1. Chapter 19 by Audrey Kinsella and Kathleen Albright
Telenursing and Remote Access Telehealth

2. Objectives
Explore the use of telehealth technology in nursing practice.
Identify socioeconomic factors likely to increase the use of telehealth interventions.
Describe clinical and nonclinical uses of telehealth.

3. Objectives
Specify and describe the most common telehealth tools used in nursing practice.
Explore telehealth pathways and protocols.
Identify legal, ethical and regulatory issues of home telehealth practice.

4. Objectives Describe the role of the telenurse.
Apply the Foundation of Knowledge model to home telehealth.

5. Key Terms Defined Call Centers Chronic Disease
Centers for Medicare and Medicare Services
Central Stations/Web Servers/Portals
Call Centers - Registered nurse-staffed facilities at which nurses typically act as case managers for callers or perform patient triage.
Chronic Disease - Range of long-term diseases, such as congestive heart failure, diabetes, and respiratory ailments.
Central Stations/Web Servers/Portals - Multifunctional telehealthcare platforms for receiving, retrieving, and/or displaying patients’ vital sign and other information transmitted from telecommunications-ready medical devices.
Centers for Medicare and Medicare Services (CMS) - The largest health insurer in the U.S., particularly for home healthcare services and for the elderly healthcare services received under Medicare.

6. Key Terms Defined Home Healthcare Home Telehealthcare
Medication Management Devices
Outcomes and Assessment Information Set
Home Healthcare - Alternate site care health services typically focusing on post-hospital discharge patient needs.
Home Telehealthcare - Home healthcare clinical and educational services provided via  telecommunications-ready tools.
Medication Management Devices - Range of telecommunications-ready medication devices to remind or otherwise alert patients to medication compliance needs.
Outcomes and Assessment Information Set (OASIS) – CMS (Centers for Medicare and Medicaid) required process of collecting and reporting performance data by home healthcare agencies.

7. Key Terms Defined Medication Management Devices
Outcomes and Assessment Information Set
Patient Health Outcomes
Patient Informed Consent
Medication Management Devices - Range of telecommunications-ready medication devices to remind or otherwise alert patients to medication compliance needs.
Outcomes and Assessment Information Set (OASIS) - CMS-required process of collecting and reporting performance data by home healthcare agencies.
Patient Health Outcomes - Can be measurable effects resulting from best practice treatment interventions that  improve/stabilize the  course of health over time.
Patient Informed Consent - Document that a patient signs to agree to treatment; document which a home healthcare patient signs to agree to receive telehealthcare services in addition to conventional home healthcare.

8. Key Terms Defined Patient Health Outcomes Patient Informed Consent
Personal Emergency Response Systems
Peripheral Biometric (Medical) Devices
Patient Health Outcomes - Can be measurable effects resulting from best practice treatment interventions that  improve/stabilize the  course of health over time.
Patient Informed Consent - Document that a patient signs to agree to treatment; document which a home healthcare patient signs to agree to receive telehealthcare services in addition to conventional home healthcare.
Personal Emergency Response Systems (PERS) - Signaling devices for patients to access emergency and other care needs.
Peripheral Biometric (Medical) Devices - Range of telecommunications-ready measurement devices, such as blood pressure cuffs and blood glucose meters, that typically use the household telephone jack to transmit patient data to a central server location.

9. Key Terms Defined Real-Time Telehealth
Sensor and Activity Monitoring System
Store-and-Forward Telehealth
Telehealthcare
Real-Time Telehealth - Live interactions between 2 or more clinicians, usually performed with videoconferencing equipment.
Sensor and Activity Monitoring System - Systems for tracking activities of daily living (ADLs) of seniors and other at-risk individuals in their place of residence.  Additional applications are sensors’ use in detecting anomalies or problems such as faucets and stoves left turned on.
Store-and-Forward Telehealth - Application of telehealthcare, in which images and other clinical data are captured and transmitted to specialist clinicians.
Telehealthcare - Health services delivered by telecommunications-ready tools, usually supervised by a nurse or other clinician.

