DPT Alum Says Telehealth is Here to Stay Because of COVID-19
By Karen Morgan, DPT ’09
Rumors of telehealth options for the practice of physical therapy have rumbled about in recent years, and I barely paid attention. Being busy with my solo practice, I didn’t take the time to pursue it in-depth, and the obstacles to telehealth seemed significant and daunting. While my state practice act included telehealth as an option (kudos to Washingtonian physical therapy leadership for being visionary), Medicare and most insurance companies didn’t recognize physical therapy as telehealth viable. Additionally, the word telehealth, even to this day, had varying definitions and names, which created confusion for payers, practitioners and patients alike. Is it telehealth? Telemedicine? Telerehabilitation? Really, people? Get it together before I invest my time in you.
Still, I was intrigued. Really? Physical therapy? Doesn’t the word “physical” imply a hands on approach? True, and yet, if I’ve learned anything practicing physical therapy (PT) over my thirty-year career in both California and Washington states, it is I expect significant change in the industry, and healthcare in general, every three to five years. I’ve observed those who resisted the changing environment and went about practicing their old “tried and true ways” without incorporating a healthy shifting of practice and embracing of technology. They succumbed to a slow, certain and significant decline of their businesses. They may have survived, but their gasping for air was hardly inspiring.
Much of this modification of environment was due to the ever changing regulations handed down by the Centers for Medicare and Medicaid Services (CMS) to health care providers in all settings, which persists to the present. These regulations profoundly impacted reimbursements to businesses, be they hospital, skilled nursing facilities, rehabilitation and outpatient settings. And that impacted healthcare practitioners’ income. CMS is the government entity which has been given power to govern all healthcare policy. Because CMS did not recognize PT as a viable option for telehealth, many other insurance companies, per usual, followed suit. However, I was noting in the past five years, there were physical therapists around the country who nonetheless, were going forward with telehealth on a private basis, and doing well with it, it seemed. I was definitely intrigued.
My Intro to Telehealth
We all have informally sought out telehealth, or as health professionals, we’ve extended it. We as physical therapists in particular, have at some point been asked to diagnose and treat a loved one remotely rather than in person, and we did pretty well. Or perhaps, when in a pinch, as patients, we have sought out help on the internet, chatting with someone online, knowing we’d eventually follow up with a real time, in-person consultation with our provider. But did we consider the online consultation to be “real” healthcare? Did we consider it as something that would take the place of an “actual” visit?
I began practicing telehealth not long after I graduated in 1990. Specifically, I recall receiving a phone call when I was living in southern California. It was my dad, asking for my “expertise.” My parents weren’t exactly sure what physical therapy was when I was in school, but once I graduated and they retired, Dad and Mom soon learned.
My folks moved from Newport Beach, CA to the mountains of Prescott, AZ following the retirement of his otolaryngology practice. They were situated on one acre of scrub oak and pine trees, in the outskirts of the Prescott National Forest and they dove head first into caring for their property. It was like going from zero to sixty in terms of exercise for them. Their active retirement life pushed me to expand my knowledge and skill set to help them negotiate their newly acquired aches and pains. “You’re just getting older” was never an acceptable answer to them. I admired their refusal to accept the current thinking that aging meant they were going to be slower, weaker, and stiffer. They believed they could be “better, stronger, faster,” and challenged me to help them optimize their health as they sought to serve their community in volunteerism even while they enjoyed the natural beauty of the surrounding area. To me, this is the beauty of physical therapy.
Dad began the conversation in his usual manner. Clearing his throat loudly, due to his incessant post-nasal drip, he used his lowest baritone to both jest and request, “Your Pater needs your expertise.” He loved to throw around Latin words at me, challenging my distant memory of my three years of high school Latin.
I chuckled, and wondered what new project he had taken on. “Yeah? What’s up? What did you do?” and kept the phrase “this time” shushed inside my head.
There was silence on the other end.
“K. Dad. What did ya do?” I repeated.
“Well, I decided to clean up the pine cones from the front yard a week or so ago. My shoulder still hurts.”
I nodded. “Yeah? Is it keeping you up at night?”
I proceeded with my diagnostic questions, as if he were sitting in front of me. “I need to know what motions were involved when you did this?”
“I chucked the pine cones over the roof, from the front yard to the backyard.”
I sunk back into the sofa, closing my eyes. I knew where we were going. “Umm, how many did you ‘chuck,’ Dad?”
“Oh, I’d say probably 50-100. Maybe 150.”
I smiled, envisioning Dad aiming and pitching pine cones over the roof, maybe 200 times. He tended to understate things. I chuckled and shook my head. “It was fun, I bet.”
“Oh yeah! It was tremendous! I figured I’d be sore for a few days, but it’s not getting any better. I figured this would be right up your alley. What do you think it is?” He was clearly proud to give me a problem to solve.
With very specific instructions, I had him go through various motions, with and without resistance. I determined he had developed a moderate strain of his supraspinatus tendon in his rotator cuff. I prescribed an explicit exercise program including specific instructions on when and how to use hot and cold modalities. We checked in every week or so on the phone to progress his program, and by six weeks, he was back to normal. Given the severity of his initial symptoms and his inability to successfully treat himself (and being the independent person he was, he sure tried), this impressed him with physical therapy and what it could offer to any age group, in-person or not.
Things Are A-Changing
Today, COVID-19 has changed our healthcare approach with radical swiftness and exceptional force. For the majority, in-person healthcare is a risky option. We are being thrust into telehealth as either consumers or providers. How can we optimize our experience?
