • Macaulay D.
      • et al.
      Impact of a Telehealth and care management program on all-cause mortality and healthcare utilization in patients with heart failure.
      • Salonen A.
      • Ryhänen A.M.
      • Leino-Kilpi H.
      Educational benefits of Internet and computer-based programmes for prostate cancer patients: a systematic review.
      and they seem promising for use in rehabilitation, given the central role of patient education in many rehabilitation interventions.
      Electronic technologies for patient education also include mobile apps, a rapidly growing type of health care technology.
      • Fairchild D.G.
      • Hogan J.
      • Smith R.
      • Portnow M.
      • Bates D.W.
      Survey of primary care physicians and home care clinicians.
      Commonly referred to as mHealth, in 2013 there were more than 17,000 health-related mobile apps targeting consumers/patients.

      Aitken M, Gauntlett C. Patient apps for improved healthcare: from novelty to mainstream. Available at: http://www.imshealth.com/en/thought-leadership/ims-institute/reports/patient-apps-for-improved-healthcare. Accessed December 11, 2015.

      More than 60% of mHealth apps have informational and/or educational components.
      • Salonen A.
      • Ryhänen A.M.
      • Leino-Kilpi H.
      Educational benefits of Internet and computer-based programmes for prostate cancer patients: a systematic review.
      A number of mobile apps have been developed for physical rehabilitation, for example, to support exercise training
      • Ahmed O.H.
      The smartphone app ‘Rotator Cuff Injury/Strain’ by Medical iRehab.
      and measurement (eg, gait, balance, and range of motion).
      • How T.V.
      • Chee J.
      • Wan E.
      • Mihailidis A.
      Mywalk: a mobile app for gait asymmetry rehabilitation in the community.

      Wai AA, Duc PD, Syin C, Haihong Z. iBEST: intelligent balance assessment and stability training system using smartphone. In: 36th Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC’14); 2014 Aug 26–30; Chicago (IL). p 3683-6.

      • Milani P.
      • Coccetta C.A.
      • Rabini A.
      • Sciarra T.
      • Massazza G.
      • Ferriero G.
      Mobile smartphone applications for body position measurement in rehabilitation: a review of goniometric tools.
      In addition, in their effort to better meet the health and behavioral needs of veterans, the Department of Veterans Affairs and the Department of Defense are in process of developing a wide array of mobile apps, including some that enable ecologically embedded assessment of self-care and behavioral function.
      • Weingardt K.R.
      • Greene C.J.
      New electronic tools for veterans.
      Although mobile app development has far outpaced its evidentiary support,
      • Kuehn B.M.
      Is there an app to solve app overload?.
      • van Mechelen D.M.
      • Van Mechelen W.
      • Verhagen E.A.
      Sports injury prevention in your pocket?! Prevention apps assessed against the available scientific evidence: a review.
      mHealth has great potential application in rehabilitation for 2 reasons: (1) enabling practice outside the clinical setting could facilitate motor learning believed to underpin outcomes for many conditions treated by rehabilitation
      • Hollands K.L.
      • Pelton T.A.
      • Tyson S.F.
      • Hollands M.A.
      • van Vliet P.M.
      Interventions for coordination of walking following stroke: systematic review.
      • Sawers A.
      • Hahn M.E.
      • Kelly V.E.
      • Czerniecki J.M.
      • Kartin D.
      Beyond componentry: how principles of motor learning can enhance locomotor rehabilitation of individuals with lower limb loss—a review.
      and (2) the broad availability and portability of mobile phones could enable provision of real-time, ecologically embedded information (ie, ecological momentary assessment).

      Shared goal setting and action planning

      One common problem with patient care is adherence—the best laid plans come to naught without adherence. Adherence and outcomes in rehabilitation can be improved by shared goal setting and action planning, personally tailored educational interventions, and feedback to patients' about their performance.
      • Keating A.
      • Lee A.
      • Holland A.E.
      What prevents people with chronic obstructive pulmonary disease from attending pulmonary rehabilitation? A systematic review.
      • Davies P.
      • Taylor F.
      • Beswick A.
      • et al.
      Promoting patient uptake and adherence in cardiac rehabilitation.
      Electronic technologies, sometimes referred to as persuasive technologies, are available to help with all these.
      • Kelders S.M.
      • Kok R.N.
      • Ossebaard H.C.
      • Van Gemert-Pijnen J.E.
      Persuasive system design does matter: a systematic review of adherence to web-based interventions.
      For example, technologies to enhance physical activity may attempt to motivate patients by personalized goal setting, providing various rewards and reminders, journaling by the patient, and linking with the patient's social network.

