HIM 301 Introduction to Health Informatics-WK2-D1

Chapter 8 Telehealth and Applications for Delivering Care at a Distance

Loretta Schlachta-Fairchild

Mitra Rocca

Vicky Elfrink Cordi

Andrea Haught

Diane Castelli

Kathleen MacMahon

Dianna Vice-Pasch

Daniel A. Nagel

Antonia Arnaert

Growth in telehealth could result in a future where access to healthcare is not limited by geographic region, time, or availability of skilled healthcare professionals.

Objectives

At the completion of this chapter the reader will be prepared to:

1.Discuss the historical milestones and leading organizations in the development of telehealth

2.Explain the two overarching types of telehealth technology interactions and provide examples of telehealth technologies for each type

3.Describe the clinical practice considerations for telehealth-delivered care for health professionals

4.Analyze operational and organizational success factors and barriers for telehealth within healthcare organizations

5.Discuss practice and policy considerations for health professionals, including competency, licensure and interstate practice, malpractice, and reimbursement for telehealth

6.Describe the use of telehealth to enable self-care in consumer informatics

7.Discuss future trends in telehealth

Key Terms

Digital literacy, 141

Telehealth, 125

Telehealth competency, 131

Telemedicine, 126

Telenursing, 126

uHealth, 141

Abstract

Rapid advances in technology development and telehealth adoption are opening new opportunities for healthcare providers to leverage these technologies in achieving improved patient outcomes. Telehealth provides access to care and the ability to export clinical expertise to those patients who require care, regardless of the patients' geographic location. This chapter presents telehealth technologies and programs as well as telehealth practice considerations such as licensure and malpractice challenges. As telehealth advances, healthcare providers will require competencies and knowledge to incorporate safe and effective clinical practice using telehealth technologies into their daily workflow.

Introduction

Rapid advances in technology development and telehealth adoption are opening new opportunities for healthcare providers to leverage these technologies in achieving improved patient outcomes. Before we discuss these technologies and outcomes, it is important to explore the definitions of telehealth-related terminology.

Telehealth encompasses a broad definition of telecommunications and information technology–enabled healthcare services and technologies. Often used interchangeably with the terms telemedicine, ehealth, or mhealth (mobile health), telehealth is “the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health, and health administration.”1 Telehealth is being used in this text to encompass all of these other terms. Telemedicine is the use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or healthcare provider and for the purpose of improving patient care, treatment, and services.2 Telenursing is the use of telehealth technology to deliver nursing care and conduct nursing practice.3,4

Telehealth enables the delivery of clinical care to those who are in need regardless of the geographic location of the patient or the healthcare provider. Well-established telehealth programs and evidence-based research supports the effective use of telehealth across most disciplines and specialties within healthcare (i.e., teleradiology, teledermatology, telepathology, telenursing, etc.).5–10 Telehealth services provide access to health assessment, diagnosis, intervention, consultation, supervision, and information across distance.11 As a result telehealth is now being integrated into routine care delivery of patients around the globe. Figure 8-1 depicts how telehealth can change healthcare delivery. Telehealth services can be classified as clinical or nonclinical. Clinical telehealth services include but are not limited to diagnosis, patient communication and education, disease management, triage and advice, remote monitoring, caregiver support, and provider-to-provider teleconsultations. Nonclinical telehealth services include but are not limited to distance education for healthcare consumers or clinicians, video conferencing or conference call meetings, research, healthcare administration, and healthcare management.

Providing care to underserved populations can be a challenge, especially in rural areas or where there is a shortage of healthcare professionals. Patients may face physical, financial, geographic, and other barriers to accessing care. However, telehealth can overcome many of these barriers. Telehealth proponents seek to improve quality, access, equity, and affordability of healthcare in the United States and throughout the

FIG 8-1 How telehealth changes healthcare delivery.

(Copyright 2010 iTelehealth Inc. All Rights Reserved.)

world by using telehealth.11 Healthcare professionals who use telehealth can export their clinical expertise to patients regardless of geographic location.

Telehealth technologies include configurations as simple as a telephone conversation between a healthcare provider and a patient or as sophisticated as a doctor performing robotic surgery on a patient across continents. Telehealth technologies include but are not limited to telephones; facsimile machines; email systems; cellphones; video conferencing; web-based, remote patient monitoring devices; transmission of still images; and Internet applications (ehealth) including patient portals, remote vital signs monitoring, continuing medical education, and direct consumer applications such as online physician consultations via the Internet.

Telehealth is used in a variety of settings, among which are rural hospitals, home health agencies and patients at home, prisons, dialysis centers, and nursing homes; telehealth is also used to provide care to astronauts in space.11,12 The benefits of remote monitoring, diagnosis, and intervention have been proven in numerous scientific studies and include increased access to care, decreased costs of healthcare and increased healthcare provider productivity, and a high level of patient satisfaction.3,13 Furthermore, the advantages of telehealth to patients are numerous and include the following:

•Decreased travel time or distance and removal of travel barriers

•Immediate access to care

•Early detection of disease processes or health issues

•Ownership of healthcare and feelings of empowerment

•Long-term health and independence

•Caregiver reassurance

•Patient satisfaction with healthcare

Examples of Successful Telehealth Programs

The following three examples of telehealth programs demonstrate the wide range of such programs currently providing services to patients at a distance.

•Rochester General Health System, Rochester, New York, developed a clinic-based telehealth program in 2008. Its healthcare providers use a video conferencing system for live patient consults with remote physician specialists. They have the capability to send video images and 12-lead digital electrocardiograms. The Director of Telehealth coordinates and schedules 34 physicians and 5 midlevel healthcare providers who see patients remotely. Rochester General's telehealth program developed a rigorous 1-day training session for all end-users.

•Sea Coast Mission Telehealth Program, Bar Harbor, Maine, provides seagoing health services to islanders living on four islands with no healthcare providers available.14 Daily use of live video conferencing from a 72-foot boat called the Sunbeam V occurs with the support of a boat crew that includes a nurse. The telehealth program coordinator, an early adopter of telehealth, described herself as “technically challenged” during the site's implementation. Since then she has developed excellent clinical and technical skills to work proficiently in an austere environment. In this setting attention to a patient's health condition can at times be urgent, requiring immediate diagnosis and treatment. The goal is to diagnose sick patients in a timely manner so that they can be transferred off the island for access to a higher level of medical care on the mainland. Maine Sea Coast Mission's most recent project has been to implement health centers with video conferencing systems on four islands (Frenchboro, Matinicus, Swan's Island, and Isle au Haut), thereby providing access to remote health and education services year-round (Sharon Daley, RN, personal communication, March 2010).

•University of Miami, Miller School of Medicine, Miami, Florida, provides both live video conferencing and store-and-forward capability as part of its telehealth program. Its program reached out in 2010 to provide medical support after the earthquake in Haiti. One unique program is the Teledermatology Program for private cruise ships. The program uses expert dermatologists to evaluate an array of skin problems such as lesions, burns, infections, and rashes seen by emergency physicians on board cruise ships. The Clinical Telehealth Coordinator provides online training to cruise ship staff for using a digital camera and image capturing and transmission via a dermatology software application. Images are then reviewed by the dermatologist and patient reports with diagnosis and recommendations are sent back electronically to the emergency physician within a specific time frame.15

Telehealth Historic Milestones

In contrast to the common perception that telehealth is new and futuristic, it actually has a long history. The first documented report of healthcare delivery at a distance dates back to 1897 in The Lancet, when a case of croup was diagnosed over the telephone. In the United States modern telehealth programs began in 1964, with a closed-circuit television link between the Nebraska Psychiatric Institute and the Norfolk State Hospital for teleconsultations. Shortly thereafter, in 1965, a cardiac surgeon in the U.S. transmitted a live video feed of a surgical case to spectators in Geneva, Switzerland, via satellite. The surgeon discussed his case and answered live questions from the spectators in Geneva.16

The National Aeronautics and Space Administration (NASA) led telehealth initiatives in the 1960s with the transmission of physiologic signals from astronauts in space to command centers on Earth. NASA also funded several telehealth research programs in the late 1960s and early 1970s that contributed to the profession as a whole.17 A landmark study completed by Kaiser Permanente in 1997 concluded that “technology in healthcare can be an asset for patients and providers and has the potential to save costs; therefore, this technology must be a part of continuous planning for quality improvement.”18(p45) The researchers were emphatic about the benefits of telehealth, inspiring many of today's telehealth programs.

From July 2003 to December 2007 the U.S. Department of Veterans Affairs (VA) conducted a home telecare program analysis to coordinate care of chronically ill veterans and reduce long-term care admissions. The program evaluation was highly successful, realizing a reduction in long-term care bed days and inpatient hospital admissions among participants. Further, the veteran participants reported a high level of satisfaction. Costs to provide the program were and are substantially less than other VA programs or nursing home care. The program is now known as Care Coordination/Home Telehealth (CCHT) and is a routinely offered VA service to support aging veterans with chronic conditions.19

In the United Kingdom the Whole System Demonstrator (WSD) program was launched by the National Health Service in 2008 in order to determine the effectiveness of telehealth. As of its start date, the study was the largest randomized controlled trial of telehealth in the world, involving more than 6000 participants. The study confirmed that telehealth promotes well-being and should be a part of any complete healthcare system.20

Leading Telehealth Organizations

Starting in the 1990s, a number of professional, industry, and government organizations have provided the leadership needed to initiate effective telehealth programs. These leaders include the American Nurses Association (ANA), United States federal government agencies, the American Telemedicine Association (ATA), and the International Council of Nurses (ICN).

