Telenursing: Is it my future?

This is the scenario for the paper. You have worked with Tomika for the past 5 years. Tomika shares with you that she has resigned and plans to work in an agency that installs tele-monitoring equipment into the homes of those with chronic illnesses. Nurses monitor the patients using the equipment with the goal of detecting problems before patients need to be readmitted to the hospital. Tomika will be working from her own home, with occasional meetings at the agency. She would not be visiting her patients in their homes, but rather would be assessing and interacting with them via videoconferencing.

She tells you that there are still job openings and encourages you to apply. You are intrigued by this, and decide to investigate whether tele-nursing would be a good choice for you, too. Is telenursing in your future? This is resources of information related to the paper. Library Search for Telenursing Resources Collecting data is a skill that allows a professional nurse to combine critical thinking with clinical judgment. Searching and choosing the desired information will impact the decision made by the nurse (Chamberlain College of Nursing, 2015).

Pubmed: Prerequisites for Effective Implementation of Telemedicine: Focusing on Current Situations in Korea. When the outbreak in the middle east occurred, the government sent telemedicine over to assist in the care. Without having sufficient conversations and decisions made amongst policies regarding the costs, system stability, legal issues, and efficient implementation of telemedicine it was difficult to get up and to run. With the development of technology today, telemedicine is capable of being instituted and utilized, the lack of sufficient discussions is the concern with telemedicine (Hyeoi-Yun Lee, Ji-Sen Lee MSN, & Jeongeun Kim PHD, 2016).

Cinahl: Implementing a telehealth service: nurses’ perceptions and experiences. Nurses knowledge and experience with telehealth service and the technology today we have the potential to enable families and individuals to obtain care from home. The study found that uncertainty and knowledge of what telehealth is causes a barrier to the development and transition into telehealth. Clear communication is essential for the implementation of the development of a strategic plan to manage and ensure confidence in staff along with strong technical support (Bassel Odeh, 2014).

Google Scholar: Examining the use of telehealth in community nursing: identifying the factors affecting frontline staff acceptance and telehealth adoption. Investigating the use of telehealth with the need for a close working interdisciplinary team along with strong technical support is essential for implementing telehealth. Staff training along with education on telemedicine with having a strong leadership, committed funding, and implementation plan. Having technology that is functional and interoperable is necessary for the success of telehealth.

Having the support of the front line staff is crucial to the innovation of telemedicine to have the positive experience of definite success (Johanna Taylor, 2014). EBSCO Databases: Back to the future? Telehealth services, tele-nursing are on the rise. A study which shows the use of telemedicine in the ICU has proven to be successful in improving patient outcomes, decrease readmissions, reduced patient mortality, shorter length of stay, and increased cost savings for the hospital. The use of knowledgeable/experienced nurses with experience and critical thinking was determined to be part of the key success in telenursing (Susan Trossman, 2014). Telehealth is capable fo equity by crossing temporal, social, and geographical barriers to healthcare (Hebda & Czar, 2012, p. 505). Telehealth has the capability to improve quality healthcare and save money. With attentions to patient safety, cost containment, managed care, disease management, shortages of healthcare providers, unequal access to health care, along with keeping the aging population to be functional in their homes (Hebda & Czar, 2012, p. 509).

Many barriers including reimbursement and licensure along with support and policies have been major concerns. Many demands are being verbalized for better coordination of planning, implementation, allocation of resources and patient safety with telemedicine (Hebda & Czar, 2012, p. 523). References Bassel Odeh, R. K. (2014, September). Implementing a telehealth service: nurses\’ perceptions and experiences. British Journal Of Nursing, 23(21), 1133-1137 5p. doi:10.12968/bjon.2014.23.21.1133 Chamberlain College of Nursing. (2015, 11).

NR-361 Week 3: Informatics in the Healthcare Professions [online lesson]. Downers Grove, IL: DeVry Education Group. Hebda, T. L., & Czar, p. (2012, 03). Handbook of Informatics for Nurses & Healthcare Professionals. [Vitalsource Bookshelf Online](5th Edition). Retrieved fromhttps://online.vitalsource.com/#/books/9781269431095/ Hyeoi-Yun Lee, M. R., Ji-Sen Lee MSN, R., & Jeongeun Kim PHD, R. (2016, January 31). Prerequisites for Effective Implementation of . 22 (1):61. Korea. doi:10,4258/hir.2015.21.4.251 Johanna Taylor, E. C. (2014, June 21).

Examining the use of telehealth in community nursing: identifying the factors affecting frontline staff acceptance and telehealth adoption. Journal of Advanced Nursing, 72(2), 326-337. doi:10.1111/jan.12480 Susan Trossman, R. (2014, September). Back to the Future? Telehealth services, tele-nursing are on the rise. The American Nurse, 46, 5, 1. United States. Retrieved from http://search.ebscohost.com.proxy.chamberlain.edu:8080/login.aspx?direct=tru&db=mnh&AN=26072644&site=ehost-live

This is the rubic for grading and requirements of paper Telenursing: Is It in My Future? Guidelines and Grading Rubric PURPOSE The purpose of this assignment is to explore the specialty of telehealth, and more specifically telenursing, as one example of the use of technology in various practice settings. Advantages and disadvantages for the patient and legal and ethical principles for the nurse of this technology will be explored.

