Informatics chap 25 telehealth

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.

Telehealth is a tool that allows healthcare professionals to do the following

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 provide services to underserved communities

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.

Which of the following is NOT a challenge to using telehealth? legal issues safety and related standards distance patient privacy and confidentiality

DISTANCE

ePrescribing (E-prescribing)

Electronic transmission of prescriptions and patient specific clinical information.

Telehealth is restricted mostly to conferences with patients. True False

FALSAE

A telehealth system should begin on as large a scale as possible. True False

FALSE

In the Internet age, telehealth has become more common than in-office visits. True False

FALSE

Interest in telehealth has stagnated since 1990. True False

FALSE

Most nurses accept telehealth as an equally effective alternative to in-person care. True False

FALSE

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.

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.

five areas of concern:

Lack of reimbursement Legal issues Safety and related standards Patient privacy and confidentiality Telecommunications infrastructure

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 interface specification that allows telehealth data to be merged easily with information from other clinical information systems. Work is in process on the development of these standards using HL7 messages constructed with Extensible Markup Language. • National Health Information Infrastructure (NHII). In succinct terms, the NHII is all about the secure exchange of healthcare information between a requestor and a provider. While work is in progress the NHII remains a vision at this time. It requires an identity management system, one trusted on a national scale, that will give information providers a means to validate the electronic identity of a requestor. Similar work is presently under way with the U.S. government. Rules are still needed to create electronic IDs for the NHII. The Department of Health and Human Services, the American Telemedicine Association, and the Rand Corporation, among other entities, have been discussing the NHII. • Homeland security. The homeland security community has not given significant consideration to telehealth technology when assessing its needs, strategies, and desired outcomes (Brantley et al. 2004). It can make use of various surveillance systems to analyze symptoms on a large scale for possible biological and chemical attacks. • Mainstream acceptance. Despite its advocates, many healthcare professionals have been slow to accept telehealth applications (Thede 2001; Williams 2007). Their reasons include the perception that telehealth applications are not "real" nursing, that telehealth offers few benefits to them, concerns over privacy and legalities, and fears that telehealth applications will reduce the number of healthcare professionals needed. Accreditation and regulatory requirements. The Joint Commission on Accreditation of Healthcare Organizations first identified medical staff standards for credentialing and privileging for the practice of telemedicine in 2001 and approved revisions in 2003. Practitioners are required to be credentialed and have privileges at the site where the client is located. Credentialing information from the distant site may be used by the originating site to establish privileges if the distant site is accredited by the Joint Commission. However, this issue for telehealth practitioners remains unresolved as the Joint Commission continues to work on this issue of acceptance of credentialing and privileging decisions by another Joint Commission accredited facility (Ctel 2010b). The Food and Drug Administration has several guidelines for the use of telehealth-related devices. • Patient safety. The majority of discussions that address patient safety emphasize the potential of telehealth to enhance patient safety through applications such as e-prescribing. Some literature makes mention of threats to patient safety when telehealth applications fail to render the same level of care as hands-on care or when problems occur with the use of electrical devices. • Limitations. Despite its many benefits telehealth suffers some limits as well. One is that the quality of transmitted skin tones is dependent upon room lighting. Another is that the distant provider cannot palpate and is dependent upon the skill of the presenter. A third is the lack of smell. Speed and accessibility to information at any time from any place are essential to quality of service (Babulak 2006). Slowdowns or outages in service are not acceptable. • Inadequate funding for technology support. Descriptions of some telehealth applications describe a lack of monies to establish and maintain the technical infrastructure needed (Bond 2006). In some cases, nurses are responsible for the set-up and basic support of telehealth devices. While the wisdom of this approach may be questioned in light of the limited availability of nurses it can be used as an opportunity to establish rapport and comfort with the technology (Starren et al. 2005). Quality of services rendered. There are two major issues surrounding the quality of telehealth services. One is that services must be at least of the same level of quality as traditional services, particularly for reimbursement services. The second issue is the paradox that geographically isolated populations that stand to derive the largest benefits from telehealth because they have limited access to traditional healthcare services often have the poorest infrastructure, resources, and capability to support telehealth (Liaw and Humphreys 2006).

