Using telehealth to deliver physical therapist services is expanding rapidly, and if you haven't already, you're probably considering it. Before adopting any telehealth solution, investigate issues such as eligibility under your state's practice act, legal and privacy considerations, payer policy, and liability; explore practice-related implications for the delivery of telehealth services.
(Note: The information provided is offered for general informational purposes only. It is not offered or intended, nor should it be relied upon, as legal advice. Legal doctrines, statutes, and case law vary from state to state. You should consult with your own attorney for specific legal advice on particular legal issues.)
Here are some things to consider:
Eligibility, Compliance, and Payment
- Check your state practice act to verify that you can provide telehealth services in your state. Your state recently may have changed regulations (or may do so soon) because of the COVID-19 pandemic, so ask now even if your state previously prohibited or was silent on it. APTA provides links to all state practice acts.
- Document the legal and ethical reasons you are converting patients to telehealth visits. While the COVID-19 pandemic in itself offers justification, you still need to document.
- Review commercial payer policies regarding your eligibility on payment for furnishing, implementing, and using telehealth to provide services.Ensure compliance with all practice and billing requirements.
- Use secure, HIPAA-compliant technology and have Business Associates Agreements in place with your telehealth vendor and any other related business associates.
- Consult your legal counsel when legal questions arise.
Check with your malpractice insurance carrier for any coverage policies specific to telehealth prior to providing physical therapist services via telehealth. APTA advises all PTs, PTAs, and students to have professional liability insurance, such as with the Healthcare Providers Service Organization. HPSO provides a helpful article titled Telemedicine: Risk Management Issues, Strategies and Resources (.pdf). Again, consult your legal counsel about any legal questions or considerations.
- Determine your primary patient, provider, and technological needs. For example, if you want to provide live video visits, then you will look for a telehealth product with strong live video capabilities. If your primary goal is to increase communication with patients, you may want to choose a product with a secure texting solution.
- Consider your patient demographics and any potential barriers associated with those demographics including, but not limited to, language and/or communication, cultural, and environmental, as well as access to and competence with technology.
- Determine in advance which interventions will be feasible and safe to implement.
- Use a decision tree to guide provider choices tailored to the needs of specified for patient.
- Develop a business plan for telehealth, including estimated expenses and savings.
- Prepare policies and procedures before you start (see below). Revise your policies regarding consent, PHI, and medical emergencies to incorporate telehealth.
- Learn how to use the selected technology. Practice using the equipment with your colleagues to understand the technology and required multitasking skills.
- Get the highest bandwidth internet connection you can. Consider having a different backup source for internet access. For example, if the main connection is fiber optic, use cable or DSL as a backup.
- Develop an IT development, installation, and support plan. Consider who will advise you on what to purchase, set up your equipment, and troubleshoot or restore your system if there are problems. Ask these questions:
- Does the software comply with HIPAA requirements for privacy and security, such as adequate encryption for PHI?
- Is connectivity reliable, in terms of IP protocol, sufficient bandwidth, and audio/video interface quality?
- Can staff easily learn and use the equipment, both onsite and remotely when needed?
- Is the system compatible with your facility's current hardware and software?
- Determine if you're in the best surroundings to conduct telehealth visits. You and the patient should be somewhere quiet and with good, even lighting so you can hear and see each other clearly. Other people should not be nearby you or, ideally, your patient, as this is a HIPAA breach as well as distracting, unless you're engaging with a caregiver who will support or assist your patient.
- Have a disaster or adverse event plan, including policies regarding emergency contact(s) on file, order of notification of emergent services, and next of kin.
- Be wary of sub-optimal telehealth platforms. Use due diligence in researching the vendors you're considering.
- Maintain a hybrid approach of telehealth and in-office visits when possible.
Policies and Procedures
Develop defined telehealth policies and procedures, which are the foundation of your telehealth program. Consider what conditions may not be appropriate to treat via telehealth (for example, patients with fractures, bleeding, acute psychological illness, and prior chronic history of falls). Some states and payers disallow the provision of telehealth services for patients with certain conditions, so consult your state practice act, state laws, and payer policies and include those exceptions in your policy. General guidelines for policies and procedures include the following:
Licensure. Establish the patient's state of residency before you begin treatment to ensure that your license makes you eligible to treat them.
Relationship. Be familiar with all applicable state laws, since some states require an established relationship or an in-person physical therapist evaluation before you can furnish telehealth.
Evaluation and treatment. Remember that the standard of care for practicing telehealth is the same as that of in-person physical therapist services.
Informed consent. Obtaining consent is much more than getting your patient's signature. It's part of a process that ensures your compliance with all rules and regulations and ethical responsibilities, and ensures that the patient is informed, understands, and is comfortable with treatment via telehealth.
- Ensure that your informed consent process or policy meets all state
practice act, state law, and payer policies. Informed consent
requirements specific to telehealth may include the following:
- Obtaining written versus oral consent.
