By:Susan K. Newbold, RN,C, MS
Defining the Terms
Where Nursing Organizations Stand
Projects with Nursing Components
How Nurses Use Telehealth
Overcoming the Barriers
Telemedicine. Telehealth. Telenursing.
You've heard the terms. But what do they mean for you? Will these concepts make a serious impact on your nursing care? Or are they merely buzzwords?
In this article, I'll discuss telehealth and telenursing, review legal aspects, and describe specific telenursing applications. But first, let's review the definitions.
Defining the terms
Telecommunications is the use of wire, radio, optical, or other electromagnetic channels to transmit or receive signals for voice, data, and video communications. The media of telecommunications include telephone, video, and computers plus a means of transmission including phone lines, fiber optics, satellites, and microwave systems.
Telemedicine involves the use of telecommunications and information technologies to provide clinical care to individuals at a distance and to transmit the information needed to provide that care. A broader term, telehealth, encompasses telemedicine but emphasizes the provision of information to health care providers and consumers.
Finally, telenursing is the use of telecommunication and computer technology to deliver nursing care. It is any nursing at a distance, provided in whole or part through electronic means.
The legal issues associated with telehealth fall into three categories:
- traditional medico-legal issues;
- conflicts in state law, which telemedicine amplifies when it connects geographically separate facilities; and
- unique telemedicine issues.
Traditional medico-legal issues include privacy and confidentiality of healthcare records. As a nurse, of course, you have a responsibility to protect the confidentiality of patient records and data.
Interstate telehealth raises licensure questions such as whether "telenurses" are practicing nursing in the remote state and need a license in that state. This may not be an issue in the future, as the National Council of State Boards of Nursing advocates a mutual recognition model of nurse licensure. This model allows a nurse to have one license in his or her state of residency and practice in other states—as long as the nurse acknowledges that he or she is subject to each state's practice laws and discipline.
What's more, telehealth could require transmitting a computer-based patient record across state lines. Laws vary as to how states handle confidentiality, privacy, and data protection.
As for unique telemedicine issues, nurses must be concerned with reimbursement of services across state lines. How would patient-to-facility home monitoring be billed? What's more, can care provided at distance from the patient be viewed as quality patient care with acceptable patient outcomes?
Where nursing organizations stand
In March 1999, the American Nurses Association (ANA) approved competencies for telehealth technologies in nursing. The ANA views telehealth technologies as tools to provide nursing services. (See
Competencies for Telehealth Technologies in Nursing.)
The ANA also promoted telehealth in a 1997 newsletter discussing what telecommunications technology will allow nurses to do. They cite the following:
- Participate in peer conferences
- Obtain consultations from other nurse administrators
- Access expanded populations for recruitment into studies
- Collect data from remote sites
- Consult with remote peers and specific clinical expert nurses on issues of clinical practice
- Consult directly with a client's primary care practitioner, pharmacist, and other disciplines as necessary.
The National League for Nursing (NLN) has a Council on Nursing Informatics, but doesn't specifically address telenursing or telehealth.
Projects with nursing components
Here are a few examples of telehealth projects with a nursing component:
- Shepherd Center, Crawford Research Institute (Atlanta, GA) is conducting research on postdischarge telephone follow-up of catastrophic injury survivors in their own homes.
- The Carle Foundation (Urbana, IL) has sponsored the Carle Rural Telemedicine Network Project since November 1993. Using interactive videoconferencing, seven healthcare delivery locations including a nursing home/senior service center are connected. The network uses desktop and interactive videoconferencing to provide clinical and emergency consultations, physician and staff education services, and community education. The Carle Network provides clinical telemedicine services in emergency medicine, trauma, cardiology, pediatrics, pediatric neurology, pre-and-post-cardiovascular surgery, anesthesiology, and home health. Educational services are also offered.
