Telehealth Advancing Nursing Practice

Ruth L. Jenkins, RN, Ph.D. Peggy White, RN, MSN
NURSING OUTLOOK   March/April 2001

The pressures to contain health care, including the early discharge of patients, combined with the closing of many home care health agencies, create higher demands for home health care at a time when such care is rapidly becoming less available. Telemedicine technology may help to close the gap between demand and availability of home health care services. It also may open opportunities for the work of community health nurses and advanced practice nurses and reduce costs. The increased use of telecommunication to deliver services raises questions of the effectiveness of services to patients, cost of care, professional licensure, and reimbursement and liability issues. Presented here is a brief historical perspective on the functions of the technology, potential barriers to implementation, and possible uses in nursing care giving. Rather than being a substitute, telemedicine technology complements the existing health care network, bringing services to persons who otherwise might not receive care. By increasing our patients' options and expanding their access to health care, home health and advanced practice nurses act as patient advocates.

      As federal regulation payment changes come into effect, home health care is changing dramatically. In a health care milieu of cost containment, early discharge, and fewer home health resources, telemedicine (TM) technology can facilitate the work of home health nurses, advanced practice nurses (APNs), and in-hospital areas. A recent report described a program in which nurses provide updates to family members on the Internet, particularly in the neonate arena.1 Typically, TM is the interactive transmission of medical images and data to provide better health care for persons in remote or medically under served locations. NASA scientists assigned to the International Space Station Project have developed many aspects of TM. In the future, this technology, designed for astronauts operating beyond Earth's orbit, may routinely serve home care patients.2
      The contributions of the space program already affect some aspects of home health care. These medical advances that incorporate NASA-developed technologies include:

•  programmable pacemakers,
•  implantable defibrillators,
•  pneumatic finger flexors,
•  new and better hip joints,
•  voice-activated wheelchairs,
•  pure carbon implants,
•  human tissue stimulators,
•  space age clothing,
•  insulin pumps and
•  improved blood analysis for persons with diabetes and cancer therapy.2
  

     The use of telecommunication to deliver health care services raises questions regarding professional licensure, reimbursement, and liability.3 Presented here is a brief historical perspective on the functions of the technology, its potential for use in nursing care giving, and barriers to implementation.

DEFINING THE CONCEPT
The definition of TM continues to evolve; it has been envisioned as the practice of health care delivery, diagnosis, consultation, treatment, and transfer of medical data and education by using interactive audio, visual, and data communications.4 The origin of the term "telemedicine" comes from the Latin "tele," meaning "at a distance," and "mederi," meaning "healing." Within this notion, the basic premise has been expanded from the current physician-driven application for diagnosis and education to one that involves nurses, physical therapists, occupational therapists, respiratory therapists, pharmacists, technicians, and other non-physical providers.4
      The term "telehealth" (TH), rather than telemedicine, has been suggested as a more descriptive state of the technology because the physician consult is only one of many uses of the technology by a variety of disciplines in administering health care.5 The terms "telehealth" and "telemedicine" will be used interchangeably.

In a managed-care environment of limited access for paid visits, TH technology can increase professional contacts without the expense of hands-on visits. Nurses in hospital settings and home health care and nurses functioning in the advanced practice role can benefit from saved expenses after factoring out the cost of equipment and training. By eliminating home health nurse's travel time between home visits and clinic sites for patients about to be discharged, the APN can contact many more patients each day, greatly increasing the nurse's efficiency. APNs could have more latitude in collaborative agreements with physicians, expanding their point of service to remote areas by telecommunication consultations with physicians. However, support for the use of TH technology by the American Nurses Association (ANA) clearly asserts that TH and tele-nursing do not replace the direct, in-person services of the registered nurse (RN), but instead serve to facilitate and supplement RN practice.6

HISTORICAL USE
     
In the past, TH technology has been used to assist physicians in rural area clinics, military health applications, and correctional and other institutions requiring high security; in some instances, it has been used to transmit images between emergency departments and specialty physicians.
     
