As far back as the 1930s, Joseph Schumpeter described “creative destruction” as the process by which businesses entering the market with new ideas and technologies can take advantage of opportunities that traditional, established firms may ignore.1 Economist Clayton Christensen later expanded on this notion with his theory of “disruptive innovation,” in which groundbreaking products or services that are convenient, simple, and easy to use do not, initially, have the appeal of their established counterparts.2 At first, these products or services may be considered to be inferior to the status quo, but their lower cost, simpler design, and ease of use appeal to specific market segments. Over time, they undergo improvement and demonstrate their value, while an increasing number of consumers adopt their use. Soon these products and services, once disdained, are viewed as the norm and may even shape best practices in a given field.
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Such products and services are sometimes described as “disruptive innovations.” In health care, examples are plentiful: balloon angioplasty, which eliminated the need for many cardiac bypass surgeries; the delivery by NPs of primary care services that were previously provided exclusively by physicians; and the formation of health care clinics within retail establishments. Each of these innovations initially met the needs of only a subset of consumers but was soon more widely accepted and adopted.
Like these advances, telehealth is a classic disruptive innovation that, having faced its share of detractors, is now being used in increasingly varied ways across health care. This article discusses telehealth's many applications, reviews literature that examines its effectiveness in both nursing practice and nursing education, and explores the trajectory of telehealth as a case history in disruptive innovation.
WHAT IS TELEHEALTH?
The Health Resources and Services Administration defines telehealth as “the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health, and health administration.”3 Also called “telehealth nursing” and “telenursing,” telehealth is a component of telemedicine, which includes such specialties as teledermatology, teleradiology, and telepsychiatry. Telehealth is not a specialty area of nursing, but rather a means of delivering care that is likely to be part of every nurse's skill set in the not-too-distant future.
Within telehealth, there are a variety of products, processes, and services whose characteristics are consistent with disruptive innovation (see The Many Uses of Telehealth Technology4, 5). Many such innovations were originally rejected by traditional health care consumers and providers, who felt that telehealth did not meet the gold standard of in-person care. But mounting evidence suggests that telehealth can extend the reach of nursing and existing health care resources.
Telehealth nurses may practice in community clinics, schools, prisons, or any setting in which on-site access to health care providers is limited. In a hospital, they may provide direct care at a distance, using a digital stethoscope to auscultate lung sounds or a digital camera to assess and document the progression of wound healing. Telehealth nurses may act as telepresenters, communicating with physicians or other providers through videoconferencing from a patient's bedside. A home care telehealth nurse has the ability to “see” many more patients through virtual visits. Using a wide range of digital and distance technologies, telehealth nurses enable patients in remote locations to connect with specialized care and resources typically available only near major academic medical centers.
According to the American Telemedicine Association, there are currently over 200 telehealth networks and 3,500 service sites in the United States.6 The Veterans Health Administration (VHA), long a leader in telehealth care delivery, provided 300,000 long-distance consultations for patients in 2011.6 With increased broadband network capabilities, it is now feasible for the use of telehealth to expand, particularly in areas in which providers are few and access to care is less than optimal.
POTENTIAL USES IN CHRONIC ILLNESS AND ACUTE CARE
By 2021, it's projected that health care will account for 20% of the U.S. gross domestic product, up from 18% in 2011.7 Treatment for chronic disease accounts for 75% of the more than $2 trillion our country spends each year on health care.8 By 2030, the Census Bureau estimates that 19% of the U.S. population will be over 65 years of age,9 and many older adults will have multiple chronic conditions. Yet, despite these unsettling statistics, telehealth technologies with the potential to lower costs and ease the burden of caring for growing numbers of older patients have not yet been widely adopted.
