Effectiveness of Telehealth for Teaching Specialized Hand-assessment Techniques to Physical Therapists

Health care reform has changed the focus of patient care from primarily inpatient to an increased emphasis on outpatient services. The reductions in hospital beds, staff complements, and lengths of inpatient stays have led to an increased need for early referral of patients to health care professionals in the community. Unfortunately, a corresponding adjustment of outpatient resources has not occurred, resulting in an imbalance of resources and making accessibility to the appropriate services in the community extremely difficult.1 This is especially true for outlying communities, since metropolitan centers have disproportionately large numbers of health care specialists.2,3 In North America, with its vast geographic areas, travel between the metropolitan centers and the rural communities is often problematic, creating difficulties for patients needing care and for rural practitioners, who experience a feeling of professional isolation.4 Telehealth technology may provide an economically feasible solution to these concerns. Telehealth has been defined as the utilization of telecommunications technology to provide health care services and medical information over distance.5 Telehealth has the potential to improve services to rural communities by providing not only direct telemediated access to clinical specialists for patients, but also the opportunity for the efficient training of rural professionals in the necessary specialty care.6 A broad range of medical specialties has demonstrated the capabilities of telehealth to assess patients in remote areas.7 Much of this research, however, has focused on domains in which visual8,9 and/or auditory1 information is sufficient for accurate assessment. It is less clear, however, whether telehealth assessment is equally effective for specialties where tactile interaction between the patient and health care professional is considered critical. For these situations the health care professional at the distant site must be the “consultant's hands.” There is a parallel in using telehealth for the purposes of clinical education. That is, telehealth may be effective for teaching knowledge-based topics, but many health profession domains, such as physical therapy assessment skills, have tactile components that require measurement and analysis. Training for these types of skills may challenge the application of telehealth beyond its current capabilities. The purpose of this research, therefore, was to determine the effectiveness of telehealth for teaching specialized assessment skills requiring “hands on” interaction with patients. Method Participants. In 1999, a total of 42 physical therapists from two Northern Ontario cities agreed to participate. They were stratified by city and were systematically allocated to one of three interventions to ensure that the groups were balanced according to age, graduation year, type of educational format utilized at the university where the participants trained, prior hand therapy experience, prior telehealth experience, and type of current clinical practice. Interventions. Three educational formats were used to teach five hand-assessment skills: volumetrics of the hand; total active movement of the index finger; joint mobilization of the proximal interphalangeal joint of the long finger; grip strength; and two-point discrimination of the ulnar nerve. The three interventions were self study (SS); direct face-to-face teaching (DT); and telehealth teaching (TT). The same information was provided to the therapists in each of the three formats. However, the manners in which this information was transmitted differed across the three formats. The therapists assigned to the SS group were provided with a package containing written information that they were able to review over a three-day period. This material outlined how to correctly perform each hand-assessment skill based on the guidelines established by the American Society of Hand Therapists. There were approximately three pages of information per skill, including history, indications, contraindications, technique, and diagrams demonstrating performance of the skill. When given the documentation, these therapists were given instructions to learn the material independently in the same manner as they would normally. The DT session involved approximately 3.5 hours of direct contact with the instructor and was organized such that the instructor taught each skill for 15 minutes, providing the relevant information as described above and demonstrating the skill using a standardized patient. Immediately following the teaching and demonstration of each skill, the therapists practiced in pairs for approximately 30 minutes using each other as the “patient,” with the expectation that when they were not interacting with the instructor they would exchange ideas to solve problems and to perfect their performances. During the 30-minute practice period each pair also received five minutes of direct contact and interactive feedback from the instructor. The TT session was identical in format and timing to the DT session. To ensure similarity of presentation, the primary investigator of the study was present at both teaching sessions. The primary difference between the DT and TT groups was that the participants were located together at one local telehealth site and the same instructor from the DT group was located at a second local telehealth site that was physically removed from the first. Participant-instructor interaction was therefore