COURSE OUTCOMES This assignment enables the student to meet the following Course Outcomes. CO #4: Investigate safeguards and decision-making support tools embedded in patient care technologies and information systems to support a safe practice environment for both patients and healthcare workers. (PO #4) CO #6: Discuss the principles of data integrity, professional ethics, and legal requirements related to datasecurity, regulatory requirements, confidentiality, and client’s right toprivacy. (PO #6) POINTS This assignment is worth a total of 200 points. DUE DATE Your completed paper is due at the end of Week 4. Submit it to the basket in the Dropbox by Sunday at 11:59 p.m. mountain time. Post your questions to the weekly Q & A Forum. Contact your instructor if you need additional assistance. See the Course Policies regarding late assignments. Failure to submit your paper to the Dropbox on time will result in a deduction of points. BACKGROUND Our text (Hebda, 2013) provides us with a broad perspective on telehealth. However, the specialty of telenursing is only briefly discussed. Healthcare is readily embracing any technology to improve patient outcomes, streamline operations, and lower costs. This technology includes the use of various applications based in various environments where registered nurses indirectly provide professional nursing care. SCENARIO The following scenario serves as the basis for your paper. You have worked with Tomika for the past 5 years. Tomika shares with you that she has resigned and plans to work in an agency that installs telemonitoring equipment into the homes of those with chronic illnesses. Nurses monitor the patients using the equipment with the goal of detecting problems before patients need to be readmitted to the hospital. Tomika will be working from her own home, with occasional meetings at the agency. She would not be visiting her patients in their homes, but rather would be assessing and interacting with them via videoconferencing. She tells you that there are still job openings and encourages you to apply. You are intrigued by this, and decide to investigate whether telenursing would be a good choice for you, too. Is telenursing in your future? DIRECTIONS 1. You are to research (find evidence), compose, and type a scholarly paper that describes telenursing as described above, and whether it is a good fit for you. Reflect on what you have learned in this class to date about technology, privacy rights, ethical issues, interoperability, patient satisfaction, consumer education, and other topics. Your text by Hebda (2013, Chapter 25) discusses telehealth in detail. However, your focus should be from the professional nurse’s role in telenursing. Do not limit your review of the literature to only what you read in your text. Nurses in various specialties need to know about the advantages and disadvantages of telenursing as it applies to their patients. For example, when you discharge a patient from an acute care setting, will a telenursing service assist that individual with staying out of the hospital? You may need to apply critical-thinking skills to development of your paper. In the conclusion paragraph of your paper, describe your current employment situation, and whether a job in telenursing would, or would not, fit with your career goals and life situation once you graduate from Chamberlain. 2. Use Microsoft Word and APA formatting to develop your paper. Consult the Publication manual of the APA, 6th edition if you have questions, for example, margin size, font type and size (point), use of third person, and so forth. Take advantage of the writing service, Smarthinking, which is accessed by clicking on the link called the Tutor Source, found under the Course Home area. Also, review and use the various documents in Doc Sharing related to APA. 3. The length of the paper should be four to five pages, excluding the title page and the reference page. Limit your references to key sources. 4. The paper should contain an introduction that catches the attention of the reader with interesting facts and supporting sources of evidence, which need to be mentioned as in-text citations. Keep in mind that APA guidelines state you are not to call this an Introduction, but you should include it at the beginning of your paper. The Body should present the advantages and disadvantages of telenursing from your perspective as an employee, and the patient’s perspective as a recipient of the care nurses provide. The Conclusion and Recommendations should summarize your findings and state your position on whether you will apply for a position with the agency. NOTE: Review the section on Academic Honesty found in the Chamberlain Course Policies. All work must be original (in your own words) unless properly cited. This assignment will automatically be submitted through Turnitin, a plagiarism detection system. Submit the completed paper to the “Telenursing . . . Is It in My Future?��� by Sunday, 11:59 p.m. MT at the end of Week 4. Please post questions about this assignment to the weekly Q & A Forum so that the entire class may view the answers. GRADING CRITERIA Category Points % Description Introduction 50 25% The Introduction provides evidence of an information search including in-text citations of the sources of evidence. It catches the reader’s attention with interesting facts and supporting sources. Body 100 50% Appropriate headings are used to delineate when the introduction ends. More than three advantages and three disadvantages are identified, discussed briefly, and supported by citations. Conclusion and Recommendations 25 12.5% Appropriate headings are used, making clear the conclusion and recommendations based on solid evidence, privacy rights, and ethical principles, and so forth. State your current employment situation, and whether a job in telenursing could be in your future. Provide pros and cons for this decision. Scholarly Writing and APA Format 25 12.5% • Title page, running head, and page numbers. (3 points) • Introduction, body, and conclusion/recommendations sections are clearly labeled. There is a logical flow between the sections. (10 points) • Grammar, punctuation, and sentence structure are correct. (2 points) • Citations throughout demonstrate support of student’s ideas and opinions. (5 points) • Reference page includes all citations. (3 points) • Evidence of spell and grammar check. (2 points) Total 200 100% A quality assignment will meet or exceed all of the above requirements. GRADING RUBRIC Assignment Criteria A Outstanding or Highest Level of Performance B Very Good or High Level of Performance C Competent or Satisfactory Level of Performance F Poor or Failing or Unsatisfactory Level of Performance Introduction 50 points Evidence of information search. Catches the reader’s attention with interesting facts and supporting sources that include citations to three or more scholarly sources. 46–50 points Evidence of information search. Catches the reader’s attention with interesting facts and supporting sources that include citations to two scholarly resources. 42–45 points Evidence of information search includes only one citation to scholarly resource. No attention- catching hook noted. 38–41 points Little or no evidence of information search. No citations provided and/or there is no attention-catching hook. 0–37 points Body 100 points More than three advantages and three disadvantages from a nursing and a patient perspective are identified and supported by citations. 92–100 points At least three advantages and three disadvantages from a nursing and a patient perspective are identified and supported by citations. 84–91 points At least two advantages and two disadvantages from a nursing and a patient perspective are identified and supported by citations. 76–83 points Only one advantage and one disadvantage from a nursing and a patient perspective is identified and supported by citations. 0–75 points Conclusion and Recommendation 25 points Conclusion is presented based on cited evidence of how telenursing affects the patient regarding personal privacy rights, and ethical principles. Includes current employment situation, and whether a job in telenursing could be in the student’s future along with pros and cons for this decision. 23–25 points Conclusion contains cited evidence for recommendation, but may lack persuasive use of privacyrights and/or ethical principles. Includes current employment situation, and whether a job in telenursing could be in the student’s future but no rationale for the choice. 