Several configurations of TM systems have been reported in clinical and scientific literature. Typically, electronic transmission of still or moving pictures is sent through the use of asynchronous time (stored images are forwarded) or real-time (interactive audio/video), which may be viewed immediately or stored. The system can consist of any number of technologies, which include audio/visual 2-way interactive systems, computers for recording and storing images, monitors for viewing, and transmissions over telephone lines referred to as POTS (plain old telephone system). This system is interfaced with the diagnostic tool of choice, depending on the purpose of the system. Such equipment has included electrocardiograms, internally advanced scopes, auto shapes, cardiac monitors and oximeters, blood pressure, and electronic stethoscopes. Some systems use dedicated fiber optic lines between sites and are quite expensive.
     
Portable TM units developed by American Telecare have been used in several TM projects.7 The units use a regular telephone line and are activated by the patient and nurse pushing one button simultaneously. The unit allows direct viewing of the patient, measurement of blood pressure, and telephonic stethoscope for auscultation of heart and lungs sounds.
     
Using this system, Jenkins,8 compared nursing assessment via TH monitor (monitor nurse) and hands-on assessment (real nurse) for elderly congestive heart patients. Results indicated no significant difference between the assessment with 4 exceptions. The monitor nurse was more likely to claim abnormality than the real nurse when assessing the color of nails (P = .048); and the real nurse noted ankle edema (P = .024), pedal edema (P = .099), and inspiratory wheeze (P = .Ol) more than the monitor nurse. Kappa coefficients to determine the extent of agreement between nurse's assessments were significant. These data were used to plan and implement a longitudinal study.
     
The video screen at the central station has a 3-in color monitor that provides 7 to 10 frames per second. It is recognized that there is a learning curve for assessing with this equipment. In addition, the nurse will need to know the patient fairly well. Use of the larger computer monitor screen allows a more accurate observation assessment. By watching the video screen, the nurse can assess the patient's mood and alertness and several neurologic functions such as facial symmetry, conjugate eye movement, gross vision, stance, tandem walking, and gait. It is also possible to conduct a finger-to-nose test, Romberg test, and range of motion of outstretched hands. An ancillary lens can be snapped onto the built-in camera to provide a close-up view of wounds or lesions, insulin syringes, and ambulatory intravenous therapy pumps!
     
This more sophisticated unit can zoom close-up pictures of the patient and store these in medical records. When using this technology for chronic conditions, there is an increase in effective and efficient nurse-patient interactions, a reduction in unnecessary emergency department visits, a reduction in unscheduled physician office visits, and a decrease in repeat hospitalization, which is attributed* to early intervention and early symptom management. Nursing assessment and intervention can be implemented sooner in an effort to avert exacerbation of serious clinical symptoms.9 Telecommunications (TC) in health care has been used for some time, notably by the military to treat soldiers in war zones; electrocardiograms were transmitted as early as 1906.10 Recently, technologic advances and federal government deregulation, legislation, and funding are making TM more readily available. It is believed that this service will decrease costs after the initial investment in hardware.

NURSING IN TELEHEALTH
Nurses have long been involved in TH without realizing it. Examples of telecommunication include educational efforts using tele-collaboration, faxing patient records, and telephone triage. As APNs assume primary care responsibilities, TH consultation can be considered as a means of communication between primary care providers (PCPs), their patients, and specialists, thus increasing heath care accessibility.

POTENTIAL OF TELEHEALTH PROJECTS
TH use has been documented to show successful treatment of patients in primary care, public health, home health, mental health, obstetrics, pediatrics, dermatology, surgery, radiology, pathology, intensive care units, and emergency departments. 11 Although TH has applications in urban settings, current interest and legislation are aimed at the rural population.
     
Case Management Advisor reports a 2-month telephonic home cardiac monitoring program for congestive heart failure (CHF). The advanced medical devices combined home cardiac monitoring with telephonic case management. The patient's weight, heart rate, blood pressure, and oxygen saturation were transmitted 3 times daily via modem to the telephone monitoring unit at a medical center. If the patient's measures fell outside the preset parameter, the unit set off an alarm that had to be manually cleared by the teleunit technician. Although the upfront cost of equipment is high, the program is considered very cost-effective, because it cuts CHF readmissions, in this population, by $607,201 in a 12-month period. However, the factor of cost for equipment compared with decrease of hospital readmission was not outlined.
     
