Chapter 19

1. Chapter 19 Telenursing and Remote Access Telehealth

2. Objectives • Explore the use of telehealth technology in nursing practice. • Identify socioeconomic factors likely to increase the use of telehealth interventions. • Describe clinical and nonclinical uses of telehealth.

3. Objectives • Specify and describe the most common telehealth tools used in nursing practice. • Explore telehealth pathways and protocols. • Identify legal, ethical and regulatory issues of home telehealth practice.

4. Objectives • Describe the role of the telenurse. • Apply the Foundation of Knowledge model to home telehealth.

5. What is Telehealth? • relatively new term in our medical /nursing vocabulary; • refers to and a wide range of health services that are delivered by telecommunications-ready tools, such as the telephone, videophone, and computer. • The growing field of telehealth, particularly in nursing practice, will allow us to improve care delivery services even more.

6. History of Telehealth • While most of the advances in telehealth have taken place in the last 20 to 30 years, Craig and Patterson (2005) describe much earlier uses such as the use of bonfires to alert neighboring villages of the arrival of bubonic plague during the middle ages. • The National Institutes of Mental Health supported a program in the mid-1950’s that connected seven state hospitals in four different states via a closed-circuit telephone system (Venable 2005).

7. History of Telehealth • The first reported use of television to monitor patients in a clinical facility occurred in the 50’s which then led to the development of interactive closed circuit applications in the mid-60’s. • Craig and Patterson (2005) suggest that ever evolving technologies in digital transmission, the falling costs of computing in general, and the explosion of mobile phones and satellite communications will sustain the advance of telehealth.

8. Evolution of Telehealth • Early uses in the 1970s of more advanced forms of telehealth in the medical field, referred to as “telemedicine,” included teleradiology and telepathology—radiological and pathological images transmitted to specialists who were located at some distance (Allan, 2006).

9. Evolution of Telehealth • Success in telehealth was achieved after decades were spent refining the technology, which resulted in clearer imaging, more speedy transmissions, and accurate replication of data from remote locations to a central hub. • The end results of telehealth interactions today have helped to insure that professionals can replicate usual clinical interactions in all specialties regardless of the distance involved in the contact.

10. Nursing Aspects of Telehealth • Understanding telehealth and the potential use of telehealth technology in nursing practice is necessary in today’s changing healthcare arena. • Telehealth interventions or contacts are: • performed off-site • require less time spent on task because of the efficiencies offered by the technology applications.

11. Driving Forces For Telehealth • demographics • nursing/health care worker shortages • chronic conditions • the new, educated consumers • excessive costs of health care services that are increasing in need and kind.

12. Driving Forces For Telehealth • The American health care system spends $1.4 trillion/year on conventional medical care. • Much more should be expected to be spent annually in the coming decades. • A solution is to develop a new clinical model for American healthcare that includes technology. • Telehealth technology should be included to fill the gap resulting from an overabundance of patients and a scarcity of health care providers.

13. American Telemedicine Association Definition (2010) Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status. Closely associated with telemedicine is the term “telehealth,” which is often used to encompass a broader definition of remote healthcare that does not always involve clinical services. Videoconferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs, continuing medical education and nursing call centers are all considered part of telemedicine and telehealth. (¶ 1).

14. Transmission Formats • Store and Forward • digital images, video, audio, and clinical data are captured and stored on the client computer or device; then, at a convenient time, the data are transmitted securely (forwarded) to a specialist or clinician at another location for interpretation • Real Time • real-time or live interaction • Remote Monitoring • devices are used to capture and transmit biometric data • Telephony • monitoring via telephone

15. Clinical Applications Examples • Transmitting images for assessment or diagnosis: transmission of digital images of wounds for assessment and treatment consults. • Transmitting clinical data for assessment, diagnosis, or disease management, especially vital signs, blood glucose, and weight • Providing disease prevention and promotion of good health such as telephonic case management and patient education

16. Clinical Applications Examples, con’t. • Using telephonic health advice in emergent cases. One example is performing teletriage in call centers. • Using real-time video. One example is exchanging health services or education live via videoconference.

