Healthcare Anywhere: The Pledge of Telehealth

Laura A. Stokowski RN, MS

Disclosures

October 30, 2008

In This Article

Chronic Disease Management

Patients with chronic diseases are among the costliest who require healthcare. In recent years, there has been a dawning realization that some chronic conditions can be managed effectively, and less expensively, with telehealth services. Chronic diseases and conditions that have been the focus of telehealth programs include hypertension, heart failure, emphysema, coronary artery disease, diabetes, and chronic wounds.[10]

Nurses are using communication technology to provide education, consultation, assess patients, supervise procedures, and monitor patients with chronic conditions that can be controlled, but not cured, at home (Figure 1). Telehealth technologies have been used to help patients achieve long-term self-management of their chronic diseases.[11] These same technologies can also facilitate collaboration among providers, an essential element in the management of patients with complicated chronic disease and comorbidities. Telenursing for patients with chronic disease can not only improve symptom management, but also provide an avenue to assess and improve compliance and adherence to prescribed regimens of care.[7]

Figure 1.

Elizabeth Buckley, RN, conducts a telenursing visit with a chronically ill patient. Interactive voice and video allows her to assess, interact and educate the patient regarding his diabetes. Image courtesy of Loretta Schlachta-Fairchild RN, PhD, FACHE, iTelehealth Inc (www.itelehealthinc.com). Used with permission.

The most important feature of a telehealth disease management program is its clinical content.[3] Rich clinical content provides 2-way communication of physiologic information as well as education and measures of compliance. Patient responses and possible comorbidities are taken into account in a system that individualizes each telehealth encounter. Utterback provides the example of the patient with CHF who demonstrates insufficient understanding of shortness of breath or taking daily medications. The telehealth system would provide this patient with appropriate education to address this problem.[3]

A primary goal of treating the individual with chronic illness is to avoid hospitalization or trips to the emergency department (ED).[12] With telenursing, patients become more involved in monitoring their own symptoms, which increases their awareness of the interplay of their actions and their choices on their chronic disease.[11] Individuals with serious chronic illnesses, such as asthma, diabetes, or angina may be able to avoid hospitalization or expensive visits to the ED, if their conditions are monitored on a regular basis by their healthcare provider via telehealth devices. "Patients are in better shape with telenursing," notes Bonnie Wakefield, "They are more balanced."

Wakefield and colleagues[13] recently completed a telehealth nursing study comparing telephone, videophone, and usual care following hospitalization for heart failure exacerbation. Although many of these chronic disease patients were eventually rehospitalized, the telenursing intervention prolonged the time before another hospitalization became necessary. Other researchers have found that telehome monitoring can improve quality of life and functional status in patients with chronic illness.[14]

Telenursing is frequently initiated following discharge of a patient with a chronic disease, and during this time period, can make a huge impact on patient safety. For example, when nurses in the study by Wakefield and colleagues began contacting patients shortly after they had been hospitalized for management of their heart failure, they found that "a critical need in the first few days at home was medication reconciliation. Patients were often sent home with new medications, schedules, or dosages, and they were confused about the mix of new and old medications, with potentially dangerous consequences. It could take several days to straighten out their medications," Wakefield explained.

Although home care agencies have many different ways of implementing telehome care, most involve some type of telemonitoring. Telemonitoring is collecting and transmitting a patient's clinical data through electronic information technologies. Portable monitoring equipment is delivered to the patient's home, where it is set up and the patient is taught how to use it (Figures 2, 3). Clinical data may include blood pressure, heart rate, pulse oximetry, temperature, weight, and blood glucose.[15] These vital statistics can be transmitted directly to a healthcare provider using a standard telephone line.

Figure 2, 3.

This patient telehealth monitoring unit, contained in a portable suitcase, contains a digital camera with tripod, blood pressure monitor, pulse oximeter, and 3-lead electrocardiography machine with 10-second rhythm strip capability. Images courtesy of Loretta Schlachta-Fairchild RN, PhD, FACHE, iTelehealth Inc (www.itelehealthinc.com). Used with permission.

When monitoring patients remotely, nurses must be skilled in interpreting the clinical data and knowing when to intervene. Telehealth allows nurses to track health patterns over time and detect deviations in physiologic data that may indicate a decline in health before it becomes acute.[3] This level of surveillance isn't possible in a traditional healthcare delivery model.[3,15]

Vasquez notes that it is important to refer patients appropriately to a telemonitoring program. Patients must be willing and able to use the equipment as instructed.[15]

The Case of Mr. H. Mr H, a 76-year-old man who had received open-heart surgery 6 days earlier, was not feeling well. It was Saturday, and he had just had a follow-up visit with his cardiologist the previous day. Ordinarily, a patient in Mr. H's situation might make a trip into the local ED, but Mr. H had what he called "his guardian angel." Mr H. called his nurse on the videophone, as he did every day since returning home from the hospital.

