What do astronauts on the International Space Station have in common with Alaska Natives on Little Diomede Island, just 2.5 miles from Russia in the Bering Strait? Not much, other than they both receive health care services via telehealth technology (also known as telemedicine).
Just as it’s impractical to send doctors and nurses out into the solar system every time an astronaut is ailing, so is the idea of patients who live on this remote, isolated island traveling many miles by air, sea or snow to see health care providers for every earache or other medical complaint. But that’s what most Diomede villagers had to do in order to receive full-scope medical care before the advent of telehealth programs.
Telemedicine, according to the Telemedicine Research Center, is the transfer of electronic medical data from one location to another. Today, a growing number of nurses and nurse practitioners are tapping into developing technology--such as computer monitoring and satellite transmission--to provide long-distance nursing to medically underserved minority populations whose geographical isolation restricts their access to medical treatment and preventive care.
Telehealth got its start as a byproduct of the Space Age. The National Aeronautics and Space Administration (NASA) needed to monitor astronauts’ physical and physiological parameters during flight. It created sensors that sent data back to Earth through microwave signals. At flight headquarters, doctors were able to track the astronauts’ pulse rates, blood pressure and other critical indicators.
Eventually, NASA recognized the potential to apply this same approach to help residents of rural communities where health care access was extremely limited. Its first endeavor was the Space Technology Applied to Rural Papago Advanced Health Care project (STARPAHC), which focused on bringing medical care to the Papago Indian Reservation in Arizona. The project, which lasted from 1972 to 1975, revealed the huge promise of this nontraditional health services delivery system.
However, STARPAHC still relied on the expensive microwave technology, which made widespread application cost-prohibitive. For the next 20 years, proponents of telemedicine pushed to advance the technology into more practical and affordable solutions. Meanwhile, the computer and telecommunications industries were also undergoing significant advancements. These innovations helped refocus attention on the possibilities of telehealth, and by 1990 four programs were underway.
Even though the technology had made great strides, telehealth programs in the 1990s were still bound by technical limitations. Often, patients’ cases were conducted through telephone conferences and choppy videoconferencing. For example, if nurses on cruise ships needed to confer with a specialist, they made ship-to-shore calls to get step-by-step consultations.
But today, in the 21st century, improved technology is finally allowing this revolutionary concept to catch up to its full potential. The Internet, DSL, broadband and satellite transmissions have elevated telehealth to a competitive level.
“Five years ago, nurses had to be in sync with [other health care providers] on the telephone. We didn’t have the computer technology that allowed telehealth to happen in a secured fashion,” says Debbie Carr, RN, a telehealth coordinator for the Alaska Federal Health Care Access Network (AFHCAN) in Anchorage.
“Huge technical advances are driving the growth of telehealth,” agrees Gerri Lamb, PhD, RN, FAAN, associate professor and associate dean of clinical and community services at the University of Arizona School of Nursing in Tucson, and associate director of nursing for the Arizona Telemedicine Program (ATP).
“We’re doing things now that weren’t possible five years ago. We can do so much more than we even imagined.”
Indeed, tiny cameras now allow nurses to take images of a patient’s eardrum and load them onto a server from which a physician hundreds or thousands of miles away pulls them up on a computer for evaluation and instructions. Other recent developments in telehealth services include computer monitoring of blood pressures, pulses, blood sugar levels, and even long-distance wound care. The field is constantly being redefined as the equipment’s capabilities evolve.
“There are forms with pop-up templates that cue nurses for information they need to provide for an assessment,” says Penny Vasileff, RN, another telehealth coordinator for AFHCAN. “It’s new technology, but nurses already do a lot with technology.”
Although the technology is impressive, the biggest impact of telehealth is its ability to help reduce minority health disparities by increasing medically underserved populations’ access to health care services. According to the Telehealth Improvement Act of 2004, 36 million people in the United States lack direct access to physicians. Alaskan Native villages are excellent examples. These small communities can’t support a full-scale hospital on their own, so community health aides (CHAs) often provide the basic treatments. For more serious conditions, patients must travel to a larger facility, but 75% of Alaska Native communities aren’t connected to a hospital by roads.
