key: cord-0901013-nnfw74h5 authors: Bettger, Janet Prvu; Resnik, Linda J title: Telerehabilitation in the Age of COVID-19: An Opportunity for Learning Health System Research date: 2020-08-19 journal: Phys Ther DOI: 10.1093/ptj/pzaa151 sha: 2b333d38fc5f45396bf68626e2c23ea2a5efe012 doc_id: 901013 cord_uid: nnfw74h5 nan The COVID-19 pandemic has impacted all aspects of health care delivery. To protect health care workers and patients across the country from the risk of disease transmission, rules, regulations and reimbursement policies were altered to enable widespread use of telecommunications technology in lieu of in-person clinical visits. 1 As a result, the delivery of rehabilitation in many settings was drastically and suddenly altered with physical therapists utilizing telehealth modalities in new ways and with new populations. 2 The shift to telerehabilitation provides a tremendous learning opportunity. This point of view provides an overview of how a learning health care system (LHS) approach to the study of telerehabilitation can promote innovation in optimal health care delivery and fuel new scientific discovery. Telehealth is a broad umbrella of modalities that includes nonclinical and clinical services. 3 Telerehabilitation refers specifically to clinical rehabilitation services with the focus of evaluation, diagnosis, and treatment. Telerehabilitation can be provided in a variety of ways, including 2-way real-time visits with audio, video, or both; asynchronous e-visits; virtual check-ins; remote evaluations of recorded videos or images; and telephone assessment and management services. The Department of Veterans Affairs was an early adopter of telerehabilitation, with use of remote services (including physical therapy) rapidly accelerating even prior to the pandemic. 4 Until precautions related to COVID-19 created a need for safer service delivery options, the uptake of telerehabilitation in other health systems and across the country was hampered by variation and restrictions in state regulations and reimbursement policies of Medicare and private insurers. 5 Recent changes in rules, regulation, and reimbursement now allow the use of telerehabilitation for physical therapy in some circumstances, providing unprecedented research opportunities to study the implementation and outcomes of telerehabilition. Several systematic reviews conclude that telerehabilitation is effective for patients with musculoskeletal conditions, multiple sclerosis, osteoarthritis, and recovery of motor function. 6 ,7-9 Some studies suggest that telerehabilitation can also reduce health care costs, improve treatment adherence, improve physical and mental function and quality of life, and be delivered in a manner that is satisfactory to patients. [10] [11] [12] Most of the telerehabilitation studies address outcomes of synchronous, real-time time rehabilitation, although there is some evidence that asynchronous telemedicine can also be effective for specific patient populations, such as those following total joint replacement. 13 More robust studies are needed to address questions about the feasibility, safety, and effectiveness of telerehabilitation modalities across subgroups of patient populations and settings, such as those who are frail or at risk of falling. Care delivery changes resulting from the COVID-19 pandemic offer key opportunities for LHS research. The LHS approach harnesses the power of data and analytics to learn what works best and to feed that knowledge back to patients, clinicians, other professionals, and stakeholders to create a continuous quality improvement cycle. 14 Thus, an LHS systematically integrates evidence established with internal data and realworld experience as part of usual care in order to provide high-quality, safer, more 15 The iterative learning that is inherent in an LHS can help us quickly understand when, how, and if it is appropriate to use the different forms of technology for delivery of physical therapy. Research in an LHS is situated within the context and infrastructure of health care delivery, which varies by service, setting and population served. LHS research embraces stakeholder involvement and innovative study designs and leverages real-world care delivery processes. 16 Designing and conducting research as part of clinical practice not only will accelerate the acquisition of evidence on telerehabilitation with easier-to-translate findings but will assist in identifying best practices for rehabilitation that are more likely to be adopted and scaled up both during and after the pandemic subsides. Recommendations from the Learning Health Systems Task Force of AcademyHealth, tailored for telerehabilitation, provide a set of research priorities in response to the pandemic. 17 The task force called for rapid-cycle research that supports learning within health systems, uses rigorous methods, and is responsive to and driven by the questions of health system leaders and key stakeholders. Rapid-cycle research typically is done in a brief period and includes multiple cycles of small changes to address a problem. 18 Six priority domains for rapid-cycle evaluations in LHS were identified: care delivery, coordination, information and technology, patients and communities, workforce, and policy. 17 With the shift to telerehabilitation, there are benefits to research focusing on each of these domains as they pertain to telerehabilitation independently as well as to studying the intersection among domains. In Figure 1 The effect of using telerehabilitation for treatment is likely to vary by patient condition and severity. Inherent in observational research is the likelihood of a significant amount of unmeasured confounding and potentially missing data due to the challenges of care delivery during COVID-19. It will be important that these types of studies examine common patient conditions and utilize appropriate analytic methods to control for severity, comorbidities, and other patient characteristics affecting care. Such methods include risk adjustment techniques (eg, use of propensity scores and control for potential confounders in models), controls for selection bias (eg, use of inverse probability of treatment weighting and instrumental variables), imputation for missing data, and other approaches common to health services research. 19, 20 Early research with sufficiently powered samples will begin to identify subgroups of patients that might or might not benefit from specific types of telerehabilitation modalities. These data will be essential for decision making about sustaining telerehabilitation services. With sufficient planning to consider equipoise in care delivery, available capacity for research in practice during or after the pandemic, and appropriate methodological expertise, more rigorous study designs including pragmatic trials and hybrid implementationeffectiveness studies should be considered. Ultimately, if telerehabilitation interventions can yield outcomes equivalent to those of usual care and are equally or more costeffective, there would be strong evidence in support of sustaining telerehabilitation as a care delivery option after the pandemic subsides. The new normal for rehabilitation services after COVID-19 is likely to include some amount of telerehabilitation in different forms in different health systems. The continuous learning within an LHS is as important to the local system as it is to the external community of practice and science. 21 COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers Impact of COVID-19 on the Physical Therapy Profession: A Report From the American Physical Therapy Association What is Telehealth? Trends in VA telerehabilitation patients and encounters over time and by rurality State occupational and physical therapy telehealth laws and regulations: a 50-state survey Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: a systematic review and meta-analysis Telerehabilitation and recovery of motor function: a systematic review and meta-analysis Use of videoconferencing for physical therapy in people with musculoskeletal conditions: a systematic review Telemedicine and multiple sclerosis: a comprehensive literature teview The effects of in-home rehabilitation on task self-efficacy in mobility-impaired adults: a randomized clinical trial Effects of virtual exercise rehabilitation inhome therapy compared with traditional care after total knee arthroplasty: VERITAS, a randomized controlled trial In home telerehabilitation for older adults after discharge from an acute hospital or rehabilitation unit: a proof-of-concept study and costs estimation Clinical outcomes of remote asynchronous telerehabilitation are equivalent to traditional therapy following total knee arthroplasty: a randomized control study Learning Health Systems: Workshop Summary About Learning Health Systems Rapid, responsive, relevant (R3) research: a call for a rapid learning health research enterprise Health Systems Respond to COVID-19: Priorities for Rapid-Cycle Evaluations Using Rapid-Cycle Research to Reach Goals: Awareness, Assessment, Adaptation, Acceleration Analytical methods for a learning health system: 3. Analysis of observational studies Review of inverse probability weighting for dealing with missing data Implementing the learning health system: from concept to action