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Virtual care

The time is now

Sensmeier, Joyce, MS, RN-BC, CPHIMS, FHIMSS, FAAN

doi: 10.1097/01.NUMA.0000552738.79448.3e
Feature

Learn all about recent advances in telehealth and how it can enable access to healthcare that isn't limited by time, place, or the availability of skilled healthcare professionals.

Joyce Sensmeier is the vice president of informatics for the Healthcare Information and Management Systems Society, a Nursing Management editorial board member, and the coordinator of the bimonthly Nursing Informatics department.

The author has disclosed no financial relationships related to this article.

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We're experiencing the transformation of healthcare from relying predominantly on face-to-face encounters to using a smart watch to remotely transmit vital signs from anywhere in the world. It's difficult to appreciate the many changes in how we deliver care today, but clearly an evolution is underway. Telehealth has been foundational to this evolution, beginning in 1897 when a case of croup was first diagnosed over the telephone.1 Closed-circuit TV links, live video feeds via satellite, and transmission of physiologic signals from astronauts in space to command centers on Earth are all part of the journey that's informed the use of telehealth as we're now experiencing it. Growth in telehealth has enabled access to healthcare that isn't limited by time, place, or the availability of skilled healthcare professionals.

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What's telehealth?

Telehealth is “the provision of healthcare remotely by means of a variety of telecommunication tools, including telephones, smartphones, and mobile wireless devices, with or without a video connection.”2 Among the early applications of telehealth were programs to provide care to individuals in the military, prisons, or rural locations. According to URAC, the top three reasons to provide telehealth services are to increase access to care, provide better coordination of care, and reduce healthcare costs. (See The Current State of Telehealth.3) The internet has played an important role in advancing this convenient vehicle for healthcare delivery. Other drivers include technologies such as remote patient monitoring that further the expansion of telehealth from addressing acute conditions to addressing episodic and chronic conditions. As the continuum of care shifts, the use of telehealth has migrated from hospitals and clinics to include home and mobile devices. Today, telehealth is being integrated into the routine care of patients around the globe.

Real-time or synchronous telehealth uses live, interactive telecommunications and/or patient monitoring technologies to connect a healthcare provider to a patient for virtual visits, include other healthcare providers for consultation, or enable a combination of the two. Videoconferencing integrates audio, video, and communication technologies to allow people in different locations to share encrypted, electronic health information in an interactive environment.1

Patient monitoring devices can remotely collect biometric data and enable secure data transfer to healthcare providers for interpretation. Other devices include blood glucose monitors, digital scales, thermometers, ECG devices, and BP and pulse monitors. These personal devices can automatically capture vital signs data, or the individual can log the data for clinician review. A monitoring center performs the data assessment and triage, and clinicians are alerted if appropriate.

Asynchronous or “store and forward” telehealth allows for the transmission of health information, such as health histories, videos, images, or audio files, to be used when healthcare providers and patients aren't available at the same time. The receiving healthcare provider's response is then transmitted electronically back to the sending provider or patient.4

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Essential components for implementation

According to a model developed by the McGill University School of Nursing, when planning for telehealth implementation, four main components must be considered: bandwidth, education, leadership, and technology, or BELT.1

Bandwidth includes the ability to move and store digital data. Adequate infrastructure and telecommunications capabilities may be problematic for rural or underserved geographic regions.

Education is necessary to ensure that healthcare providers have the competencies and skills to use telehealth technologies. As these technologies advance, healthcare providers will require knowledge of telehealth capabilities and applications to deliver safe and effective clinical care.

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Leadership requires an understanding of how operationalizing telehealth impacts current practice, policy, and care delivery. Strong leaders will anticipate and address potential barriers and resistance to telehealth that require solid staff communication and support strategies. It's vital for the leader to set the right tone and guide the strategy.

Technology to enable telehealth is rapidly evolving, which creates challenges for choosing the optimal platform, devices, and applications. It's essential to leverage technical resources across the organization to evaluate the interoperability with other systems and ensure that telehealth technologies are integrated into a single environment that supports holistic care.

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Barriers and benefits

After years of promise, it seems that telehealth is finally going mainstream. Faster internet connections, ubiquitous smart devices, and plentiful bandwidth are some of the technology-related enablers feeding telehealth's rapid advancement. More states are joining a compact that allows a healthcare provider licensed in one member state to quickly obtain a license in another, addressing the cross-state licensure barrier.5 Changes in reimbursement models are also responsible for acceleration of telehealth adoption. Numerous bills have been introduced regarding what services Medicaid will cover, redefining the reimbursement model for telehealth. And more hospitals are likely to invest in telehealth systems as they move away from fee-for-service payment to set fee-type contracts for managed care.6

In February 2018, Congress passed the Bipartisan Budget Act, which included a requirement that telehealth be allowed as a basic benefit in the Medicare Advantage program. The Centers for Medicare and Medicaid Services proposed rules in November 2018 to implement this provision and sought comments through December 31, 2018.7 If finalized, these proposed changes won't go into effect until 2020, but it's clear that regulatory barriers are decreasing, and the uptake of telehealth services is on the horizon.

