COVID-19 digital practice expansion: when allied health forgot evidence-based practice

This year has seen an explosion in the delivery of health and disability services online. From speech pathologists to GPs, physiotherapists and psychologists, there’s been a boom in the uptake of remote consultations across the world. Many consumers and clinicians have come to prefer remote consultations. It hasn’t just been a shift in service delivery models, but a drastic shift in attitudes towards the effectiveness of services delivered in this fashion.

Until recently, many clinicians had never conducted a telephone consultation or a video call with a patient. Last year, when I told people that I ran an online allied health provider, many scoffed or offered negative comments about the limited scope and lack of effectiveness of digital practice. I know that many of those people now provide a significant portion of their own services online, and even market themselves as experts in some cases.

It’s vindicating to see people jumping on board and trying it out, but the most important thing to me is that people in bush communities like mine, across Australia, now have just a little bit more choice and control over how they live their lives — because this little shift can make a huge difference.

Ed Johnson, Chief Clinical Officer and Co-Founder of Umbo.

A damaging inertia towards change in allied health

In my last decade as a practising speech pathologist, I’ve come to see that health professionals are just as scared of change and uncertainty as anyone else. Perhaps even more so. We constantly fear our own competence, and we fear a loss of face in the instance that novel approaches or service delivery models prove more effective than what we’ve always done.

Amongst community members and clinicians, uptake of online practice and consultations has risen exponentially in 2020. The only problem is that our fear is still limiting the possibilities this momentous digital shift could bring.

Working with people with complex disabilities can be… well… complex. But it is certainly possible to support them online, and this is well supported by the peer-reviewed literature. Kids with autism spectrum disorder with challenging behaviours, adults with cerebral palsy who are non-verbal and have limited mobility, and a person with schizophrenia living in supported accommodation who struggles to be understood consistently across a number of environments are examples of people many speech pathologists would shy away from supporting online. But the evidence backs the effectiveness of online interventions for people with complex needs like these. It’s just not being used.

It’s time for evidence-based practice

There are few clinicians following digital practice approaches recommended by the science. This quick shift from in-person services to digital practice has skipped a step — evidence-based practice.

Many clinicians are learning from friends, Facebook groups and peers. While peer learning is useful and commendable, there needs to be quality control driven by a focus on following evidence rather than presumed trends.

In many cases, clinicians are attempting online therapy by simply plonking people with complex disabilities in front of video screens. But online therapy doesn’t work like that. If a person with no verbal language has a goal to order their morning coffee independently, or a child with Down’s syndrome needs to learn how to sign ‘toilet’ to his teacher, then why would either of those people get any use out of sitting in front of a screen and talking with a speech pathologist? The answer is that they wouldn’t. In those situations, naturalistic learning environments must be employed or we’re wasting our time.

Best practice highlights the need to coach the people who support patients to practise those skills in naturalistic environments. If people with intellectual disabilities learn in the context in which they hope to use a new skill, the likelihood of them retaining that skill is greatly increased. Also, if we coach the people around them, we build capacity within that school, service or community, so we can increase therapeutic dosage and spread skills further than the initial client.

This is easily done by using our creative clinician minds to approach digital practice differently. Instead of putting someone in a chair in front of a computer, we might observe them via a video phone call, ask family or supporters to send a video of the relevant context or behaviour, and coach people supporting the client in real time by following them with an iPad.

These are simple yet effective solutions to improving the quality of allied health digital practice with people with complex disabilities. I very much hope that the next great shift in this technological revolution is that the industry starts to remember the most important tool we have — evidence-based practice.