Widely used is the electronic House Call patient system consisting of a computer, touch screen, monitor, speaker, and medical device for measuring vital signs. A computer-based monitoring station linked to the central monitoring station is installed in the patient's home. The system requires:

• one grounded 3-prong electrical outlet,
• a cable link into the home,
• a Pan/tilt camera,
• a Call Port microphone/speaker,
• a Zenith home works RF Modem,
• a Dell Pentium 20-MHz Minitower, and
• a Cinamap Plus vital signs monitor.

The patient system provides an interactive audio/visual conference with the central monitoring station. The patient operates the system by selecting options from a touch screen menu. With this system, health care providers can monitor heart and lung sounds with an electronic stethoscope, blood oxygen concentration, cardiac rhythm, blood pressure, body weight, and temperature. Nelson and Schlachta estimate that internal medicine procedures comprise 59% of inpatient costs, or about $6.19 million for patients who have been admitted more than 3 times. In contrast, by using TM interactive video, the cost would be about $1.4 million.4
     
Successful use of the pulse oximetry waveform systolic blood pressure for trauma paramedic field emergencies has been reported. 12  Statistical analyses reveal this method of blood pressure assessment to be fast, easy, and accurate. Advantages over auscultation and palpation include elimination of interference caused by noisy traffic environments and moving vehicles, where conventional methods have identified difficulty in auscultation assessing during ambulance transfer.
     
Also studied were 380 outpatients referred for hypertension with a continuous beat-to-beat noninvasive recording (Finapres) of blood pressure. Evaluated were persons described as having “white coat hypertension,” induced by office sphygmomanometry, Patients underwent a 24-hour ambulatory blood pressure monitoring, which was compared with office sphygmomanometry. Patients showed different levels of reaction. White coat hypertensive patients were found to be highest in reaction, and the lowest reactions were seen in reverse white coat hypertension patients. Similar responses were found in blood pressure measurements induced by conventional sphygmomanometry. 13
     
In a study of a combination of in-home and TH visits, nurses improved the quality of interactions and increased the overall number of interactions with patients.9 From a managed care and capitation perspective, the need to restructure traditional home care with cost-effective technology trends is supported for use in home care.14
     
Monitoring infants with apnea at home has been reported as undue stress because parents are trained to be within a 20- second distance of babies being monitored for apnea. Parents are afraid to leave the baby in the care of others.15 Caring Technology 1 G reports a wireless apnea monitor (I Am Fine l00), consisting of the baby belt, the base station, the pager, and the remote alarm. The base station receives radio signals for respiration and heart beat. The display appears as a digital clock with moving icons depicting breathing, heart action, and the presence of interference on the telemetry channels and whether an alarm condition is present. The pager links the infant module by telemetry, allowing the parent to monitor the infant when taking the baby on trips away from the home. However, its functions are limited to alarming for apnea, bradycardia, tachycardia, low battery, and problems with the telemetry link.

Increased Accessibility
The following examples illustrate how TH has increased health care accessibility for cases that previously would have required hospitalization. Kansas and Colorado have managed several different health problems, such as mental health, wound healing, and control of chronic health conditions, of rural home health patients that previously would have required hospitalization or would not have received adequate care because of their remote isolation.17
     
A remote physiologic monitoring network was established to investigate cardiorespiratory function during sleep in 400 infants in their homes. The objective of the study was to link detailed measurements of maternal and fetal nutrition during pregnancy and subsequent infant growth, development, and cardiorespiratory diseases. The option to measure these infants at home was to ensure physiologic accuracy and to reduce cost. Local community nurses effectively ran the network; with the exception of the size and cost of the monitors, it had all the elements of a remote primary care clinical service in Oxford, England. 18
     
Effective wound care management with TH has been reported in cases for which other patients would have had to be transported to a hospital or possible hospital stays.19 The Visiting Nurse Association of Los Angeles monitored patients with CHF at home providing better management of symptom status change. Early discovery of changes in symptoms, followed by immediate intervention, avoided unnecessary emergency department visits and repeat hospitalizations.20
     
Many rural areas are classified as health professional shortage areas because of a lack of adequate practitioners or a hospital for many miles. The use of TH has helped local rural professionals in cases of emergency care when a surgeon or specialist was needed but not physically available. A variety of procedures and surgeries, such as suturing or limb salvage, have been accomplished with TH and physician consultation. Studies indicate that the advanced nurse practitioners could treat most health care problems through TH consultation. 21