“It’s expensive to come to Anchorage, particularly if you have to accompany children or elderly patients,” says Vasileff. “It can cost thousands of dollars just to come in for an earache. The alternative used to be no care. Telehealth makes it possible to get quality care to remote villages.”
AFHCAN, which is managed by the Alaska Native Tribal Health Consortium, has developed a statewide telehealth program--utilizing sophisticated hardware and software, 42 connected servers and a satellite-based IP network--to give CHAs and regional hospitals greater access to specialists. Since 1998, the program has been implemented in 248 sites throughout Alaska.
“There was such limited access before telehealth, with 12- to 15-month backlogs to see doctors in Anchorage,” explains Stewart Ferguson, PhD, director of AFHCAN. “Now, patients stay in their villages but can be seen by specialists. There’s been a 10 to 12 percent increase in patient volume because of telehealth. Doctors have reduced backlogs so much that there are now open spots at specialty clinics.”
Such successes are not restricted to Alaska. Similar programs are popping up around the country. In underserved communities ranging from Indian reservations and inner-city neighborhoods to rural prisons, telehealth enables nurses to extend their practice and eliminate barriers that have traditionally limited these vulnerable populations’ access to quality health care services.
“A characteristic of a lot of minority communities is that the patient population is low-income, which can prohibit access,” says Carr. “In urban areas, patients may have trouble getting to providers--maybe they have to take a bus and travel a long time. But with telehealth, the case is created in the patients’ locations and then sent to remote providers, who issue orders to either stay home or come in for extended care.”
Another population benefiting from telehealth nursing is the incarcerated. Not all prisons are located near hospitals, nor do they have full medical staff. Through technology, prison nurses can treat patients more effectively without having to transport them outside the guarded walls. The Arizona Telemedicine Program estimates it has saved more than $1 million in transportation costs because more than 80% of specialty medical consultations are conducted by off-site specialists.
In most of these environments, nurses create telehealth cases by inputting patients’ vital signs and other assessment observations into the computer. Then an off-site physician or specialist obtains the data from a server for evaluation. But health care providers aren’t the only ones who are sitting down at computers to help bridge distance gaps. In some cases, patients themselves are actively involved in the telehealth process.
For more than a decade, home health care has experienced consistent growth as more people are discharged from inpatient care still requiring nursing attention. Initially, nurses were assigned a group of patients for whom they had to make routine home visits. Logistics placed limitations on how many of these patients they could see per day, as well as how much time they could devote to each patient. With telehealth technology, many of those limitations are erased.
Once patients are set up with the telehealth monitoring equipment in their homes, they input readings on a regular basis. The data are stored until nurses remotely pull up the information. Clinicians can see a more complete picture of patients’ vital signs for extended periods, enabling them to make better assessments and treatment decisions. Another benefit is that home health nurses can oversee more patients per day in addition to making traditional on-site visits.
Anecdotal research also suggests that telehealth helps increase patient compliance. The electronic charting is a visible demonstration of how treatment is progressing. “Telehealth has been tremendously useful for patient education,” notes Lamb.
Even though health care providers and patients in many parts of the country are embracing telehealth, there are still a few obstacles preventing it from being fully put into practice on a national basis. A statement released by the Commerce Department in April reported that while approximately $380 million will be spent on telehealth this year, “that is a fraction of the estimated $80 billion that will be spent on all health care technology.” The report went on to quote Under Secretary of Commerce Phillip J. Bond as saying, “There is a lag in the application of [telehealth] technology in the real world.”
Until recently, telehealth projects were beta-type programs usually tied to universities. When the grants ran out, the programs struggled to secure new funding. Many telehealth programs are just now trying to transition from research applications to full-scale businesses. “Telehealth is in its infancy in terms of market potential,” says AFHCAN’s Ferguson. “But there are private companies doing project development, so it’s definitely a growing industry.”