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In the home. Medicare and other insurers do not yet reimburse for home telehealth,10 despite that telehealth technology has been found in a number of studies to improve outcomes and lower costs. For example, when home care nurses “augmented usual care with a web-based resource… that provided patients with self-management information, self-monitoring tools, and messaging services,” the technology increased quality of life and self-management of chronic heart disease in the early postdischarge period.11 Patients with heart failure who were enrolled in a yearlong telehealth program on hospital discharge had lower 30-day readmission rates than patients with heart failure who were discharged with routine or no follow-up care.12 Patients with end-stage renal failure improved self-management and achieved better quality of life through home telehealth monitoring with remote care nurse support.13 Telemonitoring of vital signs reduced acute care hospitalizations and ED visits for home health care patients, and telemonitoring that collected information on vital signs along with yes/no patient responses regarding perceived health status increased satisfaction for both rural home health care patients and their providers.14, 15 A review of 14 home telehealth monitoring studies conducted internationally found that home monitoring had a positive effect on patients’ blood pressure control, possibly as a result of better medication adherence and health-promoting lifestyle modifications.16 A Cochrane review of 30 randomized controlled trials involving more than 8,000 patients, published on behalf of the European Society of Cardiology, concluded that both telehealth monitoring and structured telephone support were effective in improving outcomes in patients with chronic heart failure.17
In acute care. There have been numerous studies in which telehealth used outside the home has also produced better or equal outcomes at reduced costs. For example, a systematic review of telehealth ICU studies published from January 1, 1950, through September 30, 2010, concluded that telehealth ICU programs, which typically allow on-site ICU staff to collaborate with off-site intensivists and critical care nurses through the use of videoconferencing, telemetry, and electronic medical records, can reduce ICU mortality and length of stay in hospitals that lack the resources to keep dedicated intensivists on staff.18 In contrast, a study conducted in two community hospitals in which patients’ primary physicians maintained responsibility for care, though intensivist consultation was available on an as-needed basis, found no reduction in mortality, length of stay, or costs associated with the use of an electronic ICU (one that provides continuous, real-time supplemental monitoring of patients by intensivists and critical care nurses in a centralized, off-site facility).19 Owing to the tremendous shortage of intensivists, however, only about one-quarter of ICUs are equipped to have “treatment decisions cohesively managed under the guidance of an intensivist.”20 For this reason, supplemental intensivist oversight provided through technology may be welcomed by patients.
One 904-bed tertiary hospital used a robotic telepresence to reduce noise and traffic in the surgical ICU.21 To eliminate the need for a team of up to 20 people—including an intensivist, surgical residents, NPs, a pharmacist, a nutritionist, and members of other hospital services—gathering at each patient's bedside, this unit initiated a practice in which surgical residents and NPs would examine patients in the early morning, after which the entire multidisciplinary surgical ICU team convened in a conference room and communicated with patients and family members in the ICU through a robot. Of patients surveyed, 92% responded that they didn't believe the robotic telepresence meant “the doctor cared less about them,” and 84% believed their care was better because a robot was used.
In other settings with diverse populations. Children with type 1 diabetes whose schools contained “a telemedicine unit” in the office of the school nurse—permitting monthly videoconferencing between the school nurse, child, and diabetes team in addition to usual care—experienced a significant reduction in both glycated hemoglobin levels and the need for urgent encounters, with a 91% satisfaction rate among participants.22 Telehealth systems have also been used successfully in schools to help children manage asthma23, 24 and behavioral health issues.25 For patients with hearing, speech, and language disorders, a review of studies from 1995 to 2011 “generally validated” telehealth as a means of delivering services such as hearing aid fitting; programming cochlear implants; and conducting speech and language studies to diagnose neurogenic communication disorders, voice disorders, dysphagia, and fluency.26
Elderly patients at elevated risk for stroke who received preventive patient education through telehealth videoconferencing with a researcher were found to be as satisfied, as knowledgeable, and as likely to make behavioral changes to reduce vascular risk factors as those who received the same information through in-person sessions.27 Patients with mental health disorders achieved improved outcomes and better access to care through a variety of telehealth models that use phone, e-mail, and video consultation between primary care providers and specialists to create “virtual collaborative care teams.”28 When supported by telehealth systems that included video monitoring, sensors, and emergency alert pendants, patients with intellectual disabilities demonstrated greater independence in task completion than patients with similar disabilities who received standard care provided by on-site support staff.29 Patients with clinically significant levels of mental illness who received evidence-based cognitive behavioral and motivational interviewing therapy delivered via a telehealth nursing program had reduced ED utilization and improved medication adherence.30 More than 98,000 patients with mental health problems enrolled in telehealth programs sponsored by the Department of Veterans Affairs reduced psychiatric admissions by more than 24% and hospitalization days by more than 26%.31 Telehealth has also been effective and accepted as a means of delivering diagnostic and therapeutic care for mental health issues and infectious diseases to a prison population in Louisiana, with a large majority of providers expressing satisfaction and the belief that it improved patient prognosis and satisfaction.32
At a time when health care providers and policymakers are challenged to provide high-quality care in an accessible manner and at an effective cost, various uses of telehealth are demonstrating the capacity to improve quality, increase access, and lower costs for consumers.