      Munson SA, Consolvo S. Exploring goal-setting, rewards, self-monitoring, and sharing to motivate physical activity. In: 6th International Conference on Pervasive Computing Technologies for Healthcare (PervasiveHealth 2012); 2012 May 21–24; San Diego (CA). p 25-32.

      Indeed, focus groups and user feedback indicate that shared goal setting and tailored feedback in particular may better enable the patient to effect change.

      Klasnja P, Consolvo S, McDonald DW, Landay JA, Pratt W. Using mobile & personal sensing technologies to support health behavior change in everyday life: lessons learned. In: AMIA Annual Symposium Proceedings; 2009. p 338-42.

      A major advantage of the increasing wealth of electronic technology is that it supports multimodal ways to reach out to the patient. For instance, a successful cardiac rehabilitation intervention
      • Antypas K.
      • Wangberg S.C.
      E-Rehabilitation—an Internet and mobile phone based tailored intervention to enhance self-management of cardiovascular disease: study protocol for a randomized controlled trial.
      provided standardized education about cardiovascular disease through the Internet, provided access to Internet-based discussion forums, and sent the patients tailored content via the website along with mobile text messages, with resultant higher levels of physical activity as shown in a small randomized trial.
      • Antypas K.
      • Wangberg S.C.
      An Internet- and mobile-based tailored intervention to enhance maintenance of physical activity after cardiac rehabilitation: short-term results of a randomized controlled trial.
      Mobile apps have particularly broad potential applicability for both goal setting and action planning, with the Veterans Affairs taking a lead in developing tools to foster veterans' engagement in their own health care.
      • Milani P.
      • Coccetta C.A.
      • Rabini A.
      • Sciarra T.
      • Massazza G.
      • Ferriero G.
      Mobile smartphone applications for body position measurement in rehabilitation: a review of goniometric tools.
      The added information on goals and personal action plans enabled by such technologies may not only foster enhanced understanding of the patient's perspective but also stimulate discussion, which, in turn, reinforces the patient-provider relationship.

      Limitations and next steps

      These new technologies may confer novel benefits, but they also confer some novel challenges, limitations, and required next steps.

       Challenges and limitations

      Any sort of health information brings with it 3 interrelated concerns—privacy, confidentiality, and security—each of which may be uniquely affected by the type of technology, the information the technology enables, and who interfaces with the technology. The eHealth and related mHealth fields are rapidly evolving, both from a technological perspective and from a legal perspective. Clinicians who may wish to use novel eHealth technology and have questions about information security, privacy, or confidentiality should consult their local “privacy officer,” office of information technology, and/or the manufacturer or vendor of the technology; technology should be avoided if information is lacking about the risks and protection of the patient's data. The interested reader is referred to reviews by Martínez-Pérez et al
      • Martínez-Pérez B.
      • De La Torre-Díez I.
      • López-Coronado M.
      Privacy and security in mobile health apps: a review and recommendations.
      and Lumpkin.
      • Lumpkin J.R.
      e-Health, HIPAA, and beyond.
      Clinicians may worry “who has the time to watch these things or tell the patient what to film?” Increasingly, third-party payment is available to compensate clinicians for time spent using eHealth technologies, but compensation can vary according to the type of technology, the types of clinicians using the technology (eg, physician vs allied health provider), the location of services (eg, rural vs urban and clinic vs home), the condition being treated, and with the third-party payer.

      Health Resources and Services Administration. What are the reimbursement issues for Telehealth? Available at: http://www.hrsa.gov/healthit/toolbox/RuralHealthITtoolbox/Telehealth/whatarethereimbursement.html. Accessed August 4, 2016.