mediated using an intracity link between two facilities that housed compatible videoconferencing equipment, thus eliminating the possibility of the direct “hands-on” contact with the instructor during the interactive feedback components of the session. Evaluation Instruments. A modified objective structural clinical examination format was used for both a pre-test evaluation and a post-test evaluation. Each participant performed the five skills consecutively on a single standardized patient, taking up to five minutes per skill. All five skills were evaluated by the same examiner (a content expert who was blinded to the intervention condition), with a separate mark given for each skill. Two evaluation instruments were used for each skill. First, a five-point global rating scale with four domains—knowledge of the technique, the ability to perform the technique, instrument handling, and organizational skills—was used to assess the underlying characteristics of performance. Anchors were provided for points 1 (poor, unable to perform), 3 (adequate), and 5 (excellent performance). The global score for each skill was calculated as the average of the scores for the four separate domains. Pilot work on this global scoring technique confirmed inter-rater reliability (ICC2,1 = 0.78–0.91 for the five skills) and construct validity (with skill level—novice versus intermediate versus expert—accounting for 20–67% of the variations in scores for the five skills). As a second measure of performance, the examiner completed a binary question addressing competency for each skill. Procedure. The research was conducted over two five-day periods one month apart in each of two Northern Ontario cities. For each city, the participating therapists individually attended a pre-test. These were scheduled for 30 minutes, and all were completed over a two-day period. Following each participant's pre-test, the participant was given instructions relevant to his or her teaching intervention. Those in the SS group were given the manual with appropriate instructions and given a time for their post-test session. Participants in the TT and DT groups were told when and where to arrive for the instructional session and were given a time for their post-test session. All participants were asked to avoid discussing the nature of the test with other participants prior to completion of the pre-test period, and participants from each group were asked not to discuss the training material across groups in order to avoid contamination of the experiment. At each city the TT session was held in the morning and the DT session was held in the afternoon of the third day. The post-test was conducted over the last two days, with the relative time of the post-test for each participant as close as possible to the relative pre-test time to ensure almost-identical delays between pre- and post-tests for all participants. Results Performance Scores. The summary statistics for the performance scores for all five skills are presented in Table 1. It is clear that the DT and TT groups approached excellent performance on all five skills after the intervention, whereas the SS group demonstrated only adequate performance on three of the five skills and poor performance for the two remaining skills. For all five skills, the interaction terms from the two-way ANOVAs suggest significant differences in the amounts of learning among the groups (F2,39 values ranged from 4.98 to 26.65, for all analyses, p <.01). The subsequent one-way ANOVA comparing the three groups on the pre-test showed no effect for any of the five skills (F2,39 values all less than 1.00, ns), suggesting that all three groups started at the same skill level. However, the one-way ANOVA comparing the three groups on the post-test showed powerful, significant effects of the group (F2,39 values ranged from 9.96 to 35.06, for all analyses p <.01), suggesting differences in abilities among the three groups after the intervention. A series of post-hoc Tukey tests demonstrated no significant difference between the DT and TT groups but a significant difference between the SS group and both the DT and TT groups, suggesting that the members of the DT and TT groups learned equally well, and learned better than did those in the SS group. Finally, given the lower post-test scores for the SS group, a series of paired t-tests was performed on the SS group results to determine whether the SS group was a worthwhile intervention. For only three of the five hand assessment skills was there a significant difference in the pre-test and post-test performance (p < 0.05), and the difference scores for these those skills are relatively small, raising the question of whether the difference is clinically significant (see Table 1).TABLE 1: Mean Pre- and Post-test Scores of 42 Physical Therapists (in Three Groups) on Five Skills, University of Toronto, 1999*Competency Scores. A similar pattern of results occurred with the competency scores. The pre-test and post-test percent competency scores are presented in Table 2. Chi-square analyses of the pre-test competency assessments showed no significant differences between groups on any of the five skills (χ22 ranged from 0.20 to 1.03, ns, with two being incalculable because all participants were evaluated as not competent), suggesting that individuals from each group were equally likely to be competent. By contrast, chi-square analyses of the post-test results revealed significant effects of group for all five skills (χ22 ranged from 8.42 to 24.21, for all analyses, p <.01). A series of subsequent chi-square analyses