1. Nursing Trends in Telehealth Homecare
Presented by:
Norma I. Rojas

2. Objectives during this presentation we will…
Describe the trend in telehealth homecare
Describe and evaluate the hardware and software utilized with this trend
Describe and evaluate the information system used with this trend
Assess the role and functions of the nurse informaticist when working with this trend.
Examine related legal issues

3. Objectives (cont.) during this presentation we will…
Discuss the advantages/disadvantages from a nursing perspective

4. What is telehealth homecare?
Telehealth homecare provides patients with healthcare, health information, and health education across a distance with the use of telecommunications technology, and specialty adapted equipment.
(Telehealth leadership initiative, 2008)

5. What is telehealth homecare?
This service allows doctors, nurses, and other healthcare providers to assess, diagnose and treat patients without having to be in the same physical location.
(Telehealth leadership initiative, 2008)

6. The evolution of healthcare
In order to provide more services to our growing population, healthcare will evolve into a highly community-based industry.
(Auerbach et al, 2009)
With the rising costs of healthcare and the increased demand for medical attention, the healthcare industry must find creative new ways to treat our growing population. According to a report entitled:The Future of the Nursing Workforce in the United States: Data, Trends and Implications, it is estimated that the nursing shortage may reach a deficit of up to 500,000 nurses by the year Telehealth homecare is a new concept that will expand our existing home healthcare system to meet the needs of the US population. Telehealth homecare will provide a means to manage medical services without having to enter a clinic or hospital. Through the use of uncomplicated medical equipment, doctors and nurses will have the ability to assess, evaluate and determine a plan of care. Making healthcare more convenient, accessible and cost effective (Auerbach et al, 2009).

7. Hardware used in telehealth homecare
Blood Glucose Meters
Cardiac monitors
Electronic stethoscopes
Blood pressure monitors
Pulse oximetry devices
Electronic thermometers
(Liddy et al, 2008)
Now we will take a look at how consumers use telehealth. What medical hardware will patients utilize in telehealth homecare?
Some of the hardware that patients will use are non and minimally invasive devices such as blood glucose monitors, cardiac monitors, electronic stethoscopes, blood pressure monitors, pulse oximetry devices, and electronic thermometers. These devices will gather vital information that will allow doctors and nurses to treat patients from the comfort of their home. Qualified home health nurses will instruct patients on how to use this equipment and will provide 24 hour telephone information services to those who participate.

8. Hardware used in telehealth homecare
Home PC
Video conferencing devices
Telephone, fax, s
Specialized telephone adapters
(Liddy et al, 2008)
Other devices used are home PC’s, video conferencing devices, telephones, faxes, s and specialized telephone adapters. Patients will be able to transmit this information via their telephone or home PC. Specialized equipment such as video conferencing devices or specialized telephone adapters can also be used to transmit this information. Healthcare providers will have the opportunity to view this information from their medical facilities and use this information to adjust medications, make a diagnosis and monitor a patient’s progress over a period of time.

9. How to use telehealth hardware using telephone adapters
Adapter is connected to a simple telephone line
Patient logs into a system and follows a series of directions
Voice prompts patient to adhere to medication regimens and treatments
Patients vital signs, weight, electrocardiogram, etc. are transmitted to the healthcare provider
This information is used to treat patients at home
(Center for Aging Technologies, 2008)
Now lets take a look at how a patient would transmit vital information using a telephone adapter.
A study conducted by the Center for Aging Services Technologies in 2008, reviewed the efficacy of using telehealth homecare for patients diagnosed with congestive heart failure. According to their report, the treatment of CHF is one of the most costly diseases to treat in the United States. It is estimated that the nation spends nearly 27 billion dollars in direct costs for the treatment of CHF patients, half of which goes to hospitalizations. More Medicare dollars are spent on the diagnosis and treatment of CHF than on any other diagnosis. In an effort to decrease these rising costs, CAST conducted a trial using telehealth technology to treat CHF patients at home. They provided these patients with telephone adapters to transmit information to their healthcare providers.
This slide describes how patients used the telephone adapters for telehealth services.
First, patients connect this adapter to their existing telephone line.
The patient must log into this system everyday to connect with their healthcare provider.
A voice prompts the patient to adhere to their medication schedule and schedule needed appointments or a home health visit (if necessary).
The patient then transmits vital information such as temperature, blood pressure, heart rate, weight, electrocardiogram results, blood oxygenation, blood sugar results, and cardiac and lung sounds using the hardware specified in the previous slides.
The healthcare provider then uses this information to assess and monitor patients at home. Healthcare providers can determine the severity of their disease and focus on the patients that require immediate assistance. Other interventions can also be made such as adjusting medications, suggesting a lifestyle change, or the recommendation of bed rest, if needed. These interventions can decrease unnecessary hospital visits while allowing patients to stay closely monitored. (Center for Aging Technologies, 2008)

