MHI 525: Chapter 8

Chapter 8 Notes

telehealth

encompasses a broad definition of telecommunications and information technology–enabled healthcare services and technologies

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

provides access to care and the ability to export clinical expertise to care for patients regardless of their geographic location

telemedicine

the use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or healthcare provider and for improving patient care, treatment, and services

telenursing

the use of telehealth technology to deliver nursing care and conduct nursing practice

What do telehealth services provide access to?

health assessment, diagnosis, intervention, consultation, supervision, and information across distance

Telehealth services can be classified into _____ or _____

clinical or nonclinical

List examples of clinical telehealth services

diagnosis

patient communication and education

disease management

triage and advice

remote monitoring

caregiver support

provider-to-provider teleconsultations

List examples of nonclinical telehealth services

distance education for healthcare consumers or clinicians

video conferencing or conference call meetings

research

healthcare administration

healthcare management

telehealth proponents

seek to improve the quality, access, equity, and affordability of healthcare in the United States and globally by using telehealth

List examples of telehealth technologies

telephones

facsimile machines

e-mail systems

cellphones

mobile apps

video conferencing

web-based

remote patient-monitoring devices

transmission of still images

eHealth (ii.e. patient portals)

remote vital signs monitoring

continuing medical education

direct consumer applications such as online physician consultations via the internet

List examples of settings telehealth is used in

rural hospitals

home health agencies

with patients at home

prisons

dialysis centers

nursing homes

space

List advantages of telehealth to patients

decreased travel time or distance and removal of travel barriers

more immediate access to care

early detection of disease processes or health issues

ownership of healthcare and feelings of empowerment

long-term health and independence

caregiver reassurance

patient satisfaction with healthcare

List challenges the DOD faces in providing telemedicine in field or operation settings

limited resources

austerity of the environment

Described the first documented report of healthcare delivery at a distance

a case of croup was diagnosed over the telephone in 1897

When did modern telehealth programs being in the US?

1964 with a closed-circuit television link between the Nebraska Psychiatric Institute and the Norfolk State Hospital for teleconsultations

What did the landmark study by Kaiser Permanente conclude?

that “technology in healthcare can be an asset for patients and providers and has the potential to save costs; therefore, this technology must be a part of continuous planning for quality improvement”

List leading professional, industry, and government organizations that provided the leadership needed to initiate effective telehealth programs

American Nurses Association (ANA)

United States federal government agencies

American Telemedicine Association (ATA)

International Council of Nurses (ICN)

American Nurses Association (ANA)

brought together the Interdisciplinary Telehealth Standards Working Group to address the expansion and to create unified definitions and policies and a standard of care

Telehealth Standards Working Group

brought together by the ANA

composed of 41 representatives from different healthcare organizations and professional associations

publishes the Core Principles on Telehealth where they create a baseline standard of quality telehealth care

List examples of US federal government agencies that have continued to lead telehealth research programs

NASA

VA

U.S. DOD

VA

an early adopter of telehealth

operates the nation’s largest telehealth program

Office for the Advancement of Telehealth (OAT)

a division of the Office of Rural Health Policy within Health Resources and Services Administration (HRSA) at the U.S. Department of Health & Human Services (HHS

established by the US government due to widespread adoption and positive research findings regarding telehealth

promotes the use of telehealth technologies for healthcare delivery, education, and health information services

List ways the OAT increase the use and quality of telehealth delivery

fostering partnerships within HRSA and with other federal agencies, states, and private sector groups to create telehealth projects

administering telehealth grant programs

providing technical assistance

evaluating the use of telehealth technologies and programs

developing telehealth policy initiatives to improve access to quality health services

promoting knowledge exchange about “best telehealth practices

American Telemedicine Association (ATA)

a mission-driven, nonprofit organization that seeks to incorporate telehealth seamlessly into healthcare so that it is not necessarily a separate program but integrated into healthcare delivery as a whole

published a number of telemedicine practice guidelines that form a foundation for telehealth practice that are based on empirical and clinical practice evidence

International Council of Nurses (ICN)

represents more than 130 national nursing organizations, including the ANA, Canadian Nurses Association, and associations of more than 134 countries

initiated the Telenursing Network in 2008

share competencies and other jointly developed telenursing resources as telenursing advances

stand-alone systems

telehealth encounters occurred and data were stored in a telehealth system database

describes early teleheatlh technologies

List the 2 overarching ways telehealth services can be delivered

synchronous (real-time) technology

asynchronous (store-and-forward) technology

synchronous (real-time) telehealth

uses live, two-way interactive telecommunications technology and/or patient monitoring technologies to connect a healthcare provider to a patient for direct care, to other healthcare providers for consultation and collaboration, or to a combination of the two

