As you walk down the hall of the clinic, you see through the window millions of jewels as the sun is reflected off the ice on the Bering Sea. You enter the consultation room and greet your patient, Missy Becker. You have arranged for a consult with Dr. Sarah McKinnon about a lesion that Missy has. Turning on the computer you tell Missy that Dr. McKinnon, a dermatologist in Chicago, will be examining her today. When the computer monitor comes alive, you say hello to Dr. McKinnon and introduce her to Missy. You set up the camera that has finger like probes so that Dr. McKinnon can manipulate both the camera and probes. Using these touch-sensitive probes she examines Missy’s lesion just as she would if she were physically with you in the consultation room. "Good news," Dr. McKinnon says after a thorough examination, "As far as I can tell now, the lesion is benign. Do a biopsy and put it under the telemicroscope so I can see it." The fact that Dr. McKinnon is in Chicago and you and Missy are separated by over 3,000 miles does not even evoke a comment.
The above scenario exemplifies one of the promises of telehealth, providing top-specialist care to those who live at a distance from the specialist. There are others, who if asked about telehealth would see some of the perils. Some fear that telehealth will reduce the number of nurses and other healthcare professionals needed; others worry about privacy and legalities. Regardless of one’s beliefs, telehealth is not likely to go away. The articles in this section will examine some of these perils as well as some of the promises.
Telehealth is defined as the use of electronic communication networks to transmit data or information that focuses on health promotion, disease prevention, diagnosis, consultation, education, and/or therapy. In one of its many forms telehealth has been practiced ever since the advent of the telephone. Telehealth in patient care covers many areas, but can be divided into two distinct parts, the technology and the provider/client relationship. On the technology side are many different technologies including advanced image and audio capabilities that range from high resolution still images to sophisticated interactive teleconferencing systems. Technology is now available that allows a virtual simulation of tissues and blood flow. Use of the Internet to transmit the feel of a lesion, or even muscles and bones, prior to surgery will happen soon.
The telehealth technology is relatively simple compared to the telehealth provider/client relationship. This provider/client relationship encompasses not only direct care, but also the content of information that is made available electronically in Web sites to both patients and healthcare professionals. As a result there are many complex issues surrounding telehealth. These include reimbursement, privacy, licensure, jurisdiction and standards. The four introductory articles in this Online Journal of Issues in Nursing topic are designed to introduce and explore some of these issues.
The issue of who is to pay and for what has slowed down the development of telehealth. Dr. Puskin, in her article Telemedicine - Follow the Money addresses payment issues starting with the flawed Balanced Budget Act (BBA) of 1997 through the Medicare, Medicaid, and SCHIP Benefits Improvement Act of 2000 (BIPA), which became effective October 1, 2001. The BBA, although providing a beginning for telehealth payment, "...did not work because it was predicated on a very limited view of how telemedicine is actually practiced. These limitations fell into four categories: (a) who can receive services; (b) what is covered; (c) who gets paid; and (d) how are services reimbursed." The BIPA, although not fully endorsing telehealth, addresses some of these shortcomings by enlarging the number of people eligible to receive telehealth consults and adding a few methods in which telehealth can be conducted. The BIPA also required a study to identify issues that are unresolved such as who is covered and what services can be provided. Various sides of other issues such as home health care, store and forward technology and quality are also explored in this article. The author makes a case for nurses, as those who will manage and be a part of much of telehealth, to be involved in forthcoming legislation that will determine policies such as whether reimbursement should be offered for preventive telehealth.
Kumekawa in her article, Health Information Privacy Protections: Crisis or Common Sense, looks at the privacy, confidentiality and security issue. The effects of the Health Information Privacy and Accountability Act of 1996, whose rules are fairly well promulgated (although as this is written in October, 2001, several pressure groups are arguing to nullify or weaken some provisions) are thoroughly addressed by this author. One of the problems in this issue is the dilemma that appears when state laws are more stringent than federal. This author advances the thought that telehealth requirements in basic administrative procedures, physical safeguards, and technical security mechanisms present special needs for privacy that involve more than just the patient, care giver, and third party payers. Shortfalls in security by consumers who divulge personal information to online medical sites are also discussed. Although not often considered, nurses who set up web pages focusing on certain diseases, as well as healthcare agencies who provide healthcare information on the Internet, will find themselves involved in these privacy issues. The desire of Americans for the latest healthcare and healthcare information, together with a concern about privacy of medical information, creates issues that, although they have no easy answers, will need to be addressed.
Hutcherson addresses the added legal concerns that become very important in telehealth as explained in her article Legal Considerations for Nurses Practicing in a Telehealth Setting. One of the questions she addresses is, "Who should have jurisdiction over healthcare; the states or the federal government?" Prior to the advent of multi-state delivery systems and nursing call centers, regulatory functions for most healthcare matters were given to the states based on the Tenth Amendment. This answer, however, became more uncertain with the enactment of the Balanced Budget Act of 1997 and the issuance of federal grants designed to use telehealth to increase access for rural and underserved areas to quality healthcare. Another facet of this question that she presents is, "Where is the location of care when the patient and provider are in different geographical locations?" The answer of course is very relevant to the issue of licensure. State Boards of Nursing have grappled with this problem; currently the National Council of State Boards of Nursing has proposed a mutual recognition model of licensure in which a nurse licensed in one state can practice in another state if she or he abides by the Nursing Practice Act of that State (See www.ncsbn.org/public/regulation/mutual_recognition_state.htm). Another issue that she believes will be debated is whether there is enough difference in practice to warrant credentialing for those engaged in telehealth practice. Regardless of the outcome of these issues, it is imperative that standards be developed and employed that encompass safe and effective direct care and the provision of health information.
The article, Windows of Opportunity for Home Care Nurses: Telehealth Technologies by Russo focuses on the opportunities for nurses as technology becomes more prevalent in healthcare and the population ages. As the author reports, these opportunities that increase the need for nurses come at a time when half of all registered nurses are over 44 years old and nursing school enrollments have been down for the last five years. Technology, this author believes, can be used to improve the situation. She describes how it has provided nurses with the opportunity for educational experiences in their own home and on an as-needed basis. The author discusses the importance of the Internet to Seniors who use it to find healthcare information. These Seniors find higher satisfaction with telehealth and have the potential for better health outcomes using telehealth. On the technology side, the author discusses use of interactive video in telehealth which has offered many clients immediate access to care, care that prevents serious problems from developing and gives homebound clients a sense of security. Correctional institutions are another place where telehealth is very beneficial. The question the author leaves us with is "Will we take advantage of the opportunities provided by the new technology, or will we be run over by it?
Telehealth has the potential to make a difference in the health care of not only Americans, but people all over the world. Whether it achieves its potential may depend on the resolution of the issues addressed in these articles. In the near future, however, do not expect to see consensus in many of these areas. One thing that is certain, given the present and future advances in technology, telehealth is here to stay. The question then becomes, how will it be used and who will benefit?
We invite you to develop a manuscript about any aspect of telehealth and submit it to the editor of OJIN or offer feedback in the form of a letter to the editor on this topic.