21–22 points Indicates conclusion and recommendation but does not address privacy rights and/or ethical principles. Includes whether a job in telenursing could be in the student’s future but no details of current employment or the rationale for the decision. 19–20 points Fails to include conclusion or recommendation. 0–18 points Scholarly Writing & APA Format 25 points • Title page, running head, and page numbers. (3 points) • Minimum of three sections including the Introduction, Body, and Conclusions and Recommendations. Each section has at least three sentences. (10 points) • Grammar, punctuation, and sentence structure are correct. (2 points) • Citations throughout demonstrate support of student’s ideas and opinions. (5 points) • Reference page includes all citations and no errors in format are noted. (3 points) • Evidence of spell and grammar check. (2 points) 23–25 points • Minimal error in APA title page noted. • Minimal errors in grammar, spelling, punctuation, and/or sentence structure noted. • Citations are present but not in correct format. • References are present, with minimal errors in format. • Minimal red or green wavy lines within document. 21–22 points • Some errors in APA title page noted. • Some errors in grammar, spelling, punctuation, and/or sentence structure noted. • Citations are present but not in correct format. • References are present, with some errors in format. • Some red or green wavy lines within document. 19–20 points • Multiple errors in APA formatting. • Multiple grammar, spelling, and punctuation errors noted. • Citations are missing. • References are missing or incomplete. • No evidence of proofreading prior to submitting paper. 0–18 points Total Points Possible = 200 points The class book chapter is below: CHAPTER 25 Telehealth After completing this chapter, you should be able to: 1. Define the term telehealth. 2. List the advantages of telehealth. 3. Identify equipment and technology needed to sustain telehealth. 4. Discuss present and proposed telehealth applications. 5. Describe legal and practice issues that affect telehealth. 6. Review the implications of telehealth for nursing and other health professions. 7. Identify several telenursing applications. 8. Discuss some issues pertaining to the practice of telenursing. Telehealth is the use of telecommunications technologies and electronic information to exchange healthcare information and to provide and support services such as long-distance clinical healthcare to clients. Telehealth is an expansion of telemedicine with preventive, promotive, and curative applications widely used by members of the healthcare community. The American Nurses Association (1996) prefers the term telehealth as a more inclusive and accurate description of the services provided. Telehealth services include health promotion, disease prevention, diagnosis, consultation, education, and therapy. Telehealth has the unique capability of achieving health equity by crossing temporal, social, and geographical barriers to healthcare. Computers, interactive video transmissions, teleconferences by telephone or video, and direct links to healthcare instruments are tools used to deliver these services. Electronic, visual, and audio signals sent during these conferences provide information to consultants from remote sites. Many common medical devices have been adapted for use with telemedicine technology. Distant practitioners and clients benefit from the skills and knowledge of the consultants without the need to travel to regional referral centers. Telehealth is a tool that allows healthcare professionals to do the following (Coyle, Duffy, & Martin 2007; Cross 2007; Cunningham & Vande Merwe 2009; Demiris, Edison, & Vijaykumar 2005; Fincher, Ward, Dawkins, Magee, & Willson 2009; Lancaster, Krumm, Ribera, & Klich 2008; Liaw & Humphreys 2006; Lillibridge & Hanna 2008; Lutz, Chumbler, Lyles, Hoffman, & Kobb 2009; Yun & Park 2007): • Consult with colleagues • Conduct interviews • Assess and monitor clients • View diagnostic images • Review slides and laboratory reports • Extend scarce healthcare resources • Decrease the number of hospital visits for patients with chronic conditions • Decrease healthcare costs • Tackle isolation and loneliness • Provide health education • Improve case management services • Improve the equity of access to services • Improve the quality of client care • Improve the overall quality of the client’s record Numerous terms have been coined to describe these capabilities (see Box 25���1 for a partial listing). TERMS RELATED TO TELEHEALTH Initially telemedicine was the predominant term for the delivery of healthcare education and services via the use of telecommunication technologies and computers. It has since largely been replaced by the term telehealth. Telehealth encompasses telemedicine but is a broader term that emphasizes both the delivery of services and the provision of information and education to healthcare providers and consumers. For example, federal agencies use the Internet to provide healthcare professionals, consumers, and their families with medical information. The Centers for Disease Control and Prevention provides credible online sources for health information. The Agency for Healthcare Research and Quality, formerly known as the Agency for Health Care Policy and Research, places clinical practice guidelines online. The U.S. National Library of Medicine provides information on health, various medical conditions and procedures, clinical trials, and the capability to conduct searches of several databases on its Web site. There also are a number of professional journals and articles available online. Some require subscription; some do not. One example of an online journal is JNCI Journal of the National Cancer Institute. This publication incorporates a wide range of cancer information from respected sources. It allows readers to browse by topic, and does require a subscription. As a consequence of the information explosion, healthcare professionals and clients gain access to the most current treatment options at essentially the same time. No matter what term is used, the basic premise of telehealth is that it can provide services to underserved communities. Another frequently used term is eHealth, which is often used interchangeably with the term telehealth. The field of telenursing is part of telehealth. Telenursing is the use of telecommunications and information technology (IT) for the delivery of nursing care. BOX 25–1 Some Common Telehealth Terms eCare (E-care). The electronic provision of health information, products, and services online as well as the electronic automation of administrative and clinical aspects of care delivery. eHealth (E-health). A broad term often used interchangeably with the term telehealth to refer to the provision of electronic health information, products, and services using information technologies. eMedicine (E-medicine). The use of telecommunication and computer technology for the delivery of medical care. ePrescribing (E-prescribing). Electronic transmission of prescriptions and patient specific clinical information. Interactive. Describes a technology system that interacts with user input (i.e., interacts with users) and involves information exchange via an online medium. mHealth (M-Health). The use of mobile devices to collect and provide real-time monitoring of patient health data, and to provide direct provision of care through mobile telemedicine. Telecardiology. Transmission of cardiac catheterization studies, echocardiograms, and other diagnostic tests in conjunction with electronic stethoscope examinations for second opinions by cardiologists at another site. Telecare. The remote delivery of healthcare services into the person’s home facilitated by communication technologies that include the use of person-centered reactive monitoring devices. Teleconsultation. Videoconferencing between two healthcare professionals or a healthcare professional and a client. Remote health consultation, whatever the means of transmission. Tele-diagnosis. The detection of a disease by using data received from monitoring a patient at a distant site. Tele-education (telelearning). Distance learning via a computer and/or telephone connection. Telehomecare. The use of telecommunication and computer technologies