Commentary: Is Remote Technology for CRT Here to Stay?

Right now, it’s difficult to imagine anything good coming from the COVID-19 pandemic.

Yet, we know from history that some great new ideas and processes grew out of the darkest days. The pandemic has forced healthcare professionals, including seating and wheeled mobility specialists, to think more creatively than ever. And telehealth and remote technology have become valuable tools in the effort to continue serving high-risk complex rehab technology (CRT) clients.

Just a few days after the Centers for Medicare & Medicaid Services (CMS) announced it would allow occupational and physical therapists to bill for telehealth visits during this crisis, I spoke with John Pryles, Executive VP of Sales, and Scott Rea, ATP, both from Numotion. How is remote technology being used to keep seating evals moving forward even as clinics have closed to suppliers, and while some high-risk clients are choosing to stay home?

I also asked if telehealth and remote technology could have a future in CRT beyond the pandemic.

Pryles was careful when talking about any “good” that could come from this current situation.

“I hate it and wish we could undo all of it,” he said of the pandemic. “That said, we can’t undo what’s done, and there are some things that have come out of this that will forever change the world and that will also apply directly to CRT.”

He described COVID-19 as a sort of “fast-forward button” for establishing communication and telehealth efficiencies. Even before the coronavirus outbreak, Pryles said Numotion had been exploring how to expand its remote technology systems. The national provider already had a well-established remote service and repair system that enabled customers to call in and troubleshoot problems with a Numotion technician, a first step that saved a lot of commuting back and forth between customers’ homes and Numotion offices. Pryles said that 60 percent of remote evals resolve in parts being ordered same-day, a huge win for both end users and Numotion.

And that led Numotion to want to try remote technology in other areas.

“Even prior to COVID-19, we had started looking at the idea of pre-evals and CRT equipment,” he said. “We’d go out to see somebody who had said, ‘I just want a scooter,’ so our ATP would think they’re seeing somebody for a scooter. But when they got there, it would be much more involved. The customer shared with us that they are diabetic, but they forgot the part about being diabetic with multiple sclerosis. So the ATP would have to reschedule, and that was frustrating for everybody.

“So we started with this idea: We won’t do the eval remotely, but we will do a prescreen. We’ll get the customer on the phone, and an ATP will go through a medical history: How are you moving around, what does your house look like, and all we would need to know so we would know which chairs to bring. We’d make sure it was a much better experience for the customers when we got out there.”

When the pandemic struck, Numotion was able to react quickly, Pryles said.

“Numotion was very much an early adopter of remote evals and really trying to drive that,” he explained. “We use Microsoft Teams, which is similar to Zoom or GoToMeeting; it’s a HIPAA-encrypted tool, so we sat down with our general counsel and some external law firms that specialize in healthcare. We took a look at what CMS had said. It clearly said that for physicians and nurse practitioners, they’re still going to require the face-to-face [exam]; but now that can be accomplished remotely via a broader set of parameters, including a wider variety of video technology options. Physicians had always had the ability to do telehealth; the customer, on the other end, had to go to an approved telehealth-approved site that had the right HIPAA encryption. So CMS said, ‘You still have to do the face-to-face, but if you want to use FaceTime, if you want to use Skype, and other previously unapproved technologies, if your physician agrees to use it, you don’t have to meet the same encryption standards during the public health emergency.’ So we said, ‘That’s awesome news; let’s get out there in front of everyone.’

“And then we said, ‘CMS is very clear about an ATP having to be involved in the eval, and the way they’ve thought about that is the ATP being there in person. And CMS had relaxed that as well.’”

Remote Technology: Possible Scenarios

Pryles described three main scenarios in which Numotion is using remote technology. The first, he said, “applies mostly to skilled nursing, assisted living, and LTACs [long-term acute care facilities] where there’s a therapist inside, the customer is inside, but the clinic has said no one is coming in from the outside: no family members, no vendors. In that scenario, the therapist is there, the client is there, we are not. We as a company use Microsoft Teams, but if the therapist wants to use Zoom, that’s fine. We’ll set up the remote eval, and we walk through the therapist’s eval: They do their normal range of motion, strength, functional mobility, all of that. And we’re there capturing what we think the appropriate assistive technology devices would be and our recommendations. We make sure the therapist concurs, and then we digitally set up the follow-up with the physician to collect all of the documentation. That’s one scenario.

