The current era of healthcare reform is driving a shift in priorities and pressures for delivery of high quality healthcare. With a surge in the need to efficiently meet patient care demands, and to accommodate the ever-evolving sophistication and modernization of information and communication technologies (ICT), it is an opportune time for innovative care delivery by telehealth. This article reviews the emergence of telehealth in America, describes modalities of telehealth services, and considers such factors as quality, means, and cost of delivery and need for telehealth services. Telehealth can increase access to primary and specialty care, and ensure high quality care at lower cost. The authors also discuss policy considerations related to telehealth, including the roles and contribution of nurses and future consideration for this state-of-the-art care model.
Keywords: telehealth, healthcare reform, nurse, technology, synchronous telehealth, asynchronous telehealth, store and forward telehealth, mobile health, e-health, health disparities, nurse clinician, nurse educator, healthcare advocate, healthcare reform, value-based care, alternative care delivery models
Progressive development and sophistication of communication and technology, coupled with demand for novel approaches to care, positions nurses to collaborate and address health disparities in these communities through deployment of telehealth technology. Limited health resources and providers in some American communities exacerbates health disparities (Williams, 2007). Progressive development and sophistication of communication and technology, coupled with demand for novel approaches to care, positions nurses to collaborate and address health disparities in these communities through deployment of telehealth technology. Telemedicine, meaning “healing at a distance” (Strehle & Shabde, 2006, p. 956), is increasingly viewed as a mechanism to deliver more efficient and patient-centered healthcare services to individuals who face barriers to access care.
Delivery of healthcare by means of Information and Communication Technology (ICT) sources is varied, and references to this are commonly used interchangeably. Terms used to describe these services, such as telemedicine, e-health, telehealth, and even mobile health, can be confusing until the construct and meaning of telemedicine is more clearly understood.
The Institute of Medicine (IOM) simply describes telemedicine as “…the use of electronic information and communications technologies to provide and support health care when distance separates the participants” (IOM, 1996, p. 1). Telehealth offers the opportunity to deliver care to a diverse array of underserved populations, including those in rural (National Conference of State Legislatures, 2016), urban, and suburban communities. Modalities and sophistication of telehealth technology have evolved over time, and uses of telehealth in the United States will likely continue to change with the demographics and healthcare needs of the country.
Emergence of Telehealth in America
...the concepts and benefit of telemedicine were conceived in 1905 by a Dutch physiologist who utilized the telephone for transmission and monitoring of cardiac sounds and rhythms. Beginning with the invention of telephonic capability, the concepts and benefit of telemedicine were conceived in 1905 by a Dutch physiologist who utilized the telephone for transmission and monitoring of cardiac sounds and rhythms (Bashshur, Shannon, Krupinski, & Grigsby, 2013; Strehle & Shabde, 2006). The theoretical use of the television for delivery of bi-directional medical care first surfaced in 1924 on the cover of Radio News (IOM, 1996). This was represented in a novel depiction of a doctor, on the screen of a radio, assessing the health of a listener child, through the screen.
The 1940s brought transmission of radiography over telephone circuits between cities in Pennsylvania separated by 20 miles (Gershon-Cohen & Cooley, 1950). Given the potential need for healthcare delivery at a distance, as Americans began traveling to outer space, it was not surprising that the National Aeronautics and Space Administration (NASA) utilized some of the first closed circuit televisions for telemedicine (LeRouge & Garfield, 2013). Soon thereafter, Lockheed Missiles and Space Company and the Kaiser Foundation International partnered to pioneer a remote monitoring system (Gruessner, 2015), known as Space Technology Applied to Rural Papago Advanced Health Care, to provide care for the Papago Indian Reservation in Arizona (Cushing, 2015), a medically underserved rural area. While these first approaches were experimental, and not solely tested in the traditional medical setting, current advancements in technology now drive new opportunities for nurses to deploy telehealth technology in the future (Fong et al., 2011).
