Table 2.
THEMES | ILLUSTRATIVE QUOTES |
---|---|
PSYCHOLOGICAL CAPABILITY | |
Barriers | |
Clinicians perception | “Perception of no hands on as missing something in treatment, takes away the “feel” we get from using our hands to assess/treat/reevaluate etc” (P29) |
Communication | “Increased communication issues to language/education/health literacy and ability to adapt communication style” (P94) |
Diagnosis | “Having been a “hands on” physio for 35 years, I really struggle to do a thorough objective examination to compare with my subjective examination. Without being able to make an accurate clinical diagnosis, this affects my treatment plan.” (P64) |
Barriers/Enablers | |
Knowledge/skills | “I've always been hands on and prefer face to face. I think I'm better at cues and instructions when there in person as I'm so new to using telehealth.” (P115) |
“Our health system is traditionally passive so it is dependent on the patients perception on how to manage health conditions. If they can understand the benefits of a more autonomous and self efficacious program we should be able to improve patient outcomes. “ (P206) | |
“Clinician expertise- we are all-learning as we go, our team had its first virtual team meeting only on19/3/20 and we are now assessing, treating and providing virtual exercise groups! Steep learning curve+++" (P302) | |
Technology (literacy/ability) | “Variable ability of users to set up tech correctly ie position of camera to observe functional movements” (P69) |
Confidence (clinician and patient) | “Patients acceptance and confidence to use technology” (P82) |
“Lack of confidence in both the clinician and the patient that telehealth can deliver what's needed.” (P162) | |
Enablers | |
Resources | “Upskilling - no comprehensive resources for myself as a practitioner” (P403) |
PHYSICAL OPPORTUNITY | |
Barriers | |
Diagnosis | “Inability to properly objectively assess - this is especially relevant to joint special testing. Also having to rely on patients and camera angles means observation skills are more difficult and require more explanation. “ (P528) |
Risk assessment/safety | “Screening of red flags and potential serious pathology” (P90) |
“I'm uneasy around progressing patients to more difficult exercises - particularly if I've only ever met them via telehealth. To challenge them and progress towards high level goals, they will likely need more difficult exercises but I am mostly concerned around safety - particularly for patients who live alone and don't have someone who can supervise at home/provide assistance when needed.” (P513) | |
Internet quality | “Internet speed/connection. “ (P16) |
“The clients internet bandwidth and clarity of camera” (P116) | |
“Working in a rural area means there has been issues with reliability of the internet and this can be frustrating. “ (P119) | |
Assessment quality/accuracy - e.g. special test, body language | “Having a proper view of the patient not being sure of certain angles (for exampre trunk rotation or pelvic tilt). Difficult to do precise tests when I am used to rely in my hands and what I feel on palpation” (P680) |
“Inability to perform objective tests (I think it impacts ability to fully reassure patient regarding prognosis and treatment plan)" (P755) | |
Exercise guidance | “I also find some rehab exercises hard to do remotely. In person you can help demonstrate and adjust someones form so they do it correctly. For me this has been the main barrier. “ (P709) |
“Closer supervision of exercises/corrections may be lost through a flat screen. Closer observation during examination for subtle changes in movement patterns can be missed. “ (P203) | |
Environmental barriers - e.g. patient's space for consult | “Access to appropriate rehab equipment for patients in the home environment.” (P654) |
“Completing functional assessments depends on patients living space. Problems with wifi connection. “ (P616) | |
“Patients having suitable private environment for interaction " (P567) | |
Environmental barriers - e.g. health services | “space required - poor ergonomics for long periods at computer ++, noisy with multiple clinicians using telehealth in shared space " (P244) |
“Appropriate patient Settings e.g ability to see detail of what patient is doing when following your instructions. “ (P220) | |
“Infrastructure available in the public hospital ie our desktops did have speakers, we have had to source headphones/bluetooth devices to enable use/use our own laptops/have workstation on wheels with tap on tap off functionality reimaged to a typical laptop. “ (P261) | |
Patient-therapist relationship | “Creating the same sense of rappore and trust with a patient is challenging over video. “ (P53) |
“Face to face care allows contact, proximity and most patients like to see you and how we react or answer to their concerns.” (P62) | |
“Lack of presence and trust building to create therapeutic alliance” (P75) | |
“Not being able to touch patients and build a therapeutic alliance with them can sometimes leave the patient feeling they are getting sub standard care.” (p717) | |
Physical distance - lack of physical interaction | “Face to face interactions are a lot more beneficial for patents because human have evolved to interaction with touch and body language that does not convey well over video.” (p736) |
“Face to face is easier to create a patient/Physio relationship, and develop trust. I have not yet undertaken an initial Telehealth consult.” (P617) | |
Management delivery (Hands on) | “Being able to use manual skills to assess and treat ultimately leading to a potential misdiagnosis and impacting on patient time of recovery. We know that with some conditions patients may respond to exercise based therapy the same way as the may respond to exercise combined with manual therapy. Manual therapy can speed the recovery times leading to a reduction in pain, faster return to work whilst reducing risk of other joints/healthcare systems being affected” (P714) |
“Without hands on, you cannot educate the patient on correct movement patterns, identify issues and provide relief " (P207) | |
Barriers/Enablers | |
Technology (resources and access inequality) | “Quality of technology/camera and internet connection " (P56) |
“Additionally clients access to technology, familiarity with apps etc, bandwidth restrictions or limitations all impact on the ability to drivers of services, as does subscription costs for video based platforms, especially for groups.” (p103) | |
“the technology capabilities of my clientele; many elderly patients don't seem to have the technology or family support for this to be feasible with them” (P252) | |
System barriers, funding | “Patients acceptance of Telehealth and ongoing ability to receive rebates from Medicare and private health funds” (P12) |
