Thinking About Providing Telehealth? Here's Our Top 10 'To-Do' List
The COVID-19 pandemic has caused patients and providers, as well as state and federal governments, to consider the use of telehealth on a wider scale, including in physical therapy.
It's a complicated topic that deserves your time — not just because of the immediate need for change to help respond to the current health crisis, but because the expansion of telehealth to physical therapy has been long sought by many in the profession, and it is one of APTA's central advocacy targets.
APTA offers extensive resources on telehealth on its telehealth webpage, and we're adding information frequently as the on-the-ground realities continue to develop. You should review those resources before making a decision about whether telehealth is the right approach for you — or if it's even possible.
Arm yourself with as much information as possible—and follow these 10 telehealth "to-dos."
1. Know what's allowed and what's not.
Regardless of the payer or policy, if you provide and bill for telehealth services, you must do it legally and ethically. That means adhering to state and federal guidelines and paying particular attention to the laws and regulations in your state of licensure.
Understand that not all states allow telehealth by PTs or PTAs and that even among those that do, there are variations in what exactly is permitted. It doesn't matter what a commercial payer may allow, or even what CMS permits: If your state says telehealth is outside your scope of practice, you can't use it to provide services.
Carefully review your state licensure law and regulations, but remember that in many states, the law is silent on telehealth and physical therapy. If that's the case in your state, contact your state's licensing board to find out if there are limitations or restrictions. For more information, check out APTA's state practice act resources, and information from the Federation of State Board of Physical Therapy. And remember that state-mandated health orders and state emergency orders can also change what is and isn't permitted.
2. Train your staff.
Solid staff training is key to an effective telehealth program that best responds to the COVID-19 pandemic. APTA offers several resources to help you ensure that your staff is as prepared as possible for providing telehealth in this crisis. Check out these two APTA Learning Center webinars: Implementing Telehealth in Your Practice , recorded on March 26, and Digital Telehealth Practice – Connect for Best Practice, Healthcare, and Compliance, to be recorded on April 2, with a live online Q&A on April 7.
3. Educate your patients on their privacy and rights.
You need to properly educate patients about the use of telehealth, which includes their rights while being cared for under this modality. Patients need to be aware of your obligation to protect their privacy and gain their consent. For more information about informed consent, check out the Center for Connected Health Policy resources.
4. Take privacy seriously — and understand how it's affected by technology.
You need to understand the technology of telehealth, and the extensive regulation in place to protect patient privacy and security of health information, including HIPAA requirements. Also check out the additional resources listed at the end of this blog.
5. Document, document, document (just like always).
Keep in mind the documentation needed to have a proper compliant telehealth program. For more information, view APTA's Defensible Documentation resources.
6. When it comes to payment, assume nothing.
Your practice can involve multiple payers, with differing policies, including those related to telehealth. This means you'll face a patchwork of approaches.
You should command a sound understanding of variations in telehealth reimbursement, be it through Medicare, Medicaid, other federal health payers, or commercial payers. Verify with individual payers what is and isn't permitted, what CPT codes will be reimbursed, the required modifiers, and more. Confirm with each payer whether the originating and distant site can be a private home or office, if services must be real-time or can be asynchronous, and any other limitations to your use of telehealth. This APTA article offers guidance on what questions to ask your payer(s).
Also find out if your state has parity laws that require insurers to pay the same amount for telehealth services as they would for an in-person visit. For more information, check out APTA's Telehealth billing and coding resources.
7. Make sure your malpractice insurance covers telehealth.
You should check your malpractice insurance and update it if it doesn’t cover practice using telehealth. For more information, see APTA's Risk Management resources as well as the resources listed at the end of this blog.
8. Understand that your ethical responsibilities don't change when delivering services via telehealth.
It's simple: You are held to the ethical standards of your profession while practicing telehealth. Here are some resources you should review regarding ethics in telehealth. Also, check out a free APTA Learning Center webinar that discusses what you need to know to ensure compliance with regulations established by HIPAA and the APTA Code of Ethics when using telehealth and mobile health technology. Also worth a look: this blog post highlighting ethics, best practice, and law considerations for practicing telehealth.
9. Stay connected with your peers in telehealth.
Telehealth is part of APTA's Frontiers in Rehabilitation, Science, and Technology (FiRST) Council. FiRST grew out of identification of high-priority areas to advance science and innovation that our profession needs to understand and incorporate into our practice, education, and research. FiRST is intended to serve as a community for interested stakeholders, and is a great way to learn from those who've been leading the way.
