This document discusses telehealth and telenursing. It begins by defining telehealth and describing its history. Telehealth utilizes technology to provide health services from a distance. While early uses date back centuries, major advances occurred in the last 50 years as technology improved. The document then discusses driving forces for telehealth like aging populations and provider shortages. It explores clinical applications of telehealth including transmitting images, data, and providing education. Telenursing involves using telecommunications for remote nursing care. Key roles of telenurses discussed are home telehealth, tele-intensive care, and chronic disease management. The tools, software, practice protocols and legal/ethical considerations of home telehealth are outlined. The future of more

1. Chapter 19
Telenursing
and Remote
Access
Telehealth

2. Objectives
• Explore the use of telehealth technology in
nursing practice.
• Identify socioeconomic factors likely to
increase the use of telehealth
interventions.
• Describe clinical and nonclinical uses of
telehealth.

3. Objectives
• Specify and describe the most common
telehealth tools used in nursing practice.
• Explore telehealth pathways and protocols.
• Identify legal, ethical and regulatory issues
of home telehealth practice.

4. Objectives
• Describe the role of the telenurse.
• Apply the Foundation of Knowledge model
to home telehealth.

5. What is Telehealth?
• Refers to and a wide range of health services that
are delivered by telecommunications-ready tools,
such as the telephone, videophone, and
computer.
• A recent press release by IMS Research (2013)
reported that telehealth monitoring was used for
308,000 patients in the U.S. in 2012 and that the
demand worldwide is expected to reach 1.8
million by 2017.

6. History of Telehealth
• While most of the advances in telehealth have
taken place in the last 20 to 30 years, Craig and
Patterson (2005) describe much earlier uses such
as the use of bonfires to alert neighboring villages
of the arrival of bubonic plague during the middle
ages.
• The National Institutes of Mental Health
supported a program in the mid-1950’s that
connected seven state hospitals in four different
states via a closed-circuit telephone system
(Venable 2005).

7. History of Telehealth
• The first reported use of television to monitor
patients in a clinical facility occurred in the 50’s
which then led to the development of interactive
closed circuit applications in the mid-60’s.
• Craig and Patterson (2005) suggest that ever
evolving technologies in digital transmission, the
falling costs of computing in general, and the
explosion of mobile phones and satellite
communications will sustain the advance of
telehealth.

8. Evolution of Telehealth
• Early uses in the 1970s of more advanced
forms of telehealth in the medical field,
referred to as “telemedicine,” included
teleradiology and telepathology—
radiological and pathological images
transmitted to specialists who were located
at some distance (Allan, 2006).

9. Evolution of Telehealth
• Success in telehealth was achieved after decades
were spent refining the technology, which
resulted in clearer imaging, more speedy
transmissions, and accurate replication of data
from remote locations to a central hub.
• The end results of telehealth interactions today
have helped to insure that professionals can
replicate usual clinical interactions in all
specialties regardless of the distance involved in
the contact.

10. Nursing Aspects of Telehealth
• Understanding telehealth and the potential use of
telehealth technology in nursing practice is
necessary in today’s changing healthcare arena.
• Telehealth interventions or contacts are:
– performed off-site
– require less time spent on task because of the
efficiencies offered by the technology applications.

11. Driving Forces For Telehealth
• demographics
• nursing/health care worker shortages
• chronic conditions
• the new, educated consumers
• excessive costs of health care services that
are increasing in need and kind.

12. Driving Forces For Telehealth
• The American health care system spends $1.4
trillion/year on conventional medical care.
• Much more should be expected to be spent
annually in the coming decades.
• A solution is to develop a new clinical model for
American healthcare that includes technology.
• Telehealth technology should be included to fill
the gap resulting from an overabundance of
patients and a scarcity of health care providers.

13. American Telemedicine
Association Definition (2010)
Telemedicine is the use of medical information exchanged
from one site to another via electronic communications to
improve patients’ health status. Closely associated with
telemedicine is the term “telehealth,” which is often used
to encompass a broader definition of remote healthcare
that does not always involve clinical services.
Videoconferencing, transmission of still images, e-health
including patient portals, remote monitoring of vital signs,
continuing medical education and nursing call centers are
all considered part of telemedicine and telehealth. (¶ 1).

14. Transmission Formats
• Store and Forward
– digital images, video, audio, and clinical data are captured and
stored on the client computer or device; then, at a convenient
time, the data are transmitted securely (forwarded) to a specialist
or clinician at another location for interpretation
• Real Time
– real-time or live interaction
• Remote Monitoring
– devices are used to capture and transmit biometric data
• Telephony
– monitoring via telephone

15. Clinical Applications Examples
• Transmitting images for assessment or diagnosis:
transmission of digital images of wounds for assessment
and treatment consults.
• Transmitting clinical data for assessment, diagnosis, or
disease management, especially vital signs, blood glucose,
and weight
• Providing disease prevention and promotion of good
health such as telephonic case management and patient
education

16. Clinical Applications Examples,
con’t.
• Using telephonic health advice in emergent
cases. One example is performing
teletriage in call centers.
• Using real-time video. One example is
exchanging health services or education
live via videoconference.