American Nurses Association (ANA)

With the advent of technology and rapidly emerging telehealth practice in the twentieth century, healthcare professionals sought guidance on incorporating telehealth into their care offerings. Multidisciplinary standards were needed to create a cohesive unity for telehealth across professions. To address the expansion and to create unified definitions and policies and a standard of care, the ANA brought together the Interdisciplinary Telehealth Standards Working Group. This group was composed of 41 representatives from different healthcare organizations and professional associations. The report of the interdisciplinary team, Core Principles on Telehealth, represents a “sense of the profession” as a whole.21 The purpose of the core principles is to create a baseline standard of care in order to provide quality care as well as protect patients from harm.

United States Federal Government Agencies

NASA, the VA, the U.S. Department of Defense (DOD), and other government agencies have continued to lead the U.S. in telehealth research and programs. As an early adopter of telehealth, the VA operates the nation's largest telehealth program. The widespread adoption and positive research findings led the U.S. government to establish the Office for the Advancement of Telehealth (OAT), a division of the Office of Rural Health Policy within Health Resources and Services Administration (HRSA) at the U.S. Department of Health & Human Services (HHS). OAT promotes the use of telehealth technologies for healthcare delivery, education, and health information services and increases the use and quality of telehealth delivery through the following activities:

•Fostering partnerships within HRSA and with other federal agencies, states, and private sector groups to create telehealth projects

•Administering telehealth grant programs

•Providing technical assistance

•Evaluating the use of telehealth technologies and programs

•Developing telehealth policy initiatives to improve access to quality health services

•Promoting knowledge exchange about “best telehealth practices”1

American Telemedicine Association (ATA)

The American Telemedicine Association (ATA) is a nonprofit organization founded in 1993 and headquartered in Washington, D.C. The mission of ATA is to “promote professional, ethical and equitable improvement in healthcare delivery through telecommunications and information technology” through education, research, and communication.22 ATA is a mission-driven, nonprofit organization that seeks to incorporate telehealth seamlessly into healthcare so that it is not necessarily a separate program but integrated into healthcare delivery as a whole.

International Council of Nurses (ICN)

Representing more than 200 national nursing organizations, including the ANA, Canadian Nurses Association, and associations of more than 198 other countries, the ICN initiated the Telenursing Network in 2008. As telenursing advances, this virtual collaboration is serving to share competencies and other jointly developed telenursing resources.

Telehealth Technologies

Telehealth technologies enable the exchange of all types of data (i.e., voice, video, pictures of wounds, pathology or radiology images, device readings, etc.) between patients and healthcare providers or between healthcare providers on behalf of patients. Early telehealth technologies were “stand-alone” systems in which a telehealth encounter occurred and data were stored in a telehealth system database. With the increasing adoption of electronic health records (EHRs), telehealth technologies are being increasingly integrated with the EHR. Telehealth services can be delivered using two overarching types of technologies: synchronous (or real-time) technologies or asynchronous (or store-and-forward) technology.

Synchronous or “Real-Time” Technologies

Synchronous, real-time telehealth uses live, interactive telecommunications technology and/or patient monitoring technologies to connect a healthcare provider to a patient for direct care, to other healthcare providers for consultation and collaboration, or to a combination of the two.23 The most commonly used synchronous telehealth employs video conferencing or telephone-based interaction.

Video Conferencing

Video conferencing integrates audio, video, computing, and communications technologies to allow people in different locations to electronically collaborate face to face, in real time, and share all types of information, including data, documents, sound, and picture. Use of interactive video conferencing in telehealth allows for patient–healthcare provider consultations, healthcare provider–specialist discussions, and health education. The technology requires live presence of the healthcare provider and patient or healthcare provider and medical specialist in an interactive environment.

A real-time live environment can include the following:

•Video conferencing units with a codec (compressor–decompressor) capable of encoding and decoding the video conferencing stream.

•Peripheral cameras such as high-definition cameras that have remote control pan, tilt, and zoom (PTZ) features.

•Video display devices such as computer monitors, television sets such as HD Plasma or LCD displays, and LCD projectors. These display devices are used to show the images received from the video conferencing codec.

•Audio components (microphones and speakers), a network connection, and the user interface. Prior to the availability of high-bandwidth Internet connections, signals were carried over point-to-point connections established via Integrated Services Digital Network (ISDN) lines and plain old telephone service (POTS). The Internet has now simplified some of the connectivity issues and the high-bandwidth requirement of video conferencing.

Patient Monitoring Technologies

Patient monitoring technologies, including home telehealth (also known as telehomecare), use devices to remotely collect and send biometric data to a home health agency or a remote diagnostic testing facility (RDTF) for interpretation by a healthcare provider. Such applications might include a specific vital sign device, such as blood glucose monitor, digital scale, thermometer, heart electrocardiogram (ECG), blood pressure monitor, pulse oximeter, or peak flow meters, or a variety of monitoring devices for homebound patients. Such services can be used to supplement the use of visiting nurses.3 Use of monitoring devices will also allow patients to become more involved in and in many cases to oversee the monitoring process.24

Patient monitoring technologies for home telehealth consist of two major components: hardware and software. The hardware includes a base station where the patient interacts by entering data and answering questions and applies various medical devices that are used to gather patient data. The software enables healthcare providers and technicians to configure the hardware, receive data, and monitor the patient.

The telecommunications used can be wired, such as POTS or direct service line (DSL), or wireless, such as cellular (sometimes seen as code division multiple access, or CDMA), broadband, satellite, Bluetooth, infrared (IrDA), WiFi (or IEEE Standard 802.11), mobile broadband wireless access (MBWA or IEEE Standard 802.20), or Worldwide Interoperability for Microwave Access (WiMAX or IEEE Standard 802.16). mhealth and mobile health are umbrella terms that incorporate mobile or wireless telecommunications for transmitting telehealth-related data and services. Both the

FIG 8-2 Personal health ecosystem. BB, Broadband; PERS, Personal Emergency Response System; POTS, plain old telephone service.

(Copyright 2010 Continua Health Alliance. All Rights Reserved.)

telecommunication and the hardware can be incorporated in the medical device.

Figure 8-2 provides a diagram of the components of a telehealth system.

1.Personal health devices monitor basic vital signs such as blood pressure, weight, pulse, oxygen level, and blood sugar values and transmit data via a wired or wireless connection via devices or sensors.

2.The aggregation and computation manager is a critical component of the connected health system, enabling individual monitoring devices to log data in an EHR for personal and clinician review. The aggregation manager collects and transmits data from an individual's personal health devices to a server using wired or wireless connections. The aggregation manager itself can be a cellphone, a personal computer, a dedicated device, or a personal health record (PHR).

3.The health service center is a physical location where a patient's digital information is collected, stored, analyzed, and distributed. It can be the doctor's office, the home of a family member, or another type of healthcare-related facility.

Asynchronous or “Store-and-Forward” Technology

“Store-and-forward” technology allows for electronic transmission of telehealth-related information, video, images, and audio files. It can be used when healthcare providers and patients are not available at the same time. The sending healthcare provider or patient prepares an electronic consult package, which includes the patient's history, related diagnoses, and digital images such as x-rays, video, and photos. This package is either emailed or placed on a web server for the receiving healthcare provider to access when his or her schedule allows. The receiving healthcare provider then reviews the package, follows up with clarification questions, and provides a diagnosis, recommendations, and a treatment plan. The receiving healthcare provider's response is transmitted electronically back to the sending healthcare provider or patient. Store and forward technologies can be used in dermatology, radiology, pathology, dentistry, cardiology, wound care, home monitoring, pediatrics, and ophthalmology as well as other areas.

A store-and-forward technical environment can include the following:

•A personal desktop, laptop computer, tablet, or smartphone for the sender

•A personal desktop, laptop computer, tablet, or smartphone for the receiver

•Telecommunication technologies such as local area network (LAN), wireless communications, etc.

•Digital peripheral medical devices such as digital cameras, x-ray equipment, glucometers, vital sign monitors, and wearable sensors embedded in T-shirts or wristwatches

•Software such as a web-based application, encrypted email, specially designed store-and-forward software, an EHR, a PHR, and an electronic data repository

Technical Standards in Telehealth

Until recently the demand for telehealth-based medical devices was not sufficient to create unified, global technical standards. However, technical standards that were developed for associated markets have benefited telehealth. For example, use of American National Standards Institute (ANSI) H.32x standards has enabled wide-scale video conferencing interoperability, which led to further growth in nonhealthcare businesses. Not only has telehealth benefited from the video conferencing standards, but it is also benefiting from a reduction in the cost of equipment as well as the improved ability to conduct interactions between parties independent of the particular hardware used. In addition, development of Health Level Seven (HL7), which provides global interoperability standards for health information technology (health IT), and Digital Imaging and Communications in Medicine (DICOM) standards for imaging has also been of great benefit for telehealth.3

In 2006 the Continua Health Alliance was formed by a group of healthcare technology industry companies to establish interoperable personal telehealth solutions and to develop technical design guidelines. The goal is to agree on a set of common technical guidelines that will enable vendors to build interoperable sensors, home networks, telehealth platforms, and health and wellness services. The Continua Health Alliance also has developed a technical certification program based on these guidelines. Technologies that are certified by Continua Health Alliance have been technically tested and validated to work together and be interoperable.25

An example of such a standard is ZigBee/IEEE 802.15. This standard is targeted at applications that require a low data rate, long battery life, and secure networking. ZigBee/IEEE 802.15 has become a useful wireless connectivity standard for home or facility-based telehealth. ZigBee is a low-powered network capability that allows telehealth devices and sensors to operate longer and with smaller power sources, enabling miniature sensors to transmit health data. ZigBee is also a very low cost and easily installed network capability, providing usability and requiring minimal technical support. The ZigBee Alliance offers two specifications (ZigBee and ZigBee RF4CE) that serve as the base networking system to facilitate its interoperable market standards.26

Telehealth and Health Information Technology

A need exists to integrate all relevant medical device images and data from the telehealth technology with the patient's EHR. The interoperability of these systems could dramatically streamline a healthcare provider's workflow and improve the healthcare.

