Is telerehabilitation a top priority for the Bulgarian healthcare system in the post COVID-19 era?

The COVID-19 pandemic has impacted all aspects of health care delivery and changed significantly the access and the utilization of rehabilitation services in many countries throughout the world as well as in Bulgaria [1]. Although, the COVID-19 pandemic has triggered all healthcare authorities in one direction, to promote the use of digital technologies [2]. One of the key changes implemented by the health care systems was the rapid expansion of telemedicine (TM) [3].TM is defined as the exchange of medical information using electronic tools to provide various services including consultations and physiotherapy [4]. TM has been shown to be effective in past pandemics, such as the Severe Acute Respiratory Syndrome Coronavirus, Middle East Respiratory Syndrome Coronavirus, Ebola, and Zika [5], and a possible solution in case either of COVID-19 patients or of outpatients' needs [6].

Telerehabilitation (TR) is a subfield of TM, described as the delivery of rehabilitation services via information and communication technologies. It includes rehabilitation services such as assessment, monitoring, prevention, intervention, supervision, education, consultation, and counseling [7]. TR has become more widely adopted for cardiac patients and individuals who live in rural areas or have restricted mobility due to the need to provide equal access to rehabilitation for communities with barriers to traditional models of care [8].

Several systematic reviews and meta-analyses have evaluated the benefits of TR, such as reduction in hospitalizations, readmissions and treatment costs to both patients and health care providers, early discharge from rehabilitation facilities, immediate access to outpatient rehabilitation units, and improvement in clinical outcomes and quality of life [9], [10], [11]. TR interventions have been shown to be safe and effective in several conditions and have been also suggested for patients after COVID-19 [12]. There were no reported deaths or noteworthy complications resulting from remotely monitored physical exercise [13]. Moreover, it has been proven that TR can induce long-term benefits compared to conventional in-person rehabilitation services [14]. However, the adoption of TR is complicated by several impediments such as lack of evidence-based TR guidelines; lack of awareness regarding TR; lack of legislative framework and privacy for telehealth technologies and informed consent, and lack of adequate training for health professionals in optimally delivering TR to patients [15]. Additional barriers such as lack of technical resources at home, digital literacy, slow Internet bandwidth, and the patient's age may limit the successful use of TR [6]. Evidence suggests that older multi-morbid persons, are less experienced in the use of digital and smart technologies, and would be most beneficial from TR [16]. Currently, the lack of national TM standards and TR guidelines as well as the lack of both, health insurance coverage and state reimbursement were identified as the biggest obstacles to the introduction of the TR in Bulgaria.

Despite limited access to in-person rehabilitation services in Bulgaria during the previous waves of the COVID-19 pandemic, no efforts to develop a national TR standard were made by the Bulgarian Society of Physical and Rehabilitation Medicine (BGSPRM) [17]. In contrast with many European PRM societies and academies, no webinars and online references promoting the role of TR have been organized by the BGSPRM.

The global pandemic has exposed the weakness of the Bulgarian health system, which has shown an impressive inability to adapt rehabilitation services in accordance with a new model of health care delivery. A panel of PRM experts from BGSPRM as well as experts from the Bulgarian Society of Cardiology (BSC), Bulgarian Society of Lung Diseases (BSLD), Bulgarian Orthopedic and Traumatology Association (BOTA), and experts from the Bulgarian Society of Neurology (BSN) collaborating in response to COVID-19 needs to be established in order to formulate the national guidelines about TM, where the terms tele-education, teleconsultation, and TR will be proposed with a strong commitment to their application. Additionally, the panel of experts must carefully update the National Regulation (BG) No. 9/2019, which defines the package of medical activities financed by National Health Insurance Fund (NHIF), in order to enable the use of telecommunication tools for diagnosis, treatment, and rehabilitation. The update of the above-mentioned National Regulation is in line with new models of health care delivery, considering the variations in discipline-specific rehabilitation standards and practice requirements, resources, cultures while safeguarding the rights and safety of stakeholders (providers and users) and will facilitate the successful introduction of TR in Bulgaria. Nevertheless, the pandemic and its negative impact on rehabilitation services have created unprecedented opportunities for the development of a new health policy agenda in which the immediate introduction and implementation of TR in Bulgaria should be prioritized. The central issues of the new health policy agenda regarding TR must include the development of a regulation that will guarantee effective, safe, and ethical delivery of TR services in Bulgaria. Moreover, it must include the development of a coherent and standardized system for the provision of teleconsultation, tele-education and treatment, adequate training of PRM physicians and health professionals for optimally delivering TR, as well as to ensure the privacy and security of health care information in the context of telehealth [18]. Data privacy and informed consent depend on the safety of the telecommunication tools and apps used, and this has legal implications. Such issues could be potentially addressed in the development of the legal framework of telehealth in Bulgaria and in building sustainable health information systems [15]. There is an unquestionable need to change the existing rules and regulations which will allow health insurance coverage and adequate state reimbursement of TR services in Bulgaria. Several EU guidelines, as well as Medicare [19], state that TR services must be paid for like conventional in-person rehabilitation [6].

The COVID-19 pandemic presented unique challenges to the Bulgarian health care system, Bulgarian PRM physicians, health policymakers, and Bulgarian patients and underscores the need for reorganization of rehabilitation services in Bulgaria [20]. Similarly to other EU countries, in Bulgaria TR is not perceived as medicine and patients have difficulties understanding TR interventions [6]. A mobile application designed and supported by BGSPRM may effectively serve as a tool for the promotion of TR and patient education for its successful use [17].

We hope that the Bulgarian health policymakers i.e., Bulgarian Ministry of Health (BMoH), NHIF, PRM experts from BGSPRM, and stakeholders acknowledge the challenges imposed by the current COVID-19 pandemic as an opportunity to reorganize and improve the quality of rehabilitation services in the country. Important lessons the Bulgarian health policymakers and PRM experts could have learned from other middle-income countries such as the Philippines, in which the new day for rehabilitation services in the post-COVID-19 era is likely to include TR in various forms [18]. We recommend the initial application of TR in Bulgaria, to start with the approval of clinical pathway No. 267, specially developed for the rehabilitation of post-COVID-19 syndrome after precise cost-utility and cost-effectiveness analysis by the NHIF experts. It may be achieved via mobile apps or the official website of NHIF and must be offered by PRM physicians and health care professionals, both certified in telehealth.

We suppose that the integration of the TR as a hybrid approach in several clinical pathways (musculoskeletal, neurological, cardiorespiratory, and oncological) will enable better and broader access to rehabilitation services for a larger number of users who are often disadvantaged by socio-demographic barriers and will improve the quality of rehabilitation services in Bulgaria. Finally, the Bulgarian health policymakers must prioritize the integration of TR in the new health policy agenda, in order to face the collateral damage to rehabilitation services caused by COVID-19 or other pandemics that may be occurred in the future.

Funding

This research received no external funding.

Ethical approval

Not required.

Patient consent

Not required.

Declaration of Competing Interest

The authors have no conflicts of interest to report.