Remember that most of the opportunities for telehealth at the moment are temporary, in response to the COVID-19 pandemic. And as of this writing, even though CMS now has the (again, temporary) authority to include PTs among the providers who can engage in telehealth, it hasn't moved in that direction. That’s why it's so important to continually advocate for payment and coverage policies that ensure patients have access to the rehabilitative care they need. Learn more about how you can engage in federal advocacy today and watch for advocacy opportunities on the state level.
More Telehealth Resources for PTs and PTAs
HIPAA: Business associate agreements
Health IT and telehealth
HPSO: Telemedicine: Risk Management Issues, Strategies, and Resources
APTA: Considerations for Practice Opportunities and Professional Development
HHS Security Risk Assessment Tool
HPA Tech SIG: SIG's homepage.
Novel Coronavirus: A Wake-up Call for Best Practices in Preventing Pathogen Transmission
By David Levine, PT, DPT, PhD, FAPTA, Henry Spratt, PhD, June Hanks, PT, DPT, PhD, and Charles Woods, MD, MS
Novel human coronavirus disease (COVID-19), now moving towards pandemic status, represents one of the great concerns of modern life – the rapid evolution of new human viruses that can be spread via the respiratory tract. As with other pathogens, physical therapists, physical therapist assistants, and administrative staff can take tangible steps to help prevent the spread of disease that could harm our most vulnerable populations. The Centers for Medicare and Medicaid Services has issued guidelines for infection control and is calling on health care providers to activate infection control practices.
COVID-19 is caused by severe acute respiratory syndrome coronavirus 2, abbreviated as SARS-CoV-2. As a positive-strand, enveloped RNA virus, SARS-CoV-2 is another coronavirus like the severe acute respiratory syndrome (SARS) virus that first appeared in China in 2002, infecting around 8,000 people worldwide and resulting in about 750 deaths in total. The major lesson learned from the SARS outbreak was how easily these coronaviruses can spread. To avoid additional spread of these viruses requires effective detection, protection of caregivers (eg. hand washing, protective clothing, and masks for infected individuals), and disinfection of health care facilities and equipment. These measures are a must for all physical therapy clinics.
There is still much to learn about the new virus, including how easily it spreads. Based on what we currently know about other coronaviruses, SARS-CoV-2 is spread mainly from person to person through respiratory droplets among close contacts, especially under crowded conditions. It is easy to see how the first cases of COVID-19 appeared in Wuhan, China, a large city about the size of Chicago last December. However, this new virus is not the only airborne virus that can cause epidemics — think influenza.
In addition to taking precautions to avoid aerosolization (the production of airborne particles containing an infectious virus or bacteria), we must disinfect surfaces touched by infected people. Thus, in physical therapy clinics, in anticipation of future patients being infected by the SARS-CoV-2 virus, we must think holistically in terms of clinic disinfection and protection.
What Should We Be Doing in Physical Therapy to Prevent Pathogen Transmission?
Most people infected by the virus — around 80% — show mild symptoms, much like having the common cold, from which they will recover over the course of several weeks. It is the remaining 20% of people who are most at risk of more severe symptoms and potential critical outcomes. This latter group includes older individuals, the very young, and immunocompromised patients. Keeping individuals with mild symptoms away from the most susceptible persons is paramount in reducing serious complications and even death.
By the nature of our profession, physical therapists and physical therapist assistants use our hands and therapeutic equipment extensively and have frequent direct patient contact. We also work in crowded environments and with individuals that may be immunocompromised. While there are many precautions we can take that are specific to SARS-CoV-2, the virus serves as a reminder for all health care providers and administrators to be vigilant in preventing the spread of any transmissible disease or infectious bacteria.
1. Practice proper hand and wrist hygiene.
When you don't know what you don't know, then do what you do know: Wash your hands—and your wrists! Hand and wrist hygiene should occur before and after each patient encounter.
With the very short time between this writing and actual publication, researchers will learn more about COVID-19 and recommendations are likely to expand. That said, the practice of appropriate handwashing remains as the most basic strategy to prevent the spread of SARS-CoV-2, the influenza virus, and the common cold. Proper hand/wrist hygiene using soap and water or alcohol-based hand sanitizers (ABHS) significantly impacts microbe transmission and should be incorporated into routine patient care.