A key to telehealth success is healthcare providers' access to patients' health records at the time of a telehealth encounter—just as it is with in-person care. Telehealth networks serve to establish a link between provider EHRs, and securely moving health-related information that is exchanged among patients, hospitals, and healthcare providers as needed for care and treatment. Telehealth in HIE initiatives is expected to lead to the next generation of interoperability for health IT across and among healthcare enterprises. Existing telehealth infrastructure will also serve as a highway for EHRs and information exchange between and among rural and remote areas.27

Telehealth Clinical Practice Considerations for Healthcare Professionals

Healthcare providers have used the telephone as a communication tool for patient interaction for decades. Adding to the complexity of remote care delivery today, it is becoming increasingly common to use computers, remote monitoring devices, and interactive audio and video conferencing for patient interaction. With expanding telehealth technology capability, new and more efficient models of care are facilitated, allowing for removal of time and distance barriers.

Equal to or Better Than In-Person Care?

Telehealth is considered to be so effective that in 1997 the World Health Organization (WHO) announced that it has become part of the WHO's “health for all” strategy and should be made available to all people.28 Physician–patient encounters via telehealth have been supported by research to be as effective as standard face-to-face visits held in a physician's office or clinic. In 2008 Dr. Gregory Jicha, assistant professor of neurology at the University of Kentucky's Sanders-Brown Center on Aging, led a study called Telemedicine Assessment of Cognition in Rural Kentucky. “The goal of the project was to adapt and validate the UDS [National Institute on Aging's Uniform Data Set, a standard set of questions asked of every patient being screened for Alzheimer disease] and other measures for diagnosing mild cognitive impairment (MCI) and early dementia in the telemedicine setting. An important aspect of the goal was to determine whether the telemedicine consultations were as effective as face-to-face meetings with a doctor.”29(p32) Jicha stated that “developing and validating this telemedicine approach for diagnosing and treating MCI and early dementia will become a model for clinician-researchers at other centers serving rural populations.”29(p32) Per Jicha's perception of using telemedicine to expand healthcare resources, “the bottom line is, our goal is to ensure that though telemedicine is not better than an in-person evaluation, it's as good as an in-person evaluation.”29(p34)

Beginning in 2008, two studies (one in the United Kingdom and the other in Quebec, Canada) concluded that “telemedicine is increasingly seen as an efficient and cost-effective means for improving clinical outcomes and increasing patient involvement in their own care.”30(p59) Both studies demonstrated two important factors that influence healthcare professionals' acceptance of telemedicine: training and support.

Telehealth Clinical Competency

As healthcare providers' use of ever wider and broader technological tools increases, so does the need to ensure telehealth competency to provide safe and optimal patient care. As healthcare further embraces telehealth to gain efficiencies, improve access to care, and reduce costs, there must be a focus on educating and preparing healthcare providers in telehealth technology, techniques, skills, coordination, and “on camera” communications. A telehealth clinical encounter involves multiple new components and competencies, including coordinating healthcare provider and patient scheduling, knowledgeable telepresenting skills (i.e., steps needed to facilitate a telemedicine encounter between a patient and remote healthcare provider), the exchange of prior medical record and new telehealth information, and an understanding of video and audio technology.

From initial academic preparation through ongoing continuing education requirements, healthcare providers practice in a dynamic field with ongoing changes in care delivery. All healthcare providers are required and expected to maintain and update clinical competency in the care they render to patients. Telehealth also requires competency for optimal healthcare delivery. A number of professional associations have stepped forward to identify the specific competencies required. As described earlier in this chapter, the ANA and 41 major healthcare provider organizations developed and endorsed core principles for telehealth delivery in 1998.21 A year later the ANA created and published Competencies for Telehealth Technologies in Nursing.31 In 2001, with further expansion in telehealth, the ANA endorsed the development of telehealth protocols.32 These protocols were developed to encompass the needs and concerns of both clients and practitioners. On an international level the ICN published the research-based, validated International Competencies for Telenursing based on an international survey of practicing telenurses in 36 countries around the globe.4

The National Initiative for Telehealth Framework of Guidelines (NIFTE Guidelines) was a critical milestone in development of telehealth not just for those who authored the guidelines in Canada, but globally.33 This highly important and superbly designed framework was developed in Canada by a multistakeholder interdisciplinary group. The NIFTE Guidelines are designed to assist individuals and organizations to develop telehealth policies, standards, and procedures. NIFTE examines and offers principles and suggested guidelines for five overarching content areas related to telehealth:

•Clinical standards and outcomes

•Human resources

•Organizational readiness

•Organizational leadership

•Technology and equipment

In addition, Canadian nurses have provided more than a decade of telenursing leadership and developed extensive practice guidelines for nurses who are becoming or presently in the role of telenurse.34

In November 2011 the ATA developed an expert opinion consensus document on interactive video conferencing. The Expert Consensus Recommendations for Videoconferencing-Based Telepresenting defines the requirements for serving as a telepresenter in a live, synchronous telehealth encounter. As with all patient interactions, processes for patient registration, consent, clinical information, reimbursement information, and privacy are applicable to telehealth encounters.35 The ATA has also developed Telemedicine Standards and Guidelines for Diabetes, Telemental Health, Teledermatology, Home Telehealth, and Telepathology.

Confidentiality, Privacy, and Informed Patients

Patient confidentiality and privacy are paramount when using technology for the transmission of health data and live video presentation of the patient to geographic environments at a distance from the patient's location. The requirements for ensuring confidentiality, privacy, and informing patients receiving care via telehealth are the same as for in-person care. This is particularly true when the possibility exists of others being present in a room but off-camera. Attending to the presence of others at either the sending or receiving locations is an additional, important privacy task for healthcare providers using telehealth. Another important concern is ensuring that patients are being adequately informed and educated regarding telehealth consultation and assessment and evaluation via video conferencing technology.4,32

Scope of Clinical Practice

For healthcare professionals the use of technology does not alter or change the practitioner's inherent standards of practice, ethics, scope of practice, or legalities of practice.32,34 Healthcare professionals may use telehealth for patient consultations or for consultation with other healthcare providers. When telehealth is used for patient consultations, the healthcare professional's credentialing and clinical privileges at the site where the patient is located must be completed. The practitioner will need education, training, and technical support for the necessary technologies before, during, and after telehealth consultations.

The decision to refer a patient to a healthcare professional for consultation via telemedicine or telehealth is determined by multiple factors. Referrals for a telehealth consult need to consider the following factors:

1.Does the service requested provide telemedicine or telehealth access as an option?

2.What is the level of the practitioner's expertise and comfort with telemedicine or telehealth?

3.Is the patient's diagnosis appropriate for telemedicine or telehealth consultation?

4.Going forward, who will manage the patient's plan of care and how will this be managed?

As with any in-person patient encounter, documentation is of major importance. Appropriate documentation for telemedicine consults at both the sending and the receiving sites is essential for providing accurate and optimal continuity of care for the patient. Both sites need current patient demographic information, billing information, and consultant notes. Referring practitioners need consultant notes in a timely manner to carry out the patient's plan of care. After a telehealth consult, evaluation of telehealth processes and patient satisfaction is essential. The quality assurance and evaluation processes identify how to improve telehealth procedures, safety, effectiveness, and quality of care.32

Types of Clinical Telehealth Applications

In the past 15 years, telehealth specialty areas, such as telecardiology, teledentistry, teledermatology, home telehealth and remote monitoring, teleICU, telemental health, teleopthalmology, telepediatrics, teleradiology, telestroke, telewoundcare, and teletrauma, have been successfully developed and implemented in a variety of healthcare settings. Other telehealth programs outside the hospital setting include emergency preparedness, disaster response, correctional telemedicine, forensic telemedicine, telerehabilitation, and school telehealth.