10. Types of software used in telehealth homecare
AFHCAN Software
CapSure Software
GIGISim
Philips Web-based Clinical Software
Omnivisor
WebVMC and more…
Here is a list of some of the software applications presently used in telehealth.
Examples are: AFHCAN, Capsure, GIGISim, Philips Web-based, Omnivisor, and WebVMC to name a few.

11. Use of Philips Web-based software
Software flags patients vital signs if they are out of range
Library of surveys available for patients with various diseases
Care plans and protocols available
Tracks trends and generates reports
Patient contact information available to facilitate a rapid response
(Phillips, Inc., 2008)
Let’s take a look at one kind of software that is currently on the market for telehealth services. As previously mentioned, one example of telehealth software is Philips Web-based Software. This software gathers patient data and processes and displays it in an easy to read screen that allows the healthcare provider to visually prioritize which patients need rapid interventions.
This software also includes a library of patient surveys that can be customized for each patient depending on their specific disease. Survey questions test for comprehension and knowledge retention to promote better patient self-care and motivate healthier behaviors.
Philips Web-based system also includes care plans and protocols which can be customized. These features can provide step-by step information that can provide important guidelines and teaching to improve outcomes.
Trends and reports are also generated to track progress and to determine if any changes need to be made to a patients plan of care.
Aside from these features, this software also organizes patient data and stores contact information such as family member information, primary care physician and specialists on the case to facilitate a rapid response if a change in status is detected. (Philips, Inc., 2008)

12. Philips Web-based software usability
Easy to use
Easy to learn
Patients reported
satisfaction with its use
Efficient
Error tolerance- minimal
workarounds
The system fit
with the task at hand
(Staggers, 2003)
(Phillips, Inc., 2008)
According to Staggers (2003), the usability of technology can be evaluated using the following criteria.
Patients using Philip’s Web-based software have stated that this software is easy to use and moderately easy to learn. The software and hardware are relatively simple to install and manipulate. Patients surveyed who have used this software were very satisfied with its use. They stated that the software was efficient and convenient to use. When problems occurred with the software use, patients felt that they had the ability to troubleshoot the equipment and software fairly easily. Appropriate technical support was also available if they experienced a problem that they could not correct. Most patients felt that the software correlated with the needed tasks and most of the people who were surveyed also expressed an overall satisfaction with this software.

13. Cardiocom’s Telehealth Computer-based Clinical Information System
Collects, stores and manipulates healthcare data in real-time
Provides secure access by multidisciplinary healthcare team
User-friendly system
Used for observation, interventions and documentation
(Mastrain, K. & McGonigle, D., 2009)
(Cardiocom, 2008)
Now we will review a telehealth information system. An example of a telehealth information system is the Cardiocom telehealth system. This system is a comprehensive multi-disease management system. Cardiocom provides healthcare professionals with the software and hardware necessary to provide telehealth services.
Like most telehealth systems, Cardiocom is a computer-based clinical information system. A clinical information system is the most commonly used type of patient care support system within healthcare organizations. It is patient-centered and allows for the collection, storage and manipulation of data in real-time. All members of the healthcare team can access this system with secure codes for patient confidentiality. The user-interface is also easy to use which allows healthcare providers to make observations, interventions, and documentations easily.

