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Chapter 8

Telehealth and Applications for Delivering Care at a Distance

Introduction

Telehealth: Use of electronic information and telecommunications technologies to support long-distance clinical healthcare, health-related education, public health, and health administration

Telemedicine: Use of medical information exchanged from one site to another via electronic communications for the purpose of improving patient care, treatment, and services

Telenursing: Use of telehealth technology to deliver nursing care and conduct nursing practice

Terms are often interchanged in discussion and in the literature, along with ehealth, mhealth.

All healthcare providers can export their clinical expertise using telehealth, not only physicians.

Although telehealth has been documented since 1897, it is still perceived as new in many instances.

Introduction (Cont.)

Successful Telehealth Programs

Rochester General Health Telehealth Program (Rochester, New York)

Seacoast Missions Telehealth Program (Bar Harbor, Maine)

University of Miami, Miami Miller School of Medicine (Miami, Florida)

Introduction (Cont.)

Telehealth Historic Milestones

1897: First report was documented.

1964: Modern telehealth programs began.

1960s: National Aeronautics and Space Administration (NASA) led telehealth initiatives.

July 2003 to December 2007: Veteran’s Administration (VA) conducted a home telecare program analysis.

2008: Whole System Demonstrator (WSD) Programme was launched.

Introduction (Cont.)

Leading Telehealth Organizations

American Nurses Association (ANA)

United States federal government agencies

American Telemedicine Association (ATA)

International Council of Nurses (ICN)

Telehealth Technologies

Telehealth technologies enable the exchange of all types of data (e.g., voice, video, wound, pathologic or radiologic images, device readings) between patients and providers or between providers on behalf of patients.

How Telehealth Changes Healthcare Delivery

Figure 8-1 from text

Telehealth Technologies (Cont.)

Synchronous: Real-time or live

Example: Videoconferencing; Internet chat

There are two overarching types of telehealth technologies: synchronous (live/realtime) and asynchronous (store and forward).

An example of synchronous is live, interactive videoconferencing between patient and provider.

Personal Health Eco-System

Figure 8-2 from text.

Telehealth Technologies (Cont.)

Asynchronous: Store and forward

Example: E-mail teledermatology consultation

An example of asynchronous is sending an email package comprised of patient history, pictures of rash, complaints, pertinent related diagnoses to request a dermatology consultation when the dermatologist is available to respond.

Telehealth Technologies (Cont.)

Telecommunications:

Wired, such as plain old telephone service (POTS), direct service line (DSL)

Wireless, such as cellular or sometimes seen as Code Divisions Multiple Access (CDMA), broadband, satellite, Bluetooth, infrared (IrDA), WiFi (otherwise known as the Institute of Electrical and Electronics Engineer (IEEE) Standard 802.11), mobile broadband wireless access

There are two types of telecommunications technologies for telehealth: wired or wireless. Future trends are toward wireless.

Telehealth Clinical Practice Considerations

Telehealth clinical competencies: United States, Canadian, and international competencies for telehealth are developed.

Confidentiality, privacy, and informed patients: Are the same as in-person care; telehealth requires additional attention to privacy if cameras cannot show who is in the room with the patient.

Clinical Competencies: American Nurses Association and 41 major health care provider organizations developed and endorsed Core Principles for Telehealth delivery. Specific to telenursing, the International Council of Nurses published research-based/validated International Competencies for Telenursing. In the US, the American Nurses Association published Competencies for Telehealth Technologies in Nursing. In Canada, the NIFTE Framework has interdisciplinary telehealth policy, procedures, guidelines and/or standards.

Confidentiality, Privacy and Informed Patients: same as in-person plus telehealth requires additional attention to privacy if cameras cannot show who is in the room with the patient.

Telehealth Clinical Practice Considerations (Cont.)

Telehealth scope of clinical practice: Is the same as with in-person care.

Clinical telehealth procedures: Need defined protocols for telehealth care, with evaluation and quality measures for iterative improvement.

Telehealth Scope of Clinical Practice: same as with in-person care.

Clinical Telehealth Procedures: need defined protocols for telehealth care, with evaluation and quality measures for iterative improvement.

Telehealth Operational Success Factors and Barriers

Training key to provider telehealth acceptance and use:

Telehealth technology training

Technology and computer literacy training

Workflow changes with telehealth; preparation of providers

Key success factors

Barriers to telehealth success

Technology trends have moved toward online courses or certificate education programs for telehealth. Two types of training are required for telehealth success: telehealth-specific instruction using live scenarios if possible and technology literacy training (if needed).

Clinical workflow is modified when implementing telehealth technologies. Health care providers can adjust by mapping out the new workflow and by continuing to use the same patient exam rooms for the telehealth patient, using similar medical devices for telehealth exams, learning how to use the communication and telehealth technologies, and interacting with the same physicians and specialists for telehealth consultations as used for in-person referrals.

Key Success Factors: Designated and dedicated telehealth project manager or coordinator; designated interdisciplinary telehealth team; adequate facility network infrastructure to support the telehealth system; Project Management to include and allow time for professional telehealth education and training.