Advantages
TH increases accessibility to health care for patients in isolated areas or with transportation difficulties. TH usage has the potential to decrease costs for the patient and the entire health care system. TH decreases professional isolation and offers role expansion for APNs and home care, nurses. Clearly, TH provides an invaluable consultation resource, a monitoring device, and a means to provide immediate feedback to anxious patients and their families. The quality of life for the patient and the family has been reported to be related to access and the decreased need for caregivers to take off work for doctor visits and unplanned emergency department visits. Some industry observers have endorsed TH as part of the solution for developing capable cost-effective health care delivery.22 The increased number of visits made possible by the technology increases accessibility.

Barriers
Several issues challenge developers of TH systems, including cost, reimbursement, confidentiality issues, licensure, liability, and ethical concerns.

Costs. Initial costs to establish a network may be high, depending on the type of equipment required. A Tl telephone line, the equivalent of 24 regular telephone lines, provides high quality images but costs more than a Tl line split into 4 lines.23 The split line may accomplish the specific TM application for which it is intended but may not provide the clearest visual image. The industry will need to develop standards that specify the quality of image necessary for the intended application.

Funding for the establishment of certain TM networks has been mandated by legislation and is offered through many government agencies. The Telecommunications (TC) Act of 1996 deregulated TC, making rates more affordable and requiring TC providers to offer discounted services to rural areas. 24 Federal money may decrease in the future, but it is believed that funding will increase in the private sector as large TC companies and managed-care entities recognize the investment opportunities of reaching more persons,25 particularly as the number of insured visits is decreased.

Reimbursement. Numerous TM bills have been introduced to Congress. The language regarding reimbursement typically addresses physicians and has not properly addressed APNs. An exception is the Comprehensive Telehealth Act of 1997, effective January 1, 1998. This act mandates Medicare reimbursement, regardless of provider type, in rural and under served areas. 26 The Healthcare Financing Administration (HCFA), which oversees Medicare and Medicaid regulations, currently authorizes reimbursement for radiology and pathology consultations .

HCFA's study of TM may allow relaxation of the face-to-face visit requirement of Medicare 26; it is hoped that private insurers will follow that lead. California legislation requires both Medicaid and private payers to reimburse TM consultations 24 In August 1997, President Clinton signed the Budget . Reconciliation Bill that includes provision for Medicare reimbursement for TM services to residents of counties characterized as Health Professional Shortage Areas (HPSAs). That reimbursement began on January 1, 1999.

Reimbursement will not cover facility costs or telephone line charges, which will be shared between consulting practitioners and referring physicians. Kansas Blue Cross/Blue Shield is the first private insurer to approve payment for TM servers. The state's Medicaid program has been providing reimbursement since June of 1997.27

Confidentiality. Current laws address the issue of confidentiality but do not specify how to protect electronic transmission. Fiber optic lines are more difficult to tap than are copper lines, but there are no safeguards against computer hackers. Resolution of confidentiality and privacy issues will be the shared responsibility of the health professional, the consultant, and the TC company.25

Licensure. Licensure issues concern patient care given across state lines. Issues include whose patient it is and what license the professional must have to assess, diagnose, and prescript treatment across state lines. The legal standard is that health care is given at the site of the patient, so a consultant must be licensed in all states in which he or she practices. Each state has its own rules, regulations, and scope of practice, which can become confusing. The National Council of State Boards of Nursing is considering a mult-istate licensure for nurses 28 and the National Federation of State Medical Boards has proposed a licensure model, 25 but these models may take years for acceptance and establishment.

Current options for physician licensure are:

(1) licensure in each state of practice,
(2) special consulting license or sponsorship, and
(3) consultation possible only if made on an irregular basis.29

Licensure issues may effect the APN using consultation from bistate providers. Home health nurses providing TH care to patients across state lines may have similar licensing issues.

Most recently, the multistate nursing licensure compact is being consider by the member boards of the National Council of State Boards of Nursing (http://www.ncsbn.org) .26 To date, 9 states have passed legislation to enact the compact; those states are:

• Arkansas,
• Iowa,
• Maryland,
• Nebraska,
• North Carolina,
• South Dakota,
• Texas,
• Utah, and
• Wisconsin.