10. Key Terms Defined Telehealth Telemedicine Telemonitoring Telenursing
Telehealth - Telecommunication technologies used to deliver health-related services or to connect patients and healthcare providers to maximize patients’ health status. A relatively new term in our medical/nursing vocabulary, referring to a wide range of health services that are delivered by telecommunications-ready tools such as the telephone, videophone, and computer.
Telemedicine - Health services delivered by telecommunications-ready tools supervised or directed by a physician.
Telemonitoring - Remote measurement of patients’ vital signs and other necessary data.
Telenursing - Health services delivered by telecommunications-ready tools supervised or directed by a nurse; refers to the use of telecommunications and information technology for providing nursing services in health care to enhance care whenever a physical distance exists between patient and nurse, or between any number of nurses (Skiba, 1998). As a clinical field, telenursing is part of telehealth, and has many points of contacts with other medical and non-medical applications, such as telediagnosis, teleconsultation, and telemonitoring. Telenurses do not, in effect, work outside of the broader clinical team effort, no matter where they are located. They are indeed an integral part of the healthcare delivery team.

11. Key Terms Defined Telephony Teleradiology Telepathology
Telephony - Telephone monitoring of patients at home by off-site telenurses.
Teleradiology - Use of telecommunications technology to electronically transmit and exchange radiographic patient images with the consultative text or radiologist reports from one location to another.
Telepathology - Use of telecommunications technology to facilitate the transmission and transfer of pathology data for the purposes of diagnosis, education and research; transmission and exchange of image-rich pathology data between remote locations.

12. Nursing Aspects of Telehealth
Understanding Telehealth
Telehealth Interventions
Understanding telehealth and the potential use of telehealth technology in nursing practice is necessary in today’s changing healthcare arena.
Telehealth interventions or contacts are performed off-site and often require less time spent on task because of the efficiencies offered by the technology applications.

13. Driving Forces For Telehealth
What will affect nursing in the next decades to come?
Estimations by the year 2040
The Nursing Shortage Crisis is Two-Fold
The driving factors that will influence nursing practice significantly in the next decades are: demographics; nursing/health care worker shortages; chronic conditions; the new, educated consumers; and excessive costs of health care services that are increasing in need and kind.
By the year 2040, 21% of the U.S. population—one in five Americans—will be 65 years old or older and there will be almost four times as many very old people, over 85, as there are today, as documented by the Institute of Aging (1996).
The crisis in the well known nursing shortage is two-fold: there is a greater need for nurses by more persons, particularly those living lifetimes with sometimes multiple co-morbidities; and there is a significant decrease in the number of young persons entering the nursing profession

14. Driving Forces For Telehealth
Health Resources and Services Administration 2002 Report
Pennsylvania Homecare Association and Penn State University 2004 Study
How many Americans are living with one or more chronic conditions?
A recent report from the Health Resources and Services Administration (HRSA) (2002) on the shortage of RNs notes that the shortage is expected to rise from 6% today to 12% by the year 2010 and more than triple in size to 20% as soon as 2015.
A recent study by the Pennsylvania Homecare Association and Penn State University (2004) determined that telehealth use may enhance nurses job satisfaction and help to retain nurses in their current positions.
More than 100 million Americans are living with one or more chronic disease or condition.
As noted in a more recent report, from the Centers for Disease Control and Prevention (2005), medical care costs of people with chronic diseases account for more than 75% of the U.S.’ $1.4 trillion medical care expenditures.
Securing appropriate, adequate, and affordable care services for these populations should be a national concern.

15. Driving Forces For Telehealth
Centers for Disease Control and Prevention 2005 Report
Securing Necessary Resources
A recent report from the Health Resources and Services Administration (HRSA) (2002) on the shortage of RNs notes that the shortage is expected to rise from 6% today to 12% by the year 2010 and more than triple in size to 20% as soon as 2015.
A recent study by the Pennsylvania Homecare Association and Penn State University (2004) determined that telehealth use may enhance nurses job satisfaction and help to retain nurses in their current positions.
More than 100 million Americans are living with one or more chronic disease or condition.
As noted in a more recent report, from the Centers for Disease Control and Prevention (2005), medical care costs of people with chronic diseases account for more than 75% of the U.S.’ $1.4 trillion medical care expenditures.
Securing appropriate, adequate, and affordable care services for these populations should be a national concern. 15

