What do astronauts on the International Space Station have in common with the Alaska Natives on 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. Just like venturing to the solar system every time an astronaut is ailing is unrealistic, so is the idea of patients traveling by air, sea or snow to see providers for every earache, but that’s what most villagers had to do in order to receive full-scope medical care. That is, until the implementation of telehealth.
An Unlikely History
Telehealth, according to the Telemedicine Research Center, is the transfer of electronic medical data from one location to another, and it’s 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 back data through microwave signals. At flight headquarters, doctors tracked pulse rates, blood pressure and other critical indicators.
Eventually, NASA recognized the potential to apply the same approach for 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 (STARPAHCP), which lasted from 1972 to 1975. That time revealed the huge potential of this nontraditional delivery system. However, STARPAHCP still relied on the expensive microwave technology, which made widespread application cost-prohibitive. Still, health care experts didn’t classify telehealth as a “worthwhile, but impossible experiment.”
For the next 20 years, proponents pushed to advance the technology. Meanwhile, the computer industry was also undergoing significant improvements. These circumstances primed the industry to give telehealth another attempt, and by 1990, four programs were underway.
Technology Catches Up
Even though the equipment had made great strides, in 1990 clinicians were still bound by technical limitations. Oftentimes, cases were conducted through telephone conferences and choppy videoconferencing. Regardless, telehealth was working. For example, if nurses on cruise ships needed to confer with a specialist, they made a ship-to-shore calls to get step-by-step consultations.
Improved technology, however, has made significant differences. The Internet, DSL, broadband and satellite transmissions have elevated telehealth to a competitive level.
“Five years ago, nurses had to be in sync with 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) based out of Anchorage.
“Huge technical advances are driving the growth of telehealth. We’re doing things now that weren’t possible five years ago. We can do so much more than we even imagined,” comments Gerri Lamb, PhD, RN, FAAN, the associate dean of Clinical and Community Services and associate professor at the University of Arizona School of Nursing in Tucson, as well as the associate director of nursing for the Arizona Telemedicine Program (ATP).
Indeed, tiny cameras now allow nurses to take images of an eardrum and load them onto a server from which a physician hundreds or thousands of miles away pulls up on a computer for evaluation and instructions. Other telehealth services include monitoring blood pressures, pulses, blood sugar levels, even wound care. The field is constantly being redefined as the equipment’s capabilities evolve.
“There are forms with popup templates that cue nurses for information they need to provide for an assessment,” explains 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 most influential aspect is telehealth’s ability to expand accessibility. According to the Telehealth Improvement Act of 2004, 36,000,000 people in the United States lack direct access to physicians. Alaskan villages are excellent examples. These communities can’t support a full-scale hospital on their own, so Community Health Aides (CHA) provide the basic treatments. For more serious conditions, patients have to travel to a larger facility, but 75 percent of Alaskan 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. It can cost thousands of dollars to come in for an earache. The alternative used to be no care,” says Vasileff. “Telehealth makes it possible to get quality care to remote villages.”
AFHCAN has developed a telehealth program, including software and hardware that use satellite transmissions to give CHAs and regional hospitals more access to specialists. Since 1998, it’s been implemented in 248 sites.
“There was such limited access before telehealth, with 12- to 15-month backlogs to see doctors in Anchorage. 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,” explains Stewart Ferguson, PhD, AFHCAN director. “Doctors have reduced backlogs so much that there are now open spots at specialty clinics.”
A National Trend
Successes, however, are not restricted to Alaska. There are similar programs popping up around the country. Not surprisingly, a large percentage of them focus on traditionally underserved areas that also happen to be minority communities in many cases. In Native American reservations, inner-city neighborhoods and rural prisons, telehealth enables nurses to extend their practices.
“A characteristic of a lot of minority communities is that the patient population is low income, which can prohibit access. 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,” says Carr.
Another population benefiting from telehealth is the incarcerated. Not all prisons are located near hospitals nor do they have full medical staff. Through technology, prison nurses can treat inmates to a greater degree without having to transport them outside the guarded walls. ATP estimates it has saved more than $1 million in transportation costs because more than 80 percent 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’ vitals and other assessment observations into the computer. Then a physician or specialist obtains the data from a server for evaluation. This direct interaction, however, isn’t the only method in telehealth. Patients can play an active role.
For more than a decade home health has experienced consistent growth as people are released from inpatient care still requiring nursing attention. Initially, nurses were assigned a group of patients for whom they had to make routine visits. Logistics placed limitations on how many clients they could see per day, as well as how much time they could devote. With telehealth, many of those limitations are erased.