Three other states: Delaware, Idaho, and Mississippi, have introduced the legislation. In the recent Telehealth Improvement Act of 1999, it was re-emphasized that there is federal interest in reducing licensure as a barrier to the interstate provision of TH services.26

Liability. Liability issues arise when courts attempt to determine whether the PCP or the consulting physician is primarily responsible for the patient. This is not always clear, and case law has not been consistent, showing either to be responsible. Communication also has been shown to not always be necessary between consultant and patient to establish a provider-patient relationship. 30  However, the majority of courts have held that telephone consultations in which the specialist did not examine or speak, with the patient, review the patient's medical record, or otherwise direct the course of the patient's treatment do not result in a physician- patient relationship.31 This caveat bears thoughtful caution for the APN. In addition, liability associated with TC quality has been considered within medical-legal circles.

Ethical Concerns. When seeking a specialist opinion, PCPs may fear losing patients to a consultant or a large tertiary medical center. However, TM is designed to diagnose, treat, and keep the patient in his or her community, not transfer care to another provider. California and Kansas have attempted to decrease those fears by legislation that allows TM consultation, as long as the PCP in that state maintains care for the patient.

Some health care providers will miss the important diagnostic capabilities of tactile input that TM cannot provide. However, TM offers a larger visual field and the ability to freeze an image.

Health care practitioners are concerned that the provider patient relationship will be weakened, and that persons will be replaced by equipment. Studies have shown that patients accept and embrace TM, sometimes seeing it as a form of social contact. A Nebraska survey of 200 patients showed 97% acceptance of TM.24 Patients with CHF reported a need for both monitor nurse and real nurse visits. These elderly persons reported that their concerns were decreased sooner when they were able to call and see their nurse in the same time it took to make a telephone call.8  In addition, caregivers have reported to be empowered by having help just a telephone call away.31 Patient satisfaction was found to be no different by patients participating in a computer Home Talk TM home care service. 32  However, to reiterate the American Nurses Association position, TH and tele-nursing do not replace the direct, in-person services of the registered nurse, but instead serve to facilitate and supplement registered nurse practice.6

C O N C L U S I O N
TM is not a substitute for, but a complement to, the existing health care system, bringing needed health care to persons who otherwise might not receive care. By improving our patients' health care options and increasing accessibility to health care, APNs act as patient advocates, home care nurses monitor more closely treatment protocols, and collaborations between health care professionals provide greater access to patients in underserved areas.

TH provides APNs opportunities for expanding their role, reaching more patients, and providing more services. This role expansion can strengthen patient health outcomes and professional growth. Advanced practice nurses already have played a role in research to demonstrate that TM can improve health care by decreasing costs and increasing quality and accessibility to health care.

Informed APNs can serve as gatekeepers to health accessibility by educating patients, physicians, colleagues, care and community agencies. Innovative advanced nurse practices could be set in less accessible public school sites, where child health assessment data could be sent to PCPs or specialists as necessary. APNs should be aware of current federal and state legislation and could help lobby for TM projects in their state.

With the use of TH and home health nurse monitoring, patients can stay at home longer. Frequent rehospitalizations of patients with chronic conditions can be decreased. The costly use of emergencv department. facilities can be decreased. TH provides an earlier point of patient-care management. Patients can become more involved in self-management and responsibility for their own health. TH makes health care available to persons who are unable to travel because of illness, age, cultural perspectives, or simply a lack of transportation.

Early patient discharge, cost-containment, and a possible decrease in home care all combine to create the potential for a gap in health care services. Advanced practice and home health care nurses can play a key role in filling that gap through the use of TH technology.

