1. Introduction to Health Informatics:
Health Informatics in Low- and Middle-Income Countries
Short Course for Health Information System Professionals
Introduction to Health Informatics:
Telehealth

2. Teleheath Learning Objectives
Discuss how telehealth communication technologies support clinical care
Discuss the effectiveness and economic benefit of telehealth
Examine how smart technology in the home and remote links to health information systems can enhance the quality of patient care
This lecture, Patient Monitoring Systems, Lecture B, has the following objectives:
Discuss how telehealth communication technologies support clinical care
Discuss the effectiveness and economic benefit of telehealth
Examine how smart technology in the home and remote links to health information systems can enhance the quality of patient care

3. mHealth Technologies Mobile phones and smartphones
Personal digital or data assistants and palmtop computers
Wireless tablet computers
Wearable devices, such as watches, fitness monitors, wireless bio‐sensors, and wireless chronic disease monitoring devices
mHealth applications
Source: Nelson, 2012, para. 2
As you learned in the first lecture, both patient monitoring systems and telehealth are considered to be a type of mHealth technology. Rosemary Nelson, chair of the mHIMSS Task Force, described the most commonly used mHealth technologies as:
“Mobile phones/smart phones
Personal digital assistants (PDA)/palmtop computer or personal data assistant
Wireless tablet computers
Wearable devices, which can include watches, fitnet monitors, wireless bio‐sensors and/or wireless chronic disease monitoring devices
mHealth applications (“apps”) which are software loaded on any of the above mobile devices that aid in collecting community and clinical health data, delivery of healthcare information to practitioners, researchers and patients, real-time monitoring of patient vital signs, and direct provision of care” (Nelson, 2012, para. 2).
Lecture B will focus on telehealth and the role of smart technology in the home.

5. Telehealth World Health Organization definition:
“Telehealth involves the use of telecommunications and virtual technology to deliver health care outside of traditional health-care facilities. Telehealth, which requires access only to telecommunications, is the most basic element of ‘eHealth,’ which uses a wider range of information and communication technologies (ICTs).”
To gain an understanding of what telehealth is requires a review of the definitions used in the industry. Three will be provided.
First, according to the Health Resources and Services Administration (HRSA), “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” (HRSA, n.d., para. 1).
HRSA includes videoconferencing, the Internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications in their description of technologies associated with telehealth (HRSA, n.d.).
Equipment used in telehealth may include computers, fax machines, telephones, video monitors, robotics, and telecommunication networks connecting two or more sites.
Subsets of telehealth are: telemedicine, telenursing, teleradiology, telepathology, etc.
Source: World Health Organization (2018). Telehealth. Retrieved from:

6. How Telehealth Supports Clinical Care
Long-distance clinical healthcare
Patient and professional health-related education
Public health and health administration
There are three general areas where telehealth supports clinical care.
They are:
Long-distance clinical health care, e.g., telehealth permits the provision of care in situations where a face-to-face meeting between patient and provider may be impossible or costly. This may occur, for example, by “store-and-forward” technology which captures clinical information (e.g., images, video, audio or X-rays) and forwards it to another clinical site for evaluation.
Patient and professional health-related education, for example, telehealth has the capability to provide professional education to wide geographic areas
Public health and health administration, e.g., telehealth can make available healthcare to underserved communities where otherwise this care would not be available.
Each area will be examined in the next few slides.