A complete remote physical examination can be achieved by viewing images and hearing sounds. Healthcare providers can assess and treat a variety of health care problems such as cardiac or respiratory illnesses by listening to digital heart, lung, or bowel sounds live; by sending the data over a video conferencing system; or by using a computer with Internet connection to the computer of another clinician, who can then assess the information. The healthcare provider can use video scopes to conduct ear, nose, throat, oral cavity, eye, pelvic, or rectal exams; cameras or microscopes for skin examinations; radiology images to diagnose orthopedic injuries; and computed tomography (CT) scans of the head to rule out bleeding, brain injuries, or skull fractures. Teleradiology is one of the most commonly used and accepted telehealth applications, where digital images are captured and transmitted to the radiologist, who makes a diagnosis, sends a report, and stores the image. Healthcare providers can send complete readings for a 12-lead digital electrocardiogram to a cardiologist to diagnose heart problems or send a digital spirometry reading to a pulmonologist to diagnose respiratory lung capacity.

Telehealth Operational and Organizational Success Factors and Barriers

Despite the advancements in telehealth technologies, significant barriers and gaps exist in the successful implementation of robust, integrated healthcare technology delivery systems.

B.E.L.T. Framework

In planning for implementation of telehealth technology, four main components must be considered: bandwidth, education, leadership, and technology (B.E.L.T.). The B.E.L.T. framework (Fig. 8-3) is a metaphoric representation of these four interrelated components and may be used to guide planning at macro, meso, or micro levels of implementation.

Bandwidth includes elements of telecommunication technology, including information transmission and connectivity to move and store digital data. Infrastructure and telecommunication architecture in some geographic areas may limit use of telehealth applications and have direct implications for access to and delivery of healthcare. This is particularly problematic for rural, isolated, and underserved regions.36

Education encompasses the preparation of both the existing workforce and future healthcare providers in developing

FIG 8-3 The B.E.L.T. framework.

(Copyright McGill University School of Nursing. Montreal, Quebec.)

competencies in the adoption and use of telehealth technologies. Although research has been done in some areas of competency development, particularly in healthcare informatics and telenursing, scant research has been done in the broader use of telehealth technology to inform curriculum development and education of healthcare providers.4,37 Patient safety in telehealth technology use is one aspect of healthcare delivery that is essential to professional practice and relates to competencies in clinical decision making.

Leadership reflects a broad range of management, change theory, and policy aspects that affect operationalizing telehealth technologies. Barriers to successful telehealth adoption frequently relate to factors such as resistance to technology, information security, stakeholder support, reimbursement, and financial commitment.36,37

Technology spans a large number of considerations such as the types of telehealth software, hardware, and devices available for care delivery and the choice of appropriate telehealth technology. To date, telehealth platforms have limited capacity to address the range of health conditions experienced across the population lifespan, resulting in a narrow focus on overall individual health, fragmentation of care, and duplication of effort for data retrieval and documentation. Since many current telehealth technologies are not interoperable and cannot be integrated into a single environment to support holistic care, data silos are created where information on the same individual may be contained in different systems and cannot be accessed in an efficient, seamless manner. This further fragments care, leads to duplication of services (e.g., repeat of blood work, diagnostics, or information retrieval), and creates unnecessary cost to the patient and to the healthcare system. Another limitation is that most current telehealth technologies focus on direct delivery of clinical services to individuals and do not readily support the broader goals of primary healthcare, such as enhancing health promotion, prevention opportunities, or generating necessary epidemiologic data needed to evaluate and inform healthcare delivery.

Operationalizing Telehealth

Several important steps exist for the success of telehealth programs and services. The first is planning, which includes a needs assessment and analysis to define patient populations and healthcare problems in which telehealth services can have a positive impact. A workplace environment with staff prepared to implement telehealth using specific standards and guidelines is the second important factor for success. Technology preparedness is a third factor for successful telehealth services. For successful telemedicine implementation, appropriate “user-friendly” technology that allows for creative use and quality as well as responsive and accessible technical support are crucial factors.38 The final, critical step is learning how to implement, manage, and support a telehealth project or program. This becomes more complicated when more clinical specialties are involved. New telehealth programs should begin with one focused specialty application, such as teledermatology, and not add other specialties until the initial program has been implemented successfully. Specific procedures are listed in Table 8-1, and project steps are outlined below.

Telehealth Acceptance and Training

Technology education trends have moved toward online courses or certificate education programs in telehealth to reach out to more healthcare providers throughout the United States and globally. Online and on-site telehealth training courses are available through several Telehealth Resource Centers (TRCs), federally funded by OAT. Additional information about these resource centers can be found at www.telehealthresourcecenter.org. The ATA located at www.americantelemed.org provides annual meetings with scientific research presentations, special interest group meetings, educational webinars, educational products, training program accreditations, and white papers and policies.

According to Duclos et al. “the acceptance of a telehealth program by providers who use it is crucial to its success.”39 Healthcare providers who use telehealth in their practice should know how telehealth technologies work and should understand their capabilities in providing patients with better access to healthcare services.

Opportunities abound for clinicians to become adept at using telehealth technologies beginning with a basic proficiency in using room-based video conferencing systems on personal computers (PCs) and mobile video conferencing systems on iPads and smartphones. It is advantageous for healthcare providers to learn to use medical devices with video scopes attached for patient assessments and video or digital cameras for exams. Healthcare providers need to be comfortable using a variety of audio, video, and medical device tools, video conferencing systems, and computer hardware and software applications. New technical challenges often emerge for clinicians, such as using a video ophthalmoscope to view retinal images inside the eye and on a display monitor. Hearing new heart sounds from a digital stethoscope with different high- and low-pitched sounds due to magnification can be another challenge. Clinicians may encounter workflow changes with telehealth software applications in paperless environments, such as digital ECG and spirometry readings that identify patients' heart rhythm and lung measurements. Technology literacy training may also be required for clinicians. Technology literacy includes knowledge of basic computer skills and communication technologies, basic skills to navigate the Internet for up-to-date health information, and the ability to access web-based telehealth software applications. For example, healthcare providers who are fluent in using digital cameras to take dermatology images and who are Internet savvy can access online resources to identify a skin lesion or obtain the latest treatment for the lesion online.

In the 2005 International Telenursing Survey, telenurses were found to have various job skills and to work in more than 30 clinical telehealth settings ranging from nurse call centers to urban and rural hospitals, public and private health clinics, schools, prisons, community health centers, military facilities, native tribe reservations, and private physician and nurse practitioner practices.40 Specific telehealth knowledge regarding equipment, workflow, clinical processes, and technology training is different for each clinical setting.

TABLE 8-1 Telehealth Procedures

1. PREPARATION

2. PROVIDER AND PATIENT “REAL-TIME” TELEHEALTH ENCOUNTER

3. FOLLOW-UP, QUALITY, AND SAFETY

Provider credentialing completed at patient site and remote site

Provider is knowledgeable and competent in healthcare needs being addressed during patient-to-provider telemedicine visit

Review plan of care conveyed by provider or consultant and instructions provided regarding treatment plans, with time for patient and family questions and answers

Referral reviewed as appropriate for specialty service and accepted by telespecialist

Introduce patient to all individuals that will be in the patient room and to any individuals at the evaluating physician's location

Complete any necessary forms (e.g., patient consent to treat form; HIPAA forms) and share reimbursement information with both patient and physician sites

Knowledgeable regarding scheduling procedures and policies of facility and scheduling resources

Identify camera and microphone locations to patient and explain any potential for audio or video delay

Provide patient and family with consulting physician contact information, as needed for follow-up

Obtain and review preconsult clinical information and testing

Presenting site provider is knowledgeable of exam requirements, including patient preparation, patient positioning, and use of peripheral devices (i.e., electronic stethoscopes, Doppler, digital cameras, etc.)

Schedule follow-up appointments, treatments, etc. as ordered by physician

Obtain reimbursement information, such as copies of insurance cards, Medicare cards, etc.

Provide support to patient and family and be alert to nonverbal body language

Provide the referring primary care provider with the telemedicine encounter documentation

Provide patient with the appropriate forms for “consent to treat” and HIPAA compliance information

Provide time within the clinical visit for patient and family questions and answers

Evaluate outcomes of the telemedicine encounter, quality of encounter, and patient satisfaction and assess for improvements for future telemedicine encounters; clinical effectiveness is one of the factors associated with success in telemedicine

Contact patient to explain a telemedicine encounter and provide directions to the telemedicine site

Educate patient and family of their right and ability to terminate the telemedicine clinical visit at any time

Ensure that equipment and technology has been tested and is in safe working order, provider and patient have clear audio and video of each other, extraneous noises are reduced, and any necessary peripheral devices and supplies are accessible at time of encounter

Assess and prepare for cultural, language, or disability issues

Establish a backup plan and be prepared to enact it in the event of technical problems

Scheduling dedicated time for healthcare providers' telehealth training is an obstacle and is one of the major barriers to a successful telehealth program. Actual hands-on training is beneficial, using telehealth case scenarios similar to those the healthcare provider would typically encounter. As mentioned earlier, clinical workflow is modified when telehealth technologies are implemented. Healthcare providers can adjust by continuing to use the same patient exam rooms for the telehealth patient, using similar medical devices for in-person and telehealth exams, training with telehealth technologies, and interacting with the same physicians and specialists for telehealth consultations as for in-person referrals.

Telehealth Implementation

There are three phases for successful telehealth program implementation: preimplementation, implementation, and postimplementation.