17. Real-Time Clinical Telehealth • Telemental health • Telerehabilitation • Telehomecare • Teleconsultations • Telehospice/ telepalliative care

18. Telenursing • Telenursing refers to the use of telecommunications and information technology for providing nursing services in health care to enhance care whenever a physical distance exists between patient and nurse, or between any number of nurses (Skiba, 1998).

19. Telenursing • The most developing area of telenursing today is in home telehealthcare. • According to regular surveys by the Association for Retired Persons (AARP, 1996), more than 90% of seniors want to remain independent at home and age in place. • Care at home is clearly a key concern and preference.

20. Telenursing • The home care industry’s newest challenge is to work with sicker patients, many of whom have been discharged from hospitals to home earlier than in the past. • Home care telenursing can also involve other activities such as providing customized patient education in dietary or exercise needs, nursing teleconsultations, review of results of medical tests and exams, and assistance to physicians in the implementation of medical treatment protocols.

21. Telenursing • Home care telenurses can well expect to play a vital and dynamic role in the changing delivery systems that are to be in place in the next decades.

22. Telehealth Patient Populations • Homebound • Limited access to transportation • Lack of primary care and emergency resources in rural or remote populations • As a strategy to reduce hospital length of stay • Managing patients in a major disaster, large scale nuclear/bio-chemical attack or in the case of an outbreak of highly infectious disease.

23. Chronic Disease Patients • At significant risk of having an acute episode when subtle but significant changes in their medical condition occur. The most common categories of chronic patients that are currently monitored include: • congestive heart failure (CHF), • chronic obstructive pulmonary disease (COPD), • diabetes, • those who require long-term wound care.

24. Elder Care Telehealth • In assisted living facilities or subacute care centers a kiosk can be used to obtain vital signs for large groups of people. • Vital sign reports can then be forwarded on a regularly established schedule to physicians and other involved in the patient’s care.

25. Employers/Wellness Programs • Monitor workers and offer telehealth options as a wellness program to: • reduce absenteeism and increase productivity. • lower healthcare costs and associated insurance premiums. • create financial incentives for achieving healthcare objectives such as appropriate weight, reduced blood pressure, and levels of exercise.

26. Tools of Home Telehealth • Central stations/web servers are key components to telehealth that can be as minimal as a single screen display or may be more comprehensive software applications that provide various functions including triaging  the data according to medical alerts which allow clinicians to quickly identify patients requiring immediate attention. 

27. Tools for Home Telehealth • Peripheral biometric devices can consist of fully integrated systems such as a vital signs monitor or they may be stand-alone telecommunications-ready devices such as blood pressure cuffs and blood glucose meters.

28. Tools of Home Telehealth • Telephones are already the most familiar household communications tool used in telehealthcare. • A telephone device can also be augmented for easier use by patients, as needed, with a lighted dial pad, an auto-dial system, and/or louder ringer.

29. Tools of Home Telehealth, con’t. • Video cameras and videophones are easily available consumer items that can be used in telehealth for show-and-tell demonstrations by nurses for patients, or to capture wound healing progress, among other applications. • Personal Emergency Response Systems (PERS) are well-known signaling devices worn as a pendant or otherwise made easily accessible to patients to ensure their safety and to access emergency care when needed, must usually in case of a fall.

30. Telehealth Tools, con’t • Sensor and activity monitoring systems can track activities of daily living of seniors and other at-risk individuals in their place of residence. • Medication management devicesare addressing a well-recognized major problem in healthcare today: medication management and compliance. • 32 million people are taking 3 or more medications daily, with even more medications typically being taken by those 65 years of age or older.

31. Home Telehealth Software • Allows creation of a digital health record (DHR): • Information to be recorded over time. • Trend information can also be developed for groups of patients or populations, allowing for population based analyses of interventions. • set an acceptable range of values for an individual patient when he or she is enrolled in the monitoring program.

32. Home Telehealth Software, con’t • Advanced telemonitoring software has sophisticated electronic notification protocols: • readings from multiple pieces of equipment on a single patient calculate risk of an acute episode • Sophisticated protocols can be developed related to both routine and alert information organizing communications with physicians, nurses and care givers.

33. Home Telehealth Practice and Protocols • Home telehealth programs will differ depending on the type of technology used and the focus of the telehealth programs. • Informed written consent must be obtained from the client or designee before beginning the use of telehealth consultations. • Telehealth pathways and protocols ensure more focused work with patients and allow for targeted interventions.

