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Journal of Cardiovascular Nursing:

Videoconferencing and Telehealth Technologies Can Provide a Reliable Approach to Remote Assessment and Teaching Without Compromising Quality

Winters, Jill M. PhD, RN; Winters, Jack M. PhD

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Author Information

Jill M. Winters, PhD, RN Director, Office of Nursing Research and Scholarship, and Associate Professor, College of Nursing, Marquette University, Milwaukee, Wis.

Jack M. Winters, PhD Professor, College of Engineering, Marquette University, Milwaukee, Wis.

This work was funded in part by Health Resources and Service Administration (D09HP00571), the Rehabilitation Engineering Research Centers on Telerehabilitation (H133E980025) and Accessible Medical Instrumentation (H133E020729) (National Institute of Disability and Rehabilitation Research, Department of Education), and the Falk Foundation.

Corresponding author Jill M. Winters, PhD, RN, Office of Nursing Research and Scholarship, College of Nursing, Marquette University, PO Box 1881, Milwaukee, WI 53201-1881 (e-mail:

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Cardiovascular disease remains a significant chronic healthcare problem in this country, with considerable associated economic and quality-of-life challenges. Along with these challenges, there is high demand for healthcare provider time, particularly in the areas of management of complex healthcare needs and patient education. At the same time, a critical nursing shortage exists. Telehealth technologies provide opportunities to meet the rapidly growing needs of consumers and healthcare practitioners. Many in need of services have limited access to high-end technologies. An argument has been made that the lowest level of technology needed to carryout a task should be used, if it is capable of providing the necessary services. Videoconferencing capabilities allow healthcare practitioners to engage in virtual face-to-face encounters with patients or other healthcare providers. A variety of levels of sophistication in these videoconferencing systems are available. In an effort to evaluate the effectiveness and consumer satisfaction with videoconferencing, 3 pilot studies were conducted to compare face-to-face, low-bandwidth, and high-bandwidth approaches to performing common assessments and patient education activities. In one study, a variety of experienced healthcare practitioners performed functional assessments of stroke subjects using a collection of validated scales by varying approaches (face-to-face, low-bandwidth, and high-bandwidth videoconferencing) in a randomized order. In a second study, undergraduate nursing students performed similar performance measures and taught an unfamiliar individual how to program and use an intravenous pump device, take a tympanic temperature, or to draw up insulin in a syringe. In the third study, advanced practice nursing students assessed vital signs and performed cardiopulmonary assessments on community-dwelling subjects using low-bandwidth and face-to-face approaches. Healthcare practitioners and students generally preferred high-bandwidth approaches over low-bandwidth alternatives when videoconferencing was performed; however, most participants and practitioners were satisfied with the encounters, regardless of the level of technology used.

In 2003, 71.3 million Americans had some form of cardiovascular disease.1 The estimated direct and indirect costs associated with cardiovascular disease and stroke in the United States in 2006 is $403.1 billion.1 In addition to the high economic and quality-of-life challenges associated with cardiovascular disease, there is high demand for healthcare provider time, particularly in the areas of management of complex chronic healthcare needs and patient education. Given the current nursing shortage, it will become increasingly difficult to meet these needs, and creative solutions must be identified to meet these needs.

Recently, Beurhaus et al2 reported findings from 2 surveys of nurses. Ninety-eight percent of registered nurses who completed the surveys viewed the nursing shortage as a source of stress, 93% believed that it lowered the quality of patient care, and 93% believed that it would result in more nurses leaving the profession. These challenges must be faced directly, and use of telehealth technologies may be a useful strategy to extend the availability of nurses without imposing additional burden.

Telehealth technologies are revolutionizing the healthcare delivery system and altering conventional methods of providing patient care. Although implementing new healthcare delivery systems with increasing levels of technology may not solve all of these challenges, use of telehealth technologies to assist nurses in the workplace may begin to address some of the obstacles. Recent studies have shown that integrating home telehealth with a healthcare institution's electronic database can significantly reduce resource use and improve cognitive status, treatment compliance, and stability in chronic disease for homebound elderly with common complex comorbidities.3,4 Significant cost savings4-8 and satisfactory or improved outcomes have been reported when comparing telehealth approaches with traditional care for chronic disease management of asthma,9 diabetes,6,7,10,11 heart failure,6,7 and psychiatric disorders,11,12 as well as acute and chronic wound management.6-8

