The remote delivery of physiotherapy services using electronic communication technologies is becoming increasingly prevalent. The use of these technologies enables increased access to physiotherapy services for individuals living in rural and remote areas. It also enables access to providers with unique skills for all physiotherapy patients, regardless of where the patient or provider are physically located. The proportion of physiotherapists living in urban areas is greater than the proportion of the general population living in urban settings,1 and there are challenges in recruiting physiotherapists and other health professionals to work in rural and remote areas. The use of telerehabilitation provides an innovative means to match providers to patients and address this disparity.
Broadly speaking, telerehabilitation refers to rehabilitation services that use any form of technology (including but not restricted to video conferencing, internet and telephone) as an alternative to face-to-face interventions.2 This use of electronically-mediated communication to deliver health services can occur over large or small distances3 or across jurisdictional borders.2,3
When providers engage in the provision of telerehabilitation services, they are expected to be aware of and comply with all regulatory expectations and legislation that applies to their practice and to deliver physiotherapy services that meet the same expectations for quality, competent care as services delivered in person.
This resource is intended to assist physiotherapists to understand these expectations and develop policies and procedures to support quality, effective physiotherapy care using technology. This document should be read in conjunction with the Standards of Practice relevant to the physiotherapist’s practice. Physiotherapists who wish to deliver physiotherapy services across jurisdictional borders must be aware of all regulatory requirements related to the delivery of cross-border physiotherapy services, such as those established by the Canadian Alliance of Physiotherapy Regulators.
Click here to download the Telerehabilitation Resource Guide as a PDF.
Click here to download the Telerehabilitation in Physiotherapy Patient Information PDF.
The physiotherapist:
As with all physiotherapy services, for consent to be valid it must first be informed. In addition to the general requirements for consent outlined in the Standards of Practice and related documents, with regards to telerehabilitation the patient must have a clear understanding of the “limitations that telehealth services present as compared to in-person treatment”4 and “specific differences between in-house care and telehealth.”4 Patients must be aware of available treatment options, including options to receive in-person care and the unique risks and benefits that telerehabilitation provides.
The physiotherapist:
Physiotherapists are expected to practice in compliance with all legislative and regulatory requirements relevant to their practice; the practice of physiotherapy using telerehabilitation technologies is no exception. Physiotherapists need to be aware of and comply with the privacy legislation that is relevant to their practice. They also must be aware that when providing services to patients located in a different province or territory, the privacy legislation of both jurisdictions applies. In addition, the Personal Information Protection and Electronic Documents Act (PIPEDA) applies when transmitting information across provincial or territorial borders.
The physiotherapist:
“Clients (patients) can expect to be safe in the care of the physiotherapist and in the practice environment.”5 That over-arching expectation seems obvious, however, the question of how to achieve this in a telerehabilitation practice is less so. The first step is to consider the various safety issues that are possible within this type of practice, which may include:
All physiotherapists are responsible to consider the potential critical events that they may be faced with in their practice and to develop plans to manage such events.
At no time should physiotherapists compromise the quality and safety of physiotherapy services by delivering telerehabilitation services that are inappropriate or unsafe.
The physiotherapist:
The use of Critical Event Management Plans can help physiotherapists to consider adverse events that they may potentially encounter within their practice environment and to identify the procedures, equipment, personnel, and other resources required to manage these events.
The use of telerehabilitation in physiotherapy is an emerging practice. As with any other emerging practice, physiotherapists must consider if they have the knowledge, skills, and abilities to safely and effectively engage in the practice. They should also actively seek out further education to ensure they are using these technologies appropriately and effectively and to further develop their knowledge and skills.
The physiotherapist:
Services delivered via telerehabilitation are subject to the same Standards of Practice as in-person physiotherapy services; however, several additional documentation and recordkeeping considerations must be addressed.