Today, patients may be a ferry or car ride away, or many miles from the nearest major medical center, critical access hospital, or primary care provider. All scenarios can result in healthcare delivery service gaps and barriers to access urgent or non-urgent healthcare; contributing to risk for disease and death. Video conferencing and other telehealth methods promote the opportunity to ensure timely care that is efficient, safe, and patient-centered. These outcomes cannot be accomplished without a cadre of nurses and other healthcare professionals.
Providers are increasingly looking to telehealth as a viable care delivery model for the future... Providers are increasingly looking to telehealth as a viable care delivery model for the future, and the adoption of certain telehealth technology and delivery of services is on the rise (HimSS Analytics, 2016). Concurrently, growth in technology and changes in consumer behavior are generating younger, technologically savvy patients, who represent diverse populations (Powell, Chen, & Thammachart, 2017). These patients demand efficient ambulatory care at the tap of a finger, driving advances in mobile health technology to provide health education and services via mobile devices (National Conference of State Legislatures, 2016). As one of the most widespread professionals with high level skills, nurses across America are called to action to determine how to leverage informatics and technology in the transformation of care delivery to improve the nation’s health with high quality, cost efficient, and convenient care (Sensmeier, 2011)
Modalities of Telehealth Services
Direct and indirect telehealth services commonly deployed include synchronous, asynchronous, mobile health and ehealth, and remote monitoring. More recent technologic advancements and wireless communications have catapulted telehealth services and the possibilities for nurses to participate in delivery of remote care (Fong et al., 2011; LeRouge & Garfield, 2013). Understanding the modalities and options for telehealth is important to determine precise means of implementation. Telehealth services are conducted in a variety of ways depending on the location of the patient (end user), intended delivery of services, and various means for interaction with patients and healthcare providers (Fong et al., 2011). Direct and indirect telehealth services commonly deployed include synchronous, asynchronous, mobile health and ehealth, and remote monitoring. This section provides a brief overview of each of these services with select examples and literature support, and describes education of healthcare providers through Project ECHO (Extension for Community Healthcare Outcomes) and eConsult.
Synchronous telehealth communication is defined by a live, face-to-face interaction between a patient and healthcare professional or between healthcare professionals, in consultation, via audio-video conferencing. In this traditional healthcare setting, patients check in to a clinic in their area equipped with a video cart that allows for bi-directional interaction between the patient and healthcare provider and a camera with zoom capability (Ferguson, 2006; Verhoeven, Tanja-Dijkstra, Nijland, Eysenbach, & van Gemert-Pijnen, 2010). The cart may be equipped with Bluetooth enabled digital and peripheral equipment (e.g., stethoscope, otoscope, or ophthalmoscope with camera capability) to use for more sophisticated physical examination and evaluation (Fong et al., 2011). Synchronous visits are typically facilitated at the originating site (where the patient is located), commonly by a nurse trained as a telepresenter. The telepresenter uses the equipment to examine the patient for a provider offering healthcare services from a distant site (Wechsler, 2015). Synchronous visits enable assessment, diagnosis, and treatment in hospital or clinic settings, and facilitate nurse to patient education.
Critical access hospitals with limited resources can benefit from prompt, synchronous consultation by a neurologist, in the event a stroke is clinically suspected and timely treatment with thrombolysis is critical. Telestroke services are those wherein synchronous assessment of the patient by a neurologist occurs. Telestroke services have increased prompt access to specialized care with improved rates of evidence based care and interventions (Cutting, Conners, Lee, Song, & Prabhakaran, 2014).
Synchronous telehealth models improve convenience, access, and efficiency of care by offering walk-in telehealth services. Synchronous telehealth models improve convenience, access, and efficiency of care by offering walk-in telehealth services. One study (Neufeld & Case, 2013) compared the same services at walk-in telehealth clinics and scheduled, in-person mental health medication visits (staffed by nurse practitioners and medical doctors). The in-person clinics had noted significant no-show rates and incurred the expense of long distance travel by staff. This study demonstrated that the walk-in telehealth clinics provided significantly shorter wait times and more open access for initial and routine follow-up psychiatric visits, with more reliable utilization of the clinic time (Neufeld & Case, 2013).