to monitor and render services and support to home care clients (the use of telecommunication to provide care services to a patient in his or her place or residency). Telementoring. Real-time advice offered to a practitioner in a remote site via telecommunications technology. Telenursing. The use of telecommunication and IT for the delivery of nursing services. Telepathology. Transmission of high-resolution virtual images, often via a robotic microscope, for interpretation by a pathologist at a remote site. Teleprevention. The use of tele-education technology to provide opportunities to promote health. Telepsychiatry. Variant of telemedicine that allows observation and interviews of clients at one site by a psychiatrist at another site through videoconferencing. Telerehabilitation. The use of interactive communication technology to facilitate assessment of patient’s functional abilities and provide exercise and rehabilitation therapies. Teleradiology. Transmission of high-resolution radiological patient images for interpretation or consultation by a radiologist at a distant location. Telesurgery. Technology that allows surgeons at a remote site to collaborate with experts at a referral center on techniques. Teletherapy. The use of interactive videoconferencing to provide therapy and counseling. Teleultrasound. Transmission of ultrasound images for interpretation at a remote site. Teleconferencing Teleconferencing implies that people at different locations have audio, and possibly video, contact, which is used to carry out telehealth applications. The terms teleconference and video-conference may be used synonymously, because both use telecommunications and computer technology. Videoconferencing Videoconferencing implies that people meet face-to-face and view the same images through the use of telecommunications and computer technology even though they are not in the same location. It saves travel time and costs, which actually encourages people to meet more frequently. Videoconferencing is an appealing concept that can be used for many applications, especially distance learning and telehealth (although some applications may require high resolution and audio quality and high-speed transmission). For example, videoconferences provide a means to improve quality and access to care in Alaska, where clinics are connected. Live conferences are used to view critically ill clients, and specially adapted medical equipment is used to collect and send assessment data digitally. Communities benefit by saving travel time and costs for this arrangement, and appropriate care can be initiated in a timely fashion (Smith 2004). For some vulnerable populations, videoconferencing is an effective alternative to traditional psychiatry. For example, cognitive-behavioral therapy was successfully delivered through videoconferencing to children and adolescents with functional abdominal pain (Sato, Clifford, Silverman, & Davies 2009). Desktop Videoconferencing Desktop videoconferencing (DTV) is a synchronous, or real-time, encounter that uses a specially equipped personal computer (PC) with telephone line hookup, DSL, or cable connections to allow people to meet face-to-face and/or view papers and images simultaneously. DTV is less expensive than custom-designed videoconference systems, but it may not be acceptable for telehealth applications that require high-resolution or high-speed transmission, such as interpretation of diagnostic images where slower frame rates produce a jerky image or lengthy transmission times. HISTORICAL BACKGROUND Telehealth began with the use of telephone consults and has become more sophisticated with each advance in technology. During the past five decades the U.S. government played a major role in the development and promotion of telehealth through various agencies. Interest waned as funding slowed to a trickle in the 1980s, but subsequent technological advancements made telehealth attractive again. Federal monies and the Agriculture Department’s 1991 Rural Development Act laid the groundwork to bring the information superhighway to rural areas for education and telehealth purposes. Historically, the most aggressive development of telehealth in the United States has been by NASA and the military (Brown 2002). NASA provided international telehealth consults for Armenian earthquake victims in 1989. Following the January 12, 2010, Haitian earthquake, telemedicine was part of the coordination efforts for ongoing health services in Haiti. The military has also had several projects to feed medical images from the battlefield to physicians in hospitals and on robotics equipment for telesurgery for improved treatment of casualties. Another large U.S. telehealth application has been the provision of care to state inmates by the medical branch of the University of Texas at Galveston (Brown 2002). Other states also use telehealth to treat prisoners, avoiding the costs and danger of transporting prisoners. New York piloted a telepsychiatric project that was well received (Manfredi, Shupe, & Batki 2005). The American Psychiatric Association (2010) reports that telepsychiatry is one of the most effective ways to increase access to mental healthcare for rural underserved populations. For example, Walter Reed Army Medical Center (2010) has expanded the availability of mental healthcare to outlying military treatment facilities through use of telepsychiatry for community mental health services. One major barrier to telehealth was removed with the passage of the Telecommunications Act of 1996, which allowed vendors of cable and telephone services to compete in each others’ markets (Schneider 1996). This event helped to open the door to create the information superhighway needed to provide the framework to support telehealth. The Snowe–Rockefeller Amendment required telecommunications carriers to offer services to rural health providers at rates comparable to those charged in urban areas so that affordable healthcare may be available to rural residents. The American Recovery and Reinvestment Act of 2009 provides for billions of dollars in stimulus funding for research, operations, and grants in the telemedicine, telehealth, and informatics sectors. More than 24 government agencies provide grant monies to fund telehealth, telemedicine, and health information technologies, including the U.S. Departments of Health and Human Services, Homeland Security, Defense, Veterans Affairs, Commerce, Agriculture, Energy, Justice, Interior, Education, Labor, State, and Transportation. There are also private, nonprofit, national, and global groups such as the Center of Excellence for Remote and Medically-Underserved Areas and the Acumen Fund that use entrepreneurial approaches to solve health services problems. The majority of private parties providing funds focus on specific applications, often to promote a particular product. Additional research is needed before there will be widespread acceptance of telehealth applications (Bahaadini, Yogesan, & Wooton 2009; Bonneville & Pare 2006; Gagnon, Lamothe, Hebert, Chanliau, & Fortin 2006). Questions remain about the evidence of the efficacy, cost-benefits, and quality of telehealth applications. These questions arise not so much because of a lack of projects or funding but rather because of a lack of a coordinated approach to the development, research, testing, and evaluation of applications. The Lewin Group (2000) noted that despite an earlier call by the Institute of Medicine (IOM) (1996) to evaluate telemedicine applications in terms of quality of care, outcomes, access to care, healthcare costs, and the perceptions of clients and clinicians, methodology problems remained. These included small sample sizes and a lack of control groups (AHRQ 2001). Telecommunication technologies are continuing to evolve along with advancements in telehealth. Telehealth will soon become an integral part of healthcare delivery services (AHRQ 2010). The Agency for healthcare Research and Quality is funding organizations across the United States that are investigating telehealth with projects such as improving diagnostic quality and therapeutic decision in ambulatory care settings, using telemedicine to reduce blood pressure in a cost-effective manner, evaluating a automated medication management system for effectiveness in terms of satisfaction and patient medication nonadherence, use of automated telephone self-management