E-Health

An important passage from the vision on future care (2022) issued by the Dutch government is: Appropriate care increasingly means hybrid care: a mix of digitally and physically offered care and health support, personalized and tailor-made where possible. Principles here are: self if possible, at home if possible and digitally if possible. In this, there is a lot of emphasis on self-management and e-health. Although physiotherapy is mostly regarded as a “hands-on” profession, physiotherapists began incorporating innovative technology in traditional in-person care delivery. This is known as e-health. E-Health is the use of information and communication technology (ICT) to support health and healthcare. Two major contributors to e-health are telemedicine and smartphone Apps. Telemedicine or telerehabilitation refers to the use of ICT to provide rehabilitation services to people remotely in their home or other environments. Such services include remote therapeutic interventions (such as training), remote diagnostic procedures, remote monitoring of progress, remote education and consultation and a means of networking for people with disabilities. The purpose of telemedicine is to increase accessibility and improve continuity of care in vulnerable, geographically remote populations with disabilities with the potential for saving time, costs and resources in health care.

Prior to the recent outbreak of COVID-19 telemedicine was acknowledged as an effective adjunct to traditional in-clinic methods. During the COVID-19 pandemic however telemedicine was used as a replacement of face-to-face physiotherapy, to allow patients to continue with a current therapy treatment plan, while adhering to shelter-inplace and social distancing orders. Will this also be a big element in the future of physiotherapy? Is it possible to replace a significant part of the physiotherapy meetings by telemedicine or by remote physiotherapy? And how will smartphone Apps (like Goniometer App or movement analysis Apps) will add to the physiotherapeutical process?

The Dutch professional competence profile for the physiotherapist (2021) states the following: The physiotherapist deploys healthcare technology, such as blended care and other e-health applications, when it suits the patient's care needs and living environment. Seven first year students of THIM-NL and six students of THIM-CH were interviewed by peers about their thoughts and opinions on the role of telerehabilitation in the future of physiotherapy.

Do you think it’s going to be easy for elderly people to adjust to the digitalization of physical therapy? If yes, why so? If not, why not?

Most students agree that this will be challenging for the elderly. A Dutch student states: ‘Most of the elderly are barely able to text, so this can provide a substantial challenge’. A Swiss student adds: ‘they really don’t know how to use a Handy or iPad’. However, most students think that although elderly people didn’t grew up using technology, this doesn’t mean they can’t learn: ‘They probably won’t learn fast but they can learn if they have people around them who can teach them how to use the technology’ There are more students that believe it is important for older patients to have people around them that can educate them in digitalization, such as relatives. Some students think the physiotherapist should play a role in this. One Swiss student believes this might be a good fit for physiotherapy interns, to help elderly patients with this digitalization.

They see several advantages. One student states that ‘it enables patients who are restricted in mobility for example, to gain access and can thus be a lower barrier for entry. It could also be useful for people who want more online assistance or guidance during exercise’. One student adds that digitalization of physiotherapy might enable patients with busy agendas to make the step towards care an appointment: ‘people have less and less time. Everyone has thousands of appointments these days, and when physiotherapy is added to the list, it becomes difficult. Not having to change location for an appointment, might increase willingness to go the physiotherapy appointment’. Another student adds: ‘everything is becoming more digital, so why not health too? Its importance will grow because people of the next generation doesn’t want to talk face to face anymore and is more comfortable with ecommunication. They are more into social media and communication with screen. You can have an appointment wherever you are and win time’

However, according to one Swiss student: ‘Ehealth may create a gap between generations and we need to make sure that no generation will be left out’

E-health may create a gap between generations and we need to make sure that no generation will be left out’

Would you prefer to work digitally (e-health) or rather face-to-face? And why?

In the end, students believe that the way in which elderly can improve their technological skills is dependent on their behavior towards innovation and technology: ‘there are elderly that are open minded towards the usage of new technology, but there are also the exact opposite’

Do you think the importance of e-health will grow in the future?

Students are unanimously in their answer: YES! They think the importance of e- health will definitely grow but that it won’t fully outgrow the need of face-to-face contact. They believe it would be something additional to use in combination with face-to-face sessions, instead of replacing it.

