Explain seamless care what is the relationship to health informatics

Chapter 8 Telehealth and Applications for Delivering Care at a Distance

Loretta Schlachta-Fairchild

Mitra Rocca

Vicky Elfrink Cordi

Andrea Haught

Diane Castelli

Kathleen MacMahon

Dianna Vice-Pasch

Daniel A. Nagel

Antonia Arnaert

Growth in telehealth could result in a future where access to healthcare is not limited by geographic region, time, or availability of skilled healthcare professionals.

Objectives

At the completion of this chapter the reader will be prepared to:

1.Discuss the historical milestones and leading organizations in the development of telehealth

2.Explain the two overarching types of telehealth technology interactions and provide examples of telehealth technologies for each type

3.Describe the clinical practice considerations for telehealth-delivered care for health professionals

4.Analyze operational and organizational success factors and barriers for telehealth within healthcare organizations

5.Discuss practice and policy considerations for health professionals, including competency, licensure and interstate practice, malpractice, and reimbursement for telehealth

6.Describe the use of telehealth to enable self-care in consumer informatics

7.Discuss future trends in telehealth

Key Terms

Digital literacy, 141

Telehealth, 125

Telehealth competency, 131

Telemedicine, 126

Telenursing, 126

uHealth, 141

Abstract

Rapid advances in technology development and telehealth adoption are opening new opportunities for healthcare providers to leverage these technologies in achieving improved patient outcomes. Telehealth provides access to care and the ability to export clinical expertise to those patients who require care, regardless of the patients' geographic location. This chapter presents telehealth technologies and programs as well as telehealth practice considerations such as licensure and malpractice challenges. As telehealth advances, healthcare providers will require competencies and knowledge to incorporate safe and effective clinical practice using telehealth technologies into their daily workflow.

Introduction

Rapid advances in technology development and telehealth adoption are opening new opportunities for healthcare providers to leverage these technologies in achieving improved patient outcomes. Before we discuss these technologies and outcomes, it is important to explore the definitions of telehealth-related terminology.

Telehealth encompasses a broad definition of telecommunications and information technology–enabled healthcare services and technologies. Often used interchangeably with the terms telemedicine, ehealth, or mhealth (mobile health), 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.”1 Telehealth is being used in this text to encompass all of these other terms. Telemedicine is 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 the purpose of improving patient care, treatment, and services.2 Telenursing is the use of telehealth technology to deliver nursing care and conduct nursing practice.3,4

Telehealth enables the delivery of clinical care to those who are in need regardless of the geographic location of the patient or the healthcare provider. Well-established telehealth programs and evidence-based research supports the effective use of telehealth across most disciplines and specialties within healthcare (i.e., teleradiology, teledermatology, telepathology, telenursing, etc.).5–10 Telehealth services provide access to health assessment, diagnosis, intervention, consultation, supervision, and information across distance.11 As a result telehealth is now being integrated into routine care delivery of patients around the globe. Figure 8-1 depicts how telehealth can change healthcare delivery. Telehealth services can be classified as clinical or nonclinical. Clinical telehealth services include but are not limited to diagnosis, patient communication and education, disease management, triage and advice, remote monitoring, caregiver support, and provider-to-provider teleconsultations. Nonclinical telehealth services include but are not limited to distance education for healthcare consumers or clinicians, video conferencing or conference call meetings, research, healthcare administration, and healthcare management.

Providing care to underserved populations can be a challenge, especially in rural areas or where there is a shortage of healthcare professionals. Patients may face physical, financial, geographic, and other barriers to accessing care. However, telehealth can overcome many of these barriers. Telehealth proponents seek to improve quality, access, equity, and affordability of healthcare in the United States and throughout the

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FIG 8-1 How telehealth changes healthcare delivery.

(Copyright 2010 iTelehealth Inc. All Rights Reserved.)

world by using telehealth.11 Healthcare professionals who use telehealth can export their clinical expertise to patients regardless of geographic location.

Telehealth technologies include configurations as simple as a telephone conversation between a healthcare provider and a patient or as sophisticated as a doctor performing robotic surgery on a patient across continents. Telehealth technologies include but are not limited to telephones; facsimile machines; email systems; cellphones; video conferencing; web-based, remote patient monitoring devices; transmission of still images; and Internet applications (ehealth) including patient portals, remote vital signs monitoring, continuing medical education, and direct consumer applications such as online physician consultations via the Internet.