Another area of success is continuity of care in the transition of chronically ill patients from hospital to home during an acute phase of illness, including synchronous visits with nurses upon discharge. In a mixed methods study (Day, Millner, & Johnson, 2016), patients received various devices for self-monitoring and video-conferencing. This study observed use of telehealth equipment by nurses to monitor self-care, coaching, and supervision of patients during an acute exacerbation of a chronic illness. In telehealth interactions with nurses and remote monitoring, patients became more involved in self-care; understood the time to report symptoms or a change in health (sooner rather than later); and reported a perceived mastery of their self-care. Competent and effective utilization of telehealth technology and equipment by nurses in provision of healthcare can positively impact patients (Day et al., 2016).
Mobile Health or eHealth
Mobile health or eHealth is another example of synchronous telehealth wherein healthcare visits are initiated and conducted on patient personal computers and mobile devices or smart phones, from the patient’s preferred location, instead of the traditional clinical setting. This form of synchronous consultation with healthcare providers, including nurse practitioners, is convenient for delivery of urgent care services and growing in popularity. Psychiatric care via a smartphone (telepsychiatry) highlights the benefits of healthcare delivery to high-risk patients in serious need of psychiatric services. The convenience of mobile healthcare breaks the barriers of transportation issues and need for caregiver accompaniment, and transcends symptoms and conditions like agoraphobia, factors which often isolate patients and prevent access to psychiatric care (Powell et al., 2017).
Asynchronous telehealth communication represents contact that is not face-to-face, but in real time, by way of email, internet, text messaging (Verhoeven et al., 2010) or as ‘store and forward’ wherein information is sent and picked up or responded to at a later date. Most commonly supporting medical care in a non-urgent setting, this modality has been utilized for years in the radiology space where radiologic films are uploaded for review at a later date (Agrawal, Erickson, & Kahn, 2016). Another example of this utility is the assessment of dermatologic conditions by way of uploaded digital photos or other patient data (Ferguson, 2006; Wade, Karnon, Elshaug, & Hiller, 2010).
Remote telemonitoring is a well-established means to monitor various conditions and associated data, including cardiac monitoring for those who suffer heart failure, or general monitoring of chronic diseases. In a study of over 3000 patients in the United Kingdom, researchers demonstrated that patients with diabetes mellitus, heart failure, or COPD had a nearly 50% reduction in one year mortality and 18% fewer hospitalizations when using a simple home monitoring device, compared to those who did not (Steventon et al., 2012).
An example of telemonitoring in the acute care setting is the recording of vital signs, continuous electrocardiogram tracing, and hemodynamic values in the Intensive Care Unit (Fuhrman & Lilly, 2015) and transmitting this clinical information to the teleICU. Critical care medicine experts then interpret the data in real time and assist the originating/remote site with clinical decision making. This type of monitoring is utilized in health systems to promote efficiency and quality (e.g., reduce waste, deliver evidence based standards of care) and decrease redundancy, such as costly positioning of equipment and professionals in community or critical access hospitals. In one study across 15 states that included 100,000 patients, researchers found that patients in the teleICU group had a 16% and 26% lower risk of hospital and ICU mortality, respectively (Lilly et al., 2014).
Project ECHO and eConsults
... nurses can also receive bonus training in remote locations where educational resources may be limited. In contrast to the above programs, which provide direct consultations to patients, Project ECHO increases knowledge amongst primary care nurse practitioners, physician assistants, and primary care physicians through synchronous, audio-video conferencing for professional education from academic centers and specialists to primary care providers (PCP) in remote areas. This initiative, developed by Dr. Sanjeev Arora at the University of New Mexico School of Medicine, illustrates how technology can be used to train nurses at all practice levels in core specialty knowledge (Arora et al., 2007). Participants reported less professional isolation, greater job satisfaction, and more confidence in managing complex chronic diseases (e.g., hepatitis C; Arora et al., 2010). Through Project ECHO not only do patients receive expert assessment and care, but nurses can also receive bonus training in remote locations where educational resources may be limited.
eConsults are similar to Project ECHO in that the consultative exchanges are between PCPs and specialists. However, it differs in that consultations are asynchronous and not part of a larger conference. In this model, the PCP sends a professional consult request regarding a patient with a specialty problem, and, at a later date, the specialist returns expert information to the PCP (Davis et al., 2015). This is especially helpful to ensure timely care for patients who would otherwise have long wait times to see a specialist, or perhaps where it is impossible to see a specialist, depending on geographic location. In summary, both Project ECHO and eConsults help PCPs develop core specialty knowledge crucial to care delivery in the present and along the patient care continuum, and improve convenience and access to patients who require specialty care.
