Question

Answer the following questions in essay form and use atleast 2 peer reviewed articles within the past 5 years to support your answers. You are working as an RN in the community health department. You have been assigned as the first tele-nurse for the clinic outpatients. Your writing assignment must discuss the following concepts:

1.       What is your role as a tele-nurse?

2.       What tele-health tools will you be using?

3.       What are the clinical and nonclinical uses you to which you

          will apply informatics?

4.       What types of patients will you be using tele-health for?

5.       What are the legal, ethical, and regulatory issues that you

          must consider in using tele-health?

6.       Apply the Foundation of Knowledge Model to your work as a

          tele-health.

Answer 1

Telenursing refers to the use of telecommunications and information technology in the provision of nursing services whenever a large physical distance exists between patient and nurse, or between any number of nurses. As a field, it is part of telehealth and telemedicine, and has many points of contacts with other medical and non-medical applications, such as telediagnosis, teleconsultation, and telemonitoring. The field, however, is still being developed as the information on telenursing isn't comprehensive enough.

Telenursing is achieving a large rate of growth in many countries, due to several factors: the preoccupation in driving down the costs of health care, an increase in the number of aging and chronically ill population, and the increase in coverage of health care to distant, rural, small or sparsely populated regions. Among its many benefits, telenursing may help solve increasing shortages of nurses; to reduce distances and save travel time, and to keep patients out of hospital. A greater degree of job satisfaction has been registered among telenurses.

A Telemetry Nurse monitors patient's vital signs with an electrocardiogram or other life sign-measuring device. They usually provide care to patients with gastrointestinal diseases, heart failure, diabetes, and other acute diagnoses. Most often they work in hospitals or other clinical facilities.

Telemetry nurses review data from special equipment to track a patient's heart rate, blood pressure, breathing and other vitals. They also carry out more traditional nursing duties such as administering medications and communicating with patients regarding their condition.

Telehealth nursing is thought of as the use of telemedicine and technology to conduct nursing and deliver care in a remote location. This field includes telenursing, telehealth and nursing telepractice, which are all interchangeable terms. Nurses who practice telehealth come from all settings and use technology like web cameras, VOIP, the Internet and telephone lines to deliver care over a long distance. Telehealth care is effective despite being remote.

Telehealth nursing can be done anywhere. Nurses can make use of technology to conduct telehealth sessions in their homes, at doctor’s offices, in prisons, and in clinics and hospitals. Basically, any place where the proper technology is available is a suitable place for telehealth nursing.

In emergencies, nurses from around the world can participate in telephone triage set-ups. Wherever nursing is done in a telehealth setting, nurses can monitor a patient’s oxygen levels, heart rate, respiration, blood glucose and more.

Patients contact their nurses through the telehealth system to get help. In non-emergency situations, they can get the nurse to take their blood pressure readings or glucose readings, for instance. Nurses can instruct patients as to how to dress a wound or treat a minor burn.

The patients usually find their telehealth nurses through their managed health care organization. Nurses must be overseen there to regulate patient access to the system. Most of the time, the goal is to reduce the number of trips patients make to the ER.

Those circumstances where nursing care must be done quickly and efficiently where getting to a patient physically is difficult are the ideal situations. After a natural disaster, it may be that telehealth nursing is the only option available for those with minor injuries once telecommunications systems are up and running.

Routine pre surgical and post surgical care can be administered with telehealth nurse help. Nurses can also help continue to develop the best practices for specific circumstances as they arise.

The terms eHealth and telehealth are at times
incorrectly interchanged with telemedicine.
Like the terms "medicine" and "health care",
telemedicine often refers only to the provision
of clinical services while the term telehealth
can refer to clinical and non-clinical services
such as medical education, administration,
and research. Includes the use of mobile devices in
collecting aggregate and patient level health
data, providing healthcare information to
practitioners, researchers, and patients, realtime
monitoring of patient vitals, and direct
provision of care (via mobile telemedicine).

