Window of Opportunity for Home Care Nurses: Telehealth Technologies

Introduction

Stacked like dominos, from demographics to economics to politics, the factors driving the need for nurses mount, and so do the needs for technology use in their practice settings. This article will address the need for increased use of information technologies in nursing, describe how electronic technologies are changing the nursing profession and improving patient care, provide examples of telehealth nursing in home care, and discuss the future of telehealth technologies in nursing.

Nursing is one of the ten fastest growing occupations in the United States (Bureau of Labor Statistics, 2001). The number of available nursing positions has steadily increased and is predicted to climb to 2.5 million by 2008. In the next fifteen years, nearly half of all registered nurses will approach retirement. In a perfect world, new nurses would be entering the nursing profession at the same rate as nurses are retiring. However, this is not the case as nursing school enrollment has declined steadily over the past five years (American Association of Colleges of Nursing, 2001). In addition to the need for traditional hospital nurses, the future will need nurses for new positions in home health, long-term, and ambulatory care. In an environment of limited numbers of nurse, technology can help to meet the need to provide nursing care.

An aging society and organizational changes are both contributing to the need for nurses, especially nurses with enhanced skills in using technology to meet society‘s health care needs. Over the past two decades the elderly have grown in number twice as rapidly as the rest of the population. Today, there is an estimated 35 million people age 65 or older in the United States and this number is expected to grow dramatically. By 2011, the baby boomer generation will begin to turn 65, and by 2030, it is projected that one of every five people will be 65 years of age or older (Federal Interagency Forum on Aging and Related Statistics, 2000). The older population is projected to double over the next 30 years, growing to 70 million by 2030. More nurses practicing more efficiently will be required to meet the health care needs of the aging population. Technology can help to increase the efficiency of these nurses.

Key organizational changes that are increasing the need for nurses with enhanced electronic communication skills include a move from reliance on hospital-based care to greater reliance on care provided in outpatient, nursing homes and home care settings; the move to managed care; and corporate restructuring including horizontal and vertical integration. Vertical integration of a health care organization provides several levels and intensities of services to its patients, thus offering one stop shopping and a continuum of care. Now health care organizations are looking for ways to integrate care processes into these various levels to improve patient care and satisfaction. Technological innovation, such as electronic communication, can help meet these needs. Technology development, which is advancing at warp speed, is on the rise. This technological development is providing many opportunities in health care, specifically, the means to leverage health care processes to improve access to care, to facilitate collaboration in delivering care and health information, and make available key patient information to improve the quality of care delivered through interactive health communications (IHCs). These IHCs include health information and support websites and other technology-mediated applications that relay information, enable informed decision making, promote information exchange, or manage demand for health services.

How Technology is Changing the Nursing Profession

Nursing professionals have long advocated for changes in the health care system, changes that include greater access to educational opportunities to learn new ideas and skills, new methods of documentation to decrease charting time, increased access to information, improved decision making capacity to improve the quality of care, and more patient involvement in their own health care. The following discussion illustrates how electronic communication is facilitating these changes through new applications in electronic communication and telehealth. Telehealth is defined as the electronic provision of health care and information services for the direct benefit of individual patients and their families. It includes provider-patient and provider-provider interactions and the provision of education and information services designed to increase awareness of diagnoses, treatments and good health practices.

Greater Access to Educational Opportunities

Nurses have requested, and now have, better availability of educational offerings. Today nurses can attend virtual programs and interact with students across the world through the use of technology. Nurses can attend a virtual classroom via the Internet while on lunch break or while sitting in their living room. They can practice clinical skills using patient simulation modeling and more. No longer do nurses have to wait for the next semester to come around to gain knowledge or brush up on skills. The ability to assess such knowledge is immediately available at their fingertips.

New Methods of Documentation

Nurses have asked to spend less time on completing paperwork; and health care and technology companies have begun developing and implementing user-friendly software programs to promote charting efficiency thus allowing nurses to spend more time with patients. In many organizations forms are being streamlined and templates created to be used as part of an electronic record system. Hand held devices; electronic tablets, and computers using various software products are reducing documentation time and allowing nurses to spend more time with their patients.

Increased Access to Information

Nurses have also asked for better access to information. An example of improved information access is found at First Health of Pinehurst, North Carolina, a company that needed a solution to the increase case loads burdening its nurse case managers. The nurses did not have time or the manpower to search through reams of paper to look for clinical information or track down patient‘s updates over the telephone. First Health decided to try a technology tool to facilitate information access. They partnered with Canopy Systems who offered a web-based solution for care coordination deployed via an application service provider model. Using the web-based solution, First Health nurse case managers are now able to handle 10 times the number of patients than they did with their old-paper based system. Additionally, the organization has experienced improved communication, improved workflow, and improved utilization management (Kibbe & Frock, 2001).