Barriers to Success: Funding limited; lack of communication between administrative management, interdisciplinary team and participants; failure to identify remote clinical partners to refer patients or provide telehealth services; poor telehealth equipment selection or performance.

B.E.L.T Framework

Figure 8-3 from text.

Licensure and Regulatory Issues in Telehealth

State licensure: Most hurdles are bureaucratic and political, not clinical.

Mutual recognition licensure: Allows nurses to practice across states.

Credentialing and privileging: Decisions are made by facility, therefore are not conducive to telehealth.

State lines and geographic boundaries are arbitrary in the realm of telemedicine and telehealth, but licensure and state practice rules still need to be enforced. One of the major barriers to the widespread implementation of telehealth is the cost and procedural complexity of attaining separate licenses in each state.

Mutual recognition allows nurses to practice in 24 states if they have an RN license in any one participating state. Goal is to include all 50 states.

CMS modified existing credentialing rules in 2011, and allows hospitals or Critical Access Hospitals (CAHs) to utilize information from the distant-site hospital or other accredited telemedicine entity when making credentialing or privileging decisions for the distant-site physicians and practitioners.

Licensure and Regulatory Issues in Telehealth (Cont.)

Reimbursement: Varies by state and insurer; Medicare is slowly participating.

Malpractice and liability: Concepts applied with telehealth are the same as with in-person care.

Reimbursement: Medicaid varies by state; private insurers vary; Medicare telehealth services can only be furnished to an eligible telehealth beneficiary from an eligible originating site. In general, originating sites must be located in a rural Health Professional Shortage Area (HPSA) or in a county outside of a Metropolitan Statistical Area (MSA). The originating sites authorized by CMS include hospitals, skilled nursing facilities, the office of the physician or licensed health care practitioner, rural health clinics, community mental health centers, CAHs, CAH-based dialysis centers, and federally qualified health centers.

Liability jurisdictional issues include the “place of treatment” dilemma, lack of establishing a bona fide doctor-patient relationship with cybermedicine (medical care via the Internet). Overall the traditional concepts of negligence, duty of care, and practicing within one’s scope of legal license still apply to telehealth as they do in traditional face-to-face encounters.

Telehealth and Direct Services to Patients

Majority of healthcare is self-care provided in the home or community.

Applications:

Direct, online patient telemedicine care

Remote patient telehealth visits and biometric sensors

Consumers monitored and linked with online healthcare information

eHealth literacy: The e-Health Initiative (eHI); reliability and accuracy of web content

The vast majority of health care is actually consumer self-care delivered in the home or local community. Technology focus should be on this area instead of expanding acute care system approach.

Applications meet a need for access to care where there often is none.

Direct, online patient telemedicine care – Teladoc, Online Care anywhere.

Remote patient telehealth visits – Dept of VA Coordinated Care/Home Telehealth largest telehealth program in the US; AFrame Digital Watch with sensor with intelligent learning platform.

Monitor/link consumers with online health care information – WebMD; EverydayHealth.com.

eHealth literacy: The e-Health Initiative (eHI) provides helpful information to healthcare leaders in their pursuit of consumer-based HIT adoption. Based on the following guiding principles: 1) Consumer engagement in care; 2) Consumer access and control of personal health information; 3) Consumer access to electronic health information tools and services; 4) Consumer privacy; 5) Consumer trust, and 6) Consumer participation and transparency. Consumers must learn how to evaluate web healthcare info and have must also have competency in: 1)Visual literacy (ability to understand graphs, read a label or other visual information), 2) Computer literacy (ability to operate a computer), 3) Information literacy (ability to obtain and apply relevant information) and 4) digital literacy.

Components of Telehealth

Figure 8-4 from text.

Conclusion and Future Directions

Telehealth growth: Global socioeconomic, market, and demographic factors

Mobile phone use growth contributions to mhealth adoption

Telehealth growth will continue due to rising health care costs, increasing prevalence of chronic diseases, an aging population, demands for improved access to health care, and global shortages of healthcare professionals.

mHealth capabilities now provide a wide range of wireless monitoring opportunities, the transmission of information for a variety of health conditions, such as diabetes and cardiovascular diseases, and has increased access to persons and communities in rural and isolated regions.

CuRE© (Canada-India Centre of Excellence for u-Health Research and Education) Framework figure depicts creation of large telehealth ecosystems and healthcare models via an interdisciplinary and inter-sectoral approach that spans the domains of technology, education, and health management in an iterative process of knowledge sharing across various levels of to inform health care policy decisions stakeholders. uHealth means ubiquitous healthcare using telehealth, mHealth, and operationalizing the concept of international global ecosystems. ubiquitous health (u-Health) technologies integrate core components of computers, wireless networks, sensors, and other modalities, such as m-Health devices, to create an environment that can monitor, respond to, and assist in meeting healthcare needs of individuals.

Chapter 8

Telehealth

and Applications for

Delivering Care at a Distance