Preimplementation Phase

Implementing telehealth technologies in any clinical setting is no different than implementing other twenty-first century technologies. As with any informatics project, a team effort is critical to its success. Clinicians will first need to decide what types of telehealth programs provide access to remote healthcare specialists for their patients. Important preimplementation steps are listed in Box 8-1. Forming an administrative or executive team is advisable to oversee the project goals, budget, progress, and growth. The facility may already have a formal committee in place to oversee all IT projects and, if so, can tailor the governance to incorporate telehealth. The executive team should include the following:

•Hospital or facility administrator

•Clinical director (often a physician)

•Chief information officer

•Director of information technology and/or director of education

•Telehealth and telecommunications administrator

•Vendor account managers (may be only at the operational level below)

A second level of management for the telehealth program is a more operational interdisciplinary team including the following:

•Project manager

•Clinical champion (often a physician)

•Telehealth director or program manager

•Information technology engineer or support technician

•System administrator (if software is involved)

Super users and vendor trainers will also initiate, train, and support new staff for the telehealth project. The interdisciplinary teams are the change agents that assist in developing policies, procedures, project evaluation criteria, and permission forms prior to beginning the telehealth program.

Box 8-1 Telehealth Preimplementation Steps

• Identify remote physician specialists and other clinical consultants who are willing to provide remote assessment and advice for treatment

• Meet standards and requirements for safe use of telemedicine equipment: installation in designated telehealth rooms; biomedical and electrical engineering help may be required

• Select appropriate telehealth equipment to use for telehealth examinations, including disposable accessories such as nonlatex gloves, gel, measurement tapes, alcohol wipes, gowns and cover sheets, and extra camera batteries

• Identify electrical and cable sources for power outlets and secure Internet access

• Designate telehealth exam rooms or areas

• Identify 24/7 technical support for clinicians at both sending and receiving sites

• Develop policies and procedures

• Train interdisciplinary team and staff end-users on telehealth equipment

• Set up and test telehealth scenarios prior to beginning telehealth consultation

Implementation Phase

Once the equipment is configured or tailored, the implementation phase involves equipment and software testing with mock telehealth patients and remote specialists and then piloting the project by identifying a patient needing a teleconsult. Equipment testing with mock patients should encompass all staff testing all of the telehealth equipment available. Equipment testing should also be conducted periodically after the initial implementation. After identifying differences between standard and telehealth patient encounters, daily use of telehealth equipment for routine patient exams is recommended so that providers become knowledgeable and comfortable using the various telehealth examination tools (electronic stethoscope, video otoscope or ophthalmoscope, digital ECG or spirometry software, video exam camera, telehealth software applications, and audio or video conferencing systems). The goal is for a clinician to present a patient, capture and send patient data, retrieve patient information from stored telehealth software applications, and respond to cases and add patient encounters if needed.

Postimplementation Phase

As with any other informatics project, evaluation criteria address adequacy of training; implementation, equipment, technology, or training issues; and program outcomes. A program of quality assurance and process improvement should be part of the evaluation process so that iterative progress toward implementation phase telehealth program success can be achieved.

Telehealth programs of any size experience similarities in success and failure. Table 8-2 lists common success factors and barriers to successful telehealth program implementation.

Telehealth Challenges: Licensure and Regulatory Issues for Healthcare Professionals

Telehealth enables physicians, advanced practice registered nurses (APRNs), nurses, pharmacists, and other allied health professionals to offer their clinical services remotely. State lines and geographic boundaries have no effect on the potential of the technology to deliver telehealth services. For example, radiologists can read x-ray reports from other countries, mental health professionals can provide care telephonically or with real-time video, and chronically ill patients can be monitored from a distance with telehealth. Despite technological advances, legal and regulatory challenges exist. Provider licensure and the credentialing and privileging processes in facilities remain the biggest hurdles to telehealth adoption in the United States.

TABLE 8-2 Success Factors and Barriers to Telehealth Implementation

KEY SUCCESS FACTORS FOR TELEHEALTH

BARRIERS TO SUCCESSFUL TELEHEALTH IMPLEMENTATION

High-level organizational members (board of directors, administrator, medical director, champion physician, nurse administrator, nurse educator, program director) who have identified a need for telehealth and are able to provide support and finances throughout all phases of implementation, training, and maintenance of the telehealth program

No designated or dedicated project manager; not enough time or resources dedicated to manage project

Designated and dedicated telehealth project manager or coordinator

Interdisciplinary team not designated or prepared properly

Designated interdisciplinary telehealth team

Funding limited

Adequate facility network infrastructure to support the telehealth system or method selected and prepare setup for the telehealth program prior to installation

Lack of communication between administrative management, interdisciplinary team, and participants

Project management to include and allow time for professional telehealth education and refresher training classes, including participation for professional telehealth conferences, telehealth webinars, telehealth video training, and provision of telehealth resource information

Failure to identify remote clinical partners to whom to refer patients or to provide telehealth services; may be due to reimbursement issues, lack of understanding as to how telehealth works, practice and licensing issues in that state

Initiate telehealth program at local facility and then introduce to affiliated remote facilities

Poor telehealth equipment selection for specialty; poor quality and usability of telehealth equipment purchased

Provide staff with educational tools such as workflow diagrams, charts, digital photos, manuals, and descriptive pathways for how to initiate an urgent or nonurgent telehealth consult

Missing parts of equipment and supplies during installation or patient encounter

Provide education, training, and program development for teleconsultants

No designated telehealth area due to limited room availability

Schedule appointments for follow-up teleconsults with dates and times for physician and patient

Ergonomically poor placement of equipment, limited connectivity or lighting in telehealth area, poor cable management, limited counter size, small room, no storage cart for equipment, equipment not secure

Patient privacy and confidential information forms should be completed prior to teleconsult

No pretraining on telehealth system prior to telehealth installation

Provide on-site dedicated technical support throughout all phases of implementation and provide online support for main site, remote site, and teleconsultants

Healthcare providers not familiar with computer literacy (i.e., basic use of keyboard, personal computer, mouse, navigating software, data, or handling images captured)

Training not formalized, no schedule confirmed to allow for all participants to be trained, not enough time provided for hands-on training or practice of case scenarios

Staff resistant to training, no incentives, and no understanding of telehealth or technology advantages

Off-hour shifts not trained or invited to participate in training sessions

Licensure

Both the 1997 and 2001 Telemedicine Reports to Congress by OAT identified licensure as a major barrier to the development of telemedicine and telehealth.41 The cost and procedural complexity of current professional licensing policies precludes widespread adoption of telehealth. Currently, many health professionals must attain separate licenses in each state where services are rendered. Licensure authority defines who has the legal responsibility to grant a health professional the permission to practice his or her profession.42 Under Article X of the U.S. Constitution, states have the authority to regulate activities that affect the health, safety, and welfare of their citizens.42,43 Regulating the delivery of healthcare services is one such activity. Exceptions to state licensure requirements include physician-to-physician consultations, educational and medical training programs, border state recognition programs, government employees practicing in military or federally funded facilities such as VA hospitals and clinics, and natural disaster and emergency situations.42,43

Legislation such as the 2011 Servicemembers' Telemedicine and E-Health Portability Act (STEP Act) facilitates the provision of telemedicine and telehealth services. The STEP Act removes the individual state licensing requirements to allow a licensed medical professional in one state to treat a patient in another.41 As of this writing, the STEP Act rules apply only to military and federal personnel, although it is a beginning in terms of advancing telehealth services into the mainstream. Fortunately, major advancements are occurring to streamline licensure requirements. These regulatory alternatives include licensure by endorsement, state compacts and mutual recognition, reciprocity, registration, and limited licensure (Table 8-3).

Nursing has been the most successful healthcare provider group to adopt the mutual recognition model, referred to as the multistate Nurse Licensure Compact.42 The Nurse Licensure Compact law became effective on January 1, 2000, with three states initially participating. As of February 2013, 24 compact states existed. Compact status applies only to registered nurse (RN) licensure. If an RN holds a license in one of the 24 compact states, he or she may practice in any of the 24 compact states, greatly facilitating telehealth interactions across state boundaries. International nurses on a visa who apply for licensure in a compact state may declare either the country of origin or the compact state as the primary place of residency. If the foreign country is declared as the primary place of residency, a single-state license will be issued by the compact state.44 A mutual recognition model is being discussed for APRNs at the time of this writing. The target date to complete that work is 2015. However, currently, APRNs who practice using telehealth across state boundaries must first apply for RN licensure (or endorsement) in the distant state and then apply for advanced practice status, which involves extensive credentialing and privileging processes.45

TABLE 8-3 Telehealth Professional Licensure Options

LICENSURE OPTION

DESCRIPTION

Endorsement

Allows a state to grant licenses to health professionals licensed in other states that have equivalent standards. States may require additional documentation or qualifications before endorsing a license issued by another state.43

Mutual recognition

The distant state's licensing board accepts the licensing policies of the health professional's home state.45 Federal healthcare agencies operate under this type of system. An analogous licensing system would be the mutual recognition of driver's licenses between states.

Reciprocity

A process in which two states voluntarily enter into a reciprocal agreement to allow the health professional to practice in each state without having to become licensed in both states. It does not involve additional review of the health professional's credentials, as endorsement does, and it does not require the participating states to agree to a standardized set of rules or procedures, as mutual recognition does. The negative aspect of this model is that it leaves the healthcare provider subject to different regulations in each state and therefore subject to different sets of laws. This can lead to legal issues of liability and wider exposure to potential malpractice opportunity.46

Registration

The health professional licensed in one state informs the authorities of other states that he or she wishes to practice in those states part-time. The provider is licensed in the home (originating) state but still is accountable to uphold the legal stipulations and regulations of the guest (distant) states. Similar to reciprocity, the provider would still be subject to the guest state's malpractice rules as well as the home state's rules and regulations.