7. Telehealth Long-distance clinical healthcare
Applications: client monitoring, diagnostic evaluation, and data exchange, such as real-time video images
Benefits:
Improved access to care including specialist care,
Elimination of the barrier of distance, e.g., patients receive needed care without the cost of traveling, patients can be checked on more frequently, and
More timely initiation of treatment
Telehealth supports clinical care by allowing long-distance health care. The location of where telehealth is possible includes rural or remote areas, schools, prisons, and the home, to name a few. Some of the more common applications for telehealth with regards to clinical initiatives are client monitoring, diagnostic evaluation, and data exchange, such as real-time video images. Benefits to using telehealth include:
Improved access to care including specialist care, that is the ability to extend the geographic reach of medical care and provide access to medical specialists in remote and rural areas,
Elimination of the barrier of distance, e.g., patients receive needed care without the cost of traveling, patients can be checked on more frequently, and
More timely initiation of treatment, which can mean problems are addressed before they worsen and result in the need for hospitalization.
For example, in diagnostic evaluation, a medical consultation can be performed via a telecommunication system. With the use of equipment such as an online stethoscope, electronic examination is possible resulting in a diagnosis and decision regarding treatment. Telehealth provides the capability to perform an exam, make a more timely diagnosis, and institute treatment that might otherwise not have been received. This area of telehealth can improve health care quality and reduce disparities while also increasing convenience for patients.
Regarding patient monitoring and data exchange, Mostashari (2010), as a senior advisor from the Office of the National Coordinator, testified that “Home monitoring can place daily metrics of patients’ health—weight, blood pressure and other vital measures—in patients’ and providers’ hands, improving chronic care management and patient engagement. Early detection of problems made possible with real time information, but not imaginable through office visits at six-month intervals, can help avoid unneeded hospitalizations for patients with heart failure and other chronic conditions. Secure sharing and remote reading of patient information such as radiographic images on high speed channels can improve care coordination and reduce the risk of medical errors” (p. 4).

8. Effectiveness and Economic Benefits of Telehealth
Provides greater access to care
Reduces the number of interventions required
Eliminates unnecessary visits to the home or emergency room
Provides easier access to specialists’ advice
The previous few slides provided some examples of the benefits of telehealth from the perspective of the general areas where telehealth supports clinical care. Looking at telehealth from a different view, that is the effectiveness and economic benefits, Miller and Young (as cited in Hebda, Czar & Mascara, 1998) state the following advantages of telehealth:
“Greater access to care provides earlier treatment for the client, reducing the number of interventions required.
Treatment can be provided closer to home, often eliminating costly travel and greater urban medical costs. Video consultations between a rural clinic and a specialist can eliminate sometimes prohibitive travel for patients.
Home monitoring can eliminate unnecessary visits by a nurse to the home or by the client to the emergency room.
Specialists’ advice is more easily accessible, improving the quality of care” (p. 251).

9. Effectiveness and Economic Benefits of Telehealth
Availability of physicians if needed to physician extenders
Added capability of providing continuous care
Increased availability of education
Additional advantages of Telehealth that Miller and Young (as cited in Hebda, Czar & Mascara, 1998) identified are:
“Physician extenders such as physician assistants and nurse practitioners can provide care in remote locations, with the assurance of physician availability if needed.
Continuous care is provided through use of local practitioners delivering immediate and follow-up care.
Videoconferencing opens up new possibilities for continuing education for isolated or rural health practitioners who may not be able to leave a rural practice to take part in professional meetings or educational courses.
Videoconferencing can also provide education to clients at home and in rural settings” (p. 251).

10. A 56-year-old auxiliary nurse midwife in Badagaon block, Jhansi district, Uttar Pradesh, India, learns how to register a beneficiary using her tablet-based mSakhi application, a mobile phone-based job aid developed by IntraHealth International under the Manthan Project.
Photo: © 2015 Girdhari Bora for IntraHealth International, courtesy of Photoshare
Photo: © 2015 Girdhari Bora for IntraHealth International, courtesy of Photoshare

11. Telehealth Characteristics Well-integrated in existing procedures
Uses existing infrastructure where possible
Provides obvious improvement over alternative mechanisms
According to Miller & Young (2000), successful telehealth programs “…tend to be well integrated into existing procedures; using existing infrastructures, where possible, to save money and avoid wasteful duplication; and provide an obvious improvement over alternative mechanisms” (pp ).
For example, rather than setting up a separate “telemedicine room” across campus, it is likely more effective to have telehealth integrated into the physician’s workflow. A room in the clinic equipped with telehealth systems and in the same area as the other clinic visit rooms would likely be very effective.

