The purpose of this course is to provide nurses with information and current evidence-based best practices for the use of telemedicine.
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Syllabus
The purpose of this course is to provide nurses with information and current evidence-based best practices for the use of telemedicine. Upon completion of this activity, participants should be able to:
- Describe the concept of telemedicine.
- Discuss the history of telemedicine.
- List the advantages and limitations of telemedicine.
- Identify ethical-legal concerns for the use of telemedicine.
- Describe where and how telemedicine is used today.
- Discuss future trends for the use of telemedicine
The Concept of Telemedicine
According to the American Telemedicine Association (2018)
Telemedicine is defined as the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status. Closely associated with the term telemedicine is telehealth, which is often used to encompass a broader definition of remote healthcare that does not always involve clinical services.
The prefix tele is a Greek word meaning far from or at a distance. Telemedicine focuses on interactions between the patient and their healthcare provider. For example, a primary care patient may elect to be seen by their nurse practitioner via secure videoconferencing for a follow-up appointment, instead of traveling to that provider’s office. Telehealth is a broader term, which includes telemedicine as well as other healthcare services provided remotely. While telehealth is broader in scope than telemedicine, the terms are often viewed as synonyms and used interchangeably (Lyuboslavsky, 2015; American Telemedicine Association, 2018).
Perdew, Erickson, and Litke (2017) described a telehealth program implemented by the Veterans Health Administration (VA) that provides video telehealth pharmacist consultations and medication management for veterans in Alaska and the northwest. This innovative program is managed from a hub at the Boise, Idaho VA Medical Center (Perdew et al., 2017).
In the 1990’s, the National Council of State Boards of Nursing (NCSBN) stated that nursing services provided using telecommunication technology should be regulated by state boards of nursing. Telehealth nursing practice is defined as “the practice of nursing delivered through various telecommunications technologies including high-speed internet, wireless, satellite, and tele-video communications” (NCSBN, 2015, p. 16).
According to The Office of the National Coordinator for Health Information Technology (ONC, 2017) and Lyuboslavsky (2015) telemedicine applications include:
- Synchronous (live) videoconferencing: a two-way audiovisual link between a patient and a provider.
- Asynchronous (store and forward): the information, such as a recorded health history, is sent and retrieved later by the provider for review.
- Remote patient monitoring (RPM) or telemonitoring: the use of connected tools to record personal health and medical data in one location, such as the patient’s home, for review by the provider at another location, usually at a different time.
- Mobile health (mHealth): healthcare and public health information provided through mobile devices. This information may include educational information, targeted texts, and notifications about disease outbreaks.
An introduction to telemedicine would be incomplete without discussing hybrid practice. Hybrid practice allows the patient to combine face-to-face provider office visits with telemedicine (remote) visits. For example, a patient may go to the provider’s office for their first new-patient appointment and do synchronous telemedicine visits for subsequent provider encounters. Hybrid practice also gives the provider and the patient the option of deciding when a face-to-face office visit is needed (Lyuboslavsky, 2015).
The History of Telemedicine
The purpose of telemedicine is to communicate medical data over a long distance. The history of telemedicine begins with the age of the hunter-gatherer. Hunter-gatherer tribes used human messengers to communicate between tribes and to deliver medicine. Moving forward in history to ancient Greece and Rome, human messengers used smoke signals to communicate disease outbreaks. The telegraph was used during the Civil War to send information on battlefield casualties and order medical supplies. In 1905, a Dutch physiologist used the telephone to transmit cardiac sounds and rhythms. Moving forward to the space age, the National Aeronautics and Space Administration (NASA) used telemedicine to monitor and provide healthcare for astronauts in space. In the 1990’s, the internet provided a platform for patient education and real time audio and video consultation. The 2010 Affordable Care Act was a driving force behind the development and adoption of the electronic medical record (EMR) by healthcare facilities. The EMR positively impacts care coordination and quality of care (Fathi, Modin & Scott, 2018; Lyuboslavsky, 2015).