support among patients with poorly controlled diabetes, utilizing telemedicine applications for CPAP therapy adherence, and use of an IT-based approach to provide safer pediatric care for children outside the clinical setting. Projects involving chronic conditions that use the bulk of resources or have the greatest barriers to care continue to receive the highest priority for telemedicine research. The National Institute of Nursing Research solicited grant applications to study telehealth technologies that can improve clinical outcomes. The National Cancer Institute’s Center to Reduce Cancer Health Disparities has been looking for technology and telehealth applications that can facilitate early detection and screening. Despite the emphasis in this text on U.S. development of telehealth, it is an international phenomenon. The United States may lead in the development of technologies that enable telehealth, but Australia, Canada, Norway, and Sweden are among the current world leaders in the use of telehealth. Work has been done in Canada on policies and procedures for allied health professionals who provide telehealth services as a means to enhance and expand successes already achieved with telehealth delivery of services and for use by accreditation criteria (Hailey et al. 2005; Hogenbirk et al. 2006). Topics covered by these policies include the scope and limitations of services, staff responsibilities, training, reporting, professional standards, and cultural considerations. Denmark, Finland, and Sweden are countries leading in deployment of health IT (Castro 2009). According to the World Health Organization (2009), the United States lags behind international best practices in making progress in health IT systems. DRIVING FORCES Recent attention to patient safety, cost containment, managed care, disease management, shortages of healthcare providers, uneven access to healthcare services, and an emphasis upon keeping an aging population functional in their own homes makes telehealth an attractive tool to improve the quality of healthcare and save money (Brantley, Laney-Cummings, & Spivack 2004; Introducing: telehealth and telecare 2007; Smith 2004; Stronge, Rogers, & Fisk 2007). Savings may be realized via the following measures: • Improved access to care, which allows clients to be treated earlier when fewer interventions are required. • The ability of clients to receive treatment in their own community where services cost less. • Improved quality of care; expert advice that is more easily available. • Extending the services of nurse practitioners and physician assistants through ready accessibility to physician services. • Improved continuity of care through convenient follow-up care. • Improved quality of client records; the addition of digital information such as monitored vital signs and wound images, which provide better information for treatment decisions and help to decrease errors. • Time savings; the ability of healthcare professionals to cut down on the amount of time spent in travel and instead spend it in direct client care. Telehealth is also a marketing tool. Many institutions post health promotion or quality benchmark information on their Web pages with the hope that it will attract new customers. Large institutions offer links with the understanding that additional services will be rendered at their facilities. For example, imagine that a client with symptoms of coronary artery disease is seen at a community hospital that has no facilities for cardiac surgery. The client is more likely to follow up at the larger institution that has established links to the community hospital, because a rapport has been established with the consulting physician. In addition, telehealth services can eliminate the need for visas for international clients. Some facilities provide scheduling and online claim authorization as convenient services. Telehealth services deemed valuable by physicians can also attract new medical staff. As a result of the above factors, many agencies offer telehealth or plan to do so in the near future. Telehealth services need to be addressed in enterprise-wide strategic plans. Box 25–2 lists some additional benefits associated with telehealth. APPLICATIONS Telehealth applications vary greatly. Examples include monitoring activities, diagnostic evaluations, decision-support systems, storage and dissemination of records for diagnostic purposes, image compression for efficient storage and retrieval, research, electronic prescriptions, voice recognition for dictation, education of healthcare professionals and consumers, and support of caregivers. Sophisticated equipment is not always necessary. Some applications are “high tech,” whereas others are relatively “low tech.��� Real-time videoconferencing between physicians or healthcare professionals and clients and the transmission of diagnostic images and biometric data are examples of high-tech applications. An example of a low-tech application is a home glucose-monitoring program that uses a touch-tone telephone to report glucose results. Desktop PCs outfitted with microphones and video cameras can provide telehealth opportunities for applications that do not require high resolution. BOX 25–2 Telehealth Benefits • Continuity of care. Clients can stay in the community and use their regular healthcare providers. • Centralized health records. Clients remain in the same healthcare system. • Incorporation of the healthcare consumer as an active member of the health team. The client is an active participant in videoconferences. • Collaboration among healthcare professionals. Cooperation is fostered among interdisciplinary members of the healthcare team. • Improved decision making. Experts are readily available. • Education of healthcare consumers and professionals. Offerings are readily available. • Higher quality of care. Access to care and access to specialists is improved. • Removes geographic barriers to care. Clients living away from major population centers or in economically disadvantaged areas can access care more readily. • May lower costs for healthcare. Eliminates travel costs. Clients are seen earlier when they are not as ill. Treatment may take place in local hospitals, which are less costly. • Improved quality of health record. The record contains digitalized records of diagnostic tests, biometric measures, photographs, and communication. Current telehealth technologies can be grouped into at least nine broad categories, although for general discussion purposes, there are two types: store-and-forward and interactive conferencing. Store-and-forward is used to transfer digital images and data from one location to another. It is appropriate for nonemergent situations. It is commonly used for teleradiology and telepathology. Interactive conferencing primarily refers to videoconferencing and is used in place of face-to-face consultation. Interactive conferencing is frequently used for telepsychiatry. Telehealth is not a technology so much as it is a technique for the delivery of services. Increasingly it is perceived as a framework for a comprehensive health system integrating various applications, as well as the management of information, education, and administrative services. Box 25–3 lists some other actual and proposed applications. BOX 25–3 Current and Proposed Telehealth Applications • Ambulatory care settings. Clients are connected with automated systems to monitor medication adverse events and medication nonadherence. Clinicians have real-time information on a patient’s experience with medications. • Cardiology. ECG strips can be transmitted for interpretation by experts at a regional referral center, and pacemakers can be reset from a remote location. • Counselling. Clients may be seen at home or in outpatient settings by a counselor at another site. • Data mining. Research may be conducted on large databases for educational, diagnostic, cost/benefit analysis, and evidence-based practice. • Dermatology. Primary physicians may ask specialists to see a client without the client waiting for an appointment with the specialist and travelling to a distant site. • Diabetes management. Clients may report blood glucose readings by using the touch-tone telephone. • Mobile unit post-disaster care. Emergency medical technicians (EMTs) and nurses at the site of a disaster can consult with physicians about the health needs of victims. • Education. Healthcare