17. Real-Time Clinical Telehealth
• Telemental health
• Telerehabilitation
• Telehomecare
• Teleconsultations
• Telehospice/ telepalliative care

18. Telenursing
• Telenursing refers to the use of
telecommunications and information
technology for providing nursing services in
health care to enhance care whenever a
physical distance exists between patient
and nurse, or between any number of
nurses (Skiba, 1998).

19. Telenursing
• The most developing area of telenursing today
is in home telehealthcare.
• According to regular surveys by the
Association for Retired Persons (AARP, 1996),
more than 90% of seniors want to remain
independent at home and age in place.
• Care at home is clearly a key concern and
preference.

20. Telenursing
• The home care industry’s newest challenge is to
work with sicker patients, many of whom have
been discharged from hospitals to home earlier
than in the past.
• Home care telenursing can also involve other
activities such as providing customized patient
education in dietary or exercise needs, nursing
teleconsultations, review of results of medical
tests and exams, and assistance to physicians in
the implementation of medical treatment
protocols.

21. Telenursing
• Home care telenurses can well expect to
play a vital and dynamic role in the
changing delivery systems that are to be in
place in the next decades.

22. Teleintensive Care Nursing
• Nurse specialists who provide remote
monitoring, oversight, and expert
consultation of patients in rural ICUs,
– examine real time data collected at the
bedside
– look for trends indicating that an intervention
is needed
– alert the bedside nurse of the need thus
providing an extra set of eyes and an advanced
level of expertise.

23. Telehealth Patient Populations
• Homebound
• Limited access to transportation
• Lack of primary care and emergency resources in
rural or remote populations
• As a strategy to reduce hospital length of stay
• Managing patients in a major disaster, large scale
nuclear/bio-chemical attack or in the case of an
outbreak of highly infectious disease.

24. Chronic Disease Patients
• At significant risk of having an acute episode
when subtle but significant changes in their
medical condition occur. The most common
categories of chronic patients that are currently
monitored include:
– congestive heart failure (CHF),
– chronic obstructive pulmonary disease (COPD),
– diabetes,
– those who require long-term wound care.

25. Elder Care Telehealth
• In assisted living facilities or subacute care
centers a kiosk can be used to obtain vital
signs for large groups of people.
• Vital sign reports can then be forwarded on
a regularly established schedule to
physicians and other involved in the
patient’s care.

26. Employers/Wellness Programs
• Monitor workers and offer telehealth
options as a wellness program to:
– reduce absenteeism and increase productivity.
– lower healthcare costs and associated
insurance premiums.
– create financial incentives for achieving
healthcare objectives such as appropriate
weight, reduced blood pressure, and levels of
exercise.

27. Tools of Home Telehealth
• Central stations/web servers are
key components to telehealth that can be
as minimal as a single screen display or may
be more comprehensive software
applications that provide various functions
including triaging the data according to
medical alerts which allow clinicians to
quickly identify patients requiring
immediate attention.

28. Tools for Home Telehealth
• Peripheral biometric devices can consist of
fully integrated systems such as a vital signs
monitor or they may be stand-alone
telecommunications-ready devices such as
blood pressure cuffs and blood glucose
meters.

29. Tools of Home Telehealth
• Telephones are already the most familiar
household communications tool used in
telehealthcare.
• A telephone device can also be augmented for
easier use by patients, as needed, with a lighted
dial pad, an auto-dial system, and/or louder
ringer.

30. Tools of Home Telehealth, con’t.
• Video cameras and videophones are easily
available consumer items that can be used in
telehealth for show-and-tell demonstrations by
nurses for patients, or to capture wound healing
progress, among other applications.
• Personal Emergency Response Systems (PERS) are
well-known signaling devices worn as a pendant
or otherwise made easily accessible to patients to
ensure their safety and to access emergency care
when needed, must usually in case of a fall.

31. Telehealth Tools, con’t
• Sensor and activity monitoring systems can track
activities of daily living of seniors and other at-risk
individuals in their place of residence.
• Medication management devices are addressing a
well-recognized major problem in healthcare
today: medication management and compliance.
– 32 million people are taking 3 or more medications
daily, with even more medications typically being
taken by those 65 years of age or older.

32. Home Telehealth Software
• Allows creation of a digital health record
(DHR):
– Information to be recorded over time.
– Trend information can also be developed for
groups of patients or populations, allowing for
population based analyses of interventions.
– set an acceptable range of values for an
individual patient when he or she is enrolled in
the monitoring program.

33. Home Telehealth Software, con’t
• Advanced telemonitoring software has
sophisticated electronic notification
protocols:
– readings from multiple pieces of equipment on
a single patient calculate risk of an acute
episode
– Sophisticated protocols can be developed
related to both routine and alert information
organizing communications with physicians,
nurses and care givers.