14. Review of the Cardiocom Information System
Clinical computer-based information system
Used primarily by doctors, nurses, pharmacists, etc.
Used to diagnose and treat
Configuration: LAN, microcomputers, etc.
Data standards set by Health Level 7, DICOM and PACS
(Cardiocom, 2008)
(Tan , J., Cheng, W., & Rogers, W., 2008)
As mentioned earlier, the information system used in telehealth is used primarily as a clinical information system since it is used to collect, process and evaluate clinical information in real time. However, it can also be used for administrative purposes, such as for medical billing, quality improvement and evaluation. This information system can also be used as a case management information system to determine the efficacy of a patients current plan of care.
The Cardiocom system is used primarily by doctors, nurses, pharmacists and other healthcare professionals to collect and evaluate a patient's information. However, it can also be used by healthcare administrators for quality control.
The functions of this information system are used to monitor, diagnose and treat multiple medical conditions with the use of specialized hardware and software.
The configuration for the Cardiocom information system is used with local area networks and the use of microcomputers. However, with the rise of telehealth use, more options for telehealth configurations may become available.
In order to achieve successful transmission and exchange of data, appropriate health data standards must exist. For many clinicians who practice telemedicine, the most commonly used and shared standards for the transmission of clinical data and knowledge as well as medical images include HL7 (Health Level Seven) standards for health care and clinical data formats, DICOM (Digital Imaging and Communications in Medicine) for the storage of medical information and images, and Picture Archiving Communication Systems (PACS) for easing the transfer and retrieval of medical data, texts and images. These data standards provide guidelines to most telehealth users and providers. .

15. Review of the Cardiocom information system
The disease and procedure classification used in telehealth are SNOMED and ICD10
Recommended by healthcare providers
(Wikipedia, 2008)
Currently, the main disease and procedure classifications used in telehealth systems are SNOMED and ICD10.
The Systemized Nomenclature of Medicine also known as SNOMED is a universal healthcare terminology which facilitates the consistent capture, exchange and aggregation of health data. It is used as the foundation of electronic health records and other applications.
The Internal Classification of Diseases also known as the ICD 10 is a classification system that provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. The ICD 10 is published by the World Health Organization and is used worldwide for morbidity and mortality statistics, reimbursement systems and automated decision support in medicine.
While the evolution of telehealth homecare is still in its infancy, many healthcare practitioners agree that this type of information system is beneficial to the healthcare industry. The current nursing shortage and the increasing demand for healthcare services has helped many practitioners accept new ways of providing services to their patients. Cardiocom is one telehealth system that has proved to be user friendly and has received recognition for its contributions to the healthcare industry. The Cardiocom system has won several awards for innovative patient monitoring including the 2008 North American Patient Monitoring Product Innovation of the Year Award by the Frost and Sullivan Co (Cardiocom, 2008). I believe that this information system will help revolutionize the way that we practice healthcare. The benefits of implementing telehealth homecare are numerous. This type of service will create greater accessibility for patients and will make healthcare more cost-effective. Therefore, I would recommend that more practitioners begin to investigate, utilize and implement more telehealth systems nationwide.

16. (Center for Aging Technologies, 2008)
Advantages of telehealth services for nurses and other healthcare professionals
Recommended for the treatment of chronic and low acuity diseases
More cost-effective
Reduce hospital ER wait times
Provide patients with more autonomy
Increase accessibility (esp. rural areas)
Promote health through comprehensive follow-ups
(Center for Aging Technologies, 2008)
(Cardiocom, 2008)
Let’s take a look a some advantages of telehealth services.
This type of service is recommended for the treatment of chronic and low acuity diseases, such as patients with CHF, asthma, COPD, etc.
Consumers can decrease their healthcare costs by avoiding unnecessary hospitalizations with the use of close monitoring at home. Healthcare practitioners can track a patient’s progress and can determine whether a patient needs immediate assistance or just requires a medication or an activity modification.
With a decrease in unnecessary hospitalizations, emergency room wait times could also decrease, allowing ER staff to focus on the patients with the highest acuity.
Patients who have used telehealth services have stated that they enjoy the freedom and the autonomy that they get from telehealth home services. Most patients with chronic diseases prefer being involved in their care and prefer staying at home than having to be hospitalized.
Telehealth services can also increase the accessibility of healthcare services, especially in rural areas where the closest medical facility may be located miles away from a patient’s home. Doctors and nurses can oversee the progress of many patients with the help of specialized software programs that could allow them to see who needs immediate attention first.
The software used in telehealth also allows healthcare providers to perform comprehensive follow-ups on a daily basis. This can help keep patients healthier and keeps their disease under control.