The 21st Century Cures Act, passed by congress in 2016, includes requirements to improve patients’ access to and use of their EMR via a secure patient portal. The ONC studied individual patients’ use of their EMR and technology to monitor and better meet their healthcare needs. As of 2017, 52% of individuals in the United States have been offered online access to their EMR by their provider or their insurer and over half of those individuals accessed and viewed their EMR. Of those patients who accessed their EMR, 80% found it to be useful and easy to understand. As of 2017, one in three individuals in the United States used an electronic device, such as a fitness tracker or blood pressure monitor; and 40% used a health or wellness app on their tablet or smart phone (Patel & Johnson, 2018).
The Advantages and Limitations of Telemedicine
Telemedicine has several advantages. The first advantage of telemedicine is improved access to care. This is particularly important in rural areas where a clinic or hospital may be several hours away from the patient’s home. Arkansas, which is largely a rural and medically underserved state, has only one academic medical center. Every hospital in Arkansas has interactive video equipment providing a telemedicine application to manage complex patients via synchronous videoconferencing. A second advantage of telemedicine is less travel. For example, telemedicine can be used for some provider visits, which enables the patient to connect to their provider from home without traveling to an office building or hospital. The third advantage of telemedicine is convenience. Patients may not need to take time off from work for provider appointments (Imus, 2015; Thomas, 2018). A fourth advantage of telemedicine is that it is cost effective. Cost effectiveness for the patient is due to reduction or elimination of travel expenses and lost time/wages from work. Cost effectiveness for the healthcare provider is related to a decreased demand for physical office space for patient appointments and less missed appointments. A fifth advantage of telemedicine is increased patient satisfaction. Asynchronous telemedicine, where patients provide their chief complaint and recorded health history, improves patient satisfaction because providers are able to review this information and consider appropriate treatment options prior to the patient office visit (Lyuboslavsky, 2015; City of Tempe, 2017). A sixth advantage of telemedicine is positive clinical outcomes associated with the use of telemedicine. Remote patient monitoring (RPM) allows patients with chronic conditions, such as diabetes, hypertension, or heart disease, to remain stable and avoid complications. Wu & Ray (2016) described the use of technology and telemedicine, within a framework of caring, to improve clinical outcomes for patients in Australia, who have both cardiac disease and diabetes. Caring is a core value in nursing prac
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tice and nurses whose practice includes telemedicine need to be aware that telemedicine and remote visits may lead to some patients feeling less connected to the members of their healthcare team. In 2017, the city of Tempe, Arizona Fire Medical Rescue Department established a unique partnership with Tempe Saint Luke’s Hospital and the VA Medical Center in Phoenix, providing a hybrid form of telemedicine. The program was designed to assess and monitor military veterans with chronic heath conditions who are considered to be high risk. The Tempe fire department provides registered nurses who assess veterans in their homes and consult via video conferencing with a VA nurse practitioner to address medical needs. This has resulted in fewer emergency room visits for the veterans and improved clinical outcomes (City of Tempe, 2017; Wu & Ray, 2016).
While telemedicine has several advantages, there are a few limitations. The first limitation is the potential for connectivity issues, such as poor or limited internet connectivity. Telemedicine requires consistent, adequate internet connectivity and bandwidth. A second limitation is the training and education required both for the healthcare providers and for the patients who are using some form of telemedicine to meet their healthcare needs. A third limitation is patient unease with technology. Patients who are less tech savvy are often uneasy with using telemedicine to manage a portion of their healthcare needs. Each of these limitations can be addressed and minimized. With improvements in technology, internet connectivity and bandwidth continue to improve. The time and money spent to thoroughly train staff and patients on the telemedicine applications that they use will pay off in increased satisfaction and ease of use for both parties. Patient unease can also be minimized with comprehensive patient education on the telemedicine application(s) that the patient will be using. Some patients, such as retirees, may have more time and flexible schedules and therefore prefer face-to-face office visits with their provider(s) and will choose to opt out of telemedicine visits (Harrington, 2018; Lyuboslavsky, 2015; Thomas, 2018).
Ethical-Legal Concerns for the Use of Telemedicine
There are ethical-legal concerns for the use of telemedicine. The first concern is reimbursement. Reimbursement for telehealth services vary and is dependent upon federal and state guidelines. Currently, there are Medicare restrictions and limitations on both the location of telehealth services and the number of visits. In 2019, Medicare guidelines have approved reimbursement for virtual check-ins, remote physiological monitoring, and chronic care management as services separate from telehealth. Each state determines the Medicaid reimbursement rates for services provided via telehealth or telemedicine. Reimbursement by insurance companies also varies widely (National Consortium of Telehealth Resource Centers, 2019).