34. Home Telehealth Practice and
Protocols
• Home telehealth programs will differ depending
on the type of technology used and the focus of
the telehealth programs.
• Informed written consent must be obtained from
the client or designee before beginning the use of
telehealth consultations.
• Telehealth pathways and protocols ensure more
focused work with patients and allow for targeted
interventions.

35. Home Telehealth Practice and
Protocols
• The use of telehealth tools, together with clinical
oversight/practice, allows for more efficient and
effective clinical management by allowing the
patients’ needs to drive the care.
• As home telehealth protocols are utilized more
extensively, the improved clinical and operational
efficiencies may ultimately impact the home care
agencies’ bottom lines.

36. Policies and Procedures
Address:
• patient enrollment, education, and
equipment setup;
• home assessment;
• patient informed consent and privacy and
confidentiality rights.
• clinical plan of care that is specific to
patient needs should be developed.

37. Legal and Ethical Aspects
• nurses must be licensed to practice in all of the
states in which they provide telehealth services.
• scope of practice and accountability for practice
must be defined
• nurses must be vigilant about keeping extensive
documentation of their visits on and off site.
• Telehealth Resource Center --overview of
licensure and scope of practice issues

38. Confidentiality and Privacy
• Information systems must ensure a high level of
data security
• Patients and families should have the opportunity
to revise consent after they fully understand the
intrusiveness of home monitoring
• All involved parties, including the technical staff
assistants, must have appropriate training in
privacy and confidentiality issues.

39. Patient Use Considerations
• Elders may have sensory, cognitive, and
motor disabilities.
• Usability testing needed to maximize the
quality of the user experience
– special attention to design details for Web-
based interfaces, such as font choices and
color schemes to improve readability.
(Demiris et al. 2009)

40. Ethical Design Principles
Kaplan and Litweka (2008)
• How provider or patient-centric is the
technology?
• Does the shift to remote services promote
rationality and efficiency at the expense of values
traditionally at the heart of caregiving?
• How does the design affect home life and family
dynamics?
• To what extent should technology usage involve
attempts to manipulate users into different
behaviors?

41. Ethical Design, con’t.
• How might the replacement of human contact by
new technologies be ameliorated?
• To what extent is the deployment of technology
an end in itself, aimed not toward the
improvement of health or well-being, but to
create market needs?
• How do we identify the boundaries between
genuine solutions and futility in light of
technologies that may shift them? (p. 404)

42. The Foundation of Knowledge
Model and Home Telehealth
• Knowledge acquisition involves the nurse’s
receiving the information from the
telehealth devices via a variety
communication modes.
• Knowledge processing is understanding a
set of information and ways it can be useful
to a specific task.

43. The Foundation of Knowledge
Model and Home Telehealth
• After processing information, the nurse is
able to target the appropriate next steps
involving knowledge generation and
knowledge dissemination.
• The nurse considers all of the data as it
applies to this patient, and decides which is
the best course of action to be taken and
acts on the data.

44. Summary
• Telehealth is a rapidly developing mode of health
service delivery in which nurses can expect to
play a key role.
• The practice of telehealth will provide
opportunities for telenurses to play a key role in
care management across the healthcare
continuum.

45. The Future
• The technology associated with home
telehealth will become much more
sophisticated and integrated over time.
• Monitoring equipment will become more
affordable and this affordability will spur
further demand.
• Another clear future direction is that home
monitoring equipment will be much more
portable and likely will utilize wireless
technology.

46. The Future
• Home monitoring systems will be
integrated with an expanded array of
other equipment that monitor safety and
functionality.
• Emergency response devices,
environmental safety monitors, motion
sensors, activity of daily living measures
and a host of other equipment will be
integrated, providing a much more
comprehensive view of the patient, their
physical status and ability to function.

47. Thought Provoking Questions
1. Telehealth technology has extended the arms of
traditional health care delivery into homes, clinics,
and other environments outside the bricks and
mortar of hospitals. Will the increased use of these
telehealth technology tools be viewed as “de-
humanizing” patient care or will they be viewed
as a means to promote more contact with
healthcare providers and new ways for people to
“stay connected” as in on-line disease support
groups), thereby creating better long term disease
management and patient satisfaction?

48. Thought Provoking Questions
2. What types of resistance to new
technologies might be evident among
patients, caregivers, and nurses? What
evidence and strategies might help to
diminish these resistances?

49. Thought Provoking Questions
3. As telehealth technology advances
towards seamless data access regardless of
distance or health system, how can we
protect patient privacy rights and the
confidentiality of personal medical data?

50. Thought Provoking Questions
3. Consider a recent patient care scenario and
describe how it could have been managed
at a distance.
– What training would you need?
– What equipment would you use?
– How would your patient and his or her family
respond to home telemonitoring?