Telehealth is used in a variety of settings, among which are rural hospitals, home health agencies and patients at home, prisons, dialysis centers, and nursing homes; telehealth is also used to provide care to astronauts in space.11,12 The benefits of remote monitoring, diagnosis, and intervention have been proven in numerous scientific studies and include increased access to care, decreased costs of healthcare and increased healthcare provider productivity, and a high level of patient satisfaction.3,13 Furthermore, the advantages of telehealth to patients are numerous and include the following:

•Decreased travel time or distance and removal of travel barriers

•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

Examples of Successful Telehealth Programs

The following three examples of telehealth programs demonstrate the wide range of such programs currently providing services to patients at a distance.

•Rochester General Health System, Rochester, New York, developed a clinic-based telehealth program in 2008. Its healthcare providers use a video conferencing system for live patient consults with remote physician specialists. They have the capability to send video images and 12-lead digital electrocardiograms. The Director of Telehealth coordinates and schedules 34 physicians and 5 midlevel healthcare providers who see patients remotely. Rochester General's telehealth program developed a rigorous 1-day training session for all end-users.

•Sea Coast Mission Telehealth Program, Bar Harbor, Maine, provides seagoing health services to islanders living on four islands with no healthcare providers available.14 Daily use of live video conferencing from a 72-foot boat called the Sunbeam V occurs with the support of a boat crew that includes a nurse. The telehealth program coordinator, an early adopter of telehealth, described herself as “technically challenged” during the site's implementation. Since then she has developed excellent clinical and technical skills to work proficiently in an austere environment. In this setting attention to a patient's health condition can at times be urgent, requiring immediate diagnosis and treatment. The goal is to diagnose sick patients in a timely manner so that they can be transferred off the island for access to a higher level of medical care on the mainland. Maine Sea Coast Mission's most recent project has been to implement health centers with video conferencing systems on four islands (Frenchboro, Matinicus, Swan's Island, and Isle au Haut), thereby providing access to remote health and education services year-round (Sharon Daley, RN, personal communication, March 2010).

•University of Miami, Miller School of Medicine, Miami, Florida, provides both live video conferencing and store-and-forward capability as part of its telehealth program. Its program reached out in 2010 to provide medical support after the earthquake in Haiti. One unique program is the Teledermatology Program for private cruise ships. The program uses expert dermatologists to evaluate an array of skin problems such as lesions, burns, infections, and rashes seen by emergency physicians on board cruise ships. The Clinical Telehealth Coordinator provides online training to cruise ship staff for using a digital camera and image capturing and transmission via a dermatology software application. Images are then reviewed by the dermatologist and patient reports with diagnosis and recommendations are sent back electronically to the emergency physician within a specific time frame.15

Telehealth Historic Milestones

In contrast to the common perception that telehealth is new and futuristic, it actually has a long history. The first documented report of healthcare delivery at a distance dates back to 1897 in The Lancet, when a case of croup was diagnosed over the telephone. In the United States modern telehealth programs began in 1964, with a closed-circuit television link between the Nebraska Psychiatric Institute and the Norfolk State Hospital for teleconsultations. Shortly thereafter, in 1965, a cardiac surgeon in the U.S. transmitted a live video feed of a surgical case to spectators in Geneva, Switzerland, via satellite. The surgeon discussed his case and answered live questions from the spectators in Geneva.16

The National Aeronautics and Space Administration (NASA) led telehealth initiatives in the 1960s with the transmission of physiologic signals from astronauts in space to command centers on Earth. NASA also funded several telehealth research programs in the late 1960s and early 1970s that contributed to the profession as a whole.17 A landmark study completed by Kaiser Permanente in 1997 concluded 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.”18(p45) The researchers were emphatic about the benefits of telehealth, inspiring many of today's telehealth programs.

From July 2003 to December 2007 the U.S. Department of Veterans Affairs (VA) conducted a home telecare program analysis to coordinate care of chronically ill veterans and reduce long-term care admissions. The program evaluation was highly successful, realizing a reduction in long-term care bed days and inpatient hospital admissions among participants. Further, the veteran participants reported a high level of satisfaction. Costs to provide the program were and are substantially less than other VA programs or nursing home care. The program is now known as Care Coordination/Home Telehealth (CCHT) and is a routinely offered VA service to support aging veterans with chronic conditions.19

In the United Kingdom the Whole System Demonstrator (WSD) program was launched by the National Health Service in 2008 in order to determine the effectiveness of telehealth. As of its start date, the study was the largest randomized controlled trial of telehealth in the world, involving more than 6000 participants. The study confirmed that telehealth promotes well-being and should be a part of any complete healthcare system.20

Leading Telehealth Organizations

Starting in the 1990s, a number of professional, industry, and government organizations have provided the leadership needed to initiate effective telehealth programs. These leaders include the American Nurses Association (ANA), United States federal government agencies, the American Telemedicine Association (ATA), and the International Council of Nurses (ICN).

