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The Zone’in Child Development Series newsletter for education and health professionals profiled teleEducation in June 2010, and now turns to telehealth for July’s topic. As a pediatric occupational therapist concerned about the overuse of technology by children, I have recently received a number of requests for information regarding the efficacy of telehealth, e.g. the use of telecommunication systems to facilitate the delivery of health-related information and services. A school principal questioned the efficacy of telehealth for speech and language services; an occupational therapist was told by her school district that she was required to use telehealth to deliver OT services to reduce her travel expenditures, and questioned efficacy in a pediatric school-based population; a speech and language pathologist who has been providing telehealth conjointly with 1:1 therapy services stated her telehealth service “wasn’t working” and she wondered whether she was doing it “correctly”. The intent of this article is to raise awareness regarding the increased use of telehealth services as they apply to treating the pediatric population, and raises concerns regarding the utilization of telehealth services with children.

What is telehealth?

The term “telehealth” is broadly used in research literature, and could reference any or the following: video conferencing between health care professionals and clients, client education or training, and may reference client assessment, treatment intervention and follow up consultation. Related terminologies found in the literature are ehealth, telemedicine, telerehabilitation and teleoccupational therapy. This generalization of the term “telehealth” in the literature creates obvious difficultly when considering the scope of therapeutic practice. Variability in client parameters (age, diagnosis), choice of assessment and treatment type, competency level of therapist, frequency/duration/intensity of intervention, and treatment environment are but a few factors to consider regarding telehealth service delivery. Trying to determine cost-effectiveness and efficacy of a telehealth service requires research that is specific to each variable parameter encountered.

Who is doing telehealth?

It appears that telehealth is present to some degree in almost all health care disciplines, yet exactly what type of telehealth is offered, and whether this telehealth is actually effective, is difficult to determine when reviewing existing telehealth research. In the field of paediatrics, telehealth is present in ‘virtually’ all child care centres, hospitals, mental health clinics, private therapy clinics, and even many schools are now using telehealth. As telehealth technology expands its role from video conferencing into areas of assessment and treatment, more and more health professionals are using telehealth with limited knowledge regarding above noted usage parameters. Careful design of implementation protocols, and preliminary review of evidenced-based research is imperative prior to wide scale use of telehealth, particularly with the pediatric population. A brief google search indicates that a number of private practice pediatric occupational and speech and language clinics are currently offering telehealth services, yet not one of these websites cited evidenced-based research outcomes, nor did they delineate telehealth service delivery protocols or procedures. Telehealth is a relatively new treatment modality, and requires careful evaluation of existing relevant research and extensive planning prior to implementation.

Does telehealth work?

The National Initiative for Telehealth Guidelines, Environmental Scan of Organizational, Technology, Clinical and Human Resource Issues, prepared by the NIFTE Research Consortium published April 30, 2003 is a comprehensive document on telehealth and ultimately recommended that health care systems move forward to implement telehealth services, despite also citing research that profiles the lack of evidence-base for clinical efficacy and cost-effectiveness. This document may be helpful to readers who are seeking to design implementation protocols with outcome measures for the use of telehealth in their school or clinic settings. The following statement is excerpted from the NIFTE Executive Summary located at http://www.cranhr.ca/pdf/NIFTEEnvironmentalScan-ExecutiveSummary-May72003.pdf.

The clinical efficacy and cost-effectiveness of telehealth has been demonstrated for some but not all applications (e.g., Hersh et al., 2001; Roine et al., 2001; Whitten et al.,2002). It has been asserted that technological improvements are overcoming many current limitations (e.g., Bashshur, 1998) such that there are or soon will be no important clinical difference between face-to-face and telehealth consultations.

The following conclusion statements are excerpted from abstracts of above cited research studies on telehealth.

• Hersh, W.R., Helfand, M., Wallace, J., Kraemer, D., Patterson, P., Shapiro, S., & Greenlick, M. (2001). Clinical outcomes resulting from telemedicine interventions: a systematic review. BMC Medical Informatics and Decision Making 1(5): http://biomedcentral.com/1472-6947/1/5, 2001. The strongest evidence for the efficacy of telemedicine in clinical outcomes comes from home-based telemedicine in the areas of chronic disease management, hypertension, and AIDS. Conclusion: Despite the widespread use of telemedicine in virtually all major areas of health care, evidence concerning the benefits of its use exists in only a small number of them. Further randomized controlled trials must be done to determine where its use is most effective.
• Roine, R., Ohinmaa, A. & Hailey, D. (2001). Assessing telemedicine: a systematic review of the literature. Canadian Medical Association Journal 165 (6), 765-771. Interpretation: Evidence regarding the effectiveness or cost-effectiveness of telemedicine is still limited. Based on current scientific evidence, only a few telemedicine applications can be recommended for broader use.
• Whitten, P.S., Mair, F.S, Haycox, A., May, C.R., Williams, T.L., & Hellmich, S. (2002). Systematic review of cost effectiveness studies of telemedicine interventions. British Medical Journal 324, 1434-1437. Conclusion: There is no good evidence that telemedicine is a cost effective means of delivering health care.