DISRUPTING NURSING EDUCATION
Many nurse educators would readily agree that it may be time to disrupt how nurses are educated, replacing pedagogic methods in which students are passive learners, subject to much repetition, memorization, and recitation of content, with opportunities to apply and synthesize what they've learned. Such an approach would seem to be more consistent with both the dynamic landscape of health care and today's tech-savvy, highly interactive nursing students, the majority of whom are what Prensky called “digital natives,” raised in the age of technology and thus more accepting of it than their “digital immigrant” instructors and mentors.33 Such nursing students are more likely to understand that they may not always be in the same physical space as their patients and may therefore require skills in both long-distance and traditional assessment. Young nurses, whose practice will extend far into the future, need to be familiar with telehealth tools and methods. This requires that current nursing curricula stretch and grow, and incorporate various forms of telehealth technology to enhance the educational experience of nursing students and provide learning opportunities that would otherwise not be possible. For example, a team of nurses partnered with a software developer to create a virtual nursing care unit with an interactive database of electronic medical records, familiarizing students with the type of technology they will use later in practice.34 Educators have also used videoconferencing technology to deliver virtual clinical experiences of complex patient cases to nursing students in a rural area without easy access to these types of cases.35 The nursing students found that the nurse–patient interaction was “very up close and personal and very emotionally involved despite the distance.” In the future, virtual clinical experiences that employ telehealth technology and clinical simulation may be commonplace in nursing education, allowing students to experience a more diverse patient population and a wider range of health care issues while gaining confidence in using the digital assessment equipment they will be using in practice.
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In a survey completed by 719 telehealth nurses from 36 countries, more than 89% felt that telehealth technology tools should be included in the basic curricula of nursing programs.36 Respondents also expressed a need for both clinical experiences in telehealth and instruction in the use of the technology and in telehealth principles. The majority of survey respondents—who worked in settings including hospitals, colleges, call centers, clinics, and the military and in such specialty areas as medical–surgical practice, chronic care, pediatric care, psychiatric care, and obstetric care—reported receiving their telehealth training from equipment vendors or through trial and error, as necessitated by their practice. Besides the questionable reliability of this type of preparation, such on-the-fly training may be influenced more by the value vendors place on the equipment's technical capabilities than by the needs and considerations of the patient and nurse.
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For telehealth to move from marginal to broad acceptance, its use must be incorporated in nursing education. To practice effectively in the 21st century, nursing students must understand telehealth's various uses and obtain clinical experience in telehealth settings.
FORCES THAT DRIVE AND OBSTRUCT DISRUPTIVE INNOVATION
The fact that telehealth hasn't been quickly and effortlessly assimilated into the daily practice of nursing is not surprising. The general awareness of telehealth's effectiveness and positive impact on patient outcomes may not have kept pace with the rapidity of its development and sophistication. And translating research into practice is never easy. It may take decades for practitioners to begin using interventions that have been shown through research to be effective.37 Like other disruptive innovations, telehealth may be subject to more rigorous scrutiny than traditional practice because it defies what we “know” and challenges our comfort level. As with all disruptive innovations, there are stakeholders who support it and those who resist it.
