Telerehabilitation Guide

The physiotherapist:

• Complies with applicable regulatory requirements, including registration, insurance requirements, and competence. When providing telerehabilitation across borders, the physiotherapist must comply with the requirements of both the patient’s jurisdiction and the physiotherapist’s jurisdiction.
• Complies with expectations defined in the Standards of Practice and Code of Ethical Conduct. Interventions, referrals, or consultations delivered using telerehabilitation technologies are held to the same standards and expectations as those delivered in person.
• Uses their professional judgment to determine if telerehabilitation is appropriate, taking into consideration:
  • Whether telerehabilitation is the most appropriate available method to deliver services.
  • Whether a direct physical examination is required to complete the assessment and determine a physiotherapy diagnosis and treatment plan.
  • The ability to deliver substantively similar care as physiotherapy delivered face-to-face.
  • If patient factors such as physical, sensory, or cognitive deficits may impact the ability to deliver appropriate care via telerehabilitation.⁴
• Ensures that telerehabilitation does not expose the patient to greater risk than other possible service delivery methods. This can include risks to the privacy of the patient’s health information or patient safety depending on the physical environment and context in which services are provided.
• Informs the patient of the process to follow if they have a concern or complaint about their physiotherapy care, including their ability to lodge a complaint in either or both jurisdictions if they choose (when services are provided across jurisdictional borders).

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.

Informed Consent Expectations

The physiotherapist:

• Augments routine informed consent processes as required to support telerehabilitation delivery. This may include express consent:
  • To receive services via telerehabilitation rather than in person.
  • For videotaping, recording or otherwise storing information and data from the telerehabilitation session.
  • For the transmission of information via telerehabilitation technologies.
  • For the participation of other health-care providers or the patient’s family in the provision of care.
• Develops policies and procedures to:
  • Verify their identity to patients.
  • Verify the identity of the patients whom they serve (to the extent possible).
  • Document the verification policy and processes used.
• Develops policies and procedures to verify the identity of any third parties who may be observers or engaged in the delivery of care (i.e., family members, other regulated or unregulated health professionals, physiotherapy support staff) and obtains patient and provider consent for the presence of these individuals while delivering services.
• Informs patients of any limitations that telerehabilitation services impose on physiotherapy treatment, such as the inability to apply hands-on evaluation and treatment if applicable.
• Informs patients of the risks inherent in delivery of services using telerehabilitation, including risks to privacy of patient information and safeguards employed to address these risks.
• Considers the relevance and appropriateness of including a “hold harmless” clause for information lost due to technology failure³ in patient agreements, privacy statements, and consent documentation.

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.

Privacy Expectations

The physiotherapist:

• Complies with all privacy and security requirements both during telerehabilitation sessions and when in contact with the patient through other electronic means, such as arranging appointments via email.
• Documents privacy and security measures used to protect the patient’s private information.
• Employs authentication and encryption technologies as well as secure transmission systems and storage mechanisms.
• Develops policies and practices to ensure that patient records cannot be accessed by unauthorized users, tampered with or destroyed, and are protected at both the originating and remote sites.
• Secures all physical devices used in telerehabilitation and when storing information related to telerehabilitation services.
• Is aware of any employer policies for privacy and security related to telerehabilitation.
• Maintains awareness of current and emerging risks to patient privacy inherent to telerehabilitation practice and employs technical, administrative, and physical controls to address these risks.

“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:

• Failure of the communication technologies used to provide services.
• Patient medical emergencies (e.g., falls, injuries, heart attack, stroke).
• Other emergencies (e.g., fire).

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.

Safety Expectations

The physiotherapist:

• Obtains access to appropriate technical support for trouble shooting in the event of technical difficulties.
• Tests all technologies prior to patient appointments to ensure the system is functioning well.
• Has an alternative method of contacting the patient and provides the patient with an alternate way of contacting the physiotherapist. For example, in the case of an internet failure you must be able to telephone the patient.
• Has a safety protocol in place in the event of an emergency or adverse event, including:
  • Contact information for local first responders, using designated phone numbers rather than 911.
  • Contact information for others within the patient’s environment (care providers, family members), and patient consent to contact these individuals in the event of an emergency or adverse event.
  • Plans and procedures to follow to manage adverse events while waiting for assistance to arrive.
  • Plans and procedures for managing adverse events that do not require assistance from a first responder.
• Should also be aware of other service providers in the patient’s area that they may refer the patient to in the event of a patient adverse event or complication.
• Facilitates the transfer of care to another treatment provider if the physiotherapist or patient determines that telerehabilitation is not appropriate.