The physiotherapist:
The Standards of Practice require that physiotherapists engage in continuous quality improvement by developing, implementing, and evaluating new or revised physiotherapy services. The provision of care using telerehabilitation technologies is no exception. As part of ongoing competence and service development, physiotherapists should continually track:
Physiotherapists are required to provide fee schedules and invoices/receipts that are transparent, accurate, and comprehensive. When delivering services using telerehabilitation, the physiotherapist:
Unregulated health providers may be actively involved in the delivery of telerehabilitation services. In some cases, they may be physically present and co-located with the patient while the physiotherapist is located remote to the patient and deliver interventions at the direction of the physiotherapist. In other cases, the unregulated health provider may be applying telerehabilitation technology to deliver physiotherapy services remotely, under indirect supervision of the physiotherapist.
In either case, the physiotherapist retains accountability for the assignment of services and for providing appropriate supervision to ensure the patient receives quality, effective physiotherapy care. For more information, review the Standard of Practice and additional guidelines and documents related to supervision.
In Person services are those physiotherapy services provided by a physiotherapist in direct face-to-face contact with a person.
Patient’s Jurisdiction is the province or territory in which the patient is located.
Physiotherapist’s Jurisdiction is the province or territory in which the physiotherapist is located.
Telehealth is an umbrella term denoting all health care services, whether clinical or educational, which are delivered via telecommunications means.
Telerehabilitation is the term agreed upon by each of the regulators of physiotherapy in Canada and is used throughout this document to denote delivery of professional physiotherapy services at a distance, using telecommunications technology as the service delivery medium.6 It is a subgroup of telehealth. Telerehabilitation relates to the services delivered by a number of health disciplines including physiotherapy and features all aspects of patient care including the patient interview, physical assessment and diagnosis, treatment, maintenance activities, consultation, education, and training.7 It can include mediums such as videoconferencing, email, apps, web-based communication, and wearable technology. Personnel may or may not be present with the patient.8
Conceptually, telerehabilitation is an alternate mode of service delivery of traditional rehabilitation services and should not be thought of as a new rehabilitation service in its own right. As such, the practice of telerehabilitation does not remove or alter any existing responsibilities for the provider of the rehabilitation service and providers must adhere to existing ethical codes of conduct, scope of practice, state and federal laws and individual discipline policies guiding practice.
Telephysiotherapy and telepractice are synonyms of telerehabilitation, used by some individuals and organizations.
Physiotherapists are not required to become computer scientists to deliver telerehabilitation services, but they do need to have a basic understanding of how the system they are using works.
If a third-party service provider is retaining records of the patient encounter such as audio or video files, the physiotherapist must know where that data is stored. The physiotherapist must also disclose to the patient where their data is stored. The physiotherapist may wish to include a statement in their business privacy statement or similar document (similar to the one below) providing this information and directing the patient to the appropriate staff member if they have questions.
Information Stored Outside of Canada
We contract with companies outside of Canada to provide services on our behalf, such as with companies located in [list country/countries] who provide [list services]. These companies and their affiliates may store personal information outside of Canada. For further information regarding storage of personal information outside of Canada or regarding the XYZ Physiotherapy Clinic policies and practices regarding storage of information outside of Canada, please contact our privacy officer, whose contact information is listed at the end of this Privacy Statement.
Physiotherapists are responsible to practice in compliance with all legislation relevant to their practice. In the case of services provided across jurisdictional borders, the physiotherapist must be aware of and comply with the legislation in both jurisdictions. The physiotherapist retains this responsibility when they contract with third-party service providers. When selecting systems, including telerehabilitation platforms or portals, the physiotherapist must take the necessary steps to evaluate the system and confirm that both the system and their contractual agreements with the third-party will enable them to meet their legislated responsibilities.
The physiotherapist should evaluate any third-party agreement, asking “what do the standards require and what does the agreement say about:”
Physiotherapists are required to retain records in a manner that enables the complete or partial record to be retrieved and copied upon request, regardless of the media used to create the record. If video or audio files are created as part of the telerehabilitation session they comprise part of the treatment record and must be retained.
A key purpose of these requirements is that the patient will have ongoing access to their personal health information. To achieve this goal, the physiotherapist must provide a means by which the patient can contact the physiotherapist to obtain a copy of the record. Physiotherapists must develop a mechanism whereby the patient can contact them after treatment has been completed and communicate this to the patient.