17. Disadvantages of telehealth services for nurses and other healthcare professionals
Possible lack of compliance from patients
Some patients may seem overwhelmed with the equipment use (esp. the elderly)
Lack of human contact
Nurses fear of being replaced with automation
(Cassin, 2008)
While there are many advantages to using telehealth services, there are also some reported disadvantages. According to an article reported in the Telemedicine Information Exchange, there are many barriers to the implementation of telehealth services. Although studies have shown that patients have positive outcomes with telehealth services, many primary care practitioners are still reluctant to start their patients on telehealth services.
Some of the disadvantages stated in this article were the possibility of a lack of compliance from patients. Some patients may take home monitoring lightly and may not take suggested interventions from a computer seriously.
Some patients may also feel overwhelmed with the use of the new devices. Although we currently live in a computer age, there are still many people who feel uncomfortable using computer technology. Elderly people may lack the manual dexterity to complete need tasks. Before any patient begins using telehealth services, they must be thoroughly assessed for an adequate comprehension of the devices used.
Many people also complain that telehealth depersonalizes healthcare. Many feel that interactions with a computer or telephone are not proper tools for healthcare services. A lack of human contact is perhaps the biggest issue for disapproval.
Some nurses are also concerned with the lack of human interaction. Many nurses reported feeling like they were being replaced with computers. Telehealth services allows a nurse to oversee many more patients than one nurse possibly can on a one to one basis. While there are many nurses that dislike this concept, this may be one solution that could help alleviate the current nursing shortage.

18. Telehealth legal issues
Privacy issues
Reimbursement
Malpractice
Licensing issues
Accreditation and
regulations
Fraud and abuse
(Center for Telehealth and E-Health Law, 2006)
Now we will take a look at some legal issues involved in telehealth.
According to the Center for Telehealth and E-Health Law, some legal issues involved in telehealth are the following:
Privacy: With the rising concern of keeping patients electronic data confidential, telehealth service providers must work diligently to keep patients health records private in accordance with HIPPA regulations and must only allow assigned practitioners the ability to view a patients medical health record. The fear of wrongful access to patient records is a constant threat in telehealth.
Reimbursement: While telehealth is a health service, many insurance companies may not reimburse physicians at the same rate as they would for in-office visits. This is another reason why some physicians may be reluctant to use telehealth services.
Malpractice is another reason that discourages many healthcare providers from using telehealth services. Many practitioners may not feel comfortable using the specialized equipment to perform their assessments and may only want to perform their assessments with the patient present. The rise in malpractice lawsuits may make a physician weary of doing full assessments from a distance. I believe that we will see the true impact of this topic in the years to come.
Licensing issues: Telemedicine is medicine, therefore, a practitioner must hold a valid license to practice. Since telehealth may cross state lines, the issue of state licensing exists. Doctors and nurses practicing telehealth usually do so within their state’s jurisdiction. However, thanks to the Interstate Nurse Licensing Compact, nurses who hold a license in one state may practice in another state, as long as that individual abides by the other state’s laws and regulations. There are currently 23 states that are apart of the Interstate Nurse Licensing Compact. The issue of practicing across state lines is a topic that is still being addressed.
Accreditation and regulations: State laws require the accreditation of medical facilities. Private organizations such as JCAHO sets standards and oversee that healthcare practitioners in medical facilities are competent in their practice. The “virtual” facility of telehealth is monitored differently but must also face stringent accreditation policies. The Food and Drug Administration is responsible for regulating the software used in telehealth.
Fraud and abuse: Like with all healthcare services, telehealth is also vulnerable to fraudulent practices from their providers.