What does the most commonly used synchronous telehealth employ?

video conferencing or telephone-based interaction

video conferencing

integrates audio, video, computing, and communications technologies to allow people in different locations to collaborate electronically face to face, in real time, and to share information, including data, documents, sound, and picture

enables patient-provider consultations, provider-specialist discussions, and health education

What does a real-time live environment include?

video conferencing units with a codec (compressor-decompressor) capable of encoding and decoding the video conferencing data stream

peripheral cameras such as high-definition cameras with remote control pan, tilt, and zoom

video display devices (i.e. computer monitors), television sets such as ultra–high density plasma or LCD displays, and LCD projectors used to show the images received from the video conferencing codec

audio components (microphones and speakers), a net-work connection, and the user interface

patient monitoring technologies & telehomecare

use devices to remotely collect and send biometric data to a home health agency or a remote diagnostic testing facility for interpretation by a healthcare provider

can be used to supplement the use of visiting nurses

allows patients to become more involved in and oversee the monitoring process

List examples of patient monitoring technologies & telehomecare

specific vital sign device (i.e. blood glucose monitor, digital scale, thermometer, heart electrocardiogram (ECG), blood pressure monitor, pulse oximeter, or peak flow meters, or a variety of monitoring devices for homebound patients)

List the 2 major components patient monitoring for home telehealth consist of

hardware

software

hardware

includes a base station where the patient interacts by entering data and answering questions, and it applies var- ious medical devices that are used to gather patient data

software

enables healthcare providers and technicians to configure the hardware, receive data, and monitor the patient

mHealth/mobile health

umbrella terms that incorporate mobile or wireless telecommunications for transmitting telehealth-related data and services

incorporates both the telecommunication and the hardware in the medical device

List the components of a telehealth system

personal health devices that monitor basic vital signs and transmit data via a wired or wireless connection via devices or sensors

a critical component of the connected health system as it enables individual monitoring devices to log data in an EHR for personal and clinician review; collects and transmits data from an individual’s personal health devices to a server using wired or wireless connections; can be a cell phone, PC, a dedicated device, PHR

health service center a physical location where a patient’s digital information is collected, stored, analyzed, and distributed; can be the doctor’s office, the home of a family member, or another type of healthcare-related facility

store-and-forward technology

transmits telehealth-related information, video, images, and audio files when healthcare providers and patients are not available at the same time

can be used in dermatology, radiology, pathology, den- tistry, cardiology, wound care, home monitoring, pediatrics, and ophthalmology, as well as other areas

List things store-and-forward technical environments can include

a personal desktop, laptop computer, tablet, or smart- phone for the sender

a personal desktop, laptop computer, tablet, or smart- phone for the receiver

telecommunication technologies such as local area net- work (LAN) and wireless communications

digital peripheral medical devices such as digital cam- eras, x-ray equipment, glucometers, vital sign monitors, and wearable sensors embedded in T-shirts or wristwatches

software such as a web-based application, encrypted e-mail, specially designed store-and-forward software, an EHR, a PHR, and an electronic data repository

List examples of technical standards that were developed for associated markets that have benefited telehealth

American National Standards Institute (ANSI) H.32x

Health Level Seven (HL7)

American National Standards Institute (ANSI) H.32x

enabled wide-scale video conferencing interoperability, which led to further growth in non-healthcare businesses

telehealth benefited from the video conferencing standards and also benefiting from a reduction in the cost of equipment, as well as the improved ability to conduct interactions between parties independent of the particular hardware used

Health Level Seven (HL7)

provides global interoperability standards for health information technology (health IT), and Digital Imaging and Communications in Medicine (DICOM) standards for imaging has also been of great benefit for telehealth

Continua Health Alliance (CHA)

formed by a group of healthcare technology companies to establish interoperable personal telehealth solutions and technical design guidelines

its goal is to agree on a set of common technical guidelines to build interoperable sensors, home net- works, telehealth platforms, and health and wellness services

developed a technical certification program based on these guidelines

Personal Connected Health Alliance (PCHA)

represents the consumer voice in connected health

brings together a unique combination of expertise and resources focused on plug-and-play interoperable personal health devices and services that provide new opportunities for consumers to engage in health self-improvement and connect with their social networks and healthcare providers in the pursuit of better health

ZigBee/IEEE 802.15

targeted at applications requiring a low data rate, long battery life, and secure networking

a useful wireless connectivity standard for home or facility-based telehealth

allows telehealth devices and sensors to operate longer and with smaller power sources, enabling miniature sensors to transmit health data

a very low cost and easily installed network capability, providing usability and requiring minimal technical support