Quality, Means, and Cost of Healthcare Delivery
The IOM has identified the necessity and utility of technology to achieve better outcomes... Healthcare value has been defined as the health outcomes achieved, divided by each dollar spent. (Porter, 2010). In the current era of value-based care, intentional design of high quality clinical care delivery models are targeted to achieve better patient outcomes. Provision of high-value care is a major priority for all stakeholders, including consumers who are patients; purchasers represented by employers and individuals; and healthcare systems as suppliers of healthcare. The IOM has identified the necessity and utility of technology to achieve better outcomes, stating “…information technology must play a central role in the redesign of the health care system if a substantial improvement in quality is to be achieved” (IOM, 2001, p. 16).
There are many conversations and mandates around delivering high quality care, but understanding what constitutes quality, and what is meant by ‘high quality’, is essential to making effective changes in care delivery. Nine years before the Patient Protection Affordable Care Act ([ACA], 2010) was passed, The Institute of Medicine and Committee on Quality of Health Care in America (IOM, 2001), outlined a roadmap that succinctly listed essential achievements and quality aims to strive for in order to improve the health of Americans. The recommended initiatives (pp. 39-40) described care that is:
- Effective – Ensuring that care delivered is evidence based with proven efficacy
- Efficient – Minimizing waste of resources (equipment, supplies, ideas, and energy)
- Safe – Prevention of harm or injury from the healthcare delivered
- Timely –Harmful delays in care delivery are avoided
- Patient Centered – Patient’s needs, preferences, and values are respected and upheld
- Equitable – No variance in the quality of care delivered to all
In the current healthcare climate, and within healthcare organizations, significant attention is placed on these quality aims. The Agency for Healthcare Research and Quality (AHRQ) cites the importance of these six domains of healthcare quality, and promotes the framework as a way for consumers to understand the meaning of quality (AHRQ, 2016). The American Hospital Association built the quality aims into its policy and advocacy agenda (American Hospital Association, 2017). If quality aims are actively integrated into direct clinical care, they possess the potential to greatly contribute to the timely delivery of safe and quality care, at good value, in a patient-centered way with the intent to mitigate health disparities, wherein all stakeholders win. Telehealth offers the opportunity to support achievement of quality aims, addressing barriers to care through innovative means and leveraging the proliferation of technology in an increasingly mobile-friendly and technology-centric population.
Need for Telehealth Services
With the overarching goal to meet healthcare demands of Americans, it is essential to understand who is in need, and could benefit from healthcare via telehealth. In 2017, the United States (U.S.) population is estimated at over 300 million, (Index Mundi, 2017b; U.S. Census Bureau, 2017) and is increasingly represented by minority populations and older adults (Index Mundi, 2017a). Diversity will continue to grow, with a projected minority population to exceed 50% of the total U.S. population by 2043 (La Veist, 2005; U.S. Census Bureau, 2017). More than ever healthcare providers will be required to offer culturally sensitive and patient centered care with consideration for ethnic, social, and cultural backgrounds. Concurrent with the surge in minority populations, the country is aging rapidly with 53.8 million current Medicare beneficiaries (National Committee to Preserve Social Security and Medicare, 2017). This number will continue to trend upward and likely demand development of innovative solutions for care, especially for patients with chronic conditions.
Changing national demographics and geographic dispersion of populations generates significant opportunities for telehealth technology. Changing national demographics and geographic dispersion of populations generates significant opportunities for telehealth technology. Occupying 3.8 million square miles, America is one of the largest countries in the world (Nationmaster, 2017), and 72% is categorized as rural territory (U.S. Department of Agriculture, 2017a). This percentage represents 42 million people in rural America (U.S. Department of Agriculture, n.d.) with considerably higher rates of unemployment and poverty compared to their urban counterparts, and with 25% of families (with children) in deep poverty (U.S. Department of Agriculture, 2017b).