It’s been a bumpy ride for me. In the past weeks, I have spent untold hours contacting insurance providers to learn what procedural (CPT) codes they required for documentation and billing purposes. I figured I could code with the usual codes, and just add a modifier indicating how it was delivered (synchronous with video or audio). Nope. Each insurance company required a different coding system and none of them were certain of which modifier to use. It was chaotic, ridiculous and nearly impossible to keep track of by my billing people. The insurance personnel obviously were also working “in the dark” regarding this. I couldn’t fault them. They were unprepared for this unprecedented time. They literally told me, “Do your best; we’ll probably be reimbursing you. Just hang in there.” We were all being drop-kicked together into the future.
I sucked in my breath, hearing that, and realizing what this could mean. And after a long week of speaking with insurance providers and treating patients via telehealth, which by the way, requires a great deal more energy than in person, I wondered at our health system and how under-prepared we all were. To be fair, none of us saw this coming.
So how was it my first week of delivering telehealth physical therapy? It was fun and it was exhausting. Each of my patients told me it was a very positive experience, helpful and they were appreciative that they could obtain their PT while Sheltering at Home. They were thrilled to be able to continue their progress in healing and not have their functional mobility stalled or sidelined. Think of it: our functional mobility enables us to tackle our challenges and participate fully in life. Optimal mobility is a precious commodity, especially now.
For An Optimal Experience
As a provider, especially a physical therapist, be prepared to be precise and explicit in your questions and treatment directions. We are fortunate to have so much technology at our fingertips. Unlike my phone call with my dad, each of us can have a virtual visit with our patients. Nevertheless, explicit instructions are more critical than ever, because your audience may not see all of your body language, which speaks volumes. Be ready to demonstrate what you are prescribing, along with having your visual props or visual aids. Direct your patients to helpful web links. If you are a PT, use digital exercise programs for teaching.
You’ll also need a HIPAA compliant conferencing platform, although right now in the current crisis, that requirement is temporarily waived. There are free platforms for your basic needs and then it goes up from there. Your options vary from live video on PCs, tablets and mobile devices to previously recorded videos to be sent to your patient. I’ve enjoyed using Doxy.me video conferencing, and appreciate the waiting room it provides for my patients.
Obviously, don’t neglect your professional appearance as well as your “virtual office” background. How you present yourself affects your message.
Physical therapy as teletherapy? Really? Absolutely! Here is what can be addressed:
2. Assessment and referrals to improve care coordination.
3. Interventions through observation of patient movement and function to facilitate proper exercise technique.
4. Verbal and visual instructions / cues to help the patient perform various activities.
5. Modification of the patient environment to minimize injury and facilitate functional outcomes.
6. Quick check-ins with established patients, when a comprehensive in-person visit may or may not be appropriate or possible.
Now, as a patient, there are a few things you can do to optimize your experience. A computer or tablet screen will be easier to work with your care provider as it is larger than a phone screen. However a phone can be easier to maneuver while demonstrating your movement or where it is you are feeling your troublesome symptom(s). Be prepared to also be explicit in your symptoms. Grade the severity, provide descriptors such as “It feels like…” or word pictures, rather than just “it hurts,” or “I’m so tired.” Make room for movement so that you have space to adequately demonstrate your symptoms or to be able to participate in the instructions. As an example, I had a patient who was very confined by the futon sofa, his bed and desk in his room, making it difficult to teach him how to properly perform monster steps to activate and strengthen his posterior lateral hip muscles.
Not too long ago, a patient called me in desperation from her bed. “Hey doc! I am in so much pain I can’t get out of bed! Over the years I have treated her for her neck, shoulder, back, hip and foot pain and dysfunction. I was also acquainted with her lifestyle and health habits. When life was full and filled with stress, she’d neglect caring for herself and the instructions I’d given her would “fly out the window.” Here we were again in familiar territory. Walking her through some diagnostics, I got a clear picture of what motor programs were deactivated, along with her mental/emotional resting place of anxiety, all of which resulted in her pain complex. I gave her calm, simple, specific muscle activation instructions on breathing, and how to get out of bed and into sitting, and then into standing.
“Let me know when you get there,” and I waited. I heard breaths, body motions and then silence, a gasp, and then more silence.
“Are you all right?”
“For the first time in nearly 48 hours, I can stand up with minimal pain. I’m just thoroughly shocked into amazement!” she exclaimed.
“All right. We’re not out of the woods yet. You still have to be able to maintain stance and be able to walk.” And I proceeded to instruct her on what to do with her core and hips, with breath control, and where to feel the weight and pressure in her feet.
Again, more silence.
“Doris?”(not patient’s real name)
She was fine, and she was very, very happy.
For telehealth to be successful, know your patient and their history; and patients, be forthright regarding your history. The more pieces to the puzzle are shared, the better telehealth works, just like in-person. In my own practice, I have my patients fill out a comprehensive online digital intake days before their initial appointments. This provides me with important information and the time to begin analyzing and problem-solving prior to their evaluation.
Telehealth was adequate prior to the 21st century, but now, with the technology we have at our fingertips, we can create and experience thorough, thoughtful, effective care. As healthcare consumers, we can be assured that we will be able to manage our well-being and not let it go by the wayside because we can’t leave our homes. And as physical therapists, we can use telehealth to optimize our patients’ functional mobility so they can rise to the demands and challenges of the uncertain days, weeks and months ahead. Now, will the government and insurance companies move ahead with us when the dust settles from COVID-19?
Karen Morgan, who graduated from the MGH Institute in 2009 with a Doctor of Physical Therapy, owns Karen Morgan Physical Therapy in Bellingham, WA. This essay originally was published in Medium, in which Dr. Morgan regularly writes.
Read more about efforts by the IHP community during this crisis in the "Business as Unusual" series. If you have a story about how you or other people in the IHP community are reacting to the pandemic, please email John Shaw.