12. Role of Smart Technology in the Home
Telehealth
Remote patient monitoring
Given what you have learned about telehealth and remote patient monitoring, you should recognize now how closely intertwined these two are. For example, you know both are considered to be a type of mHealth technology. To review, 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. The Center for Technology and Aging (2011) states remote patient monitoring includes a number of technologies, such as point-of-care monitoring devices, which may standalone or become part of an integrated health data collection, analysis, and reporting system between the devices, patients, and clinicians.
Smart technology in the home would involve the use of telehealth and remote patient monitoring devices integrated with health information systems. The technology can be used to remotely monitor a patient’s symptoms and vital signs, immediately and automatically transmit it to healthcare providers and care givers for informed medical decision-making and care coordination. Home monitoring systems could automatically collect and store patient data from various systems and provide for remote monitoring and health delivery (telehealth) technologies. These technologies can also monitor movement within the home, monitor and report on whether medicine is being taken, and can help with communication to family and caregivers.
The medical home care model also calls for extensive use of health information technologies. This can include Wifi or cellular networks.

13. Smart Technology in Use
Diabetes self-management
Smart phones
Application software
Wearables
As reported by Goedert (2010), AT&T will sell diabetes self-management software from WellDoc Communications Inc. that operates on smart phones.
Goedert (2010) states “WellDoc's Diabetes Manager System received FDA clearance in August. The application enables Type 2 diabetic patients to enter their blood sugar readings into their mobile phone and receive real-time feedback on what they should eat and other ways they can help stabilize their blood sugar. The software also can alert patients when they need to test their levels. Further, the application sends the data to vendor servers, where it is analyzed and can be accessed by the patient's physicians and disease management caseworkers. It also can support glucose meters that can send data via Bluetooth wireless technology. AT&T will make Diabetes Manager and other WellDoc applications available on all wireless networks and compatible with most major phones and operating systems, according to the companies” (para. 2).
This is an example of how smart technology uses telecommunications and remote monitoring devices integrated with health information systems.

14. Telehealth Summary Patient monitoring systems
Purpose, attributes, and functions
Primary applications
Data integration and clinical decisions
Telehealth and clinical care
Benefits of telehealth
Smart technology in the home
This concludes Lecture B of Patient Monitoring Systems. This lecture discussed how telehealth communication technologies support clinical care, explained the effectiveness and economic benefit of telehealth, and examined the role smart technology in the home and remote links to health information systems play in enhancing the quality of patient care.

15. Telehealth References
American Telemedicine Association. (n.d.). Telemedicine/Telehealth terminology. Retrieved from Center for Technology and Aging. (2011). Remote patient monitoring. Retrieved from Centers for Medicare and Medicaid Service. (n.d.). Telemedicine. Retrieved from American Health Information Management Association. Florida Health Information Management Association comments on the Florida HIE Plan Overview. (2009). Retrieved from Goedert, J. (2010, October 14). AT&T to use, market diabetes tool. HealthData Management. Retrieved from phone-mobile html Health Resources and Services Administration. (n.d.). Telehealth. Retrieved from Hebda, T., Czar, P., & Mascara, C. (1998). Handbook of informatics for nurses and health care professionals. Menlo Park, CA: Addison-Wesley. Miller, L. M., & Young, K.M. (2000). Telehealth. In Young, K. M. (Ed.), Informatics for healthcare professionals (pp ). Philadelphia, PA: F. A. Davis Company. Mostashari, F. (201, April 22). Testimony on aging in place: The national broadband plan and bringing health care technology home. Retrieved from Nelson, R. (2012). Exploring mobile health consumer trends. Clinical Informatics Insights. Retrieved from
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16. This material was developed by Duke University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC This material was updated by Normandale Community College, funded under Award Number 90WT0003.
This presentation was produced with the support of the United States Agency for International Development (USAID) under the terms of MEASURE Evaluation cooperative agreement AID-OAA-L MEASURE Evaluation is implemented by the Carolina Population Center, University of North Carolina at Chapel Hill in partnership with ICF International; John Snow, Inc.; Management Sciences for Health; Palladium; and Tulane University. Views expressed are not necessarily those of USAID or the United States government.