key: cord-1001483-9rohvqp8 authors: Lee, Alan title: COVID-19 and the Advancement of Digital Physical Therapist Practice and Telehealth date: 2020-04-28 journal: Phys Ther DOI: 10.1093/ptj/pzaa079 sha: 1721f0d93463dc9b55b357cb4bef9f85b93e38a4 doc_id: 1001483 cord_uid: 9rohvqp8 nan During the COVID-19 pandemic, each day challenges us with sobering realities in economy, health care, and politics in our society. 1 The global pandemic has thrust the physical therapy profession and our society into digital physical therapist practice and telehealth. In light of the uncertainty with COVID-19, physical therapists are required to socially distance themselves at least 6 feet apart in health care institutions, and patients and clients cannot access necessary physical therapy services in the community due to shelter-in-place and stay-at-home restrictions. Furthermore, this unique situation magnifies the challenges and opportunities in digital practice, as practitioners may lack the necessary telehealth competencies identified in the literature. 2, 3 Therefore, it is especially important for physical therapy practitioners to consider key recommendations for safe and effective digital practice delivery. The purpose of this Point of View is to identify recommendations on digital physical therapist practice and offer future directions in advancing digital practice and telehealth in the physical therapy profession in the wake of COVID-19. A joint digital physical therapy practice task force of the World Confederation for Finally, the task force agreed on service user as the term for actual or potential recipient of physical therapy services and defined in-person care as a situation in which both the provider and service user are in the same location at the same time. The task force described the advantages, limitations, current evidence, regulatory issues, academic implications, and recommendations for future opportunities in digital physical therapist practice prior to COVID-19. 4 The advantages of digital practice were differentiated for service user, provider, and society. The common benefit for all stakeholders includes improved access to telehealth physical therapy services by building a strong relationship between service user and provider in order to deliver highquality and safe physical therapist practice via telehealth. COVID-19 presents digital practice opportunities for improved access, high quality, and safety in physical therapy services for both service user and provider when deemed medically necessary. In fact, both telehealth and e-visits have been approved by the Center for Medicare and Medicaid Services (CMS) in the United States during the COVID-19 crisis on a temporarily basis. 6 CMS noted that telehealth services provided by interactive audio and video telecommunications systems permit real-time communication between end-to-end users, whereas e-visits are non-face-to-face, patient-initiated digital communications requiring a clinical decision that otherwise typically would have been provided in the office. 6 However, specific federal and state payer guidelines, regulatory hurdles, and patient privacy barriers persist, requiring permanent fixes from CMS on telehealth and e-visits. 7 For example, health care providers on the front lines of COVID-19 have identified that some older adults prefer telephone use to digital telecommunication interactions because of a lack of technology understanding and training. 7 In order to address this immediate crisis and patient preferences, Keesara and colleagues 8 recommend expansion of telehealth broadly to include digital tools-beyond interactive audio and video-that offer 256-bit end-to-end encryption, including telephone services. Other limitations include inadequate technology training, limited knowledge translation, and regulatory barriers that can stifle innovation and impede progress for service users and providers. 6 Dialogue among physical therapy practitioners, telemedicine providers, and payers can result in timely collaborative practice based on current evidence and societal needs in health care. 4 With shelter-in-place and stay-at-home restrictions, digital practice is supported as the way forward, with many countries worldwide formally recognizing the benefits and value of using digital modes of care delivery. The body of evidence in relation to telerehabilitation 5 is limited, however. Telerehabilitation tends to require more provider time for consultations, and it is unclear whether telerehabilitation improves access to beneficial services. 9 With paucity of definitive evidence in the wake of COVID-19, the joint task force believed it is not possible to recommend conditionspecific digital practice standards. Hence, guiding principles should be reviewed by the physical therapy profession until such evidence is available. 4 The task force developed each principle based on current practice, research, and regulatory considerations that may evolve over time (Figure) . In summary, the guiding principles require strong provider-patient relationship, valid and reliable evidence, and the conduct of research to show whether telerehabilitation has greater benefit than potential risks for digital physical therapist practice. 4 Recently, WCPT identified resources including a tool kit for digital practice implementation, 10 and WCPT recommendations have been translated in Spanish 11 for proper guidance in various member countries. In addition, the Federation of State Boards of Physical Therapy (FSBPT) provided jurisdiction telehealth laws and guidance for physical therapy providers in the United States. 12 Due to COVID-19, some of the regulatory issues have been waived at federal and state levels-including licensure, copays, and deductibles and expanded digital services with remote patient monitoring in the United States. 8 Because regulatory requirements are dependent upon factors in the legislative framework that exist globally, the best guidance is for providers to be informed of the legal framework that exists in each of their own jurisdictions and to be aware that, in some countries, providers have to take into account the jurisdiction of the service user's country. 4 The task force identified global regulations in the digital landscape for Australia, Canada, the United Kingdom, and the United States prior to COVID-19. Moving forward, potential regulatory changes must be identified for individual countries in real time. 4 Therefore, practitioners should develop guidelines for selecting the ideal technology for the potential service user, risk management strategies, and competency training for digital physical therapist practice in emergent and nonemergent situations. Prior to COVID-19, the implications of digital physical therapist practice for physical therapist education were investigated. Although digital practice competency might prepare future providers for demands in primary care and might improve access to care in high-demand areas, the task force identified a lack of national digital practice Answers to these questions must be addressed now in order to advance in digital physical therapist practice and telehealth. Overall, the task force recognizes that the role of physical therapists must be advanced by informed practitioners in collaboration with physical therapy professional and international associations, accredited academic and research institutions, and patient advocacy groups. The time is now for the physical therapy profession to learn from the past and define its societal identity at large, 17 because those who cannot remember the past are condemned to repeat it-even in the digital age. 16 Covid-19-Navigating the uncharted Competencies required for nursing telehealth activities: a Delphi-study It's not just FaceTime: core competencies for the Medical Virtualist World Confederation for Physical Therapy and the International Network of Physiotherapy Regulatory Authorities. The Report of the WCPT/INPTRA Digital Physical Therapy American Telemedicine Association's Principles for Delivering Telerehabilitation Services APTA COVID-19 resources Lessons from the front lines-CMS Covid-19 Covid-19 and health care's digital revolution The current state of telehealth evidence: a rapid review Telehealth Tool Kit. How to use telehealth for your patientsduring COVID-19 Spanish version of The Digital Practice Survey Report Jurisdiction Telehealth Laws/Guidance for PTs and PTAs Preparing the healthcare workforce to deliver the digital future Technology in rehabilitation: ethical and curricular implications for physical therapist education The great influenza: the epic story of the deadliest plague in history The authors thank Richard Woolf, PT, DPT, and Leslie Adrian, PT, DPT, MPA.KEYWORDS: COVID-19, Telehealth, Telemedicine, Telerehabilitation, Digital Practice, Technology ACCEPTED: April 20, 2020 SUBMITTED: April 10, 2020