Some examples of telehealth technologies that have been implemented in the acute care setting include the electronic medical record and medication dispensing devices. The healthcare environment is experiencing an influx of telehealth technologies that allow patient monitoring and management of chronic health problems, predominantly in the home. A few examples of the telehealth remote monitoring devices are available for pulse oximetry, heart rate, blood pressure, weight, spirometry, glucometers, electrocardiogram recorders, and thermometers, to name a few. In addition, remote stethoscopes, wound cameras, dermatology scopes, otoscopes, opthalmoscopes, and videophones provide additional opportunities for remote assessment. The scope of telehealth technologies and possible applications is vast. Therefore, the focus of this article will be to address possible applications for remote monitoring and videoconferencing for performing remote assessments and engaging in patient teaching.

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Currently, there are essentially 4 modes of telecommunication, including voice only (eg, ordinary telephone), video/images (eg, digital pictures), data exchange (eg, keyboard/mouse operations), and virtual contact (eg, videoconferencing).13 Some background information on telecommunication technologies may be useful for clinicians and researchers alike. Therefore, a brief overview will be presented.

When use of a telecommunication device is considered, it is essential that the amount of information that can be exchanged per unit time be taken into account. For instance, as signal codecs have improved and been standardized, the required bandwidth for a telephone-quality voice is approximately 16 kilobits per second (kbps); for stereo-quality voice, approximately 64 kbps is needed; and for near-television-quality voice with video, approximately 400 kbps is needed.13 As a point of reference, current cell phones transmit at approximately 8 to 14 kbps. Video and detailed images require much more bandwidth than audio or data alone.

The impact of teleconferencing standards by the International Telecommunications Union has been significant. These standards were introduced approximately 10 years ago. Since that time, the cost of teleconferencing has been reduced dramatically, the quality has improved, and systems have become more user-friendly. These standards cover both the traditional telephone line infrastructure (H.320 and H.324) and the packet-based Internet protocol infrastructure (H.323). Each standard characterizes messaging protocols that control transmission of audio, video, and data between 2 or more systems. They also provide standards for video and voice codecs, security, privacy, and multiplexing and data control.14 Codecs allow for compression and decompression of audio and video data to allow these images and audio to be transmitted more quickly and efficiently.

The H.324 standard relates to videophones, intended for use over standard telephone lines, or plain old telephone service lines, using low bandwidth. This standard is generally targeted at telehomecare applications, where simplicity and ease-of-use are a priority, and when high-quality video is not essential.15 Use of these systems is very different from using high-end telephones that offer special features, and the main user-controlled features are the interactive control systems. The primary advantages of this type of system are relatively low cost, readily available telephone lines, and ease of use, whereas the main disadvantages are the slow refresh rate resulting in lower-quality audio and video, "choppy" video images, and mismatch between the audio and video timing. The typical video refresh rate is between 1 and 15 frames per second. For many home telehealth products, the use of a small video screen (eg, 3 × 5 in) makes pixelation less noticeable. These devices often can be paired with telemonitoring devices to assist in completing a complete remote assessment.

The H.320 standard typically is applied to dedicated circuit-based connections, using moderate to high bandwidth, such as the Integrated Services Digital Network (ISDN) digital telephone protocol. Each 128-kbps ISDN line requires the use of 2 standard telephone lines in parallel. Users may elect to use 1 to 4 ISDN lines, or the equivalent of 2 to 8 telephone lines operating in parallel. The additive effect results in significantly higher levels of resolution and speed of delivery as the number of ISDN lines increases. Use of 3 ISDN lines produces near-television-quality audio and video. Systems operating under the H.320 standard typically have been hub-spoke networks, allowing metropolitan medical centers to network with rural and distant sites. Today, there is widespread use of these networks for conferencing of all types, ranging from telemedicine/telehealth consultations between tertiary and rural intensive care units to routine videovisits between collaborators anywhere. An especially useful feature of this type of videoconferencing is the ability to control both local and remote camera orientations. In addition, virtually all of the newer H.320-compliant products are H.323 compliant as well, and they can be used for transmission of one or more channels of data, allowing simultaneous transmission of data, images, and/or sound. The main advantages of this type of system are the high-quality audio and video and the ability to control cameras remotely. The main disadvantages are cost and the need for both parties who are involved in the videoconference to have ISDN capacity.