comparing the methods by pairs again showed no significant difference between the DT and TT groups, but significant differences between the SS and TT groups and significant differences between the SS and DT groups for all five skills. Finally, a series of subsequent McNemar's tests was performed on the SS group competency results to determine whether this intervention was able to change the competency levels of subjects. For all five skills there was no significant change in competency levels for the SS group.TABLE 2: Percentages of 42 Physical Therapists Identified as “Competent” in Each of Three Groups, on Five Skills, University of Toronto, 1999*Discussion The primary purpose of this study was to determine whether telehealth could be utilized to effectively teach specialized assessment skills to physical therapists. This study has demonstrated that telehealth may be used in this capacity. The five hand-assessment and treatment techniques that were selected for this study all possessed components that would challenge the transmission capabilities of telehealth. Three of the skills—volumetrics, total active movement, and grip strength—required the participants to use primarily visual learning skills. All elements of these three skills are easily learned by watching a demonstration or studying written material. Therefore, it was of no great surprise that these three skills were successfully taught via telehealth. What was somewhat surprising were the low pre-test performance and competency scores for the grip-strength technique, since this skill is simple and frequently used in many areas of physical therapy. However, the low scores are easily explained by the strict guidelines set by the American Society of Hand Therapists that were used during the evaluation of the participating therapists. The two remaining skills, joint mobilization and two-point discrimination, are not strictly visual but are skills that require tactile input. Initially, there was a concern on how transmission of tactile feelings could be transmitted via telehealth. With clear, concise instructions and appropriate camera placement it was demonstrated that these two skills could be learned. In this study, it was demonstrated that telehealth teaching, when compared with the conventional teaching model of direct face-to-face teaching, resulted in no statistically significant difference between the performance scores for any of the five skills taught. However, when compared with self-study, there were statistically significant differences in the performance scores, suggesting that the telehealth group learned more. Both of these results suggest that telehealth may be used as effectively as the conventional method and more effectively than self-study to teach these five assessment skills. In examining the competency scores for the telehealth and the direct, face-to-face groups there was once again no statistically significant difference between the groups at baseline. Differences in the competency levels were determined, however, after the educational intervention, indicating that the groups had become more competent in all five skills. When the telehealth group was compared with the self-study group, there were statistically significant differences between the groups' competency scores for all five skills. The results of this study must be interpreted with some caution. We did not, for example, ask the participants in the self-study group what they had done to prepare for the post-test. Thus, although we asked them to do what they would normally do if a patient being referred required that technique, we do not know what the participants in the SS group actually did or the length of time they might have spent preparing relative to the time spent in the formal intervention groups. It is unlikely that they spontaneously practiced, and even more unlikely that they sought external feedback for their practice, two components of the formal training programs that were likely very important. Further, we did not ask them what they would normally do in these circumstances, so without further study we cannot say whether the SS group's performance is representative of normal practice. Similarly, we do not know the extent of contamination between the groups. Although the participants were specifically asked not to interact between groups, we did not subsequently determine the extent to which they had followed these instructions. This might limit the validity of the findings, although it is worth noting that the group that had more motivation to violate this injunction to speak to others continued to have lower scores. Despite these potential limitations, the current study gives us great hope for the use of the telehealth medium for teaching not only technical information but also technical skills. Establishing telehealth as an effective teaching tool provides a method of continuing education to community health care professionals who need to perform these types of technical skills. Therefore, all professionals (nurses, therapists, doctors) would benefit from this technology, allowing increasingly early referral of complex cases to the community for ongoing rehabilitation. If telehealth is utilized to transmit and teach the required information, continuity of specialized care will be maintained with support provided to the community practitioner. Perhaps teaching of all assessment skills will not be possible, but telehealth will continue to provide a rich communication link between the acute care facilities and the community.

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