Limited licensure

The health professional obtains his or her medical licensure in the home state and then obtains a second “limited” licensure in the guest state. The limited license allows for specific scope of services to be delivered under particular circumstances.46

National licensure

Individual states would voluntarily incorporate the same set of national standards into their laws. Given that most medical professionals pass the same national exam within their particular discipline, it stands to reason that standards of care and practice guidelines should not differ from state to state. Regulatory processes could be retained at the state or national level. For example, the American Medical Association could take full responsibility for the licensing of all physicians at a national level and similarly nurses could be licensed to practice nationally by their national organization, and likewise with other health professions (pharmacists, dentists, physical therapists, etc.). However, disciplinary actions or other procedural activities could be administered at the state level.

Credentialing and Privileging

Credentialing is the process of establishing the qualifications of licensed professionals and assessing their background and legitimacy. For example, if a physician does a telehealth consult from a hospital in State X but the patient resides in a skilled nursing facility in State Y, that physician must be credentialed by both facilities (i.e., the hospital and skilled nursing facility), as well as be licensed in both States X and Y. Each facility could have very different processes and rules for becoming credentialed. Similar to the need for licensing in multiple states, the need for credentialing in multiple, separate healthcare facilities is an obstacle to telehealth services. In May 2011 the Centers for Medicare & Medicaid Services (CMS) modified the existing credentialing and privileging regulations effective July 5, 2011. The new rule under part 42 CFR 410.78 of the CMS regulations allows hospitals or Critical Access Hospitals (CAHs) to use information from a distant-site hospital or other accredited telemedicine entity when making credentialing or privileging decisions for the distant-site physicians and practitioners.42 Regarding the legal risks and liabilities associated with these changes, the governing body of each hospital and CAH must weigh the risks and benefits of opting for this more streamlined process of credentialing and privileging telemedicine providers.42 Modifications still need to be made to allow Medicare and Medicaid beneficiaries who reside in urban or metropolitan areas to be eligible to receive the same services.

Reimbursement

Telemedicine is often viewed as a cost-effective alternative to the more traditional face-to-face method of providing medical care.42 As such, states in the U.S. have the option to determine whether or not to cover telemedicine- and telehealth-delivered care, what types of telehealth to cover, where in the state it can be covered, how it is provided and covered, what types of telehealth practitioners and providers may be covered and reimbursed (as long as such practitioners and providers are “recognized” and qualified according to Medicare and Medicaid statute and regulation), and how much to reimburse for telemedicine services (as long as such payments do not exceed the Federal Upper Limits).46

Reimbursement by insurance companies for medical services is based on Medicare's Current Procedural Terminology (CPT) codes billing system. As of 2012, Medicare telehealth services can be furnished only 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 the statute include hospitals, skilled nursing facilities, offices of physicians or licensed healthcare practitioners, rural health clinics, community mental health centers, CAHs, CAH-based dialysis centers, and federally qualified health centers.47 Medicaid reimbursement for telehealth varies by state, with some states electing not to reimburse for telehealth services. Internationally, in countries that provide government-based universal health care, telehealth adoption is flourishing and reimbursement has become a national budgetary decision. Providing more access to more citizens while at the same time reducing costs and more efficiently distributing clinical expertise using technology is a desired goal for any country's health service. Thus countries such as Canada, those in the European Union, Japan, China, and India are all expanding their telehealth capabilities and services.

Malpractice and Liability

Legal issues of liability and malpractice are burdensome for the telemedicine practitioner, as they “face additional vulnerability and uncertainty related to malpractice exposure in multiple states and would likely face additional expenses for malpractice insurance and for other costs should a suit be filed in a distant state.”48 Legal issues involve traditional jurisdictional issues, including the following:

•The place of treatment dilemma

•Lack of an established, bona fide doctor–patient relationship similar to the situation with cybermedicine (medical care via the Internet)

•Violating a particular state's specific regulations related to standards of care

•Failing to secure appropriate informed consent from a patient

•Negligence that may arise from technical glitches such as distorted images or poor sound quality of a particular device resulting in injury or misdiagnosis42

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. Initial case law in telemedicine and telehealth to date has been limited, primarily involving telephone triage and teleradiology. In telephone triage, if advice was given and a poor patient outcome occurred, the triage service and professionals are at risk for malpractice. In teleradiology (as is the case with in-person and in-house radiology readings), if a diagnosis of a lump or a mass is missed on an image, the radiology service and professional would be at risk for malpractice. As telehealth usage increases, further legal cases will illuminate and clarify these issues.

Telehealth and Direct Patient Health Services

While telehealth applications typically involve provider-to-provider teleconsults, patients and other healthcare consumers can use telehealth directly to support their healthcare decision making. Specifically, applications facilitate direct, online patient telemedicine care; provide remote patient telehealth visits and monitoring; and link consumers with online healthcare information.49 As the technology used to deliver telehealth services becomes easier to use and more affordable, the technology is increasingly being used by patients in interaction with their healthcare providers and at times in directing their own care.

Patient-to-Provider Telehealth-Delivered Care

Increasingly, individuals find it difficult to obtain timely care for urgent health concerns from their healthcare provider. A survey of California hospitals found that 50% of the patients who visited an emergency department thought that their medical concerns could have been dealt with by their regular physicians; however, they were unable to obtain timely access to care.50 Online telehealth direct care is a solution to this growing problem and the use of video conferencing for telehealth visits is increasing. Manhattan Research's Taking the Pulse U.S. v11.0 study indicated that nearly 7% of physicians use online video conferencing to communicate with their patients.49 Physicians consider telehealth a method for consulting with patients about nonurgent issues or connecting with geographically dispersed patient populations that may not have nearby access to specialists. The study also found that certain specialty healthcare providers, such as psychiatrists and oncologists, are more likely to use video conferencing with their patients.

Adapt TeleHealth is an example of this approach. Once a community or clinic has identified that it has a need for psychiatric services, it contracts with Adapt TeleHealth to meet its mental health needs. It purchases a consistent number of hours per week, which are fulfilled by an Adapt TeleHealth mental health provider. Other direct patient care technologies focus more on providing a platform for a healthcare provider's office to provide telemedicine care. Companies such as Secure Telehealth (www.securetelehealth.com/telehealth-uses.html), TelaDoc (www.teladoc.com), and Online Care Anywhere (www.onlinecareanywheremn.com) are examples of platforms for direct online medical care.

Asynchronous applications using store-and-forward technologies or online diagnostic surveys are gaining in popularity. Virtuwell (www.virtuwell.com) from HealthPartners in Minnesota is available 24/7 and uses an online survey asking consumers to identify their chief concern. Responses are sent to a nurse practitioner who reviews the information and responds within 30 minutes. Responses are provided via text or email and include a diagnosis, potential remedies, and tips for preventing the condition in the future. If a prescription is needed, the nurse practitioner can send it to a local pharmacy. Forty common conditions, including bladder infections, lice, and yeast infections, are treated by Virtuwell's nurse practitioners.

Another asynchronous telemedicine company is RelayHealth, an online solution to connect consumers with their healthcare providers. Providers license RelayHealth web-based software, with capability for patient visits and consultations, prescription renewal, appointment scheduling, personal health record management, delivery of lab results, referral requests, and access to medically reviewed information.

Remote Telehealth Home Visits and Biosensors

Telehealth systems previously used interactive video conferencing between healthcare providers and patients; however, the ability to self-manage care is a driving fiscal concern.51,52 Machlin and Woodwell noted that nearly two thirds of publicly insured adults in the U.S. under the age of 65 have one or more chronic conditions and that nearly 75% of all healthcare dollars were spent on managing these chronic conditions.53 Use of telehealth technologies for remote home care and biosensor monitoring instruments are gaining momentum to address chronic illnesses and to promote safety for seniors living alone.

Remote Telehealth Home Visits and Monitoring

As mentioned earlier, the most widespread telehealth program in the United States is the VA national telehealth program, CCHT. Built around Wagner's Chronic Care Model, CCHT is characterized by “the use of health informatics, disease management and home telehealth technologies … with the specific intent of providing the right care in the right place at the right time.”19(p1120) The range of technologies for CCHT includes videophones, messaging devices, biometric devices, digital cameras, and telemonitoring devices.52 The videophones and video telemonitors facilitate synchronous face-to-face encounters with a healthcare provider through regular telephone lines or through computer links and the Internet. Biometric devices and digital images are also part of the comprehensive CCHT system and are used to gather timely healthcare data employing asynchronous store-and-forward technologies.

Two specific examples of technologies used with the VA and the general public are HealthBuddy (www.bosch-telehealth.com/en/us/products/health_buddy/health_buddy.html) and miLife (www.americantelecare.com). MiLife, adopted for use by the VA in 2011, offers live, interactive video combined with remote monitoring. In between video visits, veterans measure and transmit vital signs and other physiologic measurements with devices in their homes, answer self-assessment questions, and receive disease-specific educational information.