“In the United States, it is not a nationally covered service for physical therapists, so getting this changed at a legislative is very important for PT's and the future of our profession under the current Pandemic landscape. Politics and insurance companies are the hurdle.” (P154) | |
“LACK OF FUNDING SUPPORT (for both face-to-face and Telehealth) when there is clear research showing equal efficacy and better cost effectiveness. Yet Arthroscopes/repairs are heavily subsidised, yet education, supervised exercise, weight-loss and other lifestyle/environmental strategies are not.” (P54) | |
Suitability of condition (e.g. complex acute conditions) | “Many of these clients (e.g.acute back and neck pain) are not coming forward for treatment as I think they cannot see how they would benefit from telehealth. I do think we could help them but that it would be likely to be a compromise for many conditions.” (P304) |
“The main reason is that it would be difficult to fully assess a patient to determine their musculoskeletal condition. There are issues/causes for conditions that can only be determined by a hands on/face to face consult. “ (P624) | |
“Assessing acute MS injuries, particularly if needing to assess ligamentous stability, also to check for acute fractures. (P333) | |
Enablers | |
Exercise and self-management | “Unable to provide manual techniques, massage, shockwave, dry needling, taping & splinting as per face to face - even if not most effective form of treatment in isolation, in combination with education/exercise I feel it meets patient expectations & can help with desensitization/range of motion etc depending on condition " (P88) |
“To also convince patients that many musculoskeletal can be self managed by exercise and movement rather than manual and electro therapy.” (P1) | |
SOCIAL OPPORTUNITY | |
Barriers | |
Face to face rehab (e.g. ortho, manual) | “Perception of no hands on as missing something in treatment, takes away the “feel” we get from using our hands to assess/treat/reevaluate etc” (P29) |
Lack of hands on - impact on assessment quality/accuracy - (patient perspective) | “Public awareness on the need for hands on” (P21) |
Lack of hands on - impact on management quality/accuracy - (patient perspective) | “Patient perception of what is gained through hands-on treatment is the biggest barrier for them to engage in Tele health. “ (P100) |
“Over my 28 years of clinical practice all my experience and training has been in face to face settings. I use hands on techniques with most clients, and it is these skills that I can't apply remotely. Not all clients see the benefits of Telehealth, and without face to face contact and the hands on aspects of care are unsure of it's value. “ (P103) | |
“Patients are not used to telehealth. The histoire of our profession in France emphasize manual therapy and massage over active therapy. It is difficult to make them accept exercises as the go-to way to be treated, so it is even more difficult via telehealth. “ (P223) | |
Patients not getting immediate relief from self-management strategies and therefore get discouraged (P235) | |
Barriers/Enablers | |
Patient attitude re quality/perceived or actual effectiveness | “Patient perception-General impression from patient that teleheath sessions are inferior to face-to-face session which affects uptake. However, generally positive response from clients who agreed to telehealth sessions.” (P93) |
“Some people want hands on treatment and might value the service less if they don't receive that” (P15) | |
“Patient and clinician beliefs that Telehealth is the lesser option” (P112) | |
Patient attitude regarding self-management | “The challenges are getting the patient on board with telehealth regarding its value and effectiveness compared to face to face treatment. Also patients who are used to always receiving hand on treatment who believe this is the only modality that will improve their condition. (P149) |
“Patient expectation that telehealth won't give them what they need or be as effective as face to face appointments. Patient's not wanting to take responsibility for self care and preferring to rely on hands on treatment” (P344) | |
“Patient expectations regarding what physiotherapy is. Clinic expectations from seasoned manual therapists who have built the perception that you need hands on therapy.” (P10) | |
Patients perception and engagement/social acceptance | “My patients tell me they are reassured by our conversation, advice and exercises but still want to see me face to face as soon as possible. I see a huge problem in patient expectation. They feel they are missing out and will not pay full price for session but I work harder and take longer to do follow up exercise e-mails and resources.” (P111) |
“People are not sure and are unaware of the benefits of telehealth” (P154) | |
“Patient perception. I believe that the patients perceive telehealth as lower value care than face-to-face sessions.” (P168) | |
REFLECTIVE MOTIVATION | |
Barriers | |
Impact on clinician (e.g. time, admin, isolation) | “Change in culture of being in a room with a laptop rather than in human contact with colleagues and clients. People's availability - if they don't turn up for appointment in person is clear but if not able to contact person - how to complete as not truly a DNA - how many times do you keep trying to connect?!?!" (P166) |
“Isolation from team” (P92) | |
“The biggest change is the factor of time. It takes more time to demonstrate or describe exercises using video than in a clinic setting, and time is also spent in diagnosis and assessment because pt's have to put themselves in position which is all active range of motion.” (P202) | |
Patient-therapist relationship | “Lack of confidence in both the clinician and the patient that telehealth can deliver what's needed. Therefore, perhaps the therapeutic effect of the experience is diminished.” (P162) |
“Creating the same sense of rapport and trust with a patient is challenging over video. “ (P53) | |
Lack of hands on - impact on AX quality/accuracy - (clinician perspective) | “Same goes for tactile cueing - it's just not the same. Often in person I would gentle guide my patient towards to movement, or enable them to get tactile feedback from hands on me whilst executing the exercise. My communication and fill of words has had to increase significantly.” (P767) |
“Touch is an important part of assessment. Asking the patient to do it and report back is sometimes difficult and unreliable” (P736) | |
“Being able to use manual skills to assess and treat ultimately leading to a potential misdiagnosis and impacting on patient time of recovery. We know that with some conditions patients may respond to exercise based therapy the same way as the may respond to exercise combined with manual therapy. However, manual therapy can speed the recovery times leading to a reduction in perceived pain, faster return to work whilst reducing risk of other joints/healthcare systems being affected” (P714) |