American Nurses Association (ANA)

With the advent of technology and rapidly emerging telehealth practice in the twentieth century, healthcare professionals sought guidance on incorporating telehealth into their care offerings. Multidisciplinary standards were needed to create a cohesive unity for telehealth across professions. To address the expansion and to create unified definitions and policies and a standard of care, the ANA brought together the Interdisciplinary Telehealth Standards Working Group. This group was composed of 41 representatives from different healthcare organizations and professional associations. The report of the interdisciplinary team, Core Principles on Telehealth, represents a “sense of the profession” as a whole.21 The purpose of the core principles is to create a baseline standard of care in order to provide quality care as well as protect patients from harm.

United States Federal Government Agencies

NASA, the VA, the U.S. Department of Defense (DOD), and other government agencies have continued to lead the U.S. in telehealth research and programs. As an early adopter of telehealth, the VA operates the nation's largest telehealth program. The widespread adoption and positive research findings led the U.S. government to establish the 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). OAT promotes the use of telehealth technologies for healthcare delivery, education, and health information services and increases the use and quality of telehealth delivery through the following activities:

•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”1

American Telemedicine Association (ATA)

The American Telemedicine Association (ATA) is a nonprofit organization founded in 1993 and headquartered in Washington, D.C. The mission of ATA is to “promote professional, ethical and equitable improvement in healthcare delivery through telecommunications and information technology” through education, research, and communication.22 ATA is 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.

International Council of Nurses (ICN)

Representing more than 200 national nursing organizations, including the ANA, Canadian Nurses Association, and associations of more than 198 other countries, the ICN initiated the Telenursing Network in 2008. As telenursing advances, this virtual collaboration is serving to share competencies and other jointly developed telenursing resources.

Telehealth Technologies

Telehealth technologies enable the exchange of all types of data (i.e., voice, video, pictures of wounds, pathology or radiology images, device readings, etc.) between patients and healthcare providers or between healthcare providers on behalf of patients. Early telehealth technologies were “stand-alone” systems in which a telehealth encounter occurred and data were stored in a telehealth system database. With the increasing adoption of electronic health records (EHRs), telehealth technologies are being increasingly integrated with the EHR. Telehealth services can be delivered using two overarching types of technologies: synchronous (or real-time) technologies or asynchronous (or store-and-forward) technology.

Synchronous or “Real-Time” Technologies

Synchronous, real-time telehealth uses live, 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.23 The most commonly used synchronous telehealth employs video conferencing or telephone-based interaction.

Video Conferencing

Video conferencing integrates audio, video, computing, and communications technologies to allow people in different locations to electronically collaborate face to face, in real time, and share all types of information, including data, documents, sound, and picture. Use of interactive video conferencing in telehealth allows for patient–healthcare provider consultations, healthcare provider–specialist discussions, and health education. The technology requires live presence of the healthcare provider and patient or healthcare provider and medical specialist in an interactive environment.

A real-time live environment can include the following:

•Video conferencing units with a codec (compressor–decompressor) capable of encoding and decoding the video conferencing stream.

•Peripheral cameras such as high-definition cameras that have remote control pan, tilt, and zoom (PTZ) features.

•Video display devices such as computer monitors, television sets such as HD Plasma or LCD displays, and LCD projectors. These display devices are used to show the images received from the video conferencing codec.

•Audio components (microphones and speakers), a network connection, and the user interface. Prior to the availability of high-bandwidth Internet connections, signals were carried over point-to-point connections established via Integrated Services Digital Network (ISDN) lines and plain old telephone service (POTS). The Internet has now simplified some of the connectivity issues and the high-bandwidth requirement of video conferencing.

Patient Monitoring Technologies

Patient monitoring technologies, including home telehealth (also known as telehomecare), use devices to remotely collect and send biometric data to a home health agency or a remote diagnostic testing facility (RDTF) for interpretation by a healthcare provider. Such applications might include a specific vital sign device, such as 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. Such services can be used to supplement the use of visiting nurses.3 Use of monitoring devices will also allow patients to become more involved in and in many cases to oversee the monitoring process.24

Patient monitoring technologies for home telehealth consist of two major components: hardware and software. The hardware includes a base station where the patient interacts by entering data and answering questions and applies various medical devices that are used to gather patient data. The software enables healthcare providers and technicians to configure the hardware, receive data, and monitor the patient.

