Telerehabilitation in resource constrained countries

While telemedicine offers great opportunities to healthcare in general and for rehabilitation services, it could be particularly beneficial for resource constrained countries.

July 28, 2019 Sona Ayanikalath Ph.D., Supervisor of Speech Language Pathology, Sheikh Khalifa Medical City, Abu Dhabi

Telerehabilitation (TR), which is the use of digital technologies to provide rehabilitation services from a remote location, a solution for the increasing demand being placed on the healthcare sector, constitutes a small part of the literature on telemedicine, with very few studies being reported in resource constrained countries.

The literature indicates that while telemedicine offers great opportunities to healthcare in general and for rehabilitation services, it could be particularly beneficial for resource constrained countries, where access to basic healthcare is compromised by lack of services and skilled professional care, by providing access to medical services in any part of the country or the world.

With an increase in the various disorders such as cerebro-vascular accidents, traumatic brain injury, developmental delays in paediatrics, etc., that require rehabilitation interventions like physiotherapy, occupational therapy, speech language pathology and the like in resource constrained countries, and considering their dearth, a new method such as TR needs to be considered for their intervention.

Despite increased reporting about TR research, many clinicians are still not using it, which may be due to the lack of knowledge, technical skills, understanding or its accessibility. Clinicians who have used video-conferencing, Skype, email and telephony for work have been driven by local need and the availability of infrastructure. TR has considerable potential in resource constrained countries to address the treatment gaps, but while this is theoretically feasible, attempts to implement it in public sector facilities have not been very successful.

In 2014, the Abu Dhabi Telemedicine Centre launched a round-the-clock telephone service that connects patients to nurses and doctors throughout the region. The Department of Health- Abu Dhabi currently has regulations setting minimum standards for telemedicine.

The Dubai Health Authority (DHA) has also taken an important step towards modernising the Emirate’s healthcare industry with the passing of Administrative Resolution No. 30 of 2017 concerning the Regulation of Telehealth Care Services (the “Telehealth Regulations”), which sets out minimum standards and requirements for the provision of telehealth services across Dubai. Consideration has to be given for health insurers and health maintenance organisations to cover the cost of healthcare services provided through telerehabilitation on the same basis as those provided through in-person visits, which can further supplement the implementation of TR.

Benefits of TR

The main benefit of TR is that treatment can now be accessed from patients’ homes or primary healthcare centres in remote areas. This is done by improved online infrastructure and increasing Internet connectivity or by making the country digitally empowered in the field of technology, with three core components of digital infrastructure, delivery of services digitally and digital literacy with increased connectivity in under-served areas with high-speed internet networks, which will make TR possible for people throughout a country.

In addition, treatment through this new mode has now become cost effective since it reduces the need for patients to travel to the hospitals to meet a physician or to a centre for various rehabilitation services. It is convenient for patients who experience constraints that affect their ability to travel. Another benefit is the continuity of care technology provides. The professional can access the patient from where he/she is and vice versa, if they are moving places within the country or outside the country. TR will be welcomed by patient and/or their caregivers as it will give them access to healthcare services that are not locally available, and which they might not otherwise have benefited from. Parents will feel empowered while doing speech language therapy through TR and will want to learn and interact more during the sessions.

Technology used

Skype or other applications such as Hangout and Facetime on iPhone are the most commonly used internet applications used by TR personnel. However, there are many TR platforms (video-conferencing space that allows a professional to host a session) available in business in the U.S. and also various companies that specialise in providing TR.

Challenges of TR

One of the major concerns that have emerged in relation to telemedicine in general, is the potential risk associated with the digital transmission of patient records. As such, creating reliable safeguards for the protection of sensitive patient data was one of the primary objectives for introducing a modern legal framework. Accordingly, there needs to be adequate measures taken by telemedicine and TR care providers to ensure the protection of patient data and privacy.

Another issue is if TR will be accepted by other professionals. It has been identified that service provision through TR was not widely accepted by health professionals in some countries. One main reason was that a physician would not want to liaise with another, which may be due to professional rivalry as well as a lack of awareness regarding its effectiveness.

Concerns over the severity of a patient’s condition are evident, which can affect the effectiveness of TR. Paediatric cases with attention deficit or poor eye contact posed a challenge using TR; however, a trained aide can be used at the site of the patient to assist in such situations. The most common issues faced during TR sessions can be power failures, low bandwidth and poor Internet connectivity, with power outages in resource constrained countries. While remote TR personnel may have good Internet connectivity and no power failures, this may not be the case for the patient. This is compounded by old devices, such as the laptop or a personal computer, which can hinder the audio-visual clarity at both ends. In addition, the computer literacy of patients and caregivers can also pose as a challenge.

Treatment through this new mode has now become cost effective since it reduces the need for patients to travel to the hospitals to meet a physician or to a centre for various rehabilitation services.  

TR in education

To successfully implement TR in a resource constrained country, there needs to be awareness of TR and its scope of practice. As in many such countries, the academic teaching departments are largely unaware of TR. It provides new ways to assist rehabilitation skill development – supporting ongoing learning for students and clinicians working with patients.

TR guarantees exposure to certain experiences and also aids non-technical skills training, which is an opportunity to build confidence. It can help overcome challenges of workplace isolation, such as lack of on-site mentors, limited local professional development and lack of local available cases for advanced learning and practice. It provides opportunity for massed and varied repetition, reflective practice and interdisciplinary learning. But this requires trained users to ensure optimisation of use and workplace change and investment in required technology.

A good government infrastructural support appears to be the main element influencing the effectiveness of a new intervention system such as TR. The major constraints in infrastructure could be the political and regulatory risks such as formulating government level rules and regulations to govern TR services, which would lead to its streamlining and obstacles to access financing or funding. Nevertheless, TR seems to be the future and one of the most innovative solution for the growing needs for rehabilitation services.

TR guarantees exposure to certain experiences and also aids non-technical skills training, which is an opportunity to build confidence.  

Sona Ayanikalath