Telehealth has great potential to expand access and improve the quality of rural healthcare. It can reduce burdens for patients, such as travel to receive specialty care, and improve monitoring, timeliness, and communications within the healthcare system. While one of the most common images of telehealth is of a patient speaking by videoconference with a remote physician, telehealth can take other forms including:

=Mobile health communication or mHealth
=Remote patient monitoring or RPM
=Store and forward transmission of medical information

This guide helps healthcare providers find information on telehealth services and highlights funding opportunities and initiatives to implement telehealth services. It also provides examples of telehealth projects as models for rural hospitals and clinics to develop and implement programs. The guide discusses challenges for providing telehealth services in rural areas including workforce issues, quality of care concerns, reimbursement, licensure, and access to broadband services.

Telehealth can be used to reach patients in their homes through remote monitoring where personal health and medical data is collected from a patient in his home. The data is transmitted to the provider in a different location for use in care and related support.

Health websites proliferated, ranging from those offering a wide array of health information to sites dedicated to specific disease entities. Health-related information emerged as among the most frequently sought material on the Internet. Concurrently, more sophisticated electronic monitoring and assessment tools were developed, facilitating innovative approaches to remote monitoring of health status. This remote monitoring capability resulted in creative approaches to disease management. Technology that gathers and electronically transmits patient data to the physician for evaluation holds promise for saving both patient and providers substantial dollars. Escalation in deployment of remote technology to enhance health care, accompanied by expanded public and private reimbursement for distance care, indicates that the U.S. is accepting the concept of health care delivery via telemedicine as standard medical practice. This article will discuss the foundations of telehealth nursing and addresses legal and regulatory issues emerging from this new practice modality. As is often the case, adoption of innovative new approaches to care has occurred at a much more rapid pace than legal and regulatory questions have been answered.

Regulatory Perspective
Based on the Tenth Amendment to the U.S. Constitution, each state is empowered to establish laws to protect the citizens of the respective state. A component of this "public protection" mandate is the state responsibility for establishing standards for health care professionals who provide services for citizens of that state. For almost a hundred years, America has had a firmly established system for issuing state-based licenses to health care providers, including authorization to practice within the boundaries of the state that issued the license. However, no state is empowered to grant authority for professional practice in another state. Until recent years, licensure was not seen as an impediment to providing health care because the health facility, the health care provider, and the patient were almost always in the same location; and providers were licensed where the care was given. With the advent of multistate delivery systems and nursing call centers, however, the nurse and the patient are often in different geographical locations. Thus the century old, state-based licensure structure is now being challenged by an exploding world of technology and entrepreneurial care delivery services which are completely impervious to the confines of invisible state borders.

Federal Involvement
The Balanced Budget Act (BBA) of 1997 provided an impetus to the development of telehealth when it authorized Medicare telemedicine reimbursement under certain circumstances. Additionally, substantial federal dollars were earmarked for telemedicine grants to determine the viability of telemedicine to increase access to quality health care services for the underserved through use of advanced telecommunications and information technologies by rural health providers. Medicare currently pays for teleconsultation using two-way interactive video encounters as a substitute for "face to face" visits, but only if the patient is a part of the interactive video session.

To assist with evaluation of the overall telemedicine environment, Congress mandated preparation of a comprehensive report analyzing the obstacles to the advancement of telemedicine. This 1997 Department of Health and Human Services (DHHS) Telemedicine Report to Congress identified five major barriers to adoption of telemedicine, including: legal and regulatory issues; payment issues; safety and standards; telecommunications infrastructure, as well as privacy, security and confidentiality issues. The section of this report on legal and regulatory issue primarily addressed licensure with some discussion of liability. The revised 2001 DHHS Telemedicine Report to Congress indicates that the legal and regulatory dilemmas are as yet unresolved.