- Obtaining consent for each visit versus one time at the beginning of treatment.
- Obtaining consent for specific treatments versus visits.
- Using a standardized form for the patient's consent.
- For pediatric patients, verify whether the caregiver, parent, or guardian is required to be present in accordance with state law, malpractice insurance, and/or payer policy. Also, make sure that you obtain informed consent from the parent or guardian.
- Obtain the address, demographics, and phone number of the patient.
- Obtain the names and contact information and of any prior local PT contact or other treating health care providers in case the need for a consult arises.
- Explain the technology you're using, and identify yourself and any others involved during the session, such as PTA or other provider, including their credentials.
- Explain that the patient can ask questions before, during, and after the telehealth session—and answer any that are raised.
- Make sure no one other than you and the patient can hear or see your telehealth session (other than a parent or guardian for a child), unless the patient has given consent for their presence.
- Explain that the session is not being recorded. If the patient wants to be recorded and the telehealth technology has that capacity, obtain written consent from the patient for recording and storing the session with encryption, satisfying all HIPAA requirements and state privacy law requirements.
- Explain any possible technical difficulties, including sound and video delay, and interruptions due to poor internet connection or tech breaches.
- Explain that the patient has the right to refuse the telehealth visit, be seen in the office, request to be seen in the office, and can discontinue the telehealth visit at any time.
- Explain that you, in your clinical judgment, may determine that you should see the patient in the office, for some or all subsequent visits.
- Document the start and stop time of the telehealth session.
- Document your location, the location of the patient, and the location of any others involved during the session, including a PTA and any other provider(s).
- Provide the patient with follow-up instructions and next steps of treatment.
The Center for Connected Health Policy provides a report on telehealth laws and policies (.pdf) and resources on informed consent.The Agency for Healthcare Research and Quality has also provided resources on informed consent, including a sample consent form.
In case of emergency. You should have policies and procedures for how you would handle emergencies when furnishing services via telehealth, including that you will obtain the contact information and address of your patient, and also the telephone number for your patient's emergency contact, be it a neighbor, caregiver, e-helper, family member, or durable power of attorney. Your policies and procedures should outline each staff person's role in the event of an emergency. Have your legal team review and approve your emergency policies and procedures. (Example: If your patient falls at home while you are working with them, what process do you have in place to address this emergency?) Any emergency should be documented in accordance with defensible documentation guidance. You also should have an emergency plan that can be implemented when the information obtained indicates the patient requires a referral for an in-person visit.
Medical records. Keep in mind the documentation needed to have a proper compliant telehealth program. The medical record for telehealth services should be consistent with standards required for documentation of in-person care. For more information, view APTA's Defensible Documentation resources.
Privacy and security of patient records and exchange of information: All applicable federal and state legal requirements for the privacy and security of medical records and health information should be met or exceeded.
Before adopting telehealth, you should adopt a concrete marketing plan. Remember to:
- Identify the types of conditions you may want to treat via telehealth, the conditions you would prefer to treat in person, and the conditions that may be delivered in combination.
- Identify in your marketing materials the conditions you treat via telehealth.
- Decide which media platform(s) you want to use to advertise (social media, new website or modification of existing website, local TV, local newspaper, fliers in clinic, common referral partners, etc.). Consider writing an editorial about your experience with telehealth, or work with a patient to write a testimonial, for your local newspaper. If you decide to advertise with common referral partners, make sure that you are comply with your state practice act, state law, ethical guidelines, and federal laws such as the Stark and the Anti-Kickback Statute. Consult legal counsel for any questions.
- Develop a budget for marketing, including return-on-investment projections. Determine whether you will market your services in house or hire an outside firm. If you plan to seek outside services, research the costs and solicit bids and scope of work from multiple firms. Ask the firms if they provide free consultations and quotes.
- Send emails out to your existing patients, telling them about the availability of your telehealth services. Where clinically appropriate, suggest telehealth to your patients during in-person visits. Use patient feedback to guide your efforts.
- When creating your marketing materials:
- Stress the clinical value and convenience of telehealth in easy-to-understand language.
- Map out the process for your patients, beginning from the initial consult through any follow-up and next steps for treatment.
- Address any common questions that patients have regarding telehealth.
- Provide information about the telehealth technology patients will need, depending on the types of services you plan to furnish — live audio and video, store-and-forward, other forms of remote care, etc. Consider linking to or providing information to access the telehealth vendor’s website.
- Provide hours you are available for telehealth visits.
- Provide your contact information and indicate that you are open to addressing any remaining concerns.
- Keep track of how effective your marketing material is in generating leads for business, such as by monitoring activity on your website. Redirect your marketing methods accordingly.
Telehealth Ethics, Best Practice, and the Law: What You Need to Know
As physical therapist practice expands to include telehealth, securing patients' protected health information (PHI) is more critical than ever before. (August 28, 2019)