Determinants of health, including level of education, socioeconomic status, and geographic isolation in relation to healthcare services, may keep many Americans at risk for suboptimal health outcomes (HealthyPeople.gov, 2017). With challenges to connect with healthcare resources, these populations, especially those in rural and medically underserved areas, remain at higher risk for health disparities and poorer health outcomes (Marmot & Wilkinson, 2006; Williams, 2007). Telehealth may offer a new opportunity to provide essential healthcare services to these underserved communities.
Given the potential of telehealth, especially with rapidly developing ICT and established need for services, policy considerations are important to continue the evolution of quality, accessible services. Just as important is the need for nurses to become informed and support initiatives in telehealth in this era of health care reform. This section will discuss telehealth policy considerations such as the demand for providers; the role and contribution of nurses; challenges and feasibility of delivery and reimbursement; and future considerations.
Policy Impact on Demand for Providers
With the intent to create a healthier population, the ACA (2010) established provisions that incentivize patients to access primary care and preventive health services (Davis, Abrams, & Stremikis, 2011). Calling for the elimination of out-of-pocket costs for preventive services such as cancer screenings and annual wellness physicals, the legislation placed new pressures on an already stressed primary care network across the country. Coupled with increasing numbers of insured individuals, this has resulted in a greater demand for primary care providers (Heisler, 2013).
Professional isolation for healthcare providers in these remote HPSAs also poses a serious challenge. Many rural areas especially lack reasonable numbers of and appropriate ratios of health professionals (e.g., primary and dental care, mental health) to persons offer reliable access to safe and quality healthcare. Such areas are identified as Health Professional Shortage Areas (HPSAs) (Heisler, 2013). This shortage of healthcare professionals significantly determines access to healthcare, or lack thereof, and thus the health of communities. Professional isolation for healthcare providers in these remote HPSAs also poses a serious challenge. Telehealth provides a unique opportunity to address these shortages and effectively provide care to patients and support to providers, primarily nurses and doctors, in areas of provider and resource constraints. This shortage of primary care providers is well documented, and the deliberate inclusion of nurses as a solution is a natural conclusion to continued calls for innovation to meet health needs of all patients.
Nurses as Critical Partners in Telehealth Services
Nurses are educationally and professionally prepared to provide a broad scope of skills and services across the continuum of healthcare (Bleich, 2011). The nursing workforce has doubled since 1980, and is now the largest contingency in the U.S. healthcare workforce (Committee on the Robert Wood Johnson Foundation Initiative, 2011) with 3.6 million registered nurses (McMenamin, 2016). This number includes 208,000 nurse practitioners, who are board certified to deliver specialty services and primary care (American Association of Nurse Practitioners, 2017) with a similar scope of practice as primary care physicians (Bleich, 2011).
Nursing practice, at its full scope, must include continued reform to develop and deliver telehealth services. There is an unending need for healthcare professionals, including nurses, to initiate appropriate and timely use of telehealth services to ensure Americans receive the care they need. Providers must collaborate to strengthen the infrastructure of clinical practice; delegate tasks to broaden the spectrum of caregivers; and develop care delivery pathways and models in telehealth to address quality and reimbursement requirements. Collaborative practice is key to building effective healthcare teams (Joel, 2013); improving delivery and experience for patients via telehealth technology services; and optimizing efficiencies of healthcare.
Nurses are often the only consistent, frontline healthcare providers present in communities; critically positioning them to support all aspects of the telehealth continuum, with the greatest impact on patient care. As clinicians, educators, researchers, advocates of policy, and as transformational leaders, nurses need to practice at the fullest extent of their education and training in order to derive their professional potential for all involved. Nursing practice, at its full scope, must include continued reform to develop and deliver telehealth services.