Once patients are set up with the equipment in their homes, they input readings on a regular basis. That data are stored until nurses remotely pull up the information. Clinicians can see a more complete picture of patients’ vitals for extended periods. That enables them to make better assessments and treatment decisions. In this situation, home health nurses oversee more patients per day in addition to making traditional on-site visits.
Anecdotal research also suggests telehealth helps with patient compliance. The electronic charting is a visible demonstration of how treatment is progressing. “Telehealth has been tremendously useful for patient education,” notes Lamb.
A Few Glitches
Despite patients and health care professionals embracing telehealth, there are a few obstacles preventing it from being fully put into practice. In April, the Commerce Department released a statement reporting approximately $380 million will be spent this year on telehealth. “That is a fraction of the estimated $80 billion that will be spent on all health care technology. ‘There is a lag in the application of technology in the real world,’ Undersecretary of Commerce Phillip J. Bond said.”
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 projects are just now trying to transition from research applications to full-scale businesses. “Telehealth is in its infancy in terms of market potential. But there are private companies doing project development, so it’s definitely a growing industry,” says Ferguson.
Proponents say the next step is convincing insurers of its benefits. Currently, coverage is uneven, including with Medicare and Medicaid. The 1997 Telemedicine Report to Congress notes that Arkansas, California, Georgia, New Mexico, North Dakota, Montana, South Dakota, Utah, Virginia, and West Virginia reimburse some telemedicine services through Medicaid. According to the Washington Times newspaper, 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 vitals 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 with the Telehealth Improvement Act of 2004 (S.2325). This bill defines the need for expanded telehealth provisions, and calls for further reimbursement under Medicare, including for services provided in skilled nursing and assisted-living facilities and county or community health clinics. The proposal is currently in committee.
Supporters assert telehealth will save costs in the long run by addressing health care issues earlier. “I think acceptance and reimbursement will grow, but there needs to be research that demonstrates the cost savings,” suggests Lamb.
Indeed, initial research seems to support telehealth’s cost-effectiveness. When used to track patients with chronic heart failure (CHF), researchers documented substantial savings. They concluded a potential $4.2 billion, or 52.5 percent, savings per year per CHF patient from reduced hospital days and annual labor and benefits budgeted at two nurses per patient.
By the Book
Licensure 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 the state’s Nurse Practice Act, which is overseen by the State Board of Nursing. In cyberspace, there aren’t distinctions noting where one state’s boundaries end and another’s begin.
Currently, nearly half the states permit out-of-state doctors to practice medicine in their jurisdictions online provided they obtain their state’s license, according the Center for Telemedicine Law. A separate program allows nurses to earn credentials to provide health care online in any of 17 states. Some analysts recommend adopting a system similar to the Department of Veterans Affairs and Indian Health Services, which allow clinicians with a valid nursing license issued in the United States to practice.
Creating a Niche
Telehealth is an arena that has yet to be fully explored, including nurses’ contributions. “Involving nurses is one of the most powerful things telehealth is doing right now,” comments Ferguson. “You need to be able to communicate with providers at hospitals in order to spread health care to remote and underserved areas, and that’s where minority nurses would be important.”
The importance of culture in care delivery is not downplayed in telehealth. In fact, some practitioners say it becomes even more critical. Some minority groups are naturally distrustful of health care professionals, so when technology is thrown into the picture, there’s the potential to exacerbate the situation. Its crucial nurses explain how the system works in culturally appropriate terms. That’s why culturally aware providers are valuable telehealth tools.
From the clinical point of view, telehealth nursing utilizes the same nursing skills as bedside visits. The biggest difference? More time on the computer. “Nurses need strong assessment skills to evaluate clinical situations, it’s just that technology adds another piece,” says Lamb.
“You have to have previous clinical experience, and a background in computers, servers and routers helps. Liking technology and not being afraid of it is important,” adds Carr.
Additionally, nurses are assuming administrative roles. As telehealth coordinators, they oversee other practitioners conducting patient care, lead training sessions, maintain medical data and schedules and keep communication flowing between remote sites and participating physicians. “For nurses, there are huge opportunities to get involved at all levels,” asserts Lamb.
Adds Ferguson, “The industry is being defined by the people working in it”
Despite the millions of miles separating the astronauts and villagers on Little Diomede Island, they all rely on telehealth and its specialists to maintain healthy lifestyles.
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