Factors currently driving the adoption of telehealth include rising health care costs, the public's desire to “age in place,” patients’ increasing comfort with technology, the new generation of nurses who expect to incorporate technology into their practices, and the profit motive of device manufacturers. Factors slowing more widespread adoption of telehealth include concerns about privacy, the fear of diminishing human contact in health care, and limited reimbursement.
Although privacy concerns may hinder acceptance, the same standards of confidentiality and protection of health information that govern traditional practice are applicable to telehealth practice. Even before personal health information was digitized, patients risked having paper records misplaced or misused. Within telehealth applications, such data actually benefit from additional oversight by federal agencies such as the Food and Drug Administration, the Federal Trade Commission, the Federal Communications Commission, and the Department of Health and Human Services.38 While establishing human contact with patients is always a primary nursing concern, telehealth proponents are not looking to replace traditional care with telehealth, but rather to supplement it as a means of providing quality care in situations in which traditional approaches are not plausible. And numerous studies involving the use of telehealth technology to deliver home care to a variety of patient populations—including premature infants, mental health care patients, veterans enrolled in a tobacco cessation program, and patients with heart failure or chronic obstructive pulmonary disease—have shown patients to be satisfied with the relationships established and the care provided.39-42 In fact, some patients and nurses report that the technology can make the nurse–patient relationship seem more, rather than less, intensive.43 More difficult to overcome may be current reimbursement policies. Despite telehealth's extensive and effective use within the VHA, federal reimbursement policies have limited telehealth practice to designated sites (hospitals in remote areas, for example) or purposes (radiology, pathology, or cardiology readings, for example).6 Barriers include varying state policies governing services reimbursed within public health programs; licensure and credentialing issues (when the patient and provider are in different states, for example); and the fact that most telehealth research has been based on patient and provider surveys, rather than on the gold standard of randomized controlled trials, often focusing on outcomes and satisfaction at the expense of potential cost savings.
NURSE ACCEPTANCE OF TELEHEALTH
It may be useful for nurses to examine their own technology readiness as a means of assessing their likelihood to incorporate telehealth and other disruptive innovations. Parasuraman has described an index, consisting of both contributors to and inhibitors of technology readiness.44 Contributors include optimism and innovativeness; inhibitors include discomfort and technologic insecurity. On the readiness scale, “thought leaders” and nurses who have a positive view of technology tend to rank higher than those who feel overwhelmed, not in control, or skeptical about technology.
A recent article examining telemedicine's uneven path to widespread acceptance proposed that successful integration of new health care technologies requires they be recognized as beneficial both to society (for example, in terms of cost-effectiveness or improved patient outcomes) and to the practitioners using them.45 In the case of telehealth and its evolving assimilation, nurses and other health care professionals will need to believe that, when applied appropriately, telehealth can improve their practice and the lives of their patients (see An Author's Call to Action46-48). Its value depends a great deal on its acceptance, perception of usefulness, and ease of use by both patients and practitioners.
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29. Taber-Doughty T, et al. Standard care and telecare services: comparing the effectiveness of two service systems with consumers with intellectual disabilities J Intellect Disabil Res. 2010;54(9):843–59
30. Cook PF, et al. Effects of telephone counseling on antipsychotic adherence and emergency department utilization Am J Manag Care. 2008;14(12):841–6
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32. Glaser M, et al. Provider satisfaction and patient outcomes associated with a statewide prison telemedicine program in Louisiana Telemed J E Health. 2010;16(4):472–9
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39. Battaglia C, et al. Building a tobacco cessation telehealth care management program for veterans with posttraumatic stress disorder J Am Psychiatr Nurses Assoc. 2013;19(2):78–91
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41. Gund A, et al. A randomized controlled study about the use of eHealth in the home health care of premature infants BMC Med Inform Decis Mak. 2013;13:22
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For four additional continuing nursing education activities on the topic of telehealth, go to www.nursingcenter.com/ce.
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