Distance Nursing
By using the latest advances in computer technology to increase
medically underserved minority communities' access to health care, telehealth
nursing is truly a career for the 21st century
By Anne Baye Ericksen
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 under way.
Technology Catches Up
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, as shown in the photo above, 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."
Reaching Out
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 imple-mented 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.
An Extra Set of Eyes
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.
Growing Pains
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 cyber- space, 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.
Is Telenursing in Your Future?
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 need for 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.
Anne Baye Ericksen is a free-lance writer based in Southern California.
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