There are likely a number of research studies in progress that will show specific areas where telehealth utilization is an effective method of occupational service delivery. An occupational therapist is investigating the use of telehealth to service children with disabilities in remote locations http://www.otworks.ca/otworks_page.asp?pageid=751. Delivering Developmental Occupational Therapy Consultation Services Through Telehealth is a study conducted by the University of New Mexico’s Center for Development and Disability http://findarticles.com/p/articles/mi_7520/is_200909/ai_n39229849/?tag=content;col1. The University of Alberta’s Centre for Telerehabilitation http://www.uofaweb.ualberta.ca/telerehab/research.cfm profiles a number pediatric-related areas of telehealth research such as assistive technology, FASD, preschool mental health, school-based teams and wheelchair seating. I would caution use of telehealth for assessment and treatment interventions in the pediatric population until such time as evidence-based research supports such.

Telehealth Clinical Issues

The following considerations for clinical practice are excerpted from the NIFTE Executive Summary, ‘Clinical Issues’ section located at http://www.cranhr.ca/pdf/NIFTEEnvironmentalScan-ExecutiveSummary-May72003.pdf.

Communication - As there is no consensus as to whether telehealth enhances or attenuates the therapeutic relationship or the traditional practice of medicine, further research is urgently needed on the nature and content of the communication process.

Standards/Quality of Clinical Care – There is diversity of opinion regarding whether there is a need for telehealth-specific practice guidelines, or if existing guidelines from the various professional licensing bodies and associations serve the purpose. The “appropriate” standard of care delivered via telehealth should be equivalent to the standard expected in traditional provision of care. If equivalent standard of care cannot be met, the telehealth practitioner needs to consider what the alternatives are and decide if it is acceptable to proceed.

Clinical Outcomes - Telehealth systems require assessment of relevant outcome data to promote and support the sustainability of telehealth programs. Telehealth networks need to have a systematic method of collecting, evaluating and reporting meaningful outcome data, which would include indicators of efficiency of service and clinical effectiveness between telehealth practitioners and patients. Telehealth should be integrated into the normal provision of health care services to enhance, not replace existing health care services and to improve access, appropriate use, and efficiency of health care services.

Telehealth Considerations

“…there are or soon will be no important clinical difference between face-to-face and telehealth consultations”.

Creating a technological interface between therapist and child removes the ‘human element’, an energetic connection that requires face to face interaction. Occupational therapists are trained in the ‘therapeutic use of self’ which is the true gold standard for achieving effective therapy. In the absence of a therapeutic relationship, the role of the therapist is reduced to that of an observer which while useful, yields limited information and may significantly alter treatment. If telehealth is used for the purpose of interactive communication between therapist and child, how might children interpret the concept of ‘self’ when viewing their therapist through the screen? The therapist might be perceived by the child to have an appearance similar to a TV character. Interacting with a real therapist vs. a virtual image could change the ways in which the child performs or verbalizes. To consider the term ‘self’ (child or therapist) is the same concept whether using a technological interface, or face to face interaction, is denying the fact that we are all human beings whose survival and well being depends on our ability to form healthy attachments and connections with each other. Can a child actually form an attachment with a character on a screen, and can communication be therapeutic when the therapist is not perceived as real?

In pediatric occupational therapy, the use of touch, movement and human connection are three critical modalities used to facilitate child development and ensure efficacy of treatment techniques. These critical modalities are not achievable using telehealth, significantly limiting use of specific types of assessment and treatment interventions. Relying solely on the therapist’s ability to observe, and not interact, with a child will yield a poverty of information which may result in misguided treatment interventions.

Just as with teleEducation, the rapid advancement of technology into the health care system has caught professionals unaware and unprepared regarding the consequences of unrestricted and pervasive use of telehealth services. Thinking that telehealth will prove effective (eventually) in every setting with every individual is short sighted and will likely result in client harm. For example, proceeding forward with telerehabilitation services in school-based settings without adequate evidenced-based research to support such initiatives, may prove to increase the wait time until the client actually receives his/her research proven 1:1 therapeutic interventions. There are inherent problems associated with the idea that technology is useful for every condition and situation, and even more inherent problems when society chooses to ignore the detrimental consequences of technology overuse on children. 30% of children enter school developmentally delayed and 15% have a diagnosed mental illness, both associated with sedentary technology use. Yet – we are using technology to assess and provide interventions to address these very disorders that are a result of technology overuse.

Restrictive use of telehealth is imperative until such time as specific research provides evidence to support implementation. Specific guidelines regarding utilization of telehealth must be developed to promote ‘best practice’ and result in improvements (not erosions) in occupational therapy service delivery.

Cris Rowan, OT (Reg), BScOT, BScBi, SIPT, Approved Provider for ACTBC and AOTA
CEO Zone’in Programs Inc. and Sunshine Coast Occupational Therapy Inc.
6840 Seaview Rd. Sechelt BC V0N3A4
604-885-0986 O, 604-740-2264 C, 604-885-0389 F
crowan@zonein.ca
websites: www.zonein.ca, www.suncoastot.com