Nurses Advancing Telehealth Services in the Era of Healthcare Reform

Joelle T. Fathi, DNP, MN, BSN, RN, ANP-BC; Hannah E. Modin, MHA, B.A; John D. Scott, MD, MSc, FIDSA


Online J Issues Nurs. 2017;22(2) 

In This Article

Modalities of Telehealth Services

More recent technologic advancements and wireless communications have catapulted telehealth services and the possibilities for nurses to participate in delivery of remote care (Fong et al., 2011; LeRouge & Garfield, 2013). Understanding the modalities and options for telehealth is important to determine precise means of implementation. Telehealth services are conducted in a variety of ways depending on the location of the patient (end user), intended delivery of services, and various means for interaction with patients and healthcare providers (Fong et al., 2011). Direct and indirect telehealth services commonly deployed include synchronous, asynchronous, mobile health and ehealth, and remote monitoring. This section provides a brief overview of each of these services with select examples and literature support, and describes education of healthcare providers through Project ECHO (Extension for Community Healthcare Outcomes) and eConsult.

Synchronous Telehealth

Synchronous telehealth communication is defined by a live, face-to-face interaction between a patient and healthcare professional or between healthcare professionals, in consultation, via audio-video conferencing. In this traditional healthcare setting, patients check in to a clinic in their area equipped with a video cart that allows for bi-directional interaction between the patient and healthcare provider and a camera with zoom capability (Ferguson, 2006; Verhoeven, Tanja-Dijkstra, Nijland, Eysenbach, & van Gemert-Pijnen, 2010). The cart may be equipped with Bluetooth enabled digital and peripheral equipment (e.g., stethoscope, otoscope, or ophthalmoscope with camera capability) to use for more sophisticated physical examination and evaluation (Fong et al., 2011). Synchronous visits are typically facilitated at the originating site (where the patient is located), commonly by a nurse trained as a telepresenter. The telepresenter uses the equipment to examine the patient for a provider offering healthcare services from a distant site (Wechsler, 2015). Synchronous visits enable assessment, diagnosis, and treatment in hospital or clinic settings, and facilitate nurse to patient education.

Critical access hospitals with limited resources can benefit from prompt, synchronous consultation by a neurologist, in the event a stroke is clinically suspected and timely treatment with thrombolysis is critical. Telestroke services are those wherein synchronous assessment of the patient by a neurologist occurs. Telestroke services have increased prompt access to specialized care with improved rates of evidence based care and interventions (Cutting, Conners, Lee, Song, & Prabhakaran, 2014).

Synchronous telehealth models improve convenience, access, and efficiency of care by offering walk-in telehealth services. One study (Neufeld & Case, 2013) compared the same services at walk-in telehealth clinics and scheduled, in-person mental health medication visits (staffed by nurse practitioners and medical doctors). The in-person clinics had noted significant no-show rates and incurred the expense of long distance travel by staff. This study demonstrated that the walk-in telehealth clinics provided significantly shorter wait times and more open access for initial and routine follow-up psychiatric visits, with more reliable utilization of the clinic time (Neufeld & Case, 2013).

Another area of success is continuity of care in the transition of chronically ill patients from hospital to home during an acute phase of illness, including synchronous visits with nurses upon discharge. In a mixed methods study (Day, Millner, & Johnson, 2016), patients received various devices for self-monitoring and video-conferencing. This study observed use of telehealth equipment by nurses to monitor self-care, coaching, and supervision of patients during an acute exacerbation of a chronic illness. In telehealth interactions with nurses and remote monitoring, patients became more involved in self-care; understood the time to report symptoms or a change in health (sooner rather than later); and reported a perceived mastery of their self-care. Competent and effective utilization of telehealth technology and equipment by nurses in provision of healthcare can positively impact patients (Day et al., 2016).

Mobile Health or eHealth

Mobile health or eHealth is another example of synchronous telehealth wherein healthcare visits are initiated and conducted on patient personal computers and mobile devices or smart phones, from the patient's preferred location, instead of the traditional clinical setting. This form of synchronous consultation with healthcare providers, including nurse practitioners, is convenient for delivery of urgent care services and growing in popularity. Psychiatric care via a smartphone (telepsychiatry) highlights the benefits of healthcare delivery to high-risk patients in serious need of psychiatric services. The convenience of mobile healthcare breaks the barriers of transportation issues and need for caregiver accompaniment, and transcends symptoms and conditions like agoraphobia, factors which often isolate patients and prevent access to psychiatric care (Powell et al., 2017).

Asynchronous Telehealth

Asynchronous telehealth communication represents contact that is not face-to-face, but in real time, by way of email, internet, text messaging (Verhoeven et al., 2010) or as 'store and forward' wherein information is sent and picked up or responded to at a later date. Most commonly supporting medical care in a non-urgent setting, this modality has been utilized for years in the radiology space where radiologic films are uploaded for review at a later date (Agrawal, Erickson, & Kahn, 2016). Another example of this utility is the assessment of dermatologic conditions by way of uploaded digital photos or other patient data (Ferguson, 2006; Wade, Karnon, Elshaug, & Hiller, 2010).

Remote Telemonitoring

Remote telemonitoring is a well-established means to monitor various conditions and associated data, including cardiac monitoring for those who suffer heart failure, or general monitoring of chronic diseases. In a study of over 3000 patients in the United Kingdom, researchers demonstrated that patients with diabetes mellitus, heart failure, or COPD had a nearly 50% reduction in one year mortality and 18% fewer hospitalizations when using a simple home monitoring device, compared to those who did not (Steventon et al., 2012).

An example of telemonitoring in the acute care setting is the recording of vital signs, continuous electrocardiogram tracing, and hemodynamic values in the Intensive Care Unit (Fuhrman & Lilly, 2015) and transmitting this clinical information to the teleICU. Critical care medicine experts then interpret the data in real time and assist the originating/remote site with clinical decision making. This type of monitoring is utilized in health systems to promote efficiency and quality (e.g., reduce waste, deliver evidence based standards of care) and decrease redundancy, such as costly positioning of equipment and professionals in community or critical access hospitals. In one study across 15 states that included 100,000 patients, researchers found that patients in the teleICU group had a 16% and 26% lower risk of hospital and ICU mortality, respectively (Lilly et al., 2014).

Project ECHO and eConsults

In contrast to the above programs, which provide direct consultations to patients, Project ECHO increases knowledge amongst primary care nurse practitioners, physician assistants, and primary care physicians through synchronous, audio-video conferencing for professional education from academic centers and specialists to primary care providers (PCP) in remote areas. This initiative, developed by Dr. Sanjeev Arora at the University of New Mexico School of Medicine, illustrates how technology can be used to train nurses at all practice levels in core specialty knowledge (Arora et al., 2007). Participants reported less professional isolation, greater job satisfaction, and more confidence in managing complex chronic diseases (e.g., hepatitis C; Arora et al., 2010). Through Project ECHO not only do patients receive expert assessment and care, but nurses can also receive bonus training in remote locations where educational resources may be limited.

eConsults are similar to Project ECHO in that the consultative exchanges are between PCPs and specialists. However, it differs in that consultations are asynchronous and not part of a larger conference. In this model, the PCP sends a professional consult request regarding a patient with a specialty problem, and, at a later date, the specialist returns expert information to the PCP (Davis et al., 2015). This is especially helpful to ensure timely care for patients who would otherwise have long wait times to see a specialist, or perhaps where it is impossible to see a specialist, depending on geographic location. In summary, both Project ECHO and eConsults help PCPs develop core specialty knowledge crucial to care delivery in the present and along the patient care continuum, and improve convenience and access to patients who require specialty care.