Telementoring.

Real-time advice offered to a practitioner in a remote site via telecommunications technology.

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.

Strategies to Ensure Successful Teleconferences

Select a videoconferencing system to fit your needs, such as a desktop or mobile system or customized room. • Locate videoconferencing facilities near where they will be used, yet in a quiet, low-traffic area. • Schedule sessions in advance to avoid time conflicts. Start on time. • Establish a working knowledge of interactive conferencing features. • Provide an agenda to keep the conference on track. • Introduce all participants. • Set time limits. • Send materials needed in advance to maintain focus and involve participants. • Summarize major points at the conclusion. • Start by asking all participants if they have a good audio and video feed. • Participate in a conference call as if it were a face-to-face meeting. Enunciate clearly.

STORE AND FORWARD

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 is frequently used in telehealth. True False

TRUE

Some aspects of telehealth do not allow for proper medical aid. True False

TRUE

Telehealth solutions may not be available to all hospitals. True False

TRUE

The first instance of telehealth involved sending results over the telephone. True False

TRUE

Telesurgery. T

Technology that allows surgeons at a remote site to collaborate with experts at a referral center on techniques.

You are a nurse at Good Samaritan General Hospital in 2009. You have been hearing from colleagues at other hospitals about telehealth technologies, though GSGH has remained on the sidelines with respect to the technology, saying it's too expensive. However, after reading the newspaper one day, you realize that something has happened in Washington, D.C., that could solve the telehealth expense issue for GSGH. What did you read?

The American Reinvestment and Recovery Act of 2009 contains substantial resources for institutions like GSGH to build out their telehealth capabilities.

Tele-diagnosis

The detection of a disease by using data received from monitoring a patient at a distant 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.

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).

eMedicine (E-medicine).

The use of telecommunication and computer technology for the delivery of medical care.

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.

Teleradiology.

Transmission of high-resolution radiological patient images for interpretation or consultation by a radiologist at a distant location.

Telepathology.

Transmission of high-resolution virtual images, often via a robotic microscope, for interpretation by a pathologist at a remote site.

Teleultrasound.

Transmission of ultrasound images for interpretation at a remote site.

Telepsychiatry.

Variant of telemedicine that allows observation and interviews of clients at one site by a psychiatrist at another site through videoconferencing.

Teleconsultation

Videoconferencing between two healthcare professionals or a healthcare professional and a client. Remote health consultation, whatever the means of transmission.

Telehealth services include

health promotion, disease prevention, diagnosis, consultation, education, and therapy.

Teleconferencing

implies that people at different locations have audio, and possibly video, contact, which is used to carry out telehealth applications.

Videoconferencing i

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 For example, videoconferences provide a means to improve quality and access to care in Alaska, where clinics are connected

eCare (E-care)

lectronic provision of health information, products, and services online as well as the electronic automation of administrative and clinical aspects of care delivery.

eHealth

often used interchangeably with the term telehealth refer to the provision of electronic health information, products, and services using information technologies.

Interactive conferencing

primarily refers to videoconferencing and is used in place of face-to-face consultation. Frequently used for telepsychiatry.

the incorporation of national standards of care and drug information eliminates

redundant efforts by individual institutions to prepare their own standards and formularies.

plans for the use of telehealth applications should be in concert with the overall strategic plan of the organization. A telehealth plan minimizes duplicate effort and helps to ensure success. Goals should address the following:

Current services and deficits • Telehealth objectives • Compliance with standards • Reimbursement policies that favor desired outcomes rather than specific processes • Periodic review of goals and accomplishments in light of changing technology and needs • How telecommunication breakdowns will be handled: Will backup be provided? What happens when a power outage in the home severs a link?

