Telemedicine, the term initially used to describe the delivery of healthcare services from a distance through the use technology, began as early as the 1920’s when Doctors would utilize radio to diagnose patients and give recommendations. In the 1960’s, with the advancements into aerospace, the term “telemedicine” was vastly replaced with the term “telehealth” as astronauts began to transmit crew members’ psychological reports back to physicians on earth. Telehealth encompasses the use of many applications such as videoconferencing, store and forward imaging (images, video, audio, and clinical data securely transmitted to alternate locations), mobile monitoring, and robotics (Stokowski, 2008). The intention of telehealth is to remove distance as a barrier to health care and bridge the gap between local and global health care while utilizing evidence base practices to improve outcomes (IOM, 2012).
With the advancements in technology many subsets have emerged in the field of telehealth such as telepediatrics, telepsychiatry, teleradiology, telecardiology, and telenursing. Currently the use of telehealth and telenursing services is best recognized in the fields related to home care, management of chronic health conditions, obstetrics, diabetes care, and more recently ICU post care. Hebda & Czar (2013, p. 506) state “Telenursing is the use of telecommunications and information technology (IT) for the delivery of nursing care“.
In addition, Stokowski (2008) further adds “telenursing focuses on the delivery, management, and coordination of care and services using telecommunications technology within the domain of nursing…the nursing process and scope of practice are the same in telenursing as in traditional nursing practice.” The purpose of this assignment is to discover the professional nurse’s role in telehealth nursing as well as explore the advantages and disadvantages as it relates to patient care including use of technology and accessibility, quality of healthcare, and user satisfaction.
There are many advantages to using information technology in the field of healthcare. Technology has the ability to connect patients and their families with doctors, nurses, radiologists, psychiatrists, cardiologists, and many other clinicians and specialists from across the globe. A report issued by The University of Arizona identified that “telemedicine services have been provided in over 61 subspecialties” and “substantial evidence exists to support that telemedicine is a viable alternative to traditional face-to-face medicine that yields equal health outcomes between the two approaches” (Hincapie, Warholak, & Armstrong, 2001, p. 3). Telecommunication can take place through a variety of outlets, increasing accessibility to nursing care, such as telephone service, cell phones, life lines, digital networks, T1 databases, satellite, cable, and internet. Today’s information technology allows for interactive, real-time consultations using electronically transmitted live or store and forward data in conjunction with the many diagnostic applications on the market today (Hebza & Czar, 2013).
With the increasing technological improvements and inventions, patient access will continue to increase as will the accuracy and scope of services provided. Recently, telenursing has been used to set up remote clinics in rural and disaster areas where resources are sparse and access is difficult to obtain. The benefit is that the nurse is able to utilize video conferencing to consult with doctors and specialists around the world to obtain orders and treatment options and also able to triage patients making note of critical supplies needed and then remotely communicate the population needs to relief and aid workers that are collecting supplies. This enhanced access to care provides continuity and increased consumer satisfaction. Telenursing has been shown to reduce visits to emergency departments for skilled-nursing patients with the use of algorithms, protocols, guidelines on systematically assessing patients, call back instructions, and education. Call centers are set up with experienced nurses that are able to, through nursing informatics, assess patients, supervise procedures, provide basic consultation and education, monitor chronic conditions, and facilitate collaboration among clinicians (Stokowski, 2008).
Recently studies have been conducted to identify how effective telehealth can be and identify areas of improvement. One study conducted by the IOM (2012) “showed that teleradiology reduced transport for head injuries out of rural areas and that the availability of teleconsultation with radiologist significantly affected diagnosis and treatment plans.” For example, if: a patient calls 911 with a possible TBI that occurred from falling off building during a construction job. EMS arrives to the small local hospital with the patient afterhours for immediate MRI. No radiologists are available to read the MRI, so it is sent out to a teleradiologist who immediately reads the MRI and returns a report. The surgical team is called and treatment is started. Without teleradiology the patient would have had to travel to the nearest trauma center 3 hours away and treatment would have been delayed. Telenursing, and telehealth overall, provide improved quality of care through Team-based patient centered care.
The IOM defines patient-centered care as: “Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.” It has been well established that involved patients that are engaged in the healthcare processes tend to be more knowledgeable about their condition and often have better health outcomes as a result. Many aspects of patient engagement can be achieved through telenursing. Communication between nurse and patient is often increased therefore decreasing the hassle of making an appointment, the discomfort of driving, and decreasing stress, worry, and fear by having a live person available at the time of need or question. Provider effectiveness can be achieved through a team consultation approach, expanding resources through global technology, and increasing patient options.