Another example of a project that uses information technology to enhance access to an electronic medical record is the Diabetes Education and Telemedicine Project (IDEATel), which began in February, 2000. The project is a 4 year, 28 million dollar randomized clinical trail designed to maximize Medicare patients‘ control of their diabetes by providing them a computer link to their caregivers. Patients utilize a home telemedicine unit that allows them to interact in multiple ways with their online charts. Peripheral devices allow readings of glucose, blood pressure and other vital signs to be captured and transmitted over the Internet to the Columbia University Web-based Clinical Information System that is equipped with case management software. Patients and their diabetic nurse case managers can also communicate through a secure email system as well as utilize the videoconferencing component of the system. Case managers also receive alerts when patients transmit values that exceed set thresholds, and case managers and physicians have just in time information that allows better management of the patient‘s therapy. Patients also learn how to monitor their own condition by receiving immediate feedback after finger stick glucose testing and comparing blood values over time by accessing run charts of their values (Tsai & Starren, 2001).

Improved Decision-Making Capacity

In addition information technology is now improving patient care decisions throug the use of medical knowledge management, decision support systems, and computer-assisted management protocols, thus allowing all practitioners to make better informed decisions affecting their patients‘ care. Medical knowledge management gives providers easy access to relevant, reliable information in an effective and efficient way through various programs, rather than necessitating that practitioners locate the latest information through hard copy journals or other time consuming resources (Silverman, 1999). This saves time and money; and it will likely result in better patient outcomes. The solutions focus on the needs of health care professionals by affording them the right answers in the right form at the right place at the right time (Detmer, 2001). Devices now available that remotely monitor patients collect data such as vital signs, blood sugar readings, and weights, as well as responses to disease-specific questions and health status questionnaires. These products not only assist the caregiver in helping patients in preventing and/or managing their diseases, but also actually guide health-related behaviors thus improving outcomes.

More Patient Involvement in Health Care

Nurses have long hoped that patients would become more active participants in their own health and they are.

Nurses who view patients as valuable partners recognize the Internet as an important vehicle for improving health care delivery. Consumers wanting to take a more active role in their health care are going to the Internet to get just in time information to guide their health-related behaviors. The use of the Internet continues to increase, especially among older adults; and websites specifically designed for older adults have emerged. Senior Internet training courses and programs have and continue to be redesigned to utilize Internet technologies that help older adults gain access to health-related services. The Setting Priorities for Retirement Years (SPRY) Foundation works to promote successful aging by helping older adults to become better informed in four areas: financial security, health and wellness, mental health and social environment, and intellectual pursuits www.spry.org. To this end, SPRY has developed research-based models that use the Internet as a source of readily available health and care giving information for older adults. SPRY is working to research what older adults want to access and the barriers they face in using the technology due to age-related changes that are occurring to their bodies. SPRY has also developed a curriculum to teach older adults and their caregivers how to improve their health habits through interaction with government web sites. This curriculum helps older adults to conduct a general self-assessment of their lifestyle with regard to health issues; search reliable information on web sites to find information on these issues; and then create a personal portfolio of ways in which they can improve their health habits to promote successful aging. SPRY also shares information by providing publications and conferences on areas to consider when designing websites for older adults. Together health care entities and technology developers are learning what works and what does not with this elderly population.

Another example of a technology application for older adults is Senior Health Online, created by Crozer Keystone Health System in partnership with Community Transit of Delaware County, Senior Community Services, Inc. and Delaware County Office of Services to the Aging. This service provides seniors living in Delaware County, Pennsylvania, with in-home connections through their televisions using WebTV, giving the seniors access to community services, contact with their health care providers, and Internet service. The interactive network helps older adults remain independent (Russo, 2000).

Examples of Telehealth Nursing in Home Care

Home care nursing is an arena that already benefits considerably from the use of telehealth technology to offer health care and education through the use of technologies, such as interactive video systems and monitoring technology using plain old telephone lines, integrated services digital networks, digital subscriber lines and the Internet. In the past a patient at home may have had a problem that needed immediate attention. However, they may have thought that the problem could wait till the home care nurse visited in three days, when actually the problem should have been addressed immediately. Through an interactive video system the patient can now contact the on-call nurse any time and arrange for a video visit to address the problem; for example, the patient can ask how to change a dressing or give an insulin injection, or discuss their increasing shortness of breath. This ease of access to care improves the patient‘s quality of life, and provides the nurse with great satisfaction in meeting patient needs real-time (G.S. Slater, personal communication, June 22, 2001)

Home care agencies have begun using interactive two-way video technology as well as remote monitoring devices, called "store and forward" devices, to allow more frequent interaction with patients. These tools offer data that can be used by nurses in triaging patients, and determining next steps, thus avoiding unnecessary complications and emergency room visits. These tools provide reassurance to patients as information can be forwarded to the clinician and acted upon immediately or stored for future consultation with another provider.

Kaiser Permanente has also pioneered telehealthnursing in home care. In a study by Barbara Johnson (2000), 100 patients received cardiopulmonary, cancer, wound, and/or diabetic home health care in the traditional face to face fashion, and 100 patients received some of their visits via a video system staffed 24 hours a day by trained home care nurses. In this study, Kaiser utilized a device called the Personal Telemedicine System, produced by American Telecare, Inc., which allows home health nurses to see the patient in real time, listen to heart and chest sounds, and check to see if that patient is taking his or her medications properly. Johnston reported that cardiopulmonary disease patients received the greatest benefit from the system. She noted, "Patients who had the home video system loved it. They liked the idea that even though they didn‘t have to call the nurse at 2 a.m., they knew they could" (p. 43). There was some concern that there would be cases of abuse and overuse, but that simply did not happen. Additionally, patients in end-stage pulmonary disease used their units to contact the home care nurses whenever they felt short of breath. As a result of the Telehome project‘s success, Kaiser has begun using a new system that allows store-and-forward snapshots that enable nurses to track wounds and compare a series of snapshots over time.