REFERENCES
1. Gray J, Pompilio-Weitzner, Jones PC, Wang Q, Coriat M, Safran C. Baby CareLink: development and implementation of a www based system for neonatal home telemedicine. In: Proceedings of the AMIA Annual Symposium; 1998. Philadelphia: Hanley & Belfus; 1998. p. 351-5.
.2. Coleman C. Aerospace technology comes home. Caring Magazine 1997;July:40-1.
3. Ziel SE. Telecommunications in Health care. AORN J 1998;67: 458-9.
4. Nelson R, Schlachta L. Nursing and telemedicine: merging the expertise into "telenursing." J Healthcare Information Manage Systems Soc 1995;17:17-22
5. Wakefield BJ, Specht JK, Johnson-Mekota JL, Flanagan JR, Frantz RA, Buresch KA, et al. Implementation and evaluation of telemedicine to improve health care symposium. Proceedings of the Midwest Nursing Research Society 23rd Annual Conference Nursing Research & Policy: Moving to the 21st Century; 1999; Indianapolis, Indiana. p. 99-100.
6. Helmlinger C, Milholland K. Telehealth discussions focus on licensure. Am J Nurs 1997;97:61-2.
7. Baines BK. Tele-home care in a managed care setting. Remington Rep 1996;4(6):27-9.
8. Jenkins RL. T 1 e emedicine technology: home health nursing for cardiorespiratory problems. Proceedings of the Midwest Nursing Research Society 23rd Annual Conference Nursing Research & Policy: Moving to the 21st Century, 1999; Indianapolis, Indiana. p. 64.
9. Waner I. Introduction to telehealth home care. Home Heal&care Nurse 1996;14:791-6.
10. Morgan-Jones R Telemedicine in trauma surgery: advantages and disadvantages as seen by an orthopedic surgeon. Health Inf 1996;2: 188-93.
11. Home monitor reduces CHF re-admissions. Case Manage Advisor 1997;March:48.
12. McCluskey B, Addis M, Tortella BJ, Lavery RF. Out-of-hospital use of a pulse oximeter to determine systolic blood pressures. Prehosp Disaster Med 1996;11:105-7.
13. Musso NR, Giacche M, Galbariggi G, Vergassola C. Blood pressure evaluation by non-invasive and traditional methods. Am J Hypertens 1996;9:293-9.
14. Ciszewski P. Home health care: a growing industry continues to flourish. Med Interface 1997; 10(5):70-5.
15. Jenkins RL, Champion V. Assessing parent apprehension related to apnea home monitoring. Neonatal Intensive Care 1999;12(7):27- 30, 32-5.
16. Caring Technology, Inc. Technical report home user manual, LAFl00 Infant Apnea Monitor. Washington (DC): Life Systems; 1997.
17. Carroll L. Telemedicine changes the way physician's practice. Med Tribune Fam Phys (Med Trib Web) 1996;16-17,. 19, 22.
18. Johnson P, Andrews DC. Remote continuous physiological monitoring in the home. J Telemed Telecare 1996;2:107-13.
19 Penney N, Gibbons B. Rural nurses retool for expanding health needs. Reflections 1996;22(2):14-5.
20. Miller I? Home monitoring for congestive heart failure patients. Caring 1995; 14(8):53-4.
21. Nordberg M. Remote control: telemedicine revolutionizes EMS in rural America. Emerg Med Serv l996;25(8):35, 41, 43-5, 52-6.
22. Kinsella A. Home telehealthcare services: their role in home care today. Home Healthcare Nurse 1998;2(5): 17-22.
23. Ramsey W. Telemedicine. Topics Emerg Med 1995; 17(4): 1 l-6.
24. Schneider P. Telemedicine's legal and financial battlefields. Healthcare Inf 1996;13(10):50-2, 54, 56.
25. McMichael M. Telemedicine: a review and legal perspective. J Legal Nurse Consult 1997;8: 1725.
26. Fox A. Federal Telemedicine legislation: 105th Congress. Available at: http://www.arentfox.com
27. A service of American TeleCare, Inc. New legislation to allow Medicare reimbursement for telemedicine. Tele-Gram 1997; l(2): 1.
28. Esry C. Update on mutual recognition compact legislation. Missouri State Board of Nursing Newsletter 2000;2(2): 1.
29. Canavan K. Telehealth: nursing grapples with increasing care access without endangering quality. Am Nurse 1996;28(8):1-2.
30. Gobis L. Telenursing: nursing by telephone across state lines. J Nurs Law 1996;3(3):7-17.
31. Dimmick SL, Welsh T. A case study of benefits and potential savings in rural home telemedicine. Home Healthcare Nurse 2000; 18:124-35'
32. Stricklin ML, Jones S, Niles SA. Home talk TM/healthy talk: improving patients' health status with telephone technology. Home Healthcare Nurse 2000; 18:53-61.

Top - Back to Article Archive