“Another scenario is the in-patient clinic has closed, we have customers that are in need of equipment, the therapist can’t be there, but the ATP can. The ATP will go to the customer’s house or school or wherever they are, set up the eval and the technology, and then the therapist is able to log in and do their walk-through: The client interview, basic range of motion limits. Obviously, there needs to be a caregiver there if the patient is going to try to transfer or stand; we don’t do that alone without the therapist.”

The third scenario is the delivery, where the customer and ATP are together and once again, the therapist is remote.

“We’ll put the end user in the chair, make sure it’s set up correctly, make sure they go through the training, and in many cases we’re also following up a couple of weeks after, again with the remote technology, just to make sure,” Pryles said. “Do they have any follow-up questions, do they understand how everything on their wheelchair works, are there any adjustments that need to be made, is everything going okay?”

Remote Technology in the Real World

Scott Rea, MOT, OTR, ATP, works from Numotion’s Colorado Springs location. Many of the end users he sees live hours away.

“In our field, it comes down to how can we connect with people and make it work?” Rea said. “I’ve been taught for a long time to keep adapting to whatever the situation is.”

Rea was working in acute care during the 2009 H1N1 and 2003 SARS pandemics. “All of them have been so different,” he said. “Obviously, all of the technology has been different. During those last two, we couldn’t even think of doing what we can do now. The technology just wasn’t there yet.”

And how does Rea think healthcare is responding to remote technology options now?

“I think healthcare in general is ready to go there,” he said. “I’ve seen physicians, PTs, OTs, speech pathologists, all jumping on board with this. I think there’s been a lot of decentralization of healthcare over the last few years, where it’s not always as hierarchal as it used to be, and there’s a lot more teamwork in general. Doctors are listening to therapists, who are listening to patients, who are listening to the nurses. There’s a lot more peer-to-peer interaction. I’m not sure we were in that space 10 or 15 years ago. I think everyone is more accepting of the change.”

While Rea was also sensitive to the suffering the pandemic has brought, he’s aware that physical distancing in the current environment has given CRT a new opportunity to use remote technology.

“Obviously, the industry has been stressed in a lot of different ways,” he said, referring to decades-old instances of DME-related fraud. “With all the regulations that came to bear, it felt like access was being really limited by regulatory affairs. Now it feels like everything is being freed up, and we’re trying new things.

“Inside this industry, we’ve wanted to do [remote technology] like this for a long time, and now we’re getting to try it. It’s been exciting to see how quickly we can open up access for our patients and not have them feel like they’re stranded.”

Asked how he’s using remote technology in his day-to-day work with clinicians and clients, Rea said, “I keep using the word ‘triage’ over and over again. I think it takes a skilled clinician to be able to look at the situation in front of them and say, ‘What can I accomplish with this technology?’ And probably the more important question is ‘What can’t I accomplish with this technology?’

“This gives us the ability to get eyes on somebody and be able to decide, ‘Your logical next step is XYZ.’ We do some level of an evaluation, gather some data, make an initial plan, and then we can start that plan and see if we start getting the results that we intended. The beautiful part is that little triage visit doesn’t take anyone moving anywhere. We can do a lot of that over the phone.”

As an example, Rea said, “Last week, I had my first in-person outpatient clinic. In my clinic, there’s a doctor, a PT, and myself. In Colorado, we’re starting to open up a little bit, but to make sure those clinic visits were going to be as efficient and productive as possible, two days before clinic and at the request of the doctor and the PT, I saw all of our patients virtually to get a good idea of what the cases were, what they were requesting. We recognize that healthcare itself right now is a finite resource, so we want to make sure that every visit there counted.”

Remote technology, Rea noted, could help to reduce the clinic backlogs already being anticipated once clients feel safe to venture out.

“I do believe there’s going to be a little bit of a backlog when we start bringing things back online, so we’re not just treating PPE [personal protective equipment] as a precious commodity right now. We’re treating all healthcare as a precious commodity. By me doing those visits before, we had one of the most productive clinic visits I’ve participated in in a long time. It was an awesome experience. Even the patients said it was amazing. They knew what they were coming into, we had an idea of the equipment they wanted, and we hit the ground running.”

How did clinic participants react to the introduction of remote technology?