16. Driving Forces For Telehealth
Baby Boomers are Shifting Health Care Needs
Many Baby Boomers are More Comfortable With Technology
How much does the American health care system spend on conventional medical care?
Is this figure expected to grow?
What is the solution for this growing need?
The Use of Telehealth Technology
The wave of today’s aging Baby Boomers is driving some of the usual health service practices toward a very different course.
Many of these individuals are more educated than their parents and more comfortable with use of technology.
New plans for this new generation of consumers are very much leaning toward meeting their demands for when-needed, as-needed care—or, care services delivered on their own terms and timing.
The American health care system spends $1.4 trillion/year on conventional medical care.
Much more should be expected to be spent annually in the coming decades.
A solution is to develop a new clinical model for American healthcare that includes technology.
Telehealth technology should be included to fill the gap resulting from an overabundance of patients and a scarcity of health care providers.

17. Telehealthcare “Telehealth” and it’s Broad Meaning
Store-and-Forward Telehealth
Real-Time Telehealth
The Use of Computers in Telehealthcare
“Telehealth” is generally used as an umbrella term to describe all of the possible variations of healthcare services which use telecommunications.
In store-and-forward telehealth, digital images, video, audio and clinical data are captured and “stored” on the client computer or device; then, at a convenient time, the data are transmitted securely (“forwarded”) to a specialist/clinician at another location where they are studied by the relevant specialist/clinician.
In real-time telehealth, a telecommunications link between the involved parties allows a real-time or “live” interaction to take place.
Use of computers for real time two-way audio and video streaming between centers over ever improving and cheaper communication channels is becoming common.

18. Telehealthcare Examples telehealth applications: Telemental Health
Telerehabilitation
Telehomecare
Teleconsultations
Telehospice/ Telepalliative care
Remote Monitoring Devices
Telephone Monitoring and Telehealth
Examples of real-time clinical telehealth applications include:
Telemental health
Telerehabilitation
Telehomecare
Teleconsultations
Telehospice/ telepalliative care
In remote monitoring, devices are used to capture and transmit biometric data.
Telephone monitoring is the most basic type of telehealth.

19. Telenursing The most developing area of telenursing
Association for Retired Persons 1996 Study
Care at Home
Telenursing refers to the use of telecommunications and information technology for providing nursing services in health care to enhance care whenever a physical distance exists between patient and nurse, or between any number of nurses (Skiba, 1998).
The most developing area of telenursing today is in home telehealthcare.
According to regular surveys by the Association for Retired Persons (AARP)(AARP, 1996), more than 90% of seniors want to remain independent at home and age in place.
Care at home is clearly a key concern and preference.

20. Telenursing The Home Care Industry’s Newest Challenge
Home Care Telenursing Involvement
Home Care Telenurses Expectations
The home care industry’s newest challenge is to work with sicker patients, many of whom have been discharged from hospitals to home earlier than in the past.
Home care telenursing can also involve other activities such as providing customized patient education in dietary or exercise needs, nursing teleconsultations, review of results of medical tests and exams, and assistance to physicians in the implementation of medical treatment protocols.
Home care telenurses can well expect to play a vital and dynamic role in the changing delivery systems that are to be in place in the next decades.

21. Terms of Home Telehealth
Telecommunications-Ready Tools
Multifunctional Telehealthcare Platforms and Application Servers.
Key Components to Telehealth
There is a wide and growing range of telecommunications-ready tools readily available for nurses’ and patients’ use in the home.
Central stations, web servers and portals are various terms presently used for multifunctional telehealthcare platforms and application servers.
Central stations/web servers are key components to telehealth that can be as minimal as a single screen display or may be more comprehensive software applications that provide various functions including triaging  the data according to medical alerts which allow clinicians to quickly identify patients requiring immediate attention. 

22. Terms of Home Telehealth
Peripheral Biometric Devices
What is the most popular household communication tool for telehealthcare?
A Telephone Device Can be Augmented
Peripheral biometric devices can consist of fully integrated systems such as a vital signs monitor or they may be stand-alone telecommunications-ready devices such as blood pressure cuffs and blood glucose meters.
Telephones are already the most familiar household communications tool used in telehealthcare.
A telephone device can also be augmented for easier use by patients, as needed, with a lighted dial pad, an auto-dial system, and/or louder ringer.