- The University of Kentucky Chandler Medical Center (Lexington, KY) sponsors the Kentucky TeleCare project. Since December 1995, it has grown to include four sites on campus, eight rural hospitals, and two primary care centers. TeleCare utilizes interactive video-conferencing equipment and systems for image applications. Clinical applications include dermatology, pediatric cardiology, child/adult psychiatry, emergency/trauma, pre-op anesthesia screening, vascular surgery clinics, tumor boards, nutritional counseling, and neurology, neurosurgery, nurse case management, and plastic surgery consults. TeleCare is also used for administrative and education programs.
- Marshfield Medical Research and Education Foundation (Marshfield, WI) hosts the Marshfield Clinic Telemedicine Network. This consists of 38 regional linked sites to provide a telecommunications network of administrative and business functions, including e-mail, shared medical records, video-business conferencing, internet/intranet access, as well as patient care conferencing. The telemedicine project provides clinical telemedicine services. Access to health care services will be expanded via telemedicine in two medically underserved communities. Initially, telemedicine services will be provided in emergency medicine, oncology, psychiatry, dermatology, radiology, occupational medicine, nurse triage services and compliance follow-up.
How nurses use telehealth
Major uses of telehealth by nurses include:
- Telephone triage. Nurses are involved in telephone triage in such programs as Ask a Nurse.
- E-mail consultation. Brennan and colleagues at Case Western Reserve University in Ohio studied e-mail. Persons living with AIDS and caregivers of Alzheimer's disease patients used computer technology to communicate with each other as well as electronic information sources.
- Home care. Telecommunication is currently used by nurses in home care. The Nightingale Tracker (Fitne, Inc.) is a hand-held point of care device that allows a nursing student to have contact with a clinical data repository, a faculty supervisor, and the Web. The product is currently used by over 40 sites in the United States. Some home health agencies look to telehealth to save costs on a per-contact basis, but researchers haven't yet determined if there is a cost savings by using the technology.
- Distance education. Although slow, the trend to offer online programs is growing. Duquesne University (Pittsburgh, PA) now offers a doctorate in nursing completely via online distance education. Regents College (Albany, NY) claims to be the country's first virtual university and offers a certificate program in healthcare informatics.
- Internet. Nurses are beginning to use the Web to disseminate educational and other materials. Because no uniform standards for these programs exist, nurses must be aware of the quality of these programs.
As a leading profession in healthcare, nursing needs to explore potential applications in telenursing, such as the following:
- Examination of skin lesions and wounds. Nurses could digitally photograph wounds and pressure ulcers, allowing the progression or regression of the wound to be viewed by an expert wound care nurse. The expert nurse could make recommendations for dressings and treatments.
- Consultation with professionals where transportation to another facility may cost time, money, or safety. For example, the estimated cost of transporting a prisoner from jail to a hospital is $700 per day per inmate for medical care. North Carolina and Texas currently link hospitals with the state prison medical system through telemedicine. The states expect to reduce costs because more than 50% of the inmates can be diagnosed and treated in the prison.
- Hospice services, surveillance care for the elderly, and management oversight in chronic conditions such as diabetes mellitus, asthma, chronic obstructive pulmonary disease, AIDS, heart failure Alzheimer's disease, and cancer.
Overcoming the barriers
What can nurses do to prepare for the new world of telenursing? Here are a few practical suggestions:
- Get involved in disseminating healthcare information on the Web. You're in a unique position to use the Web as a teaching tool for patients and colleagues.
- Support the mutual recognition model of nurse licensure.
The barriers to implementation of telenursing include regulations, cost, fear of change, and lack of acceptance by health care professionals. But by understanding telenursing, you can help bring together technology and nursing to promote patient care.
Susan K. Newbold, RN,C, MS, is a doctoral candidate in nursing informatics at the University of Maryland in Baltimore. She is also associate editor of Computers in Nursing, chair, Healthcare Information and Management Systems Society Nursing Informatics Advisory Committee, and member at large, National League for Nursing Council for Nursing Informatics. Reach her at firstname.lastname@example.org, www.nursing.umaryland.edu/students/~snewbol/
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