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.

Competence Expectations

The physiotherapist:

• Ensures their competence to use the technology.
  • Understands the system’s capabilities and limitations.
  • Has technology supports available if needed.
  • Evaluates and develops individual eHealth competencies to support the use of these technologies.
• Develops skills related to the delivery of services using telerehabilitation technologies.
  • Assessment and outcome measurement(s).
  • Development of rapport and therapeutic relationship.
  • Provision of interventions using a third party or delivered by the patient at the direction of 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.

Documentation Expectations

The physiotherapist:

• Complies with the documentation standards of both jurisdictions when telerehabilitation is delivered across borders.
  • If the clinical or financial record retention periods differ between jurisdictions, the physiotherapist must retain the record for the longer period of time required.
• Retains accountability for evaluating any information gathered from a third-party source (such as a non-physiotherapist health provider physically co-located with the patient), to determine its reliability and accuracy and the ability to incorporate the information into the assessment or treatment.
• Maintains written records summarizing all interventions consistent with the Standards of Practice.
• Retains any video or audio recordings generated as part of telerehabilitation interventions as part of the patient record.

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:

• Patient outcomes (effectiveness of treatment interventions).
• Patient satisfaction.
• Cost-effectiveness of services, including:
  • Business costs compared with other service models.
  • Patient/payer costs.

Physiotherapists are required to provide fee schedules and invoices/receipts that are transparent, accurate, and comprehensive. When delivering services using telerehabilitation, the physiotherapist:

• Ensures that the patient is aware of what services they can be expect in return for fees charged.
• Provides receipts that clearly reflect that physiotherapy services were delivered via telerehabilitation.

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.

What system are you using and how does it work?

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.

• Is it an online portal or a software system that the physiotherapist owns?
• Does the service provider or software company retain records of the patient encounter?
• What type of information are they collecting?
• Who has access to the information, for what purposes, and under what circumstances?
• How is that information protected?

Where’s the data stored?

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.

Does the third-party telerehabilitation system provider comply with relevant legislation?

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.

Does the contractual agreement with the third-party telerehabilitation system provider enable the physiotherapist to comply with relevant regulatory rules and expectations?

The physiotherapist should evaluate any third-party agreement, asking “what do the standards require and what does the agreement say about:”

• Retention of information.
• Ongoing access to patient records:
  • For the length of the retention period.
  • Regardless of whether the physiotherapy business ceases to operate.
  • Regardless of whether the contractual agreement between the physiotherapist and the service provider is discontinued.
• Who else will have access to patient private information? What information? Under what circumstances?
• How is data protected on an ongoing basis by the third-party? What physical, technical, and administrative security measures does the third-party employ?

How do you notify patients about access to their health information?

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.

1. Sutherland, Greg. The Market Profile of Physiotherapists in Canada. Ottawa: The Conference Board of Canada, 2017.
2. Medical Board of Australia. Guidelines: Technology-based patient consultations. 2012. Available at: http://www.medicalboard.gov.au/Codes-Guidelines-Policies/Technology-based-consultation-guidelines.aspx. Accessed on January 31, 2018.
3. Federation of State Boards of Physical Therapy. Telehealth in Physical Therapy: Policy recommendations for appropriate regulation. Available at: https://www.fsbpt.org/Portals/0/documents/free-resources/TelehealthInPhysicalTherapy2015.pdf. Accessed January 31, 2018.
4. Billings & Russell. Federation Forum: Telehealth: Research update and novel applications to meet the Triple AIM.
5. Core Standards of Practice for Physiotherapists in Canada. 2016. Available at: http://www.alliancept.org/wp-content/uploads/2018/01/Core-Standards-of-Practice-Final-May-2016.pdf. Accessed January 31, 2018.
6. Russell T. Physical rehabilitation using telemedicine. Journal of Telemedicine and Telecare 2007; 13: 217-220
7. Australian Physiotherapy Association. Background Paper: Telerehabilitation. Available at: http://www.physiotherapy.asn.au/DocumentsFolder/Advocacy_Background_Papers_Telerehabilitation.pdf. Accessed January 31, 2018.
8. Canadian Alliance of Physiotherapy Regulators. Memorandum of Understanding: Cross Border Physiotherapy. Available at: http://www.alliancept.org/wp-content/uploads/2016/03/MEMORANDUM-OF-UNDERSTANDING-Cross-Border-Signed-x-10-May-16-2017-EN.pdf. Accessed January 31, 2018.