Telehealth proponents say the next step is getting insurers on board, including Medicare and Medicaid. Currently, reimbursement coverage for telehealth services is uneven. The 1997 Telemedicine Report to Congress notes that Arkansas, California, Georgia, Montana, New Mexico, North Dakota, South Dakota, Utah, Virginia and West Virginia reimburse some telemedicine services through Medicaid. According to The Washington Times, Louisiana and Texas recently passed laws prohibiting insurers from discriminating between traditional and telehealth services.
What’s preventing full-scale reimbursement is determining who should be covered. Telehealth has two distinct participants: The nurse on-site inputting patient information and the physician off-site assessing the information, making a diagnosis and creating a care plan the nurse or CHA will carry out. Insurers haven’t decided how to divvy up the reimbursement payments.
Congress got involved this year by introducing the Telehealth Improvement Act of 2004 (S. 2325) on April 21. This bill, proposed by Democratic Vice Presidential candidate Sen. John Edwards, defines the need for expanded telehealth provisions and calls for further coverage under Medicare, including reimbursement for services provided in skilled nursing and assisted-living facilities and in county or community health clinics. The legislation is currently in committee.
Supporters assert that telehealth programs will save costs in the long run by addressing medical conditions earlier, when they are more easily treatable. “I think acceptance [by insurers] and reimbursement will grow, but there needs to be research that demonstrates the cost savings,” suggests Lamb.
Initial research seems to support telehealth’s cost-effectiveness. When telemonitoring was used to track patients with chronic heart failure (CHF), researchers documented substantial savings. They estimated a potential $4.2 billion, or 52.5%, savings per year per CHF patient from reduced hospital stays and annual labor costs and benefits budgeted at two nurses per patient.
Licensure of telehealth nurses is another issue demanding attention, because there are questions as to what regulatory body retains disciplinary rights. In the acute care setting, nurses adhere to the parameters set forth by their state’s Nurse Practice Act, which is overseen by the state Board of Nursing. But in cyberspace, there aren’t distinctions noting where one state’s boundaries end and another’s begin.
According to the Center for Telemedicine Law, nearly half of the state medical boards in the U.S. currently permit out-of-state doctors to practice or consult via telemedicine technology in those states’ jurisdictions, as long as the physicians have a current license in their home state. A separate program allows RNs to earn licensing credentials to provide health care online in any of 17 states.
Some analysts recommend that states adopt a telehealth licensing system that would be similar to policies currently in place at the Department of Veterans Affairs and the Indian Health Service. These federal agencies allow RNs with a valid nursing license issued anywhere in the U.S. to come work in their facilities. For example, a licensed RN from Arizona who gets a job with a VA hospital in Maryland doesn’t need to apply for a Maryland license; his or her Arizona credential is sufficient. Proponents of this type of regulatory system say the streamlined approach would remove obstacles that are preventing the expansion of telehealth services.
Telehealth is an arena whose potential has yet to be fully explored, and that includes the contributions nurses can make to the field. “Involving nurses is one of the most powerful things telehealth is doing right now,” comments Ferguson. “You need to be able to communicate in order to spread health care to remote and underserved areas, and that’s where minority [telehealth] nurses would be important.”
The importance of culturally competent care is not downplayed in telehealth. In fact, some practitioners say it becomes even more critical. Some minority health consumers are distrustful of the majority health care system, so when technology and the digital divide are added into the picture, it can create even more barriers. Minority nurses can play a crucial role in explaining how telehealth technology works in culturally and linguistically appropriate terms.
What does it take to become a telehealth nurse? From the clinical point of view, telenursing utilizes the same skills and competencies as traditional bedside nursing. The biggest difference? More time on the computer. “Nurses still need strong assessment skills to evaluate clinical situations,” Lamb explains. “It’s just that technology adds another piece.”
“You have to have previous clinical experience,” adds Carr, “and it helps to have a background in computers, servers and routers. Liking technology and not being afraid of it is important.”
Telehealth nurses also have opportunities to move into administrative roles. For example, they can become telehealth coordinators, who oversee other practitioners, lead training sessions, maintain medical data and schedules, and keep communication flowing between remote sites and participating physicians. As telemedicine technology continues to evolve and become accepted as an important tool for leveling the health care playing field, “there are huge opportunities for nurses to get involved at all levels,” says Lamb.