HealthBuddy does not include a video visit component but otherwise works in a similar way. Patients access the system and update their health status by answering a series of questions about their health and well-being using the HealthBuddy application. The data are sent over a telephone line or Ethernet Internet connection to a secure data center; the data are then available for review by a healthcare provider via the HealthBuddy desktop system. Peripheral monitoring devices such as blood glucose meters, blood pressure monitor, peak flow meters, pulse oximeters, and weight scales are also supported.

Both miLife and HealthBuddy allow nurses, social workers, and other healthcare provider coordinators to prioritize their patient caseload and develop treatment plans based on the patient's risk. Emerging research findings show that telehealth home visits and home monitoring are care and cost effective.19,54

Biometric Sensors

A number of healthcare applications use information and communication core components to help patients stay safe in their homes and communicate vital healthcare data to providers.52 Box 8-2 provides an overview of biometric sensors. Peripheral health monitoring tools such as blood glucose monitors, pulse oximeters, blood pressure and ECG monitors, and electronic scales, already described as components of a telehomecare visit, fit this definition. They are the backbone of a viable remote disease management program.

More recently, a group of assistive technology devices dubbed “sensor technologies” have emerged and add a layer of connectedness between patients and their healthcare providers by monitoring patients' activity levels and physiologic parameters. Sensor technology has the potential to not only manage disease but also promote a safe and healthy environment for seniors.52 AFrame Digital (www.aframedigital.com) has engineered a low-stigma, intuitive, wristwatch-based sensor system with an intelligent learning and predictive modeling platform that acquires physiologic data from the wearer every 30 seconds. After collecting sufficient data points, the system learns the physiologic normal for the individual. If deviations from normal occur, an alert is sent to a neighbor, relative, friend, or emergency responder. Personalized, tailored remote monitoring and intelligent alerting is the hallmark of this innovative system.

Box 8-2 Biometric Sensor Overview

Purposes

• Detect changes in patterns that signal improvement or early failings

• Signal need for urgent or emergency help

• Integrate with websites or mobile units to promote communication

• Have ubiquitous monitoring for peace of mind for older adult and family

• Keep an inventory of supply levels for medications and other resources

• Coach and monitor exercise effectiveness and participation in games

Information Potentials

• Physical: motion, location, activity

• Physiologic/medical: pulse, temperature, sweat, blood chemistry

• Social: telephone or web interaction counts or identification

• Memory support: monitoring cooking stoves, adherence to regimens

• Communication safety issues: stove use, fire, unsecured doors

Communication

• Devices and protocols networked to connect to computers

• Statistical and computational paradigms for analysis

• Applications for interaction with emergency rescues, healthcare providers, and social network

Monitoring Target Examples

• Restlessness as indicator of disturbed sleep

• Gait changes as indicator of drug side effect or physical debility

• Extended bedrest as indicator of depression or physical debility

• Pill counts as indicator of adherence or side effect issues

One example of sensor technology that may be used in the future to promote a safe and healthy environment is the smart home. The “smart home or intelligent house”52(p237) is expected to use radio frequency identification (RFID) technology.55 RFID technology uses a microchip to uniquely identify and track objects, record and update information, and make all of this accessible through a global network.56 Depending on their use, RFIDs can be active or passive and are capable of being ingested, implanted, or attached externally. While concerns about potential privacy and security breaches exist, RFID benefits include unlimited sight connection and rapid information processing, predicting better utility than other technologies such as bar-coding. Treatment-based applications such as monitoring handwashing practices, transmitting neuromuscular stimulation data, and authenticating medications have the potential to transition from the hospital to the smart home.

Sensor technology also supports next-generation healthcare by virtue of its mobility. Two forms of mobile sensors are wearable embedded technologies and wearable attached technologies.52 Clothing with “smart fabrics” and embedded sensors is currently in use for measuring body temperature and heart activity or signaling a risk for falls. Recently, companies have designed sensors to integrate with smartphones. One example of an integrated sensor comes from WIN Human Recorder Co. Ltd. in Japan.57 Consumers wear a small, portable sensor attached to the body and readings are accessed easily via a cellphone or a networked computer. The WIN Human Recorder is capable of monitoring electrocardiography signals, heart rate, brain waves, accelerated velocity, body temperature, respiration, and pulse waves. Biosensor fabrics will have the capacity to analyze blood chemistry levels from collected perspiration or immunosensors integrated in dressings will be able to detect healing.

Telehealth Technology and Healthcare Consumers

The proportion of American adults seeking information about a health concern from a source other than their physician dropped to 50 percent in 2010, down from 56 percent in 2007.58 At first glance, readers may assume that consumers are not seeking information about their healthcare needs; however, the drop is actually attributed to an 18% decline in their use of print sources: books, magazines, and newspapers. Adults, especially the elderly and those with chronic disease conditions, have increased their Internet use for seeking health information, contributing to their engagement in self-care.58 Online healthcare resources have the potential to aid consumers by supporting shared decision making with healthcare providers, providing personalized self-management tools and resources, building social support health networks, delivering tailored accurate health information, and increasing health literacy.59

Health information websites have been available to consumers since the mid-1990s.60 Websites such as WebMD, a publicly traded company, and the National Institutes of Health's MedlinePlus, a federal government site, have provided healthcare information to a broad population of consumers, including the general public, employers, employees, health plans, and healthcare providers. More recently, however, some health websites have moved beyond one-way communication and developed innovative features and interactive tools that enable consumers to greatly increase their self-knowledge and promote greater safety and independence. Tools such as drug interaction checkers, symptom checkers, various health-related calculators, pill identifiers, patient forums, fitness trackers, and PHRs are becoming more prevalent and helping consumers to gain more control over their health.60

Everyday Health (www.everydayhealth.com) is an example of an interactive, consumer-based website. Everyday Health has partnered with experts from Harvard University, Cleveland Clinic, and the American Association of Family Practitioners to provide consumers with healthcare information and has also developed interactive consumer-oriented tools. Consumers can use assessment and tracking tools and online calculators, speak live with a pharmacist, find drugs and treatments, and create a personal plan for health. Additional information concerning interactive consumer-oriented recourses is included in Chapters 13 and 14.

eHealth Literacy: Critical Element for Telehealth Adoption

The proliferation of online healthcare resources has caused the development of a national and international quality standards agenda to help health professionals and consumers alike access and evaluate high-quality online health information that is accurate, current, valid, appropriate, intelligible, and free of bias.61–63

Health consumer advocates espouse the need for ehealth literacy as a way of evaluating the information and services delivered using IT tools.64 Consumers must have basic reading skills in their search for online healthcare resources and use of telehealth tools. They also must have the following skills:

•Visual literacy: ability to understand graphs and read a label or other visual information

•Computer literacy: ability to operate a computer

•Information literacy: ability to obtain and apply relevant information

•Digital literacy: competency with digital devices of all types; technical skills to operate these devices and conceptual knowledge to understand their functionality; ability to creatively and critically use these devices to access, manipulate, evaluate, and apply data, information, knowledge, and wisdom in activities of daily living; ability to apply basic emotional intelligence in collaborating and communicating with others; ethical values and sense of community responsibility to use digital devices for the enjoyment and benefit of society65

eHealth literacy skills are critical for future telehealth adoption for both consumers and healthcare providers alike.

Conclusion and Future Directions

Telehealth, considered futuristic by some, is actually not a new concept, dating back to 1897. Currently, telehealth services are being provided in diverse settings from islands off the coast of Maine to across the U.S. for remote care of military veterans. Two major types of telehealth exist: asynchronous and synchronous. Applications include teleradiology, teleconsulting, telepathology, telesensors, and remote home visits. Telehealth has the potential to decrease care costs and speed treatments but the field also has challenges, including issues regarding licensure, standards, reimbursement, credentialing and privileging, and lack of integration with other health IT, especially EHRs.

Growth in telehealth could result in a future where access to healthcare is not limited by geographic region, time, or availability of skilled health professionals. The potential to realize comprehensive, integrated, and seamless delivery of healthcare services through virtual environments, capable of spanning a broad range of prevention and health promotion interventions, already has been made possible through advances in telehealth technology. Conditions exist for expanding telehealth to other sectors for sustainable telehealth: rising healthcare costs, increasing prevalence of chronic diseases, an aging population, demands for improved access to healthcare, and global shortages of health professionals.36,37,66–69 Creation of telehealth ecosystems and novel healthcare models requires interdisciplinary and intersectoral approaches spanning technology, education, and health management (Fig. 8-4).

The CuRE framework in Figure 8-4 depicts the Canada-India Centre of Excellence for uHealth Research and Education (CuRE). It provides a uhealth (ubiquitous health) view for operationalizing future global collaboration in advancing telehealth.

Policy decisions to adopt and implement telehealth technology in healthcare delivery are influenced by many drivers, such as global socioeconomic contexts, political motivations, capacity of technology to address healthcare needs, and fundamental understandings of telehealth capabilities.66,70 Inconsistencies in telehealth research methods and data reporting have had an impact on empirical data available to evaluate telehealth technology in the areas of cost–benefit, effectiveness, and patient engagement.67,68 Issues of authentication, data security, and practical aspects of telecommunication infrastructure remain critical challenges for the adoption and broader use of telehealth technologies.71,72

A consistent and coordinated approach in tracking healthcare technology use is lacking; therefore the effectiveness of

FIG 8-4 Components of telehealth.

