1. Telenursing and Remote Access Telehealth
Bonnie Westra, PhD, RN, FAAN, FACMI

2. Objectives
Define telenursing/ telehealth and the use in various settings
Identify populations served by telehealth
Describe the role of the telehealth nurse
Explore various types of systems/ equipment
Examine teaching methods

3. Definitions of Telehealth Nursing
Telehealth nursing is the use of telecommunications technology in nursing to enhance patient care. It involved the use of electromagnetic channels (e.g., wire, radio, and optical) to transmit voice, data and video communications signals. It is defined as distance communication, using electrical or optical transmissions between humans and/or computers.
(Skiba, D.J. & Barton, A.J.,2000)
Telehealth nursing is the delivery, management, and coordination of care and services provided via telecommunications technology within the domain of nursing.
(American Association of Ambulatory Nursing 2004)
Telehealth nursing is the practice of nursing over distance using telecommunications technology.
(National Council of State Boards of Nursing, 1997)
There are a variety of definitions for telehealth as you can see on this slide.
Common to these definitions are that telehealth nursing is still nursing practice.
It uses a variety of telecommunication technologies.
The goal of telehealth nursing is to enhance patient care.
Please read the definitions. When you’re done, click the forward button to continue.

4. Use of Telehealth Home health care - monitoring, education, support
Nursing home - specialty consultations
Ambulatory care - specialty consultations
Hospital consultations - stroke care
Prison settings – mental health services
Mentoring – i.e. wound care specialists
ICU monitoring – neonatal intensive care, cardiac care
Health promotion – obesity, exercise/ fitness

5. Role of Telehealth Nurse
Nurse presenter – ambulatory
Nurse case manager – i.e. diabetes care
Public health nursing– Text4babies, Text2Quit
Health coach
Tele-ICU nursing
Clinical tele-health coordinator

6. Example – Nurse Presenter
Planning telehealth program i.e. specialty consultations in rural clinic/ hospital
Coordinate scheduling patients
Evaluating and preparing equipment
Assessing patients
Presenting patient
Facilitating remote exam
Documentation
Follow up care

7. Telehealth Methods Real-time
Telephone-based – limited to education/ counseling
Web-consults (two-way audio and video)
With or without peripheral devices
Store and forward – images, audio, video
Combination

8. Telehealth Equipment Phone lines/ internet
Phone/ computer with or without camera/ microphone
Cell phones
Life line
Sensor Technology
Peripheral devices
Peripheral Devices
Blood pressure
Scales
Glucose monitoring
EKG/ cardiac monitoring
Dermascope
Otoscopes
Pedometers

9. consults
Although correspondence between patients and providers is not so futuristic, it is just starting to be used in patient care. The high consumer demand for contact begs the question – what is it about current service delivery models that leaves the patient wanting more? between providers and patients has the potential to improve communication, increase involvement from patients in their own health care, and reduce the need for in-person visits. Used in conjunction with office visits, telehealth is particularity effective as a visit extender. It also offers increased opportunities for interaction and for follow-up, allowing improved continuity of care.
Few providers have yet to see communication as an extension of their practice. They do however, find communications less disruptive than a phone call. Reimbursement is a barrier. Providers have concerns about the legal and ethical aspect of care, as well as security. The American Medical Informatics Association has established guidelines for communication between providers and existing patients that can guide the development of this service.
Research on the use of to assist patients with behavioral changes, motivation, and better disease compliances have noted significant success in comparison to the groups who receive traditional care. Many corporate wellness programs and disease-focused programs are using to provide small, frequent bits of information to help motivate employees or patients on an ongoing basis. Versus getting information overload during a traditional visit or counseling session, consults provide information in is small doses, on a frequent basis, over a period of time.