      The Centers for Medicare and Medicaid Services provide compensation for “telehealth” at the same rate as other face-to-face care, but only if that care is provided using real-time televideo and it further limits payment for some services to one of several rural health demonstration projects.

      Centers for Medicare and Medicaid Services. Telehealth. Available at: https://www.cms.gov/Medicare/Medicare-General-information/telehealth/. Accessed August 4, 2016.

      The Centers for Medicare and Medicaid Services has 2 Common Procedural Terminology (CPT) codes broadly relevant to the use of eHealth technologies: The CPT codes 99090 may be used for the “analysis of clinical data stored in computers (eg, electrocardiograms, blood pressures, hematologic data)” and 99091 for “the collection and interpretation of physiologic data (eg, electrocardiogram, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional.”

      American Telemedicine Association. Update on CMS payment decision—two steps forward, one back. Available at: http://www.americantelemed.org/news-landing/2014/11/07/update-on-cms-payment-decisions–-two-steps-forward-one-back#.VwPYWDZf2Uk. Accessed August 4, 2016.

      Both CPT codes 99090 and 99091 may be used in any location.

       Next steps

      Electronic technology has great potential to enhance the rehabilitation patient-provider relationship. However, meeting that potential will require dedicated attention to 3 critical areas: (1) policy, regulations, and payment; (2) research and evidentiary support; (3) clinician and patient training. In general, policy, payment, and regulations pertaining to Telehealth, eHealth, and mHealth are rapidly evolving and can vary considerably by payment source, by state, and within particular health care organizations. The Veterans Health Administration has developed detailed policy, regulations, and training for Telehealth,

      U.S. Department of Veterans Affairs. VA Telehealth services. Available at: http://www.telehealth.va.gov/. Accessed December 28, 2015.

      and more recently mHealth.

      U.S. Department of Veterans Affairs. VA mobile health. Available at: https://mobile.va.gov/. Accessed December 28, 2015.

      The American Telemedicine Association

      American Telemedicine Association. ATA State Telemedicine Toolkit: improving access to covered services for telemedicine. Available at: http://www.americantelemed.org/docs/default-source/policy/ata-state-telemedicine-toolkit–-coverage-and-reimbursement.pdf?sfvrsn=4. Accessed August 4, 2016.

      and the Center for Connected Health Policy

      Center for Connected Health Policy. Telehealth Medicaid & state policy. Available at: http://cchpca.org/telehealth-medicaid-state-policy. Accessed August 4, 2016.

      are good sources of information on current reimbursement and regulations.
      Research and implementation studies are needed within and across conditions to inform clinicians and policymakers about when, where, and what types of eHealth to support. For example, most eHealth technology has targeted toward less disabled populations, so concerns may be raised about its use with persons who have more severe impairments. Pilot studies supports potential applicability of eHealth technologies to persons with more severe impairments,
      • Forducey P.G.
      • Glueckauf R.L.
      • Bergquist T.F.
      • Maheu M.M.
      • Yutsis M.
      Telehealth for persons with severe functional disabilities and their caregivers: facilitating self-care management in the home setting.
      but further research is needed to show efficacy, to adapt the technology for use by special populations, and to develop appropriate training both for patients and for providers. Training requirements for patients and providers are complex; however, lessons learned from implementation science might be fruitfully applied to help with “technophobia” and skill acquisition.
      • Kilbourne A.M.
      • Neumann M.S.
      • Pincus H.A.
      • Bauer M.S.
      • Stall R.
      Implementing evidence-based interventions in health care: application of the replicating effective programs framework.
      • Grol R.
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      From best evidence to best practice: effective implementation of change in patients’ care.
      We believe that eHealth technology has broad potential applicability in rehabilitation and that it is particularly germane to the patient-provider interface so critical to successful rehabilitation. Although more work still is needed (eg, to provide evidentiary support and policy/regulatory development), the technological building blocks already are there. Rehabilitation providers have significant expertise and comfort with technology and they have broad expertise in effective patient-provider communication, which means the field is well-placed to take a leader role in use of eHealth technologies to enrich the patient-provider relationship.

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