Mr. H's telenurse, Brenda, saw that Mr. H was lying on his couch, alert, but complaining of feeling poorly. Brenda asked him if he had chest pain or shortness of breath, both of which he denied. Mr. H transmitted his vital signs with the telemedicine unit. His blood pressure was 98/59, heart rate 72, and blood glucose 147mg/dL. Brenda knew that Mr. H's blood pressure medication had been increased the previous day. She called Mr. H's cardiologist, who then called Mr. H at home and instructed him to readjust his medication dosage again. Brenda called Mr. H back later in the day to check on him and recheck his blood pressure. Mr. H's blood pressure was stable and within normal limits and he was doing well.

Both the nurse and physician involved in this telehealth interaction believed that, at the very least, an ED visit had been avoided by their intervention. It is also possible that telehealth permitted lifesaving action in the case of Mr. H because the negative effects of hypotension for a post-open heart surgery patient included reocclusion of vessels, arrhythmias, or even death.

The preceding scenario illustrates the tremendous benefit that telenursing can offer patients who are "in the gap" between cardiac surgery and structured rehabilitation programs. A recent study evaluated the safety and feasibility of a remote, home-based post discharge cardiac monitoring rehabilitation program for postoperative coronary artery bypass graft surgery patients. Patients received telenursing monitoring visits that included surgical incision assessments, vital sign monitoring (heart rate, pulse oximetry, blood pressure, 3-lead electrocardiography), a standardized, medically approved pain/physical assessment and brief educational interventions and support during each telenursing visit (Figure 4). Compared with patients who received traditional care, the telenursing monitored patients scored better on measures such as physical function, social functioning, role limitations due to physical health, and pain (Smith R, Walker J, Tavaf-Motamen H, Schlachta-Fairchild L; unpublished research).

Figure 4.

LTC Joy Walker, RN, conducts a telenursing monitoring visit with a patient following surgery. Image courtesy of Loretta Schlachta-Fairchild RN, PhD, FACHE, iTelehealth Inc (www.itelehealthinc.com). Used with permission.

Millions of Americans, many of them elderly, are living with chronic wounds. A shortage of wound care nurses is a significant barrier to healing the wounds of patients living at home or in long-term care facilities. Expert wound care is a specialized service that may not be available in every community. A viable alternative offered by telehealth uses videoconferencing and photography equipment to transmit images of wounds to wound care nurses in distant locations. These nurses can assess and monitor wound healing, and make treatment changes without having to visit the home of each patient.[16]

Remote wound assessment can also be conducted for geriatric patients residing in long-term care settings, obviating transporting these frail, elderly patients to a wound care clinic.[17]In the case of chronic wound consultations, nurse experts can provide diagnostic and evaluative support to geriatric nurses caring for patients with chronic wounds in long-term care settings.

In addition to improving chronic wound outcomes of individual patients, these consultations also provide an opportunity to enhance the wound care skills and knowledge of the remotely located nurse. Research demonstrates that wound assessment using video technology is comparable to in-person wound assessment.[18]Wound characteristics such as tunneling, undermining, granulation tissue, necrotic tissue, epithelial tissue, purulent exudate, erythema, edema, and induration were successfully assessed by wound care practitioners using an interactive video telecommunications system.

The nurse who is with the patient assists in the assessment by performing actions such as measuring the wound's size and depth, evaluating the health of its edges, and looking beneath the skin line to assess the presence of undermining and tunneling. This nurse can also detect the presence of edema, induration, and granulation, how much epithelialization is present, and if the wound has an odor. These observations are reported, in real time, to the wound care specialist.[19]

Studies of telehealth for wound assessment and management of long-term care patients have demonstrated significant cost savings over traditional care.[19,20] But lowered cost was not the only benefit observed with remote wound management. Several investigators noted an increase in knowledge of wound assessment and treatment on the part of remote-based nurses who were present during the consultations.[18] Wakefield also discovered that when video technology was used to send images of wounds to wound specialists, some patients with sacral pressure ulcers were seeing their own wounds for the first time. These patients were shocked at the appearance of their pressure ulcers, and seemed to finally understand why nurses encouraged them to change position and reduce pressure on these areas.

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