Almost all students agree that they would rather work face-to-face. Only one student said he/she would prefer to start digitally, for example in a screening and then switch to face-toface when this proves more effective. Although most other students acknowledge that a mix would be good, they prefer face-to-face contact with the patient: ‘you can see the patient, touch the patient, see their expressions, see the way they react to certain tests, do the necessary testing and that’s very important to a physical therapist’ Several students also believe that face-to-face results in a better understanding between the two;, ‘if you have a deeper connection this leads to a more effective treatment’. A student adds that communication is more difficult digitally: ‘when you are in a meeting you won`t say everything because you don`t know if it will be understood the way you meant it’

A Swiss student summarizes: ‘I think any profession with the domain of health should always include person to person contact. No technology can replace this. However, a balance between the two should be of importance’.

How can we assure that the patient is doing the exercises right, when working digitally?

Students believe that this would be hard if the physiotherapist only works digitally: ‘we would need to see the patient from all angles’. Thereby, ‘you cannot give tactile input or feedback, so your communication needs to really be on point’.

They acknowledge that good instructions would be key: ‘it is difficult for the physical therapist to assure that the patient is doing the exercises right at home because the physical therapist is not physically there, so it is of importance that the physical therapist makes sure the patient knows how to execute the exercise the right way before leaving the practice’.

However, several students add that the instruction should not only be limited to the praxis. They believe that with proper instruction videos, patients could get clear instructions, which they can repeat whenever they like. Some students also acknowledge the use of a mix between face-to-face and online physiotherapy (blended physiotherapy) where the physiotherapist can check whether the exercises are done correctly: ‘We can always set up a meeting, in which the patient comes in for a quick review. He will then perform the exercises, and we will control them.’

A Swiss students thinks that ‘there will be technology in the future, where we might be able to see the therapists or patient performing the exercises “in front” of us’. Another student adds that motivation also might play a major role in performing the exercise right, when working digitally:

Could online treatment ever become better then real life treatment in your opinion? Why so?

Most students don’t think so. They believe that emotions, thoughts and feelings of humans, can be best picked up through face-to-face contact. But, several students name a hybrid form a good opportunity for the future: ‘This means you have a mixture of online and personal treatments’. They state that some treatments can be done independently at home without supervision (after a good instruction). ‘For example stretching/ activation exercises’. But for other treatments this would be much harder. ‘Hands on treatments like massage can of course never be done through EHealth’. Another student adds: ‘We would always need some kind of human contact, because it’s always nicer to talk to a real person instead of a robot or someone behind a computer. It’s also hard to decide what’s wrong with a patient from a distance if you can’t physically do the testing. Online treatment could definitely be implemented in some kind of way but not in a way where it’s taking over the real life treatment’.

Several students also believe that a functional online treatment is heavily dependent on the type of patient;: ‘I can imagine that patients with a sports background have it easier to execute some exercises. I can hardly imagine this with elderly people, because they may need more (physical) support’.

Some students however don’t believe that e-health will continue to play an effective role in rehabilitation: ‘E-Health can be a good solution for example in times of COVID, but it will never be the same as face to face treatment’

‘If the patient isn’t motivated to improve whatever the patient is there for, then the patient wouldn’t pay as much attention to executing the exercise the right way and just do it because the physical therapist says he/she needs to do it. In this case the physical therapist could try to improve the patient’s motivation’.

First year full-time students of THIM CH

What is your vision on how to integrate ‘lifelong learning’ into daily practice?

In the late 1960s and early 1970s, it became apparent that undergraduate education (nowadays: bachelor’s degree) did not fully prepare an individual for working life or imply lifelong competence. As a result, a half-life concept to estimate the extent of becoming out of date with new technology and knowledge was proposed. A half-life of 5 years was applied to medicine and engineering, whilst 10–12 years was applied to psychologists. Mandatory continuing education was then first introduced in the USA for medical practitioners in 1971. It was another 10 years before it was introduced in physiotherapy in several countries.