10. m-Health Will Transform Healthcare
Mobile technology will transform healthcare more then any other communication technology currently on the market. It will allow for information to be sent and received from basically any location in the world. mHealth Initative defines m-health as the connection and coordination of all participants, including consumers, in optimizing health ( . The term is most commonly used in reference to using mobile communication devices, such as cell phone, PDA’s, ipads, etc., for health services and information.
Currently, there are over 5800 health, nutrition and wellness smart phone applications. The inventors and consumer see the benefit, but health care has been slow to integrate this technology.
A few health care programs are starting to use mobile devices to send patient reminders and education vignettes, and to even provide care via mobile telehealth. Providers are able to access information from wherever they are as well as receive live-time data from patients. Many product manufacturers now include remote access to be able to view the data from their products on smartphones.
With m-health, patients can be continuously monitored no matter where they are or what they are doing. M-health has significant promise for developing countries where traditional infrastructure does not exist, but wireless technology is available. For example only 9% of Mexicans have access to the Internet, but 80% have a cell phone.
As devices continue to advance, they become smaller and more integrated, putting more power in the user’s hands. Consider how far we’ve come from the very first cell phone that only did phone calls to current models that allow you to take a picture, access to , get driving directions, and watch a movie. Apple is currently seeking to embed a heart monitor into an iPhone, that will transmit an ECG simply by holding the device.
The FCC has promoted the use of wireless devices and applications in health care as part of its national broadband plan released in March 2010, and has proposed to develop a bandwidth specifically for m-health applications.
The applications for m-health are endless. The impact on healthcare will be significant.
Marilyn’s note: these are lifted from a website. Would like similar representation with medical stuff on them. Maybe on the ipad, could be a patient representing a telehealth consult? Susan’s Note: Will try to add a photo of patient on iPad after recording is done…

11. Monitoring - eICU Care
Baptist - eICU eight ICUs for a total of 142 beds 4 nurses/ shift – average 19 years experience Real time vital signs and cardiac monitoring Entire electronic record Alerts if any change that could be a problem Activation of camera and speaker from eICU for visual assessment and communication with the floor staff or patient

12. Mr. Smith’s House is Calling
Caregiver Alerts Voice Prompts Floor Sensors Safety Features Smart Beds Video Monitors Vital Sign Monitoring Medical Condition Monitoring
Today when one says “smart home” you might be thinking about a house that has sound system through out the house, the ability to adjust the temp from your cell phone, and a security system. But in the future, smart homes will be much more. They will have assistive devices and monitors to allow the disabled and elderly to live independently longer. Instead of being forced to move into a nursing home when unable to achieve full self-care, individuals can rely on their smart home appliances.
A smart house will have devices that monitors a person and can learn to recognize their habits so loved ones can be notified if habits change. Caregivers can be alerted if a person goes into the bathroom and is not out within a certain period of time or has not opened the refrigerator in 24 hours. Voice prompts will also help with reminders to shut the refrigerator door or if the main door was opened at inappropriate times. A smart home will have a floor that senses a change in walking patterns to identify change in condition or advance of diseases. Smart beds will detect changes in sleeping patterns. Safety features will be standard such as a stove automatically shutting off at a certain temperature or if left unattended too long. Video monitors will let you know who is at the front door with the remote ability to unlock the door. For the cognitively impaired, when the phone rings, a picture of who is calling will be shown, along with a brief information about the caller.
Smart houses will have the capability of monitoring the vital signs of a person as well. If the person has a medical condition that is concern, routine vitals signs can be sent to the appropriate care givers. The smart home, equipped with artificial intelligence, will learn to distinguish dangerous readings, and alert medical personnel immediately.
Some worry about privacy and the intrusiveness of the continuous monitoring, but for the elderly and disabled, these would be minor tradeoffs for the ability to be independent. Smart homes are only as smart as one would allow them to be, so the occupant has control over what and what is not used. Designs of smart homes will integrate the monitoring devices so that they are invisible to the average eye.
Mariiyn’s note. I would like a similar picture except more of a kitchen scene. Stove and refrig with alerts, door and intruder alert, floor sensor, video phone with picture of “jane- daughter calling” and wearable sensors llke in the prior slide
Susan’s note: Will update photo with modern kitchen and some sensors. Too difficult to create all that Marilyn listed above in any given stock photo…