The telecommunications used can be wired, such as POTS or direct service line (DSL), or wireless, such as cellular (sometimes seen as code division multiple access, or CDMA), broadband, satellite, Bluetooth, infrared (IrDA), WiFi (or IEEE Standard 802.11), mobile broadband wireless access (MBWA or IEEE Standard 802.20), or Worldwide Interoperability for Microwave Access (WiMAX or IEEE Standard 802.16). mhealth and mobile health are umbrella terms that incorporate mobile or wireless telecommunications for transmitting telehealth-related data and services. Both the

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FIG 8-2 Personal health ecosystem. BB, Broadband; PERS, Personal Emergency Response System; POTS, plain old telephone service.

(Copyright 2010 Continua Health Alliance. All Rights Reserved.)

telecommunication and the hardware can be incorporated in the medical device.

Figure 8-2 provides a diagram of the components of a telehealth system.

1.Personal health devices monitor basic vital signs such as blood pressure, weight, pulse, oxygen level, and blood sugar values and transmit data via a wired or wireless connection via devices or sensors.

2.The aggregation and computation manager is a critical component of the connected health system, enabling individual monitoring devices to log data in an EHR for personal and clinician review. The aggregation manager collects and transmits data from an individual's personal health devices to a server using wired or wireless connections. The aggregation manager itself can be a cellphone, a personal computer, a dedicated device, or a personal health record (PHR).

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

Asynchronous or “Store-and-Forward” Technology

“Store-and-forward” technology allows for electronic transmission of telehealth-related information, video, images, and audio files. It can be used when healthcare providers and patients are not available at the same time. The sending healthcare provider or patient prepares an electronic consult package, which includes the patient's history, related diagnoses, and digital images such as x-rays, video, and photos. This package is either emailed or placed on a web server for the receiving healthcare provider to access when his or her schedule allows. The receiving healthcare provider then reviews the package, follows up with clarification questions, and provides a diagnosis, recommendations, and a treatment plan. The receiving healthcare provider's response is transmitted electronically back to the sending healthcare provider or patient. Store and forward technologies can be used in dermatology, radiology, pathology, dentistry, cardiology, wound care, home monitoring, pediatrics, and ophthalmology as well as other areas.

A store-and-forward technical environment can include the following:

•A personal desktop, laptop computer, tablet, or smartphone for the sender

•A personal desktop, laptop computer, tablet, or smartphone for the receiver

•Telecommunication technologies such as local area network (LAN), wireless communications, etc.

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

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

Technical Standards in Telehealth

Until recently the demand for telehealth-based medical devices was not sufficient to create unified, global technical standards. However, technical standards that were developed for associated markets have benefited telehealth. For example, use of American National Standards Institute (ANSI) H.32x standards has enabled wide-scale video conferencing interoperability, which led to further growth in nonhealthcare businesses. Not only has telehealth benefited from the video conferencing standards, but it is 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. In addition, development of Health Level Seven (HL7), which 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.3

In 2006 the Continua Health Alliance was formed by a group of healthcare technology industry companies to establish interoperable personal telehealth solutions and to develop technical design guidelines. The goal is to agree on a set of common technical guidelines that will enable vendors to build interoperable sensors, home networks, telehealth platforms, and health and wellness services. The Continua Health Alliance also has developed a technical certification program based on these guidelines. Technologies that are certified by Continua Health Alliance have been technically tested and validated to work together and be interoperable.25

An example of such a standard is ZigBee/IEEE 802.15. This standard is targeted at applications that require a low data rate, long battery life, and secure networking. ZigBee/IEEE 802.15 has become a useful wireless connectivity standard for home or facility-based telehealth. ZigBee is a low-powered network capability that allows telehealth devices and sensors to operate longer and with smaller power sources, enabling miniature sensors to transmit health data. ZigBee is also a very low cost and easily installed network capability, providing usability and requiring minimal technical support. The ZigBee Alliance offers two specifications (ZigBee and ZigBee RF4CE) that serve as the base networking system to facilitate its interoperable market standards.26

Telehealth and Health Information Technology

A need exists to integrate all relevant medical device images and data from the telehealth technology with the patient's EHR. The interoperability of these systems could dramatically streamline a healthcare provider's workflow and improve the healthcare.