The Intersection of Telehealth and Healthcare Reform
The 2009 American Recovery and Reinvestment Act included billions in funding to update healthcare IT systems, research, and facilities (LeRouge & Garfield, 2013). The National Broadband Plan, in 2010, identified and directed funds for further development and use of information technology by expanding the infrastructure for high speed internet access aiding in the establishment of telemedicine and remote monitoring (Federal Communications Commission, 2010; The White House: President Barack Obama, 2016). In 2010, the ACA became a driver of healthcare delivery and payment reform, and aspects of the legislation focused on improving care quality, value, transparency, and health information technology.
Telehealth is a means to achieve many aims of healthcare reform, particularly goals to improve value and deliver affordable care with high quality outcomes, while reversing rising healthcare costs. Telehealth is a means to achieve many aims of healthcare reform, particularly goals to improve value and deliver affordable care with high quality outcomes, while reversing rising healthcare costs (Rosenfeld, 2015). In the Accountable Care Organization (ACO) model, a product of the ACA, health systems are responsible for the care of a defined population, which requires seamless cooperation of multiple facilities and providers across the care continuum. The ACO model creates an ideal testing environment for novel models of care delivery like telemedicine, focused on better coordination and efficiency (National Advisory Committee on Rural Health and Human Services, 2015).
In the Centers for Medicare and Medicaid Services (CMS) Comprehensive Care for Joint Replacement (CCJR) program, hospitals are financially responsible for quality and cost of the entire care episode for Medicare beneficiaries receiving hip and knee replacements, including 90 days post discharge. As part of the CCJR program, CMS waived certain geographic reimbursement requirements for telehealth, encouraging the use of telehealth to care for patients during the episode of care, especially as they transition out of the hospital (CMS, 2017; mHealth Intelligence, 2016).
Now, value-based programs including the Medicare Access and Chip Reauthorization Act (MACRA), which will replace Meaningful Use in 2017, and the Delivery System Reform Incentive Payment Program, openly invite expansion of virtual services as a means to provide timely and cost-effective care (Becker's Health IT & CIO Review, 2016). The new payment tracks under MACRA will affect over 700,000 clinicians in 2017, including payments for nurse practitioners, clinical nurse specialists, and certified registered nurses (Advisory Board, 2017).
Challenges and Feasibility of Delivery and Reimbursement
... telehealth provision must adhere to Health Insurance Portability and Accountability Act requirements and always ensure patient privacy. Increasingly, healthcare providers are driving innovation with intent to deliver care, promote wellness, and keep people healthier in new and cost effective ways, such as telehealth. However, there remain many evolving and unresolved challenges of telehealth, such as the determination of permissible practice environments; ethical considerations; licensing and credentialing; and interstate compact agreement statutes. Patient privacy and information security are other concerns. For example, telehealth provision must adhere to Health Insurance Portability and Accountability Act (Public Welfare, n.d.) requirements and always ensure patient privacy. This may require extra steps for providers (e.g., entering a business associate agreement) to ensure protection of patient health information (Center for Connected Heath Policy, 2017b). Services rendered electronically may be vulnerable to hackers and other security breaches, requiring the utilization of software encryption features and advanced protocols for security (Telehealth Resource Centers, 2017b).
Engaging in telehealth, in practice, also depends on identifying specific services that can be rendered; practical development and implementation; and determination of the feasibility of reimbursement. Reimbursement for telehealth services varies amongst Medicare, Medicaid, and private payers (Center for Connected Heath Policy, 2017a; Robert Wood Johnson Foundation, 2016). In 1997, Medicare was one of the first payers to acknowledge and promote reimbursement for telehealth services as part of the Balanced Budget Act (Telehealth Resource Centers, 2017a). However, Medicare has coverage restrictions for telehealth services, and traditionally only reimburses synchronous telehealth services for designated rural and underserved areas.