13. Smart Homes
A smart home can assist in monitoring a patient and promoting a safer environment, but can it pick up a dropped article for a disabled person? Soon the elderly and disabled will have the assistance of care robots to assist them in their homes with daily activities and allow them to be independent in their everyday lives.
Robots are being developed with soft fingertips nimble enough to grasp a drinking straw, and arms strong enough to lift adults out of bed. Additionally robots are being created with artificial intelligence which allows them to interact with patients, from taking a resident to physical therapy in a nursing home to playing a game of chess. Robots will become “companions” for the home bound. The robot can attend to someone’s personal needs, send your vitals to a healthcare professional, and be your best friend. (Susan’s note: I don’t think this is a very comforting thought… I’d rather have a dog! Maybe we can leave the ‘best friend’ part off!?)
If you think of robots as big and not very agile check out the Sony Dancing Robots, or Honda’s Asimo
Marilyn’s note: some type of robot and person interacting

14. Ethical/ Legal Issues Competent Care
AAACN - Scope and Standards of Telehealth Nursing
ATA – Standards and Guidelines
Devices
Center for Telehealth and eHealth Law
License to practice
In 2000, NCBSN launched a new initiative to expand the mobility of nurses as part of our nation's health care delivery system. The Nurse Licensure Compact (NLC) allows nurses to have one multistate license, with the ability to practice in both their home state and other party states

15. Safety Issues
Assess appropriateness of telehealth for the patients ability and status
Know equipment
Evaluate reliability and effective use of equipment
Infection control
Information safety
Compliment with nurse judgment

16. Benefits and Challenges
Benefits of Telehealth
Challenges of Telehealth
Health care access
Financial return
Coordination of care
Quality of care
Expansion of usage
Technology infrastructure/interoperability
Financial investment
Licensure and credentialing
Reimbursement
Evaluation/outcomes
While challenges still exist, the stars are starting to align for telehealth. There is more research available to document the benefits and technology is becoming more available and affordable. Insurance companies are realizing the benefits and are taking the lead on reimbursement. Soon telehealth will be a cornerstone for the delivery of healthcare.

17. Teaching Activities
Briefing on telehealth - Select a target population i.e. CHF, MCH, other about the use of telehealth
Population, technology (ies), benefits, barriers
Interview 5 older adults about their use of technology, preferences, and willingness to receive care via telehealth
Simulate telehealth visit using Skype
Explore nursing roles in telehealth
Describe regulator issues related to telehealth
Debate – barriers and strategies for overcoming barriers using telehealth
Compare telehealth center websites – similarities and differences in services

18. Telehealth Jeapardy
Have students create a Jeopardy game about telehealth
Category
What is?
Concept
Resource
Equipment
dermascope
What is a skin surface contact miscroscope?
Nursing roles
Methods of telehealth
Populations
Legal Issues

19. Explore Research Funded by AHRQ http://healthit. ahrq
Describe potential implications for nursing practice realted to AHRQ funded research
Grant
Creating Online Neonatal Intensive Care Units (NICU) Networks to Educate, Consult & Team
HIT-based Regional Medication Management Pharmacy System
Home Heart Failure (HF) Care Comparing Patient-Driven Technology Models
Implementing Technology to Transform Quality in SE Kern
Measuring the Value of Remote ICU Monitoring
Project ECHO (Extension for Community Healthcare Outcomes)
Technology Exchange for Cancer Health Network (TECH-Net)
Telewoundcare Network
Valuation of Primary Care-Integrated Telehealth

20. Associate Professor & Co-Director
Bonnie Westra, PhD, RN, FAAN, FACMI
Associate Professor & Co-Director
Center for Nursing Informatics University of Minnesota, School of Nursing W