Licensing and regulatory boards are a second ethical-legal concern. Each state regulates the licensing of providers and nurses who reside in that state. Telehealth and telemedicine may require a nurse or other healthcare professional to provide services beyond their state borders. The enhanced Nursing Licensure Compact (eNLC) enables nurses to be licensed in their home state and by extension, practice in states which are also part of the eNLC. However, this does not currently pertain to all 50 states. A third concern are the laws which regulate prescribing. Individual states control how medications, except controlled substances, are prescribed via telehealth, and regulations vary from state to state. The Ryan Haight Act is federal legislation that specifies how telemedicine may be used to prescribe controlled substances. A fourth concern is HIPAA compliance. HIPAA does not have specific telehealth requirements, so a telehealth provider must meet the same HIPAA requirements as a provider engaged in a face-to-face visit. In addition to HIPAA, states may have additional privacy and security laws. The final ethical-legal concern we will mention here is malpractice insurance. Some insurance carriers may not provide malpractice coverage for any telehealth services or may not cover telehealth services provided in another state (Fathi, et al., 2017; Loughran, 2017; National Consortium of Telehealth Services, 2019).
Where and How Telemedicine is Used Today
One of the earliest adopters of telemedicine is the VA. Many military veterans live a considerable distance from the nearest VA Medical Center or VA Clinic. In addition, older veterans often have significant chronic health conditions that may make it difficult to travel. Telemedicine allows veterans to use remote monitoring to manage chronic health conditions or synchronous videoconferencing for some of their provider appointments (U.S. Department of Veterans Affairs, 2016; Thomas, 2018).
Skilled nursing facilities have begun to use telemedicine as part of the care provided for nursing home residents. TripleCare is a telehealth program deployed in 45 facilities in six states that provides virtual evaluation for residents with a change in condition to better manage their care and avoid hospitalizations (Chess & Croll, 2016).
The American Heart Association Stroke Council’s Scientific Statement for Healthcare Professionals on Telemedicine Quality and Outcomes in Stroke noted that telemedicine connects stroke experts with smaller hospitals that lack providers with experience in assessing and managing patients who present to the emergency room with stroke symptoms in order to improve patient outcomes (Wechsler, et al., 2017).
The American Telemedicine Association (2018) defines teleICU as a collaborative interprofessional model focusing on the care of critically ill patients using telehealth. The purpose of teleICU is to provide patient care advice and guidance to the ICU nurses at the patient’s bedside to implement best evidence-based practices and improve patient outcomes (Canfield & Galvin, 2018).
Telemedicine is a global initiative. The World Health Organization views telehealth as a cost-effective strategy that can improve healthcare access and patient outcomes. Currently in Kenya, patients with HIV have face-to-face home visits while their health status is tracked by a handheld personal digital assistant (PDA) which interfaces with the patient’s EMR, improving continuity of care (World Health Organization, 2019).
Future Trends for the Use of Telemedicine
In conclusion, the future will see continued growth in the adoption of telemedicine. Big data analytics and precision medicine have the potential to shift patient care from curing disease to a holistic outcomes-based model focused on disease prevention. The technology that develops and supports wearables, such as fitness trackers, will continue to improve and produce meaningful data to improve chronic care management and health outcomes (Kamani, 2019; Van Alstin, 2016).
Nursing education should also be future-oriented. With the continued growth of telemedicine and telehealth, nursing students need to be educated from the beginning on the use of telemedicine to provide patient care (Love & Carrington, 2018; Skiba, 2015).
References
American Telemedicine Association. (2018). Telemedicine Glossary. Retrieved from https://thesource.americantelemed.org/resources/telemedicine-glossary
Canfield, C., & Galvin, S. (2018). Bedside Nurse Acceptance of Intensive Care Unit Telemedicine Presence. Critical Care Nurse, 38(6), e1–e4. doi:10.4037/ccn2018926
Chess, D. & Croll, D. (2016). Telemedicine provides bedside care in the nursing home. Caring for the Ages, 17(8). 12.