Handwashing with soap and water is recommended after treating patients with known or suspected norovirus or Clostridium difficile, since ABHS are not effective against these pathogens, and is recommended for SARS-CoV-2 as well. While soap doesn't kill the virus, it does wash it away if done properly: Wash hands with soap and water, place the hands under running water, apply the soap, and vigorously rub all surfaces of the hands and wrists together for 15-20 seconds (sing "Happy Birthday" twice), rinse, use a disposable towel to dry, and use the towel to turn off the water faucet. Make sure you clean under your fingernails, as well.
ABHS are the most efficacious method to reduce bacteria on the hands and wrists. ABHS should be used according to manufacturer recommendations, which generally include putting the product on and rubbing all surfaces together for at least 20 seconds until dry. If it is dry before 20 seconds, you have not used enough ABHS.
Fingernails should be kept less than ¼ inch long, and excessive jewelry should be avoided. Frequent use of hand lotions that do not interfere with hand sanitizing products may help reduce hand dryness from frequent cleansing.
2. Cover your coughs and sneezes with a tissue.
Cover your mouth and nose with a tissue when coughing or sneezing. If no tissue is available, sneezing or coughing into a bent elbow is recommended. It may prevent those around you from getting sick. Flu and other serious respiratory illnesses, like respiratory syncytial virus (RSV), whooping cough and SARS, are spread by cough, sneezing, or unclean hands.
3. Stay home when you are sick.
If possible, stay home from work, school, and running errands when you are sick. This will help prevent spreading your illness to others.
4. Avoid touching your eyes, nose, or mouth.
Germs are often spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth.
Cleaning and Disinfection in the Clinic and Other Settings
This is an area that we don't emphasize enough within the physical therapy profession. No matter what type of practice setting, we all have objects and equipment — tables, walkers, wheelchairs, goniometers, pulse oximeters, crutches, gait belts, exercise equipment, countertops, treadmills, light switches, doorknobs, cabinet handles, etc. — that are frequently touched and contaminated. We don't yet know how easily SARS-CoV-2 can be transmitted by objects, but as a rule surfaces should be cleaned between each patient encounter using an appropriate disinfectant. The Environmental Protection Agency has released a list of disinfectants approved for use against the SARS-CoV-2 virus.
It is beyond the purpose of this blog to discuss the numerous types of disinfectants that have advantages and disadvantages in terms of effectiveness, kill time, safety, cost, and ease of use. For example, hydrogen peroxide wipes are commonly used in health care, but take one minute of contact/wet time to kill methicillin resistant staphylococcus aureus (MRSA), three minutes of contact/wet time to kill norovirus, and five minutes to kill mycobacterium bovis. How often do we achieve a wet time of even 30 seconds when cleaning equipment? The bottom line: Read the labels and learn about the products.
For more information on where bacteria commonly grow in the clinic and how to prevent its spread, see this blog post.
PTs who work in home health don't have as much control over their environment, but should still practice hand and wrist hygiene, "distancing" (avoiding droplets from a patient's cough) as much as possible, and avoiding patient visits when they are ill.
What If My Patient Is the One Coughing/Sneezing, or Exhibits COVID-19 Symptoms?
Advise patients who are sick to call their primary care providers and stay at home. It is hard to know how to tell people when and when not to go see their doctor, urgent care center, or minute clinic. The Centers for Disease Control and Prevention currently recommends that you call your physician if you develop a fever, cough, and shortness of breath AND have been in close contact with a person diagnosed with COVID-19 or have recently traveled from an area with ongoing spread of SARS-CoV-2.
Request patients who are coughing or sneezing to wear a mask while in the clinic and, if possible, move them into an individual room for treatment. Provide alcohol-based hand sanitizer and face masks at all facility entrances. Educate your patients on proper hand and wrist hygiene and the other preventive practices outlined above.
Make a plan for how you will educate your front desk and clinical staff about protecting themselves and cleaning their workspace frequently.
The World Health Organization website includes the following helpful resources:
David Levine is professor in the department of physical therapy at The University of Tennessee at Chattanooga (UTC) and a board-certified clinical specialist in orthopaedic physical therapy. June Hanks is associate professor in the department of physical therapy at UTC. Henry Spratt is a microbiology professor in the UTC department of biology, geology, and environmental science. Charles Woods is chair of the department of pediatrics of the UT College of Medicine Chattanooga and professor of pediatric infectious diseases.