The H.323 standard for packet-based Internet protocol conferencing serves as a suite for a large umbrella of other standards. A significant category of H.323 is the "voice and data" mode that does not require video, often called "voice-over Internet protocol."15 H.323 videoconferencing can be integrated into the electronic health record and then used for desktop and mobile computing operations. The advantages of using H.323 are that the Internet is relatively low cost and readily accessible, whereas disadvantages include lack of predictability and guaranteed quality of service and the convention for asynchronous allocation of downstream versus upstream bandwidth for either digital subscriber lines or cable modems.15

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Videoconferencing and Multimedia Collaboration

Videoconferencing equipment makes televisits possible. Televisits should be goal directed, and specific tasks must be accomplished by persons who have been educated and trained to perform these tasks.16 There are essentially 5 types of televisits:

* Tele-assessment (active remote assessment)

* Telemonitoring (generally minimally intrusive using sensors and measurement devices)

* Telesupport (goal of the encounter is to provide support for patients and/or providers, eg, emotional support)

* Telecoaching (support and instruction for a prescribed therapy are conveyed)

* Teletherapy (actual interactive therapy)

Although the possibility of using videoconferencing initially may be seen as an important adjunct for patients who are being managed remotely for chronic health problems, it is not necessary for all patients. Specific situations in which video connections have been very useful include heart failure,17 cardiomyopathy,18 wound care,19,20 asthma,9 psychiatry,11,12,21 dermatology,11 and diabetes management.11,22 More widespread applications of videoconferencing have been recognized with cardiovascular patients in acute care settings, including patients with myocardial infarction18,23,24 and congenital heart disease.25,26 When determining the utility of videoconferencing, decisions regarding the type of equipment required must be made. Because of cost implications and potential lack of availability of more sophisticated telecommunication systems, it is always desirable to use the lowest level of technology needed to accomplish the task at hand. This choice also may be based on consideration of the abilities and preferences of the users. From this perspective, videoconferencing could be considered one alternative of multimedia collaboration, where the modes selected depend on needs, abilities, and preferences. That is, videoconferencing may merely include transmission of audio and video of the individuals engaged in the encounter, or it may include additional media such as digital photos, electrocardiogram tracings, or written instructions that could be printed or saved electronically, to name a few. Furthermore, the equipment used for videoconferencing can include such devices as a set-top box on a television, a videophone, a computer with a Webcam, a "smart" personal digital assistant, or cell phones housing small displays with built-in cameras and wireless monitoring capabilities.

To provide empirical data comparing the efficacy of face-to-face encounters with use of low-bandwidth (H.324; 28-33K) and high-bandwidth (H.320; 384K) videoconferencing equipment to perform clinical assessments or procedural teaching, a series of 3 studies were carried out.27

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Study 1: Healthcare Practitioners and Survivors of Stroke

An exploratory study was carried out with 6 healthcare providers and 6 stroke survivors. The healthcare providers included physical therapists (n = 3), registered nurses (n = 2), and a physiatrist (n = 1). The stroke survivors had varying degrees of hemiplegia. All testing was conducted in the Telerehabilitation and Performance Assessment Laboratories at Marquette University.

Healthcare providers and stroke survivors were randomly assigned to each other and to condition. Each healthcare provider and stroke survivor engaged in one session using low-bandwidth videoconferencing equipment, high-bandwidth videoconferencing equipment, and one face-to-face encounter. Healthcare providers conducted a number of assessments under each condition, including the Motor Activity Log,28 the Barthel Index,29 the 9-Hole Peg Test,30 the Functional Independence Measure,31 the Fugl-Meyer Assessment,32 and the Jebsen-Taylor Hand Test.33 The Fugl-Meyer Assessment was completed only by those practitioners with certification to do so.

During the planning phases, usability testing was conducted to determine the number and placement of cameras necessary to perform the desired activities. Equipment was selected based on reliability and robustness. Before the actual trials, approximately 1 hour of training was provided for each healthcare provider, along with educational materials and copies of the data collection forms. During the actual trials, a healthcare professional (physical therapist or registered nurse) was present in the room with the patient, and the encounter was videotaped at both the patient and provider location. The practitioner present with the patient performed a face-to-face assessment. Videotapes were coded by a physical therapist and registered nurse. Upon completion of each session, both practitioners and stroke survivors completed satisfaction surveys.