Both information and encouragement are provided to the patient through the use of nursing informatics. The nurse is better able to track data and goal progress through increased communication and provide feedback to the patient in a timely manner. The nurse is also able to access a multitude of electronic resources in any comprehension level and language, the nurse can then direct a patient to resources through mailing, direct link, or referral to a local agency. Lastly, patient incentive can come through many facets, consultations via information technology is often more frequent than in home or office visits, Telenurses are often able to spend more time with the patient than a nurse in a doctor’s office, and cost savings may occur through less use of gas / resources as well as possible insurance benefits. (Hebza & Czar, 2013)(IOM,
Despite all technological and regulatory advancements being made, obstacles remain to the expenditure of telehealth modalities. Telehealth utilizes expensive technology in order to run, and it involves a countless amounts of hardware, software, and technicians. When utilizing technology in homecare, for example, the patient needs to be versed in using and understanding the role of the technology. Patients are not always accepting of the technology, may have unanticipated preferences, or may fear that the addition of continuous monitoring is an invasion of privacy (IOM, 2012) As with all electronic information there is the risk of a data integrity security breach which can result in disclosure of patient information over the web or hospital network. This has been played out many times in the Veteran’s Affairs healthcare system. In 2006 a VA worker was allowed to take a company computer, containing unencrypted patient information, out of the facility to work from home, the computer was stolen and “sensitive data for up to 26.5 million veterans, their spouses, and active-duty military personnel” was in the hands of the public.
In 2012 the VA mistakenly released personal records to ancestry.com, and earlier this year a “software deficit” caused the leak of 5,000 personal records making it public to anyone who could log onto the system (Hoffman, 2014). There is concern that patient satisfaction may be compromised by the lack of face to face interactions. Hebda & Czar (2012, p. 515) caution that telenursing may be perceived as inferior due to lack of hands on examination and should be “used to augment, not replace, existing services.” Often there is a misconception that nursing has to be “hands on” and patients must be educated in the definition of nursing practice. If a nurse is assessing a patient over the phone and uses the information gathered to “plan, intervene, and evaluate the outcomes of care, [the nurse] is undoubtedly engaged in the practice of nursing” albeit with a different means of delivery (Stokowski, 2008).
Lastly, cost of service and reimbursement is not recognized by Medicaid and reimbursement services are dictated by each individual state. States can choose which insurance codes they want to cover and can some insurance companies may only offer reimbursement in specific rural or underserved regions (Hebda & Czar, 2012). In addition, the IOM (2012) states that reimbursement restrictions “result from fears that telemedicine either will allow providers to abuse the healthcare system or will lead to overutilization and drive up costs.”
Conclusion and Recommendations
Based on Manuel’s extensive med-surge experience I would conclude that he likely has a broad enough knowledge base to proficiently assist patients via telenursing to achieve long term health maintenance while remaining hospital free. He would likely benefit from spending less time on his feet, no heavy lifting, and no running to call lights. I would recommend that prior to starting, Manuel should ensure he has or will be provided with proper dependable equipment with good interoperability, ensure he will get paid regardless of insurance reimbursement to the company, educate himself about licensure requirements in the case of out of state calls and learn the company policy about such matters, and the company’s stance on malpractice and liability. I would also advise Manuel that, as a telenurse specialist, he remains bound to follow the nursing scope of practice, adhering to all ethical principles and boundaries. He should also be mindful that his communication with patients should not sound rehearsed, scripted, or mechanical. This is essential for building rapport and trust in the absence of face-to-face interactions (Hakimnia, Holmstrom, Carlsson, & Hoglund, 2014).
Hakimnia, R., Holmstrom, I. H., Carlsson, M., & Hoglund, A. T. (2014). Exploring the communication between telenurse and caller–A critical discourse analysis. Int J Qualitative Stud Health Well-being, 9(24255), 1-9. Retrieved from http://dx.doi.org/10.3402/qhw.v9.24255 Hebda, T., & Czar, P. (2013). Handbook of informatics for nurses & healthcare professionals (5th ed.). Saddle River, NJ: Pearson. Hincapie, A., Warholak, T. L., & Armstrong, E. P. (2001). Socioeconomic Impact of Mandated Helath Coverage for Telemedicine in the State of Arizona. Retrieved from The University of Arizona website:
http://crh.arizona.edu/sites/crh.arizona.edu/files/Telemedicine %20Report%20V12Ana-1.pdf Hoffman, M. (2014, February 24). Report: VA Data Breach ‘Practically Unavoidable’. Military.com News. Retrieved from http://www.military.com/daily-news/2014/02/24/report-va-data-breach-practically-unavoidable.html IOM (Institute of Medicine). (2012). The Role of Telehealth in an Evolving Health Care Environment: Workshop Summary. Washington, DC: The National Academies Press: Author. Stokowski, L. A. (2008, October 30). Healthcare Anywhere. Medscape. Retrieved from http://www.medscape.com/viewarticle/581800_3
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