What is key to telehealth success?

healthcare providers’ access to patients’ health records at the time of a telehealth encounter—just as it is with in-person care

The National Initiative for Telehealth Framework of Guidelines (NIFTE Guidelines)

a critical milestone in development of telehealth not just for those who authored the guidelines in Canada, but globally

a highly important and superbly designed framework was developed in Canada by a multistakeholder interdisciplinary group

designed to assist individuals and organizations to develop telehealth policies, standards, and procedures

List the 5 overarching content areas related to telehealth examined in the NIFTE principles and suggested guidelines

clinical standards and outcomes

human resources

organizational readiness

organizational leadership

technology and equipment

confidentiality, privacy & informed patients

are paramount when using technology for the transmission of health data and live video presentation of the patient to geographic environments at a distance from the patient’s location

requirements for ensuring confidentiality, privacy, and informing patients receiving care via telehealth are the same as for in-person care

ensuring that patients are being adequately informed and educated regarding telehealth consultation, assessment, and evaluation via video conferencing technology is also of paramount

scope of clinical practice

the use of technology does not alter the practitioner’s inherent standards of practice, ethics, scope of practice, or legalities of practice

credentialing and clinical privileges must be completed at the site where the patient is located when telehealth is used

List factors that determine whether a patient is referred to a healthcare professional for consultation via telemedicine or telehealth

does the service requested provide telemedicine or telehealth access as an option?

what is the level of the practitioner’s expertise and comfort with telemedicine or telehealth?

is the patient’s diagnosis appropriate for telemedicine or telehealth consultation?

going forward, who will manage the patient’s plan of care and how will this be managed?

What is essential for providing accurate and optimal continuity of care for patients?

appropriate documentation for telemedicine consults at both the sending and the receiving sites

List the 4 components that must be considered in planning for implementation of telehealth technology

bandwidth

education

leadership

technology

B.E.L.T. Framework

a metaphoric representation of these four interrelated components, and it may be used to guide planning at macro, meso, or micro levels of implementation

bandwidth

includes elements of telecommunication technology, including information transmission and connectivity to move and store digital data

education

encompasses the preparation of both the exist- ing workforce and future healthcare providers in developing competencies in the adoption and use of telehealth technologies

leadership

reflects a broad range of management, change theory, and policy aspects that affect operationalizing telehealth technologies

technology & interoperability

spans a large number of considerations such as the choices and types of telehealth software, hardware, and devices available for care

List significant barriers and gaps that exist in the successful implementation of robust, integrated healthcare technology delivery systems

infrastructure and telecommunication architecture in some geographic areas may limit use of telehealth applications and have direct implications for access to and delivery of healthcare

scant research has been completed about the broader use of telehealth technology to inform curriculum development and education of healthcare providers

factors such as resistance to technology, lack of interoperability, information security, stakeholder support, reimbursement, and financial commitment

telehealth platforms have limited capacity to address the range of health conditions experienced across the population lifespan, resulting in a narrow focus on overall individual health, fragmentation of care, and duplication of effort for data retrieval and documentation

most current telehealth technologies focus on direct delivery of clinical services to individuals and do not readily support the broader goals of primary healthcare, such as enhancing health promotion, prevention opportunities, or generating necessary epidemiologic data needed to evaluate and inform healthcare delivery

List steps that exist for success of telehealth programs and services

planning (includes a needs assessment and analysis to define patient populations and healthcare problems in which telehealth services can have a positive impact)

a work environment with staff prepared to implement telehealth using specific standards and guidelines

technology preparedness

user-friendly technology that enables quality clinical decision making as well as responsive and accessible technical support

learning how to implement, manage, and support a telehealth project or program

digital literacy

includes knowledge of basic computer skills and communication technologies, basic skills to navigate the internet for up-to-date health information, and the ability to access web-based telehealth software applications

What is one of the major barriers to a successful telehealth program?

scheduling dedicated time for healthcare providers’ telehealth training

List the 3 phases of successful telehealth program implementation

preimplementation

implementation

postimplementation

preimplementation

a team effort is critical to its success

what types of telehealth programs provide access to remote healthcare specialists for their patients must first be decided

forming administrative or executive team is advisable to oversee the project goals, budget, progress, and growth

a second level of management for the telehealth program (operational interdisciplinary team) is also needed

operational interdisciplinary team

the change agents that assist in developing policies, procedures, evaluation criteria, and permission forms before beginning to use telehealth

implementation

involves equipment and software testing with mock telehealth patients and remote specialists, and then piloting the project by identifying a patient needing a teleconsult

equipment testing with mock patients should encompass all staff testing all of the telehealth equipment available

equipment testing should also be conducted periodically after the initial implementation

daily use of telehealth equipment for routine patient exams is recommended so that providers become knowledgeable and comfortable using the various telehealth examination tools

goal is for a clinician to present a patient, cap- ture and send patient data, retrieve patient information from stored telehealth software applications, and respond to cases and add patient encounters if needed

postimplementation

evaluation criteria address adequacy of training; implementation, equipment, technology, or training issues; and program outcomes

quality assurance and process improvement should be part of the evaluation process so that iterative progress toward implementation-phase telehealth program success can be achieved