With the exception of a few sections of the Fugl-Meyer Assessment, practitioner participants were able to score all tests remotely. Frequently, healthcare providers commented that the audio was more important than the video, but the video was generally necessary to verify the audio transmission. Few differences were noted between scoring, regardless of whether the testing was completed face-to-face or by means of low- or high-bandwidth videoconferencing. Furthermore, there were no discernable trends in deficiencies or incorrect ratings between low- and high-bandwidth assessments. When differences were noted, they seemed to be more related to practitioner comfort with the technology than the adequacy of the audio and video data. However, practitioners noted that when performing remote assessments, it was very beneficial to have a caregiver present to assist the participant with some of the testing procedures.

A high level of satisfaction with the video encounters was expressed by stroke survivors and their caregivers, and most expressed a willingness to use these approaches for consultations with their healthcare providers. Some stroke subjects and their caregivers went so far as to say they would prefer the video encounters, if it meant that they would not have to leave their homes.

Satisfaction with high-bandwidth assessments approached that of face-to-face encounters for healthcare providers. When comparing satisfaction with low- and high-bandwidth approaches, higher confidence was expressed in ability to perform assessments when using high-bandwidth videoconferencing. If remote assessment was going to be used, healthcare providers expressed a preference for high-bandwidth video; however, a willingness to use the low-bandwidth was conveyed if the high-bandwidth video was not available. Healthcare providers indicated that 1 hour was sufficient for training, and it provided adequate competency with the equipment.

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Study 2: Simulated Practitioner-patient Interactions for Undergraduate Nursing Students

Thirty-four undergraduate nursing students participated in this exploratory study, designed to compare face-to-face interactions with televisits using low- and high-bandwidth technologies. Common neurological assessments and educational activities were performed. Students ranged in age from 18 to 50 years; 30 were women, and representatives from freshman (n = 3), sophomore (n = 2), junior (n = 22), and senior (n = 7) levels were included. All testing was completed in the Telerehabilitation and Performance Assessment Laboratories at Marquette University.

Neurological examinations and teaching activities were randomly assigned to condition, and all students served as "patient" before assuming the role of "practitioner." In all instances, the sequence of conditions was low-bandwidth, high-bandwidth, then face-to-face encounters. The common neurological assessments included the Jebsen-Taylor Hand Function Test33 and the 9-Hole Peg Test.30 The Jebsen-Taylor Hand Function Test was divided into pairs of activities, such that for each condition, participants carried out only 2 of the tests. Common neurological tests were paired with a single teaching activity for each condition. The teaching activities included drawing up insulin from a vial, programming an intravenous pump, and taking a tympanic temperature. These teaching activities were randomly assigned to condition, such that each activity was taught only once during each sequence. These activities were selected because they lent themselves to verification of correct execution of the procedure. Upon completion of the "patient" and "practitioner" portions, participants completed evaluation and satisfaction instruments.

Preliminary evidence of the efficacy of this study was provided by the usability testing in the previously reported study. In this second study, students were provided with approximately 15 minutes of orientation to each condition. Written guidelines were provided to assist students when serving in the healthcare "provider" role. For the freshman and sophomore students, all procedures were new. The Jebsen Taylor Hand Function Test and the intravenous pump were unfamiliar for all participants. For remote conditions, a member of the research team served as an assistant to set up equipment for the neurological examinations and to assist with occasional verifications. The research team member also served as a surrogate caregiver.

Under all conditions, students were able to follow directions when serving as "patients," and they performed well in the healthcare provider role, giving directions and making evaluations. Use of the research team assistants was needed more frequently for verifications when the low-bandwidth videoconferencing was used than the high-bandwidth approach. When using high-bandwidth technology, the "practitioner" was almost always able to verify insulin dose in syringes, temperatures on thermometers, and settings on the intravenous pump. When using the low-bandwidth equipment, participants often expressed that the audio was more valuable than the video, but the video was necessary for the teaching and assessments to be completed and evaluated.

Participants completed 2 satisfaction/evaluation instruments. In general, participants expressed satisfaction with their experiences under all 3 conditions. However, they found the assessments and teaching sessions easier to complete when using the high-bandwidth equipment or in the face-to-face encounters. Several students included narrative comments on their evaluation forms that conveyed their satisfaction with the experiences. Participant 412 noted, "Both the high and low band were useful and either one could save a lot of time for both patients and health care providers." Similarly, participant 414 shared, "This technology is fascination. It would save both patients and doctors so much time and is great for being able to perform simple tests, do teaching about meds, or asking/answering questions patients may have. The quality of the high bandwidth was excellent." Participant 421 conveyed that although she could perform the necessary activities using the videoconferencing equipment, she would miss the physical contact that she enjoys when interacting with her patients in face-to-face encounters. Interestingly, no physical contact between participants was noted during any of the face-to-face encounters in this study. Furthermore, it was noted that eye contact was much more consistent during the videoconferencing encounters, and participants turned their backs on each other only during the face-to-face situations.