(Copyright 2012 Daniel Nagel and Antonia Arnaert. All Rights Reserved.)

telehealth is difficult to determine. Much available information on use and trends has been generated through industry and market analysis rather than through independent research. Significant challenges exist in tracking telehealth technology use and trends in healthcare, including the following:

1.How telehealth is defined; terms such as telehealth, telemedicine, and informatics are frequently and inconsistently used interchangeably in the literature

2.The variety in modalities of telehealth technologies being used and the capacity to which they are used

3.The vastly different contexts in which telehealth may be employed, such as varying models and settings for healthcare delivery, geographic regions, and cultural settings

Telehealth Industry Growth

One market research firm valued the market for remote patient monitoring, one form of telehealth care, in the United States at about $7.1 billion in 2010 and anticipated this market will grow to $22.2 billion by 2015.73 Healthcare technology usage in Canada during 2010 includes delivery of 260,000 telehealth encounters and 2500 patients enrolled in telehomecare services, reflecting a 35% annual growth during the previous 5 years.74 In Europe, outpatient telehealth services are provided by either public or private hospitals. A report provided to the European Commission in 2011 indicated that 8% of hospitals provided telemonitoring to patients.74 Continued global growth in telehealth is anticipated as technology evolves and the need for cost-effective healthcare delivery increases in both developed and developing countries.36,37,66,75

Rapid advances in technology, such as electronic platforms for healthcare services and technologies used in transmitting data, continue to expand the reach of healthcare delivery and the potential services available. Initially telehealth relied on Internet connections; however, a shift to more mhealth formats has occurred, particularly in developing countries. Growth in the mobile phone industry in countries such as China and India has increased 321% compared to 46% in developed countries.76 In India, use of cellular phones is estimated at 742 million phones, with many of these new “mobile citizens” living in poorer and rural areas with scarce infrastructure and facilities, low literacy levels, and low Internet access.77 mHealth capabilities now provide a wide range of wireless monitoring opportunities to transmit information for a variety of health conditions, such as diabetes and cardiovascular diseases. mHealth has also increased access to healthcare for persons and communities in rural and isolated regions.66 A recent endorsement of 4G standards in wireless telecommunications by the International Telecommunications Union, a branch of the United Nations, will have significant implications for speed and quantity of data transmission and for the future capacity of mhealth technologies in healthcare delivery.

Telehealth to uHealth

At present a lack of integrated, secure technology “spaces” exists to facilitate migration of data between the various telehealth platforms, ehealth technologies, and mhealth devices for effective and efficient support of healthcare delivery. This gap in interoperability largely reflects industry strategies to protect proprietary rights; however, the lack of interoperability between technologies limits sharing of health information and the ability to implement a cohesive model of healthcare delivery in a virtual environment.36

Advancements in “cloud computing” technology, a more integrated wireless telecommunication architecture that supports accessible and seamless transmission and storage of digital data, may make it possible to facilitate a connection between healthcare information systems and to expand the capacity of healthcare delivery.71,72

More recent research and development has focused on ubiquitous (uhealth) technologies that integrate core components of computers, wireless networks, sensors, and other modalities (such as mhealth devices) to create an environment to monitor, respond to, and assist in meeting the healthcare needs of individuals.78,79 An example of the utility of uhealth is the development of smart home systems that provide persons who have health concerns with a safer environment in which to live more independently.78 As the number of people living longer with complex health conditions grows and the elderly population increases, uhealth innovations can be used to detect changes in health status, communicate pertinent patient information, and alert healthcare providers to facilitate efficient interventions.79

Improve Healthcare Provider Shortages and Access to Care

As telehealth expands, further integration with informatics will continue. Telehealth encounters will be integrated within PHRs and EHRs. Self-care data will also be integrated into data repositories for individuals and populations. As the global population increases, the supply and distribution of healthcare providers can be optimized using telehealth to provide services regardless of the geographic location of those in need. Shortages in primary care providers and nurses, for example, can benefit from redistribution of portions of clinical expertise using telehealth as the export mechanism.4,40

Future migration of telehealth to uhealth will require practicing healthcare provider licensure models that are not only interstate, but also international, enabling healthcare providers to practice in countries that have healthcare needs that can be met using telehealth technologies. This will require cooperation on the part of politicians, governments, and policy-makers on behalf of fully operationalized telehealth.70,80

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Discussion Questions

1. What licensure model would be most useful to support telehealth clinical practice across international boundaries, for example, Canadian doctors or nurses (virtually) seeing and treating U.S. patients or U.S. pharmacists and occupational therapists (virtually) seeing and treating Australian patients?

2. How do the different models for delivering healthcare, including covering the cost of that healthcare, affect the telehealth programs in different countries?

3. What actions can individual healthcare providers take in the next 3 years to advance the benefits of telehealth for their profession?

4. Why has telehealth adoption taken so long in the healthcare industry when Skype, cellphones, and other video conferencing applications have been used in personal and business interactions for decades?

5. How much does usability affect you and your friends when deciding to accept or not use a new technology? Does this also apply in your role as healthcare provider?

6. What actions can individual healthcare providers take to improve their patients' ehealth literacy?

7. What needs to occur on an international basis in order for uhealth to be operationalized?

8. What are the first five steps you would take to start a telehealth program or application in the healthcare facility where you work?

9. What key success criteria for telehealth programs are “must have” and what criteria are “nice to have” when considering a new telehealth initiative?

10. What factor or factors will be most important in driving the exponential growth of telehealth in the future?

Case Study

Mrs. Smith is 82 years old and is diagnosed with hypertension, diabetes, and congestive heart failure. Her two children live in California, while she lives in North Carolina in a small family home on 10 acres of land in the Blue Ridge Mountains. Mrs. Smith has been in the hospital four times in the last year due to congestive heart failure. As her eyesight and mobility get worse with age, she found it a challenge to stay on her medical plan and to do her shopping for the right foods she knows she should be eating. Mrs. Smith's health plan, Purple Cross of North Carolina, assigned a nurse case manager to address her situation. Purple Cross provided a digital scale and a remote monitoring device that recorded Mrs. Smith's condition every day by uploading her weight and transmitting the answers to a series of questions on a touch screen kiosk. The case manager also coordinated delivery of Meals on Wheels, providing low-sodium, diabetic-compliant dinners to Mrs. Smith on an ongoing basis. The case manager calls Mrs. Smith twice a week, taking the time to educate her about her medications, her activities, and the disease-specific elements that will keep her healthy and out of the hospital. When the case manager identifies that Mrs. Smith can no longer organize her daily medications, a digital medication dispenser will be provided that will keep her on her medication regimen. The medication dispenser will be preloaded with Mrs. Smith's medications and will issue a subtle doorbell tone when it is time to take her medicines. With the combination of remote and real-time (telephonic) support persons and technologies, Mrs. Smith is able to remain in her home and avoid further inpatient admissions.

Discussion Questions

1. Which components are critical to Mrs. Smith staying safely in her home?

2. Describe whether Mrs. Smith's regimen might be augmented using mhealth applications.

Pageburst Integrated Resources

As part of your Pageburst Digital Book, you can access the following Integrated Resources:

Bibliography and Additional Readings

Web Resources

Chapter 8 Telehealth and Applications for Delivering Care at a Distance

Loretta Schlachta

-

Fairchild

Mitra Rocca

Vicky Elfrink Cordi

Andrea Haught

Diane Castelli

Kathleen MacMahon

Dianna Vice

-

Pasch

Daniel A. Nagel

Antonia Arnaert

Growth in telehealth could result in a future where access to healthcare is not limited by geographic

region, time, or availability of skilled healthcare professionals.

Objectives

At the completion of this chapter the reader will be prepared to:

1.Discuss the historical milestones and leading organizations in the development of telehealth

2.Explain the two overarching types of telehealth technology interactions and provide examples of

telehealth technologies for each type

3.Describe the cl

inical practice considerations for telehealth

-

delivered care for health professionals

4.Analyze operational and organizational success factors and barriers for telehealth within healthcare

organizations

5.Discuss practice and policy considerations

for health professionals, including competency, licensure

and interstate practice, malpractice, and reimbursement for telehealth

6.Describe the use of telehealth to enable self

-

care in consumer informatics

7.Discuss future trends in telehealth

Key

Terms

Digital literacy, 141

Chapter 8 Telehealth and Applications for Delivering Care at a Distance

Loretta Schlachta-Fairchild

Mitra Rocca

Vicky Elfrink Cordi

Andrea Haught

Diane Castelli

Kathleen MacMahon

Dianna Vice-Pasch

Daniel A. Nagel

Antonia Arnaert

Growth in telehealth could result in a future where access to healthcare is not limited by geographic

region, time, or availability of skilled healthcare professionals.

Objectives

At the completion of this chapter the reader will be prepared to:

1.Discuss the historical milestones and leading organizations in the development of telehealth

2.Explain the two overarching types of telehealth technology interactions and provide examples of

telehealth technologies for each type

3.Describe the clinical practice considerations for telehealth-delivered care for health professionals

4.Analyze operational and organizational success factors and barriers for telehealth within healthcare

organizations

5.Discuss practice and policy considerations for health professionals, including competency, licensure

and interstate practice, malpractice, and reimbursement for telehealth

6.Describe the use of telehealth to enable self-care in consumer informatics

7.Discuss future trends in telehealth

Key Terms

Digital literacy, 141