With the growth of our nation‘s inmate population comes the opportunity for more correctional nurses to enhance their job opportunities by working in telehealth. An example of the added opportunities for nurses wishing to expand into the area of correctional telehealth is a program in Texas. These entities provide their telehealth nurses with specialized training that extends far beyond learning how to operate the machinery to receiving specialized training in subspecialties ranging from neurology to dermatology. This training encompasses both the skills needed to present patients to the video camera and also to identify tests physicians are most likely to request before a consultation and why. Physicians there have found the nurses in this program to be key in improving the access to, and the quality of, care provided in prisons. Stein (2000) describes Allan Sapp, assistant director of the Texas Correctional Managed Healthcare Committee, as noting that the facilities now have better mid-level providers because of better communication and interaction during daily face-to-face virtual consultations. Stein cites Sapp as adding, "It‘s an undocumented benefit, but I really think it has helped us improve the quality of care provided at the [prisons]" (p. 82).

What the Future Holds Is Up to All Nurses

The power to redesign and improve health care delivery has arrived and nurses can either help by forging ahead with an open mind and a vision for improving care or miss an enormous opportunity. Technology is a tool in the toolbox that will allow patients and nurses more choices. Nurses time and effort will be better spent where and when it is needed. Collaboration and coordination will no longer just be words used to comply with regulatory and accrediting bodies, but a necessary function that now can be done almost effortlessly to enhance the nursing profession while improving patient outcomes.

Technology provides the means to leverage health care process to improve access to care and facilitate collaboration. Whether used to deliver care, provide information on disease processes, monitor patient progress and adherence to a health care regime, or provide access to patient records, electronic-technology fosters communication and collaboration among all parties. It is nursing‘s window of opportunity to work with others to enhance services, participate in information sharing, and improve how care is delivered.

Granted the picture is not yet perfect. Issues such as design problems, technology looking for an application rather than stemming out of actual need, equipment failures, problems with devices not being interchangeable, regulatory and licensure barriers, high costs of devices and connectivity, privacy, security and confidentiality issues, and the substantial time needed to learn how to use the technology and gain an acceptable comfort level, remain.

Certainly, privacy, security, and confidentiality concerns are not unique to the Internet or telehealth. Consumers and policy makers both share concerns about the privacy and confidentiality of all data. Today, however, with the Health Insurance Portability and Accountability Act privacy standards, some issues revolving around the storage, communication, and presentation of health information will be addressed. However, only certain entities fall under these standards. There is still a need to establish broader safeguards for all health care consumers.

Yet in spite of these issues, telehealth technology will enable employment options to flourish. Nursing will be able to move from traditional roles to roles never though about or dreamed possible. Employment in hospitals, the largest sector of health care employment, is expected to grow more slowly than in other health-care sectors. Employment in home health care is expected to increase 36 percent or more over the next 7 years (Bureau of Labor Statistics, 2001). This is in response to a growing number of older persons with functional disabilities, consumer preference for care in the home, and technological advances which make it possible to bring increasingly complex treatments into the home. Home care will require nurses to utilize these technological tools to assist them in delivering care.

In summary opportunities are endless for nurses who want a future that offers new and better ways to improve the health of their patients more than ever before. Making use of new knowledge requires that health care professionals develop new skills or assume new roles. It requires that professionals use new tools to access and apply the expanding knowledge base. It requires ongoing training to maintain competencies.

By enhancing skills and remaining open-minded and flexible, nurses can enhance the health of our society in ways undreamed of not many years ago. Opportunities to gain knowledge about tools that are available and their appropriate uses are frequently offered at industry conferences. Nursing and medical schools have begun to offer training programs in "telehealth" including hands-on laboratory experiences. It is up to nurses to avail themselves of these opportunities so as to improve patient care and also enhance the profession of nursing.

Author

Holly Russo, MSN, RN
Email Hollyeve7@aol.com

Ms. Russo holds an Associate degree in nursing from Palm Beach Community College, a Bachelor of Science degree in the human resource management from Palm Beach Atlantic College, and a Masters of Science degree in clinical evaluative studies from Dartmouth College. She currently works as an Associate with the Corridor Group, Inc. and is an associate of Telemedicine Solutions and Telehealth Works. She was previously employed as a health telecommunications policy analyst for the National Telecommunications and Information Administration in Washington, D.C. Additionally Ms. Russo has worked in the acute and post-acute care areas of health care for 22 years, specializing in operations/systems analysis, CQI, outcomes measurement, multi-disciplinary personnel competency assessment, and specialty program design; and she has consulted for home health agencies, clinics, and managed care organizations. In addition she teaches credit and non-credit health care courses for colleges and universities.