professionals in geographically remote areas can attend seminars to update their knowledge without extensive travel, expense, or time away from home. • Emergency care. Community hospitals can share information with trauma centers so that the centers can better care for clients and prepare them for transport. • Fetal monitoring. Some high-risk antepartum clients can be monitored from home with greater comfort and decreased expense. • Geriatrics. Videoconference equipment in the home permits home monitoring of medication administration for a client who has memory deficits but who is otherwise able to stay at home. • Hypertension management. Clients receive automated reminders and education feedback regarding hypertension treatment guidelines. • Home care. Once equipment is in the client’s home, nurses and physicians may evaluate the client at home without leaving their offices. • Hospice. Palliative and end-of-life services via technology can increase access to services in remote areas or supplement traditional care. • Military. Physicians at remote sites can evaluate injured soldiers in the field via the medic’s equipment. • Pharmacy. Data can be accessed at a centralized location. • Pathology. The transmission of slide and tissue samples to other sites makes it easier to obtain a second opinion on biopsy findings. • Psychiatry. Specialists at major medical centers can evaluate clients in outlying emergency departments, hospitals, and clinics via teleconferences. • Radiology. Radiologists can take calls from home and receive images from the hospital on equipment they have in place. Rural hospitals do not need to have a radiologist onsite. • School clinics. School nurses, particularly in remote areas, can quickly consult with other professionals about problems observed. • Social work. Social workers can augment services with telehealth home visits. • Speech–language pathology. More efficient use can be made of scarce speech/language pathologists. • Virtual intensive care units. Remote monitoring capabilities and teleconferencing allow experts at medical centers to monitor patients in distant, rural hospitals, particularly when weather conditions or other factors do not allow transport. • Extended emergency services. Remote monitoring and teleconferencing support allow emergency care physicians to view and monitor ambulance patients, supervise EMTs, and initiate treatments early and redirect patients to the most appropriate facilities, such as burn centers or trauma units, without being seen first in the emergency department. Online Databases and Tools Online resources can include the following: • Standards of care. These may include recommended guidelines for care for a particular diagnosis. • Evidence-based practice guidelines. Best practices based upon research findings are increasingly available online for reference and use. • Computerized medical diagnosis. This database assists the physician to match symptoms against suspected diagnoses. • Drug information. One important application is the determination of the most effective, least expensive antibiotic for a particular infection. • Electronic prescriptions. This permits the physician to “write” a prescription that is sent automatically to the pharmacy. It decreases errors associated with poor handwriting and sound-alike drugs. When integration exists among healthcare systems, physicians, and pharmacies, there is no need to enter patient history, allergies, demographic, and insurance information more than once. Electronic prescribing is being adopted in more systems as part of patient safety initiatives. • Abstracts and full-text retrieval of literature. These can be retrieved easily at any time of the day. • Research data. This information is available via literature searches and Web access. • Bulletin boards, reference files, and discussion groups on various specialty subjects. Ready access to information improves care delivery and decreases related costs. For example, the incorporation of national standards of care and drug information eliminates redundant efforts by individual institutions to prepare their own standards and formularies. It also decreases malpractice claims through adherence to standards of care. Standards of care reflect best practices based on research findings. Online research databases facilitate research through the systematic collection of information on large populations, with potential for data mining at a later time. Further benefits from online resources will be accrued as more projects are implemented to develop common terms to facilitate sharing of data, such as the National Library of Medicine’s Unified Medical Language System. Education Telehealth affords opportunities to educate healthcare consumers and professionals through increased information accessibility via online resources, including the World Wide Web, distance learning, and clinical instruction. Grand rounds and continuing education are two of the most touted applications for education. Grand rounds are traditional teaching tools for health professionals in training (Cross, Barnes, & Jawad 2010; Ellis & Mayrose 2003). As the name indicates, a group of practitioners review a client’s case history and his or her present condition, at which time they mutually determine the best treatment options. Grand rounds help to maintain clinical knowledge and expertise but are not always available in smaller institutions. Telehealth facilities allow the incorporation of diagnostic images, client interviews, and biometric measurements from outlying hospitals into medical center grand rounds, thereby allowing practitioners from two or more sites to participate. Videoconferencing allows more practitioners to attend this educational offering than might otherwise be possible. In like fashion, consultations and images from major teaching centers may be made available to remote facilities to enhance the practice of professionals in outlying areas. Continuing Education Telehealth offers direct access to traditional continuing education and extemporaneous teaching opportunities with every teleconsultation and distance education offering. Training costs for continuing education may be decreased by bringing people together from many distant sites without travel or lodging expenses or extended time away from their responsibilities. Home Healthcare Telecommunication technology can reduce costs and increase choices and the availability of services that can keep people in their own homes longer (Brennan 1996; Garrett & Martini 2007; Hi-tech home help 2007). This is particularly important as the population over age 65 explodes without a concomitant increase in funds for healthcare services (Demiris, Oliver, & Courtney 2006). Telecommunication technology also supports automatic collection of data and allows clinicians to handle more clients than via traditional care models. For example, use of a home monitoring system in Japan provides 24-hour contact and medical response for clients as needed in addition to regularly scheduled visits. Biometric measurements such as heart rate and pattern, blood pressure, respiratory rate, and fetal heart rate can be monitored at another site, with electronic or actual house calls provided as needed. Women with high-risk pregnancies, diabetics, and cardiac and postoperative clients can be monitored at home. Clients who require wound care comprise another population that can be managed well at home through telehealth applications. Nurses can also transmit digital photographs of wounds to certified wound ostomy continence nurses (WCONs). Photographs are stored in the database. The WCON can make recommendations and follow more clients through the use of telehealth than would otherwise be possible. Internet access for home health clients, and their families, provides convenient access to support groups, treatment information, and electronic communication with their healthcare providers, while decreasing feelings of isolation. The REACH (Resources for Enhancing Alzheimer’s Caregiver Health) initiative, sponsored by the National Institutes for Health, exemplifies a support program for caregivers that encourages them to engage in relaxation exercises. As the number of the elderly grows, televisits eliminate the discomfort and inconvenience of travel and long waits to be seen by physicians. Equipment needs are dictated by the nature of the monitoring. For example, telemetry requires