23. Terms of Home Telehealth
Video Cameras and Videophones are Useful Tools
Personal Emergency Response Systems
Video cameras and videophones are easily available consumer items that can be used in telehealth for show-and-tell demonstrations by nurses for patients, or to capture wound healing progress, among other applications.
Personal Emergency Response Systems (PERS) are well-known signaling devices worn as a pendant or otherwise made easily accessible to patients to ensure their safety and to access emergency care when needed, must usually in case of a fall.

24. Terms of Home Telehealth
Sensor and Activity Monitoring Systems
Medication Management Devices
There are 32 million people that take 3 or more medications daily
Sensor and activity monitoring systems can track activities of daily living of seniors and other at-risk individuals in their place of residence.
Medication management devices are addressing a well-recognized major problem in healthcare today: medication management and compliance.
32 million people are taking 3 or more medications daily, with even more medications typically being taken by those 65 years of age or older.

25. Home Telehealth Practice and Protocols
Different Home Telehealth Programs
Informed Written Consent and Telehealth
Telehealth and Patients
Home telehealth programs will differ depending on the type of technology used and the focus of the telehealth programs.
Informed written consent must be obtained from the client or designee before beginning the use of telehealth consultations.
Telehealth pathways and protocols ensure more focused work with patients and allow for targeted interventions.

26. Home Telehealth Practice and Protocols
The Use of Telehealth Tools
Home Telehealth Protocols
Telehealth, Law and Ethics
A High Level of Security Must Be Achieved
The use of telehealth tools, together with clinical oversight/practice, allows for more efficient and effective clinical management by allowing the patients’ needs to drive the care.
As home telehealth protocols are utilized more extensively, the improved clinical and operational efficiencies may ultimately impact the home care agencies’ bottom lines.
Telehealth is affected by certain legal, ethical and regulatory issues of which nurses should be aware.
Pointed efforts must be continually undertaken by the nurses’ agencies to upgrade information systems to insure that a high level of security of data is provided at all times.

27. The Patient’s Role in Telehealth
What was a “mega trend” of Telehealth in 2007?
Telehealth and Home Goals for the Patients
The importance of ensuring patient satisfaction with home health service delivery has been predicted to be a “mega trend” in 2007 (Remington, 2007).
By patients’ achieving a good understanding of and performing self care by the end of their home health admission periods, an important goal of home telehealth has been attained.

28. The Foundation of Knowledge Model and Home Telehealth
There is Much to Learn about “usual” Home Telehealthcare
Knowledge Acquisition and Telehealth
Knowledge Processing and Telehealth
We have much to learn about “usual” home telehealthcare service delivery, particularly to the elderly and chronically ill, and for this important purpose, using the Foundation of Knowledge Model, is key to learning how to use telehealthcare tools with our typical patients (elderly, needing pointed care) and operate effectively as telenurses.
Knowledge acquisition involves the nurse’s receiving the information from the telehealth devices via a variety communication modes.
Knowledge processing is understanding a set of information and ways it can be useful to a specific task.

29. The Foundation of Knowledge Model and Home Telehealth
The Next Step After Processing Information
Nurses Apply Data as it Pertains to the Patient
The Nurse Determines How the Knowledge Will be Used
Telehealth is Rapidly Developing
Telehealth Will Provide New Advances for the Medical Community
After processing all of the current information, the nurse is able to target the appropriate next steps involving knowledge generation and knowledge disseminaton.
The nurse considers all of the data as it applies to this patient, and decides which is the best course of action to be taken and acts on the data.
The nurse determines how the knowledge will be used and disseminated.
Telehealth is a rapidly developing mode of health service delivery in which nurses can expect to play a key role.
The practice of telehealth will provide opportunities for telenurses to play a key role in care management across the healthcare continuum.

30. Thought Provoking Questions
1. Telehealth technology has extended the arms of traditional health care delivery into homes, clinics, and other environments outside the bricks and mortar of hospitals. Will the increased use of these telehealth technology tools be viewed as “de-humanizing” patient care or will they be viewed as a means to promote more contact with healthcare providers and new ways for people to “stay connected” as in on-line disease support groups), thereby creating better long term disease management and patient satisfaction?

31. Thought Provoking Questions
2. As telehealth technology advances towards seamless data access regardless of distance or health system, how can we protect patient privacy rights and the confidentiality of personal medical data?