“Like America has evolved a lot in the last six weeks, their responses really evolved,” Rea said. “In the first two weeks of doing this, it was overwhelmingly positive. I was remoting into clinics where the PT was there and the patient was there, and I was working in Colorado Springs. But in that valley where these patients lived, about three and a half hours away, they had no reported cases at that point. One lady [in clinic] sticks in my mind: She said, ‘I just appreciate your doing this.’ She understood we were trying to protect everybody. She said, ‘Thanks for being here and doing this and protecting us and not just abandoning us.’ I thought that was awesome.”

Rea laughed that as time has gone on, remote technology has quickly come to be expected.

“Recently, everyone has been used to it because other doctors are jumping on board. They just know it’s part of the deal and [reactions] are not quite as gushing as earlier.

“In any scenario when you do this, if the ATP’s remote or one of the clinicians is remote or the patient is remote, any combination of that, I think everyone is starting to understand that if you eliminate just one of those contacts, that’s beneficial because we reduce the chances of other transmissions. I think everybody gets it now, and I haven’t had to explain it over the last week or so. Everybody just jumps on the call and it’s game on.”

As a clinician who now works as an ATP, is Rea getting what he needs from a remote evaluation?

“I’ve done this with all the different scenarios of who’s remote, and I have not run into a situation yet where I’ve been so uncomfortable that I felt like I couldn’t proceed,” he said. “Again, I think it goes back to a clinician using their clinical decision making and knowing when you might be taking a bridge too far.”

And he’s adapted his own procedures as well. “If there’s stuff we need to do in person, I’ve had to schedule a follow-up appointment here or there. I’m much more likely to put extra notes in my evaluation, like ‘I really need to follow up to make sure that prior to assembling the equipment, I get these two things right before we set things in stone.’ It’s utilizing that knowledge set and setting follow-ups just to make sure we’ve got everything perfect when we go for delivery.”

Rea is also giving himself more opportunity to fine-tune seating and wheelchairs during this time. “I have been making sure to build in adjustability where I can to accommodate any possible scenario if somebody wasn’t giving me perfect data,” he said. “I know I have adjustability built in, and I put notes into my delivery steps: ‘You might need to adjust chair width here or there, because I’m not quite sure we got that perfectly dialed in.’”

CRT Will Remain Client Focused

Remote technology has been put to the test in this year’s pandemic and from a CRT perspective, it seems to have delivered well.

But Pryles emphasized that remote technology and telehealth won’t be the best answer for every client.

“I want to be careful: I don’t want to say that I think you can do the PT’s or the ATP’s job indefinitely without being present,” Pryles said. “I do think there are a lot of customers that benefit and absolutely need the skill set that a PT or OT offers in person — like very complicated molds or alternative drive technology, or if someone has a skin wound. There are a bunch of different scenarios that I don’t think can be handled remotely.

“But I do think that for a lot of other scenarios, you’re actually getting a better view of the end user’s real life when you’re capturing that end user at home and therapists are able to see, ‘Okay, this is what their den looks like; they weren’t kidding about tight living spaces’ or ‘That door to get into the bathroom is not 34 inches, it’s 28. We’re going to have to rethink the access to that bathroom.’”

Remote technology has already proven that it deserves an ongoing role in CRT, Pryles said.

“I think for overall outcomes, everybody was really worried that this sort of virtual eval was going to cut into the quality of the outcomes we’re seeing,” he explained. “And we’re seeing it hasn’t — again, keeping in mind that you have to be disciplined about the customers that you’ll see with this.

“I do think it’s important to have the allied medical team together. Therapist involvement is very important. ATP involvement is very important. I just think there’s been a bit of a paradigm shift on what does that mean and how we can do it.”

As tragic as the COVID-19 pandemic has been, it might have set the stage for the accelerated adoption of and greater appreciation for remote technology.

“A lot of this is here to stay,” Pryles said. “I think customers and clinicians, the more we do it, the more we’re going to see the benefits for our end users. My hope is that people don’t look at this and say automatically ‘We can’t do that, it’s not going to be as good.’ I really challenge people and really challenge that assumption to make sure that’s the case. Because this was always about being able to continue to see our customers and support people with needs. I think what we’ve seen is this doesn’t have to be just a stopgap measure.”

In Support of Upper-Extremity Positioning