Interactive.

Describes a technology system that interacts with user input (i.e., interacts with users) and involves information exchange via an online medium.

Tele-education (telelearning).

Distance learning via a computer and/or telephone connection.

You are a nursing informatics professional at Good Samaritan General Hospital. You are establishing a new telehealth solution for your recently released cardiac patients. It will enable cardiologists to monitor their younger patients at home and answer their questions at no cost to patients. However, GSGH's CEO does not like having to pay the hospital-affiliated cardiologists the money it would cost to provide consultations, saying, "They will be able to do this by just turning on their Internet-connected computer anywhere in the world." He tells you to instead "farm out the follow-up with a telehealth firm in another country that can do the monitoring at half of the cost to GSGH." Barely one month after implementing the system, patients begin rejecting the technology en masse, and only a handful of patients decide to take advantage of the monitoring system. Why would this be? Patients do not like having doctors monitoring them in the comfort of their homes. Younger patients are fearful of technology and slow to adopt it. Patients may be uncomfortable with outsourced providers whom they have never met monitoring their health. Patients don't like paying extra for the service.

Patients may be uncomfortable with outsourced providers whom they have never met monitoring their health.

Reimbursement and licensure issues remain two of the major barriers to the growth and practice of telehealth

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. here are also concerns about the impact of telehealth on record privacy, particularly with the implementation of the Health Insurance Portability and Accountability Act (HIPAA).

Teletherapy.

The use of interactive videoconferencing to provide therapy and counseling.

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.

telehealth

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. expansion of telemedicine with preventive, promotive, and curative applications

You are a nursing informatics specialist at Good Samaritan General Hospital. You have been chosen to present at a conference on telehealth because GSGH is progressive in its use of telehealth. During the first session at the conference, a participant stands up and asks if telehealth is an outgrowth of only the last 25 years, since the Digital Revolution. You know this is false. Which of the following statements should you use to explain the evolution of telehealth?

The idea of remotely treating and caring for patients through technology is more than 100 years old.

Telerehabilitation.

The use of interactive communication technology to facilitate assessment of patient's functional abilities and provide exercise and rehabilitation therapies.

Teleprevention.

The use of tele-education technology to provide opportunities to promote health.

Telenursing.

The use of telecommunication and IT for the delivery of nursing services.

You are a nurse at Good Samaritan General Hospital. You have taken a particular interest in developing telehealth solutions for GSGH. However, you are aware of several concerns that practitioners and patients may have with adopting telehealth throughout the GSGH system. Which of the following is a concern that you must address prior to adopting the technology? There are no real concerns with telehealth because the benefits are so great. You consider whether the patient is able to receive a consultation from world-class experts. You consider whether your nurses are able to partner with other nurses to provide better overall patient care. You consider whether the telehealth nurses from other institutions with which you partner are licensed in your state.

You consider whether the telehealth nurses from other institutions with which you partner are licensed in your state. Correct. You chose to consider whether the telehealth nurses at the institutions with which you partner are licensed in your state. Cross-state licensure is one of the primary concerns with telehealth, especially for liability reasons. If an error is made, nurses who are not licensed in your state can cause a great deal of liability for GSGH. It is important to know whether your state is one of the handful of states that do not require in-state licensing of telehealth nurses.

The American Recovery and Reinvestment Act of 2009

stimulus funding for research, operations, and grants in the telemedicine, telehealth, and informatics sectors.

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.

mHealth (M-Health).

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.

telemedicine

was the predominant term for the delivery of healthcare education and services via the use of telecommunication technologies and computers. replaced by the term telehealth. --emphasizes both the delivery of services and the provision of information and education to healthcare providers and consumer

Desktop videoconferencing (DTV) is

ynchronous, or real-time, encounter that uses a specially equipped personal computer (PC) less expensive may not be acceptable for telehealth applications that require high-resolution or high-speed