19. Informatics competencies for telehealth nurses
Proficient with computers and telehealth software
Proficient with the use of specialized equipment
Obtain excellent clinical and critical thinking skills
Ambulatory care and/or informatics nurse certification
(American Nurses Credentialing Center, 2008)
Let’s take a look at some of the informatics competencies needed for telehealth nurses.
Nurses in this field should be competent in the following areas:
Nurses should be proficient with the use of computers, including many types of software. Nurses who are interested in entering this field are trained by their facilities or take a special course to use this specialized software. By the end of their training, nurses should have a good understanding of how to use this software for clinical, educational and documentation purposes.
Nurses in telehealth must also have an extensive knowledge of using the specialized equipment used in telehealth services. Most telehealth service facilities train their nurses on how to use, install and manipulate all equipment. Telehealth nurses must also learn how to troubleshoot this equipment if problems arise.
Like all nurses, telehealth nurses must have excellent clinical and critical thinking skills. Physical assessments made by the nurse from a distance may be much more challenging. Therefore, nurses must have excellent assessment skills and must be able to act quickly if acute changes occur. Nurses must feel comfortable using technology to assess patients in a different location.
Although it is not required by all telehealth service providers, a nurse should obtain certifications specifically for telehealth nursing. Certification in ambulatory care nursing and informatics nursing is highly recommended. Ambulatory care certification should be obtained by nurses who are actively monitoring patients at home. This type of certification is the gold standard in home health care. Another type of certification specific to telehealth nursing is the informatics nurse certification. This type of certification is highly recommended for nurses who are managers, coordinators or clinical specialists in telehealth services (American Nurses Credentialing Center, 2008).

20. Functions and responsibilities of an informatics nurse in telehealth
Telehealth home care nurses:
Setting up telehealth software and hardware in patients homes
Assessing and monitoring patients from a distance
Providing patients with health education and education regarding equipment
Here is a list of some of the functions and responsibilities of a telehealth home nurse.

21. Functions and responsibilities of an informatics nurse in telehealth
Telehealth home care nurses:
Act as a patient advocate and promotes
client health and safety
Performs accurate documentations of
assessments and care plans
Provides ethical care and is accountable
for own actions
Provides evidence-based care

22. (American Nurses Credentialing Center, 2008)
Functions and responsibilities of an informatics nurse specialist in telehealth
Telehealth clinical manager/coordinator:
Administration/management of facility and
staff
Theory formulation, design and development
Testing and selection of telehealth technology
Oversees training and education
Research and evaluation of services
(American Nurses Credentialing Center, 2008)
Here is a list of the functions and responsibilities of an informatics nurse specialist in telehealth services.

23. Telehealth Nursing Summary
Telehealth home care provides patients with healthcare, health information and health education across a distance with the use of specialized telecommunications technology.
In summary, we have learned that telehealth home care is a healthcare service that provides patients with healthcare, health information and health education across a distance with the use of specialized telecommunications technology.

24. Telehealth Nursing Summary
Specialized hardware devices used in telehealth: cardiac monitors, electronic stethoscopes, etc
How to use a hardware device (with a telephone adapter)
Specialized software used in telehealth: Omnivisor, Philips Web-based software, etc.
Review of Philips Web-based software including evaluating its level of usability
In this presentation we discussed the various types of hardware used in telehealth services such as cardiac monitors, blood glucose monitors, pulse oximetry devices and electronic stethoscopes.
We explained how to use a specific hardware device by detailing how to use a telephone adapter.
We also explored the various types of software out on the market for telehealth services such as Omnivisor and CapSure software.
A detailed description about Philips Web-based software was also covered including evaluating its level of usability.