Today's consumer expects less waiting time in the physician's office and seeks immediate care for minor but urgent conditions.8 The benefits of telehealth to these savvy patients are numerous, including:1

  • decreased travel time or distance
  • immediate access to care
  • early detection of health issues
  • ownership of healthcare and feelings of empowerment
  • long-term health and independence
  • caregiver reassurance
  • increased satisfaction with healthcare.
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Successful use of telehealth

Telehealth is no longer in its infancy; it's now a powerful resource that can create more efficient operations while enhancing care and improving outcomes. The term telehealth is even evolving, now being described as virtual care.9 The American Telemedicine Association notes that many organizations are implementing telehealth programs within the umbrella of innovation. Successful programs are taking an enterprise approach that maximizes the use of resources, streamlines operations, consolidates workforce, and enables scale.9

Deloitte Consulting LLP recommends addressing these eight strategic requirements to achieve a successful approach to telehealth:9

  1. strategy and governance
  2. cognitive and analytics
  3. technology, infrastructure, and interoperability
  4. workforce readiness and engagement
  5. patient experience and engagement
  6. revenue risk and progression
  7. care model design
  8. operation and workflow integration.
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Real-world examples

The University of Pittsburgh Medical Center has implemented remote patient monitoring through its digital portal. Postpartum patients receive daily text messages to their smartphones with prompts to send their BP and pulse readings and answer a few questions. These responses are checked by nurses who also respond to any alerts or patient requests. To date, 57% of patients have been able to skip the 1-week postpartum visit for a BP check, drastically reducing the number of unnecessary visits.10

At Inspira Health Network, nearly 100% of behavioral health consults are completed through a telepsychiatry provider who can document directly into the electronic health record. This approach has substantially reduced wait times and improved patient throughput.11

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On the horizon

Overall, the number of patients using telehealth jumped from 206 in 2005 to 202,374 in 2017, with an average growth rate of 52% per year.12 In recent research about innovation in health information technology (IT), telehealth ranked third in hospitals' top innovation priorities for 2019.13 The Center for Connected Medicine polled IT executives across 38 health systems for its Top of Mind survey. Telehealth ranked second and, as one CEO noted, consumer demand for easy and streamlined technology is driving its adoption.14

The growth of telehealth points to the promise of broader access for all, especially in specialty areas where access to expert care is limited. Many factors are driving a renewed interest in telehealth, including the demand for a consumer-driven healthcare system, a growing shortage of specialists, and cost containment strategies that shift financial risk from payors to providers and consumers.15 Technologic advancements have minimized the previous barriers to high-quality, seamless communication. Patients and healthcare providers increasingly incorporate, and even embrace, technology in their daily lives. Whatever term we use—telemedicine, telehealth, or virtual care—its time has finally come.

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REFERENCES

1. Schlachta-Fairchild L, Rocca M, Cordi VE, et al Telehealth and applications for delivering care at a distance. In: Nelson AR, Staggers N, eds. Health Informatics: An Interprofessional Approach. St. Louis, MO: Elsevier Mosby; 2014:125–145.
2. Dorsey ER, Topol EJ. State of telehealth. N Engl J Med. 2016;375(2):154–161.
3. URAC. The current state of telehealth. 2018. http://www.urac.org/blog/current-state-telehealth-infographic.
4. Messineo L. Telehealth: transforming care delivery. Healthcare Information and Management Systems Society. 2017. http://www.himss.org/library/telehealth-transforming-care-delivery.
5. National Council of State Boards of Nursing. Nurse licensure compact (NLC). 2018. http://www.ncsbn.org/nurse-licensure-compact.htm.
6. Beck M. How telemedicine is transforming health care. Wall Street Journal. 2016. http://www.wsj.com/articles/how-telemedicine-is-transforming-health-care-1466993402.
7. American Telemedicine Association. Medicare Advantage CMS proposed rule November 2018: how it works. 2018. https://thesource.americantelemed.org/blogs/jessica-washington/2018/11/30/medicare-advantage-cms-proposed-rule-november-2018.
8. Quora contributors. What are the latest trends in telemedicine in 2018. Forbes. 2018. http://www.forbes.com/sites/quora/2018/07/31/what-are-the-latest-trends-in-telemedicine-in-2018.
9. Roth M. Virtual care is no longer optional: what's now, what's next, and how to get there. Health Leaders Media. 2018. http://www.healthleadersmedia.com/innovation/virtual-care-no-longer-optional-whats-now-whats-next-and-how-get-there.
10. Siwicki B. Remote patient monitoring via smartphone cuts one-week post-partum visits by 57%. Healthcare IT News. 2018. http://www.healthcareitnews.com/news/remote-patient-monitoring-smartphone-cuts-one-week-post-partum-visits-57.
11. Siwicki B. Telehealth brings psychiatrists into Inspira Health's emergency rooms. Healthcare IT News. 2018. http://www.healthcareitnews.com/news/telehealth-brings-psychiatrists-inspira-health's-emergency-rooms.
12. Barnett ML, Ray KN, Souza J, Mehrotra A. Trends in telemedicine use in a large commercially insured population, 2005-2017. JAMA. 2018;320(20):2147–2149.
13. HIMSS Media. HIMSS Media announces release of health information and technology content marketing research. 2018. http://www.himssmedia.com/news/himss-media-announces-release-health-information-and-technology-content-marketing-research.
14. Harris B. Center for Connected Medicine polls top health systems about 2019 priorities. Healthcare IT News. 2018. http://www.healthcareitnews.com/news/center-connected-medicine-polls-top-health-systems-about-2019-priorities,
15. Glaser JP. Telemedicine hits its stride. In: Glaser J, ed. Glaser on Health Care IT: Perspectives from the Decade that Defined Health Care Information Technology. Boca Raton, FL: CRC Press; 2016.
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