continuous monitoring, necessitating a dedicated telephone line as well as the monitoring devices supplied by the home healthcare agency. Other clients may require less expensive, low technology monitoring, while another client group requires equipment with videoconference and monitoring capabilities. A Web-based solution for care coordination can integrate information from biometric measures and diagnostic tests and automatically alert the clinician of panic values. The benefits of telehealth technology allow clinicians to cut travel time without decreasing client contact and help to improve the organization of the health record with automatic collection of data and better coordination of care among clinicians. Figure 25–1 depicts a teleconference that connects a home healthcare client, a nurse, and a physician. FIGURE 25–1 Diagram of a teleconference involving client, nurse, and physician at separate sites The use of sensors can also detect falls and whether the refrigerator has been opened and closed as a means to alert nurses to problems in the homes of elderly and frail individuals. Coming trends include the integration of wireless sensors, wearable monitoring technology into telehealth systems, smart homes, and helper robots (Karunanithi 2007; Koch 2006; Lamprinos, Prentza, & Koutsouris 2006). Some providers of advanced home telemonitoring services have formed partnerships with home care companies that make the technology available to providers. This arrangement eliminates the need for home healthcare companies to invest in the equipment needed to support telehealth. The American Telemedicine Association developed clinical guidelines for the use of telemedicine for home care that include criteria for patients, care providers, and technology (ATA adopts telehomecare clinical guidelines 2007). These are listed on its Web site (www.atmeda.org/news/guidelines.htm). Disease Management The bulk of U.S. healthcare costs results from chronic conditions. For this reason, it is essential to find better ways to manage the health of individuals with chronic medical conditions. Telehealth applications can help. The U.S. Department of Veterans Affairs has several telemedicine initiatives nationally monitoring over 35,000 chronically ill veterans with heart disease, depression, diabetes, post-traumatic stress disorder, pulmonary problems, and other chronic illnesses in their own homes and coordinating regional programs that reduce travel and wait time (Department of Veterans Affairs 2009; Department of Veterans Affairs 2006; Kline & Schofield 2006; Lipowicz 2010; Midwest VA Service 2007; Riverside County 2006; Wertenberger, Yerardi, Drake, & Parlier 2006). Technology ranges from automated reminders to take medications and handheld vital sign monitors to two-way video computers that are equipped with everything from a stethoscope to an electrocardiograph, and a personal health record (PHR) for veterans. Monitoring devices load results into the veteran’s PHR. While technology costs maybe substantial, they are significantly less than the cost of an inpatient admission. Links to community health outpatient centers are instantaneous and travel time is significantly reduced. Consequently, telehealth is becoming increasingly popular with veterans. Similar initiatives have been under way at home care agencies and through private medical centers throughout the country. One example is the use of Health Buddy. Health Buddy is an in-home communication device that has been used to provide heart failure disease management (Rosenberg 2007). It prompts patients to take their medicine, keep their legs elevated when sitting, and monitors subjective reports of difficulty breathing or increased edema. On the other end of the connection nurses receive alerts when patients gain weight or indicate other problems. In February 2010, the Veterans Health Administration received grant money to extend the use of the Health Buddy Telehealth System. The U.S. federally funded Jewish Home and Hospital Services Lifecare Plus study showed that telehealth patients decreased their overall utilization of healthcare resources significantly with fewer office visits, ER visits, and readmissions (Lehmann, Mintz, & Giacini 2006). In a newer twist cell phones are now used to provide programmed reminders to check blood sugars, take medications, or accept downloads from blood sugar monitors, which can then be transmitted to caregivers (Goedert 2007). In Great Britain several pilot programs are using telecare systems in an attempt to help the elderly maintain a safe environment and manage their chronic conditions at home (Hi-tech home help 2007). LEGAL AND PRIVACY ISSUES Reimbursement and licensure issues remain two of the major barriers to the growth and practice of telehealth (Cwiek, Rafiq, Qamar, Tobey, & Merrell 2007; Dickens & Cook 2006; Kennedy 2005; Starren et al. 2005; Tracy, Rheuban, Waters, DeVany, & Whitten 2008). The CMS (2009a) currently provides for telehealth reimbursement for physician follow-up consultation when communicating with the patient via telehealth (G0425-G0427 reimbursement codes for 2010). The Centers for Medicare & Medicaid Services (CMS) have not formally defined telemedicine for the Medicaid program, and Medicaid does not recognize telemedicine as a distinct service. Medicaid reimbursement for telehealth services is available at the discretion of individual states as a cost-effective alternative to traditional services or as a means to improve access for rural residents (CMS 2009b; Cross 2007; Gray, Stamm, Toevs, Reischl, & Yarrington 2006). Advocates are struggling to increase state Medicaid reimbursement. Several states have passed legislation mandating private insurance coverage of telehealth services (States require reimbursement 2004). Currently 39 states acknowledge at least some reimbursement for telehealth services (Ctel 2011). There are also concerns about the impact of telehealth on record privacy, particularly with the implementation of the Health Insurance Portability and Accountability Act (HIPAA). Referral and Payment Brantley et al. (2004) concluded that federal, state, and private sector policies have impeded the advance of telehealth and that an entirely new framework is necessary to determine reimbursement for telehealth services. The Balanced Budget Act of 1997 first authorized Medicare reimbursement for some services that did not traditionally require a face-to-face meeting between client and practitioner, such as radiology or electrocardiogram interpretation. Almost 2 years passed before any reimbursement occurred. There were limitations on who could receive services, what services were covered, who got paid, and how services were reimbursed. Only clients in federally designated rural areas deemed as having a shortage of health professionals were eligible. Store-and-forward technologies were not covered in some cases. And there were issues related to which practitioners were eligible for reimbursement and how they were paid. Reimbursement rules were loosened with the Medicare, Medicaid, and State Children’s Health Insurance Program (SCHIP) Benefits Improvement and Protection Act of 2000 but not enough to make a significant difference in Medicaid reimbursement or to encourage other third-party payers in the United States to pay for telehealth services. As a result, some physicians and other providers who did teleconsultation did not receive payment for their services. Consequently, increased client volume at referral centers has been regarded as a means to make up for lost revenue. Support Personnel While the technology behind telehealth should be easy to use, technical support may be required as new and different skills are required. Support staff should be capable, flexible, and preferably experienced. At the present, questions have not been fully resolved as to who will train healthcare professionals to participate in telehealth and how compensation will be derived for the additional hours associated with installation, training, and use of telehealth technology. There is also an issue of confidentiality. Technical support staff who are present during the exchange of client information need to be aware of institutional policies as well as laws such as HIPAA that are designed to protect client privacy. These individuals should sign the same sort of statement that clinical personnel sign on the receipt of their information system