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Study 3: Advanced Practice Nurses' Experience With Remote and Face-to-face Cardiopulmonary Assessments

The purpose of this descriptive study was to examine community-dwelling participant and advanced practice nursing (APN) student satisfaction with televisits when compared with traditional face-to-face encounters. In addition, the utility of using telemonitoring equipment, videoconferencing, and remote stethoscopes to perform a basic cardiopulmonary health examinations was evaluated. A convenience sample of 20 APN students and 10 community-dwelling individuals was enrolled in the study.

Advanced practice nursing students and community participants underwent training for use of telemonitoring and videoconferencing equipment before engaging in scripted scenarios. All participants carried out these scenarios using both face-to-face and remote approaches, with order randomly assigned. Low-bandwidth videoconferencing was used. Data were collected by means of a demographic data form, documentation of the physical examination, and provider/participant satisfaction forms. Data were analyzed using descriptive statistics.

A high level of satisfaction was expressed by both APN students and community participants. Advanced practice nursing students frequently commented that the remote stethoscopes provided better sound quality when listening to heart and lung sounds than the stethoscopes they used during face-to-face encounters. Each community participant was examined twice in a face-to-face encounter and twice using videoconferencing and remote monitoring. This procedure allowed for 4 APN students to evaluate each community participant. There was more than 95% agreement on assessment data, with no pattern noted for inconsistencies.

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Perhaps, the most important application of telehealth technology in nursing practice is management of chronic health problems. Nurses have an opportunity to be leaders in proactively managing patients with many chronic health problems. Heart failure is the most expensive healthcare problem in this country. Telemonitoring allows nurses to have access to changes in a number of indicators of heart failure status in a timely fashion and at times that the nurse and patient have identified as being appropriate. Use of videoconferencing during televisits allows nurses to see how patients are using equipment as well as patient postures and facial expressions and to monitor visual symptoms. Remote stethoscopes have excellent sound quality and allow nurses to listen to heart and lung sounds without requiring patients to leave their homes or a homecare nurse to make a special visit. Many remote stethoscopes have volume control and recording capabilities. In addition, some videoconferencing equipment allows for digital pictures or videorecording. These recorded data can then be integrated into the electronic medical record. A need exists to introduce practicing nurses and nursing students to the use of these devices, to prepare nurses to practice in the 21st century with the latest technology to assist them in delivering high-quality nursing care.

Technology is becoming a mainstay in healthcare. Nursing, as a profession, needs to have a voice in how technology will be integrated into healthcare practices. Therefore, nurses need to be fluent in the language, comfortable with the equipment, and visionary in their approach to managing health and illness. Technology allows nurses to reach out and touch patients and caregivers in their own environments. It provides healthcare providers with timely access to information, allowing for more timely intervention.

Use of telehealth technologies may also provide a means of keeping some nurses in the profession who would otherwise not be able to do the physical work of nursing. It is well known that nursing requires physical strength and that many nurses experience injuries as a result of this physical work. Injuries may force nurses out of the profession. Use of telehealth technologies provides a venue for these nurses to continue to use their assessment and communication skills, draw on their years of experience and expertise, and deliver high-quality care to patients without having to engage in the physical work of nursing. Furthermore, use of telehealth technologies allows the nurse to monitor and interact with many more patients per day than the typical homecare nurse, who can see only 7 to 8 patients in a typical 8-hour day. These technologies can also provide the nurse with information about which patients have the greatest need for an in-person visit, optimizing the valuable time of the homecare nurse. All of these implications of use of telehealth technologies may provide a valuable means of addressing a portion of the nursing shortage.

Most nurses entered the profession to provide direct patient care in the traditional sense. However, the value that technology brings to healthcare cannot be ignored. Technology can be both challenging and empowering. It is our challenge in nursing to see to it that we embrace the available technology and use it to empower our practice. Nursing is well positioned to have a strong voice in how technology will be used in patient care. It is imperative that our voice is heard.

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We would like to acknowledge Adenine Stanislaus, Sarah Kolman, and Kelly Retzlaff for their assistance in carrying out the 3 reported studies.

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remote assessment; telehealth; videoconferencing

© 2007 Lippincott Williams & Wilkins, Inc.


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