34. Home Telehealth Practice and Protocols • The use of telehealth tools, together with clinical oversight/practice, allows for more efficient and effective clinical management by allowing the patients’ needs to drive the care. • As home telehealth protocols are utilized more extensively, the improved clinical and operational efficiencies may ultimately impact the home care agencies’ bottom lines.

35. Policies and Procedures Address: • patient enrollment, education, and equipment setup; • home assessment; • patient informed consent and privacy and confidentiality rights. • clinical plan of care that is specific to patient needs should be developed.

36. Legal and Ethical Aspects • nurses must be licensed to practice in all of the states in which they provide telehealth services. • scope of practice and accountability for practice must be defined • nurses must be vigilant about keeping extensive documentation of their visits on and off site.

37. Confidentiality and Privacy • Information systems must ensure a high level of data security • Patients and families should have the opportunity to revise consent after they fully understand the intrusiveness of home monitoring • All involved parties, including the technical staff assistants, must have appropriate training in privacy and confidentiality issues.

38. Patient Use Considerations • Elders may have sensory, cognitive, and motor disabilities. • Usability testing needed to maximize the quality of the user experience • special attention to design details for Web-based interfaces, such as font choices and color schemes to improve readability. (Demiris et al. 2009)

39. Ethical Design PrinciplesKaplan and Litweka (2008) • How provider or patient-centric is the technology? • Does the shift to remote services promote rationality and efficiency at the expense of values traditionally at the heart of caregiving? • How does the design affect home life and family dynamics? • To what extent should technology usage involve attempts to manipulate users into different behaviors?

40. Ethical Design, con’t. • How might the replacement of human contact by new technologies be ameliorated? • To what extent is the deployment of technology an end in itself, aimed not toward the improvement of health or well-being, but to create market needs? • How do we identify the boundaries between genuine solutions and futility in light of technologies that may shift them? (p. 404)

41. The Foundation of Knowledge Model and Home Telehealth • Knowledge acquisition involves the nurse’s receiving the information from the telehealth devices via a variety communication modes. • Knowledge processingis understanding a set of information and ways it can be useful to a specific task.

42. The Foundation of Knowledge Model and Home Telehealth • After processing information, the nurse is able to target the appropriate next steps involving knowledge generation and knowledge dissemination. • The nurse considers all of the data as it applies to this patient, and decides which is the best course of action to be taken and acts on the data.

43. Summary • Telehealth is a rapidly developing mode of health service delivery in which nurses can expect to play a key role. • The practice of telehealth will provide opportunities for telenurses to play a key role in care management across the healthcare continuum.

44. The Future • The technology associated with home telehealth will become much more sophisticated and integrated over time. • Monitoring equipment will become more affordable and this affordability will spur further demand. • Another clear future direction is that home monitoring equipment will be much more portable and likely will utilize wireless technology.

45. The Future • Home monitoring systems will be integrated with an expanded array of other equipment that monitor safety and functionality. • Emergency response devices, environmental safety monitors, motion sensors, activity of daily living measures and a host of other equipment will be integrated, providing a much more comprehensive view of the patient, their physical status and ability to function.

46. Thought Provoking Questions 1. Telehealth technology has extended the arms of traditional health care delivery into homes, clinics, and other environments outside the bricks and mortar of hospitals.Will the increased use of these telehealth technology tools be viewed as “de-humanizing” patient care or will they be viewed as a means to promote more contact with healthcare providers and new ways for people to “stay connected” as in on-line disease support groups), thereby creating better long term disease management and patient satisfaction?

47. Thought Provoking Questions 2. What types of resistance to new technologies might be evident among patients, caregivers, and nurses? What evidence and strategies might help to diminish these resistances?

48. Thought Provoking Questions 3. As telehealth technology advances towards seamless data access regardless of distance or health system, how can we protect patient privacy rights and the confidentiality of personal medical data?

49. Thought Provoking Questions 3. Consider a recent patient care scenario and describe how it could have been managed at a distance. • What training would you need? • What equipment would you use? • How would your patient and his or her family respond to home telemonitoring?