25. Telehealth Nursing Summary
Review of Cardiocom’s clinical information system in telehealth
Advantages of telehealth include: increasing accessibility, reduce healthcare costs, etc.
Disadvantages of telehealth include: lack of human contact, possible lack of compliance, etc.
Legal issues in telehealth include: licensing, malpractice, reimbursement, etc.
We continued this presentation with a review of the Cardiocom clinical information system used in telehealth.
We also took a look at some of the advantages of using telehealth services such as increasing healthcare accessibility, reducing unnecessary hospital visits, reducing ER wait times and reducing healthcare costs while providing comprehensive follow-ups.
We also looked at some of the disadvantages to telehealth services such as the lack of face to face interactions amongst patients and healthcare providers, the possible lack of compliance from patients to their suggested interventions and the problems related with equipment use.
Legal issues were also discussed, including licensing issues for doctors and nurses, malpractice issues due to limited assessments, reimbursement problems and privacy issues, to name a few.

26. Telehealth Nursing Summary
Informatics competencies in telehealth nursing include: knowledge of computers and use of specialized equipment
Functions and responsibilities of an informatics nurse in telehealth include: health education, equipment management, research, etc.
We finished this presentation by revealing some informatics competencies required in telehealth nursing such as having adequate knowledge of computers and specialized equipment, as well as having excellent clinical, communication and critical thinking skills. We also reviewed some recommended certifications.
We explored the functions and responsibilities of an informatics nurse. Functions and responsibilities include: providing health education, monitoring patients using specialized equipment, promoting research and development, and quality control.

27. In conclusion
The remarkable advances in technology continues to change the way that we conduct healthcare. Telehealth homecare provides patients with healthcare services in a new and innovative way. Healthcare professionals should embrace technology as we continue to improve our healthcare delivery methods to provide high-quality care.

28. References Auerbach, D.I., Buerhaus, P., Staiger, D.O. (2009). The
future of the nursing workforce in the united states:
Data , trends and implications. Sudbury,MA: Jones
and Bartlett Publishers.
Cardiocom Multi-disease Management. (2005). Health
plans. Retrieved December 5, 2008, from
Liddy, C., Dusseault, J. J., Dahrouge, S., Hogg, W.,
Lemelin, J., & Humber, J. (2008). Telehomecare for
patients with multiple chronic illnesses. Canadian
Family Physician, 54(1),

29. References
Center for aging services technology. (2006). Economic benefits of
e-technology in managing congestive heart failure.
Retrived October 11, 2008, from
tech.org/documents/EconomicBenefits_of_eTech.pdf
Philips, Inc. (2008). Web-Based clinical software. Retrieved
October 11, 2008, from
main/products/telehealth/products/software.wpd
Telehealth leadership initiative. (2008). What is telehealth. Retrieved
October 11, 2008, from
org/telehealth101.html.

30. Mastrain, K. & Mcgonigle, D. (2009). Nursing informatics and the
References
Cassin, K (2008). Implementation of home telemonitoring for chronic
disease: A case study of resurrection home health services.
Telemedicine Information Exchange, Retrieved December
1, 2008, from
cle=resurrectionHomeServices_kcassin_tie08.xml
Mastrain, K. & Mcgonigle, D. (2009). Nursing informatics and the
foundation of knowledge. Sudbury, MA: Jones and Barlett
Publishers.
Center for Telehealth and E-Health Law (2006). Nurse licensure.
Retrieved December 05, 2008, from

31. References
Tan, J., Cheng, W., Rogers, W. (2002). From telemedicine to e-health:
Uncovering new frontiers of biomedical research, clinical
applications & public health services delivery. The Journal of
Computer Information Systems: Special Issue, 42(5), 7-18. 
Retrieved November 1, 2008, from ABI/INFORM Global 
database.
ICD. (n.d.) Retrieved November 1, 2008, from Wikipedia Web site:
Staggers, N. (2003). Human factors: Imperative concepts for
information systems in critical care. AACN Clinical Issues,
14(3),

32. References
American Nurses Credentialing Center. (2008). Informatics nurse
certification eligibility criteria. Retrieved December, 5,
2008, from
InformaticsNurseEligibility.aspx