Legal Issues Emerging in Telehealth
While each of the respective areas of telehealth practice presents unique legal questions, three overarching "telehealth" questions are raised most frequently. The first major regulatory question, at the very heart of nursing practice and the nursing profession, is whether nursing care provided electronically over distance is actually the practice of nursing. The most widespread misperception about telenursing is that, while "tele" care may be highly interactive, it is not "hands on" and therefore not nursing practice. Additionally, nurses in call centers have been challenged about whether they are practicing nursing, since one element of their practice utilizes physician-approved protocols. Some speculate that telephone triage is actually delegated medical practice, not nursing practice, so licensure is not an issue.
The essence of the question is whether telephone and electronic nursing care are within the scope of nursing practice as authorized by the state nurse practice acts. To respond to this question, BONs have closely evaluated the definitions of nursing and scope of nursing practice. They have determined that nursing practice occurs at the point that a nurse utilizes the knowledge, skill, judgment and critical thinking that is inherent in nursing education and that is authorized through the nursing license. The state's legal definitions of nursing almost always include a) use of nursing education, b) critical thinking, and c) judgment. For example, any nurse could provide general information about preschool children with elevated temperatures. By contrast, when a parent contacts a telephone call center about a child with an elevated temperature, and a nurse initiates a series of assessment questions, e.g., other symptoms, duration of the fever, rash, fluid intake, and response to medication, and then the nurse synthesizes data as a basis for providing direction about the care, that nurse is utilizing the knowledge, judgment and expertise achieved through education and authorized by law to make decisions and recommendation about care. In these cases the nurse is indeed engaged in the practice of nursing.

A second regulatory dilemma is whether jurisdiction over telemedicine/telehealth will remain in the domain of traditional State’s Rights provisions (as is most traditional health care) with the issues being resolved by the states, or whether the practice will be deemed as interstate commerce. As described in the U.S. Constitution, interstate commerce is seen as provision of goods and services across state lines and is within the jurisdiction of the federal government. The benefit of matching the patient with the right provider, regardless of state boundaries, is without question. In recent years, the federal government has become involved with standards for health care, but only when it was determined that the wide variation and disparity among state standards was not in the best interest of the patient. One example of the federal government exerting its influence in health standards was adoption of the Clinical Laboratories Improvement Act (CLIA), which authorizes HCFA to set standards for and regulate all clinical labs across the country. Another example is the Mammography Quality Standards Act (MQSA) passed by Congress in 1992 to ensure that mammography is safe and reliable and that breast cancer is detected in its most treatable stages. The Food and Drug Administration has the responsibility for implementing and enforcing MQSA, which requires that all mammography facilities in the United States meet certain stringent quality standards, be accredited by an FDA-approved accreditation body, and be inspected annually.

As of this writing (September, 2001) recent draft language from potential federal legislation has been disseminated for review. This language would allow consultation in Community Health Centers by physicians duly licensed in states other than the state where the Community Health Center is located. Although, already supported by several health care organizations, reaction to this language is yet to be seen.

A third intriguing legal question impacts not only health care, but also other electronic services and business. With the emergence of telemedicine, there is no clear law or body of knowledge to resolve the question of "where does care occur" when the patient and the provider are in different geographical locations. Is the care legally provided at the location of the patient or at the location of the provider? If care occurs at the location of the patient, is the nurse practicing telenursing expected to obtain a nursing license in every state where there might be electronic contact with a patient? If care is determined to occur at the location of the provider, how does the patient/consumer know where and how to seek recourse in the event of substandard care or malpractice?

Regulatory Issues: Credentialing and Certification
One of the consistent questions about telehealth nursing is whether there is a need for certification or additional credentialing for telehealth practice. This question is being raised even though the last century has been replete with the introduction of new tools and technology in health care, resulting in a system that is quite adept at incorporating new technologies into patient care and that understands the expectation that users are trained, proficient and safe in using any new technology. Many of the calls for certification are from those who take a very narrow definition of telemedicine, and believe that the technology is so complex that some sort of credentialing mechanism is needed. The health care community seems to have reached consensus that current licensure authorizes the entirety of professional practice and therefore additional licensure is not necessary. However, the Office for the Advancement of Telehealth (OAT) established a task force to consider certification and delineated a number of issues to be addressed prior to establishing any certification process.

Knowledge acquisition involves the nurses receiving the information from thetelehealth devices via a variety communication modes. Knowledge processingis understanding aset of information and ways it can be useful to a specific task. After processing all of the currentinformation, the nurse is able to target the appropriate next steps involving knowledge generation and knowledge disseminaton. The nurse determines how the knowledge will be used and disseminated. 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 incare management across the healthcare continuum.