A key to telehealth success is healthcare providers' access to patients' health records at the time of a telehealth encounter—just as it is with in-person care. Telehealth networks serve to establish a link between provider EHRs, and securely moving health-related information that is exchanged among patients, hospitals, and healthcare providers as needed for care and treatment. Telehealth in HIE initiatives is expected to lead to the next generation of interoperability for health IT across and among healthcare enterprises. Existing telehealth infrastructure will also serve as a highway for EHRs and information exchange between and among rural and remote areas.27

Telehealth Clinical Practice Considerations for Healthcare Professionals

Healthcare providers have used the telephone as a communication tool for patient interaction for decades. Adding to the complexity of remote care delivery today, it is becoming increasingly common to use computers, remote monitoring devices, and interactive audio and video conferencing for patient interaction. With expanding telehealth technology capability, new and more efficient models of care are facilitated, allowing for removal of time and distance barriers.

Equal to or Better Than In-Person Care?

Telehealth is considered to be so effective that in 1997 the World Health Organization (WHO) announced that it has become part of the WHO's “health for all” strategy and should be made available to all people.28 Physician–patient encounters via telehealth have been supported by research to be as effective as standard face-to-face visits held in a physician's office or clinic. In 2008 Dr. Gregory Jicha, assistant professor of neurology at the University of Kentucky's Sanders-Brown Center on Aging, led a study called Telemedicine Assessment of Cognition in Rural Kentucky. “The goal of the project was to adapt and validate the UDS [National Institute on Aging's Uniform Data Set, a standard set of questions asked of every patient being screened for Alzheimer disease] and other measures for diagnosing mild cognitive impairment (MCI) and early dementia in the telemedicine setting. An important aspect of the goal was to determine whether the telemedicine consultations were as effective as face-to-face meetings with a doctor.”29(p32) Jicha stated that “developing and validating this telemedicine approach for diagnosing and treating MCI and early dementia will become a model for clinician-researchers at other centers serving rural populations.”29(p32) Per Jicha's perception of using telemedicine to expand healthcare resources, “the bottom line is, our goal is to ensure that though telemedicine is not better than an in-person evaluation, it's as good as an in-person evaluation.”29(p34)

Beginning in 2008, two studies (one in the United Kingdom and the other in Quebec, Canada) concluded that “telemedicine is increasingly seen as an efficient and cost-effective means for improving clinical outcomes and increasing patient involvement in their own care.”30(p59) Both studies demonstrated two important factors that influence healthcare professionals' acceptance of telemedicine: training and support.

Telehealth Clinical Competency

As healthcare providers' use of ever wider and broader technological tools increases, so does the need to ensure telehealth competency to provide safe and optimal patient care. As healthcare further embraces telehealth to gain efficiencies, improve access to care, and reduce costs, there must be a focus on educating and preparing healthcare providers in telehealth technology, techniques, skills, coordination, and “on camera” communications. A telehealth clinical encounter involves multiple new components and competencies, including coordinating healthcare provider and patient scheduling, knowledgeable telepresenting skills (i.e., steps needed to facilitate a telemedicine encounter between a patient and remote healthcare provider), the exchange of prior medical record and new telehealth information, and an understanding of video and audio technology.

From initial academic preparation through ongoing continuing education requirements, healthcare providers practice in a dynamic field with ongoing changes in care delivery. All healthcare providers are required and expected to maintain and update clinical competency in the care they render to patients. Telehealth also requires competency for optimal healthcare delivery. A number of professional associations have stepped forward to identify the specific competencies required. As described earlier in this chapter, the ANA and 41 major healthcare provider organizations developed and endorsed core principles for telehealth delivery in 1998.21 A year later the ANA created and published Competencies for Telehealth Technologies in Nursing.31 In 2001, with further expansion in telehealth, the ANA endorsed the development of telehealth protocols.32 These protocols were developed to encompass the needs and concerns of both clients and practitioners. On an international level the ICN published the research-based, validated International Competencies for Telenursing based on an international survey of practicing telenurses in 36 countries around the globe.4

The National Initiative for Telehealth Framework of Guidelines (NIFTE Guidelines) was a critical milestone in development of telehealth not just for those who authored the guidelines in Canada, but globally.33 This highly important and superbly designed framework was developed in Canada by a multistakeholder interdisciplinary group. The NIFTE Guidelines are designed to assist individuals and organizations to develop telehealth policies, standards, and procedures. NIFTE examines and offers principles and suggested guidelines for five overarching content areas related to telehealth: