Clinical Triaging Considerations for Telehealth

Original Editor - Ashmita Patrao Top Contributors - Ashmita Patrao, Jess Bell and Kim Jackson

Introduction

Telehealth enables individuals to access rehabilitation services in their home environment. However, because health professionals are unable to assess these patients in-person, they must first determine if telehealth is a viable option for healthcare delivery. This page discusses clinical triaging principles that must be considered in order to determine if a patient is a suitable candidate for telehealth.

The American Telemedicine Association states that physical therapists can see patients via telehealth on a case by case basis. Decisions must be based on clinical judgement, the client's informed consent and professional standards of care.[1][2]

Clinical Triaging Considerations

As discussed below, there are various factors that must be considered in order to appropriately triage telehealth patients. However, triage decisions will also be affected by national and regional guidelines, particularly in the context of COVID-19. The discussions below are centred on ensuring that telehealth consultations are carried out in an effective and safe way.

Patient’s Clinical Condition or Presentation

You will need to consider if the patient has a formal diagnosis (eg spinal stenosis or COPD) and how this would affect your ability to manage the patient at a distance. Symptoms severity (eg pain levels, presence of neurological symptoms, severe shortness of breath) is also an important consideration. Are the symptoms so severe an in-person consultation or referral is necessary? It is also important to consider the chronicity of the condition. More severe and acute cases may need to be triaged sooner.[3][4]

Red Flag.jpg

Presence of Red Flags/Serious Pathology

When assessing any patient, in-person or via telehealth, it is essential to consider if there are any potential or actual red flags. Red flags can indicate serious pathology and need to be directly referred to the appropriate medical professional. Red flags are discussed in more detail here, but common red flags include:

  • Escalation of pain and progressive worsening of symptoms that do not respond to medications or the usual conservative management.
  • Fever and weight loss
  • Being systemically unwell
  • Night pain that disturbs and prevents sleep
  • Changes in bladder/bowel habits[5]

Emergency Conditions

These conditions require immediate referral.

  • Cauda Equina Syndrome - spinal and leg pain, neurological symptoms, changes in bladder/bowel, or saddle anaesthesia.[6]
  • Metastatic Spinal Cord Compression - symptoms include spine pain with band-like referral, gait changes and escalating pain.[6]
  • Spinal Infection - symptoms include spinal pain, fever, worsening neurological symptoms.[6]
  • Septic Arthritis - should be expected until proven otherwise if patient is unwell, with or without a fever, and sudden onset of a hot, painful joint and multidirectional restriction in movement.[6]

Urgent Conditions

  • Primary and secondary cancers - the common presentations are night pain, escalating pain, systemic illness.
  • Insufficiency fracture - sudden onset of pain, most commonly in the thoracolumbar region following low impact trauma.
  • Major Spine Related Neurological Deficit - relatively new-onset, progressive weakness with less than grade 4 in one or more myotome. Commonly presenting with spinal pain and limb symptoms.
  • Cervical Spondylotic Myelopathy - on occasion, cervical spondylosis can progress to cervical myelopathy - patient presents with pain and diminished coordination ability, heaviness/weakness in arms or legs, gait problems, pins and needles/pain in arms and loss of bowel or bladder control.
  • Inflammatory arthritis OR rheumatological conditions:
    • Persistent synovitis (swollen arm joints) particularly of the small joints of the hand, stiffness that lasts for at least 30 mins in the morning. This would indicate rheumatoid or psoriatic arthritis.
    • Suspected new-onset autoimmune connective tissue disease (such as lupus or scleroderma) or vasculitis - will present with non-articular manifestations of rashes, Raynauds disease, mouth ulcers and/or sicca related symptoms (drying of mouth and eyes)
    • Any type of myalgia not due to viral infection or fibromyalgia, which worsens proximally. This could be polymyalgia rheumatic (refer urgently to GP) or myositis (refer urgently to rheumatologist).
    • Giant cell arteritis - headache of relatively new onset mainly in the temples which may cause jaw claudication, proximal girdle pain, visual symptoms and raised ESR and CRP. Usually in patients over 50 years.
    • Suspected inflammatory spinal pain - prolonged morning stiffness, pain radiating to buttocks and/or night pain. They may also have psoriasis, inflammatory eye disease and inflammatory bowel disease.[6][7]

Urgency to Access Care

As with face-to-face consultations, it is essential that a health professional considering using telehealth determines how urgently care is required. The red flags and serious pathologies discussed above warrant immediate or urgent referral.[6][5] However, as physiotherapists, we need to also triage patients based on more typical presentations. For instance, a patient six weeks post-ACL repair will need to be reviewed more rapidly and likely benefit from a face-to-face review when compared to a patient who has long standing non specific low back pain with no neurological symptoms.[2] However, each patient needs to be considered on a case by case basis.

Individual Patient Factors

Clinical triage telehealth.jpg

Various patient factors should also be considered when deciding if telehealth is an appropriate method of healthcare delivery.[2]

Age

The age of a patient should be considered regardless of the mode of healthcare delivery. However, with telehealth it is important to consider unique factors related to age. Patients have varying levels of familiarity with the technology required to engage in telehealth[8] and this can often be influenced by age. Similarly, it is important to consider cognitive status when exploring telehealth as an option.[2] Is the patient able to follow instructions and fully consent to the assessment and treatment?[2]

Presence of Comorbidities

While telehealth has been shown to be effective in managing certain long term conditions (eg cardiovascular disease and stroke care), particularly when delivered as part of an overarching MDT programme,[9] face-to-face triaging may be more effective for physiotherapists managing these conditions directly.[2] However, in the context of COVID-19, many regions/countries are encouraging these vulnerable groups to be treated via telehealth in order to reduce their risk of contracting the virus.

Mental Health

The presence of psychological issues may have an impact on whether or not a patient can be safely triaged by telehealth.[2] While telehealth has been found to be a cost effective solution for patients with mental illness, there are still concerns about its use, particularly in relation to clients who have physical and cognitive difficulties in addition to mental illness.[10]

Mobility of the Patient and Other Impairments

Subjects who are frail and immobile are considered a high priority when triaging patients as they have an increased risk of developing complications.[11] However, it is essential to consider their safety when determining if telehealth is an apporpiate option. Consider if a face-to-face consultation is preferable - alternatively, could a carer/support person safely assist when balance or mobility impairments are present?[2] Similarly, visual or hearing impairments can have a significant impact on a patient's ability to engage in telehealth consultations effectively.[2]

Other Considerations

What Stage of Treatment is Telehealth Appropriate?

You may determine that a patient is a suitable candidate for telehealth, but you must also consider at which point in their care you use it. Can you complete the initial assessment via telehealth or will you just use it for follow up appointments? You might decide a hybrid model is best. This decision will be based on the client's condition and individual patient factors.[2]

Physical Location

You will need to consider the patient's physical location. Are they at home or at a friend/family member's house? Some patients will be at GP clinics. Having another person present has both advantages and disadvantages. They can help with the assessment and reduce some safety risks (ie provide balance support), but having an extra person present creates issues around privacy and confidentiality.[2]

Geographical Location

When looking at telehealth for patients in rural or remote areas, it is important to consider if there may be any internet connectivity barriers.[2] Access to high speed internet is a recognised barrier for many rural telehealth programmes.[12] Problems with video calls as a result of slow internet can interrupt consultations and reduce patient satisfaction with telehealth.[12]

Privacy

As discussed here, privacy is a significant consideration when utilising telehealth. It is important to consider what application you are using for the consultation - does it have end-to-end encryption to ensure the patient's security and privacy is maintained?[13] Similarly, the patient needs to have access to a private space in their physical location - especially when dealing with sensitive issues (such as visualisation for pelvic examinations).[2]

Therapist Skill Level 

As with any clinical encounter, a physiotherapist needs to have the appropriate skills to safely carry out an assessment and intervention for the presenting condition. However, with telehealth, they need to be able to do this without actually being present to perform assessment tests.[2]

Necessary Assessment and Treatment Requirements

When considering using telehealth, a physiotherapist needs to be able to select the appropriate tests/interventions and red flag screening questions without being able to physically assist in the examination. Thus, it is important to consider if another person can be present to help with the tests (eg a local GP). Similarly, it may be necessary to refer patients for imaging if you have any concerns about their presentation.[2]

Scope of Practice and Reimbursement

It is important to check if your registration board or professional body has placed limitations on your scope of practice when utilising telehealth.[14] You should also find out if you are correctly licensed to treat a patient in a different state/region to you before undertaking a telehealth consultation.[13] Similarly, you need to check if a patient's insurer covers telehealth - this is not always the case and reimbursement is a key challenge for telehealth.[8]

Summary

Once you have considered the above issues, you should be able to determine if a patient is an appropriate candidate for telehealth, in-person or a combination of telehealth and face-to-face care.

It is essential that you consider:

  • The client's condition and screen for any red flags/serious pathology
  • The urgency of the condition
  • Individual patient factors that will affect the ability of the patient to engage in telehealth
  • And other issues such as location, privacy, skill level and how well the assessment can be adapted to telehealth, scope of practice and your ability to be reimbursed as a therapist.

References

  1. Brennan D, Tindall L, Theodoros D, Brown J, Campbell M, Christiana D, Smith D, Cason J, Lee A. A blueprint for telerehabilitation guidelines. Int J Telerehabil. 2010;2(2):31.
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 Cottrell, M. and Russel, T. Clinical Triaging and Practical Considerations in Telehealth Course. Physioplus. 2020
  3. Wand BM, Parkitny L, O’Connell NE, Luomajoki H, McAuley JH, Thacker M, Moseley GL. Cortical changes in chronic low back pain: current state of the art and implications for clinical practice. Man Ther. 2011 Feb 1;16(1):15-20.
  4. Apkarian AV, Sosa Y, Krauss BR, Thomas PS, Fredrickson BE, Levy RE, Harden RN, Chialvo DR. Chronic pain patients are impaired on an emotional decision-making task. Pain. 2004 Mar 1;108(1-2):129-36.
  5. 5.0 5.1 Finucane L. An Introduction to Red Flags in Serious Pathology. Physioplus 2020.
  6. 6.0 6.1 6.2 6.3 6.4 6.5 NHS. Urgent and Emergency Musculoskeletal Conditions Requiring Onward Referral. NHS. Report number: 001559, 2020 (last accessed 16 May 2020).
  7. Magee D. Orthopedic Physical Assesment. 4th edition. Missouri: Saunders Elsevier; 2006
  8. 8.0 8.1 Dinesen B, Nonnecke B, Lindeman D, Toft E, Kidholm K, Jethwani K. Personalised telehealth in the future: a global research agenda. J Med Internet Res. 2016; 18(3): e53. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4795318/
  9. Lee HS, Chumbler N, Brown E, Fonarow GC, Berube D, Nystrom K. et al. Recommendations for the Implementation of Telehealth in Cardiovascular and Stroke Care: A Policy Statement From the American Heart Association. Circulation. 2016; 135(7).
  10. Langarizadeh M, Tabatabaei MS, Tavakol K, Naghipour M, Rostami A, Moghbeli F. Telemental Health Care, an Effective Alternative to Conventional Mental Care: a Systematic Review. Acta Inform Med. 2017; 25(4): 240–246.
  11. Kim SW, Han HS, Jung HW, Kim KI, Hwang DW, Kang SB, Kim CH. Multidimensional frailty score for the prediction of postoperative mortality risk. JAMA surgery. 2014 Jul 1;149(7):633-40.
  12. 12.0 12.1 Rural Health Information Hub. Connectivity Considerations for Telehealth Programs. Available from https://www.ruralhealthinfo.org/toolkits/telehealth/4/connectivity (accessed 16 May 2020).
  13. 13.0 13.1 Digital Physical Therapy Task Force. Report of the WCPT/INPTRA digital physical therapy practice task force. World Confederation for Physical Therapy. 2019. 24 p. Report No. 7. Available from https://www.wcpt.org/sites/wcpt.org/files/files/wcptnews/REPORT%20OF%20THE%20WCPTINPTRA%20DIGITAL%20PHYSICAL%20THERAPY%20PRACTICE%20TASK%20FORCE.pdf
  14. Cottrell, M. and Russel, T. Introduction to Telehealth Course. Physioplus. 2020