City of Tempe Veterans Telemedicine Program. (2017). Joined forces: How Tempe fire medical rescue department and Phoenix VA combine house calls and technology to bring health care to city’s veterans. Retrieved from https://www.tempe.gov/
Fathi, J.T., Modin, H.E., & Scott, J.D., (2017) Nurses advancing telehealth services in the era of healthcare reform. OJIN: The Online Journal of Issues in Nursing, 22(2). Retrieved from http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-22-2017/No2-May-2017/Nurses-Advancing-Telehealth-Services.html
Harrington, L. (2018). From apps to mHealth: Informing, interacting, and changing behavior. AACN Advanced Critical Care, 29(3), 240–243. doi:10.4037/aacnacc2018240
Imus, T. (2015). Telehealth Nursing. ASBN Update, 19(1), 18–19.
Kamani, V. (2019). Inside interoperability. Four ways big data advances telemedicine. For the Record (Great Valley Publishing Company, Inc.), 31(5), 8–9.
Loughran, M. (2017). The enhanced nursing compact and its implications. Journal of Legal Nurse Consulting, 28(4), 10–13.
Love, R. A., & Carrington, J. M. (2018). Telehealth: Bridging the care gap in mental health treatment. Reflections on Nursing Leadership, 44(2), 145–150.
Lyuboslavsky, V. (2015). Telemedicine and telehealth 2.0: A practical guide for medical providers and patients. United States: Victor Lyuboslavsky.
National Consortium of Telehealth Resource Centers. (2019). Telehealth policy issues. Retrieved from https://www.telehealthresourcecenter.org/wp-content/uploads/2019/02/Policy-Factsheet-Feb.-2019.pdfhttps://www.telehealthresourcecenter.org/wp-content/uploads/2019/02/Policy-Factsheet-Feb.-2019.pdf
National Council of State Boards of Nursing. (2015). Position paper on telehealth nursing practice. Dakota Nurse Connection, 13(1), 16–17.
The Office of the National Coordinator for Health Information Technology. (2017). Telemedicine and telehealth. Retrieved from https://www.healthit.gov/topic/health-it-initiatives/telemedicine-and-telehealth
Patel, V. & Johnson, C, (2018), Individuals’ use of online medical records and technology for health needs. ONC Data Brief, 40, 1-17. Retrieved from https://www.healthit.gov/sites/default/files/page/2018-04/HINTS-2017-Consumer-Data-Brief-april-2018.pdf
Perdew, C., Erickson, K., & Litke, J. (2017). Innovative models for providing clinical pharmacy services to remote locations using clinical video telehealth. American Journal of Health-System Pharmacy, 74(14), 1093–1098. doi:10.2146/ajhp160625
Scott, A. (2018). Bridging gaps between silos of care with simulation and telehealth. Reflections on Nursing Leadership, 44(2), 231–235.
Skiba, D. J. (2015). Connected Health: Preparing Practitioners. Nursing Education Perspectives (National League for Nursing), 36(3), 198–201.
Thomas, M. (2018). Telehealth Revolutionizing Veterans Healthcare. Retrieved from
https://www.va.gov/HEALTH/NewsFeatures/2018/January/Telehealth_Revolutionizing_Veterans_Health_Care.asp
Van Alstin, C. M. (2016). Looking forward: HIT in 2016 and beyond. Health Management Technology, 37(1), 6–9.
U. S. Department of Veterans Affairs. (2016). VA Telehealth services fact sheet. Retrieved from
https://www.va.gov/COMMUNITYCARE/docs/news/VA_Telehealth_Services.pdf
Wechsler L.R., Demaerschalk, B.M., Schwamm, L. H., Adeoye, O.M., Audebert, H. J., Fanale, C. V., …Switzer J. A. (2017). Telemedicine quality and outcomes in stroke: A scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 48(1), e3–e25. doi:10.1161/STR.0000000000000114.
World Health Organization. (2019). Health and sustainable development telehealth. Retrieved from https://www.who.int/sustainable-development/health-sector/strategies/telehealth/en/
Wu, C. J. & Ray, M. A. (2016). Technological caring for complexities of patients with cardiac disease comorbid with diabetes. International Journal for Human Caring, 20(2), 83–87. doi:10.20467/1091-5710.20.2.83