Although Medicare has covered some iteration of telehealth services for two decades, fewer than 1% of Medicare beneficiaries use it. Expansion of reimbursement for other telehealth services has been slower amid concerns it will incentivize an increase in unnecessary utilization and drive Medicare expenses up (Galewitz, 2016). In 2000, The Benefits Improvement and Protection Act expanded Medicare coverage for telehealth, and today CMS only reimburses for a select number of services, and restricts payments to specific areas (Telehealth Resource Centers, 2017a). Although Medicare has covered some iteration of telehealth services for two decades (National Advisory Committee on Rural Health and Human Services, 2015), fewer than 1% of Medicare beneficiaries use it (Galewitz, 2016). Nurses have a critical opportunity to promote acceptance and adoption of telehealth services, advocate for nonrestrictive telehealth benefits, and educate patients on the care available through telehealth.
Medicaid reimbursement for telehealth is administered by respective states, and as of January 2016, 48 states provide some form of Medicaid reimbursement for live video telehealth services with drastically fewer states providing Medicaid coverage for store-and-forward and remote monitoring (Center for Connected Heath Policy, 2015). Medicaid reimbursement for live video is more prevalent in most states, rather than reimbursement for store-and-forward and remote patient monitoring (Telehealth Resource Centers, 2017c).
States with private payer reimbursement for telehealth... were associated with a greater number of hospitals choosing to adopt telehealth technologies. Individual states are able to establish requirements for private payers, mandating coverage for telehealth services (National Conference of State Legislatures, 2016). As of 2016, 32 states had a private payer legislative policy in place (National Conference of State Legislatures, 2016). A study reviewing hospital adoption of telehealth (Adler-Milstein, Kvedar, Bates, 2017) found that uptake of telehealth is directly impacted by state policies on reimbursement and licensure. States with private payer reimbursement for telehealth, and particularly policies requiring payment parity, were associated with a greater number of hospitals choosing to adopt telehealth technologies (Adler-Milstein et al., 2017). Such policies drive reimbursement for telehealth services, including payment parity, where legislative policy require payers to reimburse at the same rate for the same services provided in person or via telehealth (Center for Connected Heath Policy, 2015). Payment parity encourages healthcare systems and providers to deliver telehealth services, and allows providers to make necessary investments in infrastructure to support new approaches in care delivery.
Nurses as Key Contributors and Informants
Fostering essential interest and uptake of telehealth services by healthcare professionals, including nurses, demands integration of telehealth curriculum and practical training into academic programs. As noted previously, the 2010 landmark IOM report strongly recommended an increased role for nurses in the transformation of healthcare. This report outlined a future in which nurses work at the top of their license and training, achieve higher levels education through improved education systems, and work as partners with other healthcare professionals, including physicians. The report called for effective workforce planning and better data collection and information infrastructure (Bleich, 2011). Fostering essential interest and uptake of telehealth services by healthcare professionals, including nurses, demands integration of telehealth curriculum and practical training into academic programs (Ferguson, 2006). Such curriculum will enhance nurses’ ability to demonstrate proficiency to conduct telehealth visits and advocate for such services through health policy.
The Josiah Macy Jr. Foundation (2016) published recommendations for the increased role of nurses in primary care. Given current stresses on the primary care system, new practice models that include nurses in critical roles are needed to meet demand and achieve the Institute for Healthcare Improvement (IHI) Triple Aim of improved patient experience, health of populations, and per capita cost of healthcare (IHI, 2016; Josiah Macy JR Foundation, 2016). An advanced role for nurses, and redesign of primary care practices, can provide an opportunity for nurses to participate and actively lead telehealth integration in the future.
...telehealth legislation remains a significant need in healthcare reform. As telehealth continues to move from theory to practice, legislation that ensures comparable reimbursement and favorable conditions for practice of telehealth services will be critical. This telehealth legislation remains a significant need in healthcare reform. Such health policy cannot occur unless healthcare providers partner with local government officials, and actively drive telehealth initiatives. Advocacy and awareness of critical legislation is also important, such as the Nurse Licensure Compact which allows nurses a multistate license to practice (National Council of State Boards of Nursing, 2017) Without this legislation, telehealth becomes an expensive venture requiring licensure in each state where telehealth care is delivered. As key informants on the front line of clinical healthcare, nurses should not underestimate the power of their individual and collective voices to advocate for changes to health policy in their practice states.