access codes. In the case of home monitoring, support is crucial to help participants feel comfortable with the technology, particularly when using Internetaccess and Web applications (Cudney, Weinert, & Phillips 2007). Liability Telehealth is plagued by a number of liability concerns (ANA 1996; Dickens & Cook 2006). First, there is the possibility that the client may perceive it as inferior because the consulting professional does not perform a hands-on examination. The American Nurses Association (ANA) cautions that telehealth shows great promise as long as it is used to augment, not replace, existing services. Second, professionals who practice across state lines deal with different practice provisions in each state and may be subject to malpractice lawsuits in multiple jurisdictions, raising questions about how that liability might be distributed or which state’s practice standards would apply. Theoretically, clients could choose to file suit in the jurisdiction most likely to award damages. The basic question here is, where did the service occur? Third, how might liability be spread among physicians, other healthcare professionals, and technical support persons? And fourth, HIPAA legislation added new concerns to the mix. These issues remain concerns today. Telehealth has the potential to raise or lower malpractice costs. For example, Pennsylvania’s HealthNet recorded teleconferences to provide a complete transcript of the session. Clients were given a videotape for later review and as a means to clarify their comprehension, and the original videotape was kept as part of the client record. The American Nurses Association (1999) called for the development of documentation requirements for telehealth services that addressed treatment recommendations as well as any communication that occurs with other healthcare providers. This strategy should decrease malpractice claims through better documentation and improved client understanding. On the other hand, liability costs may increase if healthcare professionals can be sued in more than one jurisdiction. Major issues for nurses include questions of liability when information provided over the telephone is misinterpreted, when advice is given across state lines without a license in the state where the client resides, or, particularly, when an unintentional diagnosis comes from the use of an Internetchat room. Liability is unclear in these areas. Regulation of telenursing practice by boards of nursing is difficult when practice crosses state lines. Unless nurses are licensed in every state in which they practice telenursing, respective regulatory boards are unaware of their presence. The majority of states have laws or regulations that require licensure for telehealth practice (Reed 2005). Authority to practice telenursing across state lines provides the following advantages (National Council of State Boards 1996): • It establishes the nurse’s responsibility and accountability to the board of nursing. • It establishes legitimacy and availability to practice telenursing. • It provides jurisdictional authority over the discipline of telenursing in the event that unsafe delivery becomes an issue. Until this issue has been resolved, nurses must also be cautious when providers from other states give them directions. Several state boards of nursing specifically forbid taking instructions from providers not licensed in the current state. Box 25–4 summarizes barriers to the practice of telehealth. BOX 25–4 Barriers to the Use of Telehealth Applications • Regulatory barriers. State laws are either unclear or may forbid practice across state lines. • Lack of reimbursement for consultative services. Most third-party payers do not provide reimbursement unless the client is seen in person. • Costs for equipment, network services, and training time. Equipment capable of transmitting and receiving diagnostic-grade images is still expensive, although costs are declining. • Fear of healthcare system changes. Personnel may fear job loss as more clients can be treated at home and hospital units close. • Lack of acceptance by healthcare professionals. This may stem from liability concerns and discomfort over not seeing a client face-to-face. • Lack of acceptance by users. This may stem from discomfort with technology, the relationship with the provider, and concerns over security of information and confidentiality. Licensure Issues Current licensure issues for telemedicine relate to the state in which healthcare professionals are licensed to practice and the jurisdictional boundaries in which services are delivered. Traditionally telemedicine has required multi-state licensure for healthcare professionals, both for their primary state and for the state in which services are rendered. Application for licensure in additional states can be lengthy and expensive, with the ultimate result of restricting access to services. Telehealth advocates want to remove legal barriers to practice through either nationwide or regional licensing or changes in practice acts that permit practitioners from any state to consult with practitioners from another state without the need to be licensed in that second state. The Federation of State Medical Boards drafted legislation to address this issue, calling for the establishment of a registry for telehealth physicians, who would enjoy shorter license application periods and lower fees but have some practice restrictions. Some licensing laws pertaining to telehealth have been enacted or are under consideration, but no resolution has been achieved as yet. Task forces of the National Council of Nurses suggested multistate licensure as a means to support telenursing. The U.S. Nurse Licensure Compact (NLC) was initiated by the National Council of State Boards of Nursing (NCSBN) in 1997 (NCSBN 2009, 2007). The resulting mutual recognition model allows a nurse in a state that has adopted the compact to practice in other member states but holds the nurse accountable to the practice laws and regulations in the state where telehealth services are provided. As of 2010, 24 states had enacted legislation allowing for nurses to participate in mutual recognition of nurse licensure. No additional compacts have been reported on the NCSBN Web site as of this writing. The American Nurses Association (1998) did not support this proposed model, however, citing concerns related to discipline, revenue for individual state boards of licensure, and knowledge issues related to allowable practice in other states. Until additional changes are implemented, delivery of services across some state lines via telehealth may be illegal and practitioners must proceed cautiously. The NCSBN was awarded a grant from the Health Resources and Services Administrations Office for the Advancement of telehealth to work on licensure portability (NCSBN 2006). The second licensure issue pertains to what jurisdiction the telehealth practitioner is subject to, the physical space of the practitioner, and the jurisdiction of the recipient (Dickens & Cook 2006). Confidentiality/PrivacyAlthough telehealth should not create any greater concerns or risks to medical record privacy than any other form of consultation, records that cross state lines are subject to HIPAA regulations and state privacylaws. Security and confidentiality of telehealth services are crucial to acceptance by consumers and professionals (Hildebrand, Pharow, Engelbrecht, Blobel, Savastano, & Hovsto 2006). For this reason experts have called for the creation of standards for e-health, particularly for security and identity management. Nurses need to be mindful of these issues when technicians, not bound by professional codes of ethics, are present at telehealth sessions. At present, the Office for the Advancement of Telehealth (Department of Health and Human Services) sponsors The Center for Telehealth & E-Health Law Web site; this site provides ongoing information regarding privacy and confidentiality issues in telehealth practice (Ctel 2010a). OTHER TELEHEALTH ISSUES There are a number of other important issues related to telehealth. They include the following: • Lack of standards. The lack of plug-and-play interoperability among telehealth devices and point-of-care and other clinical information systems is cited as a major obstacle (Brantley et al. 2004; Charters 2009). There is a need for a standard int

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