List the biggest hurdles to teleheatlh adoption in the US

provider licensure

credentialing and privileging processes in facilities

List examples of exceptions to state licensure requirements

physician-to-physician consultations

educational and medical training programs

border state recognition programs

government employees practicing in military or federally funded facilities such as VA hospitals and clinics

natural disaster

emergency situations

Telemedicine and E-Health Portability Act (STEP Act)

facilitates the provision of telemedicine and telehealth services

removes the individual state licensing requirements to allow a licensed medical professional in one state to treat a patient in another

rules apply only to military and federal personnel, although it is a beginning in terms of advancing telehealth services into the mainstream

multistate Nurse Licensure Compact

a mutual recognition model that only applies to RN licensure

allows RNs who hold a license in one of the compact states to practice in any of the 25 compact states, greatly facilitating telehealth interactions across state boundaries

credentialing

the process of establishing the qualifications of licensed professionals and assessing their background and legitimacy

What is an obstacle to telehealth services?

the need for licensing in multiple states, the need for credentialing in multiple separate healthcare facilities

Centers for Medicare & Medicaid Services (CMS)

modified the existing credentialing and privileging regulations

allows hospitals or Critical Access Hospitals (CAHs) to use information from a distant-site hospital or other accredited telemedicine entity when making credentialing or privileging decisions for the distant-site physicians and practitioners

Virtuewell

offers online 24/7 direct care in 11 states

an online survey asks consumers to identify their chief concern, responses are sent to a nurse practitioner who reviews the information and responds within 30 minutes via text or e-mail with a diagnosis, potential remedies, and tips for preventing the condition in the future, and if a prescription is needed, the nurse practitioner can send it to a local pharmacy

RelayHealth

provides an online solution to connect consumers with their healthcare providers

their Medical Home support package provides a secure patient portal to facilitate easy online clinical communications, enabling patients to benefit from care coordination, including patient visits and consultations, prescription renewal, appointment scheduling, PHR management, delivery of lab results, referral requests, and access to medically reviewed information

VA Coordinated Care Home Telehealth (CCHT)

built upon Wagner’s Chronic Care Model

characterized by “the use of health informatics, disease management and home telehealth technologies ... with the specific intent of providing the right care in the right place at the right time”

sensor technology

has the potential to manage disease and promote a safe and healthy environment for senior

sensor

a device that detects and responds to some type of input from the physical environment

specific input could be light, heat, motion, moisture, pressure, or any one of a great number of other environmental phenomena

output is generally a signal that is converted to human-readable display at the sensor location or transmitted electronically over a network for reading or further processing

RFIDs

use a microchip to uniquely identify and track objects, record and update information and makes it all accessible through a global network

can be active or passive and are capable of being ingested, implanted, or attached externally depending on their use

benefits include unlimited sight connection and rapid information processing, predicting better utility than other technologies such as bar coding

eHealth literacy

defined as “a set of skills and knowledge that are essential for productive interactions with technology-based health tools

List the 6 skills identified by experts for eHealth literacy

traditional literacy (ability to read text, understand written passages, and speak and write a language coherently)

computer literacy (ability to operate a computer)

information literacy (ability to obtain and apply relevant information)

media literacy (means of critically thinking about media content, and defined as a process to develop metacognitive reflective strategies by means of study)

health literacy (skills required to interact with the health system and engage in self-care)

scientific literacy (understanding of the nature, aims, methods, application, limitations, and politics of creating knowledge in a systematic manner)

List conditions that exist for expanding telehealth to other sectors for sustainable telehealth

rising healthcare costs

increasing prevalence of chronic diseases

an aging population

demands for improved access to healthcare

global shortages of health professionals

List drivers that influence policy decisions to adopt and implement telehealth technology in healthcare delivery

global socioeconomic contexts

political motivations

capacity of technology to address healthcare needs

fundamental understandings of telehealth capabilities

What effects empirical data available for evaluating telehealth technology?

inconsistencies in telehealth research methods

data reporting

List factors that still remain critical challenges for the adoption and broader use of telehealth technologies

issues of authentication

data security

practical aspects of telecommunication infrastructure