The Future for Telehealth
In 2017, amid rising pressure of increasing health insurance costs, breakdowns in state health insurance marketplaces, and working to fulfill a campaign promise, Republicans introduced legislation to move towards repeal and replacement of the ACA. The House of Representatives voted to pass the American Health Care Act in May of 2017. The bill now moves to the Senate. For now, the ACA remains in place, but the long-term future of this legislation remains unknown. The extent to which the law will be modified or overhauled, and how healthcare coverage will be financed in the future, remains a highly polarized, partisan issue.
In spring 2017, a bipartisan bill was introduced to the U.S. Senate to expand Medicare coverage of telehealth services. Meanwhile, advancements in telehealth policy continue to emerge. In spring 2017, a bipartisan bill was introduced to the U.S. Senate to expand Medicare coverage of telehealth services. The bill is aimed at increasing access for rural patients, however, opponents raise concerns regarding the potential for increased utilization, leading to greater overall Medicare costs (Arndt, 2017). Akin to the fate of healthcare reform, the future of the bill is yet to be determined in the politically charged and polarized environment of Washington DC.
Telehealth policy aligns with current reform efforts that increasingly focus on healthcare value... It is certain that we need to meet care demands for our patients and raise the bar in delivery of quality and effective healthcare to the nation. Telehealth policy aligns with current reform efforts that increasingly focus on healthcare value, a deviation from the traditional fee-for-service model that incentivizes volume of services rendered. Videoconferencing and other ICT advancements aid in moving toward a value-based future, and thus in achieving the IHI Triple Aim of better health, and better care, at lower costs (IHI, 2016).
Healthcare reform is an ongoing process. As the market continues to expand, nurses can and will be excellent champions for telehealth. It is essential for nurses to undertake the critical advocacy task of identifying an opening opportunities to reach patients in the communities they reside through telehealth. In doing so, nurses will close healthcare delivery gaps and reduce health disparities by stepping forward and utilizing the breadth of their skills to adapt, adopt, and implement telehealth resources and services as commonly accepted, mainstream methods of care delivery.
The number of nurses reported in this article at 2.6 is incorrect. The correct number is 3.6 million as cited in the document, ANA’s Nurses by the Numbers (McMenamin, 2016). This article was amended on August 16, 2017 to include the correct number and citation. The sentence referring to 220,000 advanced practice nurses was also amended to read 208,000 nurse practitioners who are board certified to deliver primary care to more accurately reflect nurse practitioners as a category of advanced practice registered nurses.
Joelle T. Fathi, DNP, MN, BSN, RN, ANP-BC
Joelle Fathi has been in clinical practice for 23 years. With a special interest in developing clinical care delivery models and as program director, she is responsible for the development, implementation and ongoing operations of telehealth clinics at Swedish Cancer Institute in Seattle, Washington. Joelle serves on the Washington State Legislative Telehealth Collaborative to advance access to high-quality and safe care by telehealth services to Washington residents. As a Clinical Assistant Professor at the University of Washington, School of Nursing, Joelle is devoted to teaching and excellence in nursing practice through optimizing the patient experience and driving quality outcomes.
Hannah E. Modin, MHA, B.A.
Hannah Modin has direct experience leading stakeholders through the development and implementation of health programs for the underserved. While a Master of Health Administration candidate at the University of Washington, she was focused on the development and impact of alternative payment methods and novel models of care delivery, including telehealth. Most recently, as an Administrative Fellow at a multihospital, integrated health system in New York City, Hannah gained experience in the deployment of value-based care initiatives. Hannah is pursuing a PhD in health services, to understand the intersection of policy, social determinants of health and the incentives that shape care delivery.
John D. Scott, MD, MSc, FIDSA
John Scott is an Associate Professor in Medicine and Medical Director of Telehealth at the University of Washington. He launched Project ECHO, an innovative case-conference model of telehealth for hepatitis C across the Pacific Northwest in 2008. The model has expanded to other common, complex diseases such as HIV, geriatrics and heart failure. In 2015, he won the Warren Featherstone Reid Award for Excellence in Health Care from Governor Inslee, in acknowledgement of his work with Project ECHO. He is the chair of the Washington State Telehealth Collaborative.
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