My name is Bonnie Westra and I, I'm an Associate Professor at The University of Minnesota School of Nursing. And today's presentation is on Telehealth. What we're going to be covering is, what is the use of telehealth in various kinds of settings? Who are the populations that are served by the use of telehealth? I'd like to talk a little bit about the role of the telehealth nurse and then explore various types of systems and equipment. So, telehealth is actually used in a variety of different settings. One example is in home health care. Home health care will use telehealth for being able to monitor patients with chronic health conditions to provide education or to provide support. In nursing homes, instead of having to take a patient out to see a health care provider, telehealth allows the nurses to be able to get specialty consultations, therefore, saving a lot of trouble for patients as well as money. In ambulatory care, especially like in Critical Access Hospitals where they have clinics, they may not have specialists. So they may actually have telehealth where you can get like dermatology consultation, neurological consultation, and so on. And in hospital stroke care is provided, where people may not be really experienced or frequently see patients with evolving strokes. And so,being able to get consultation from such as University of Minnesota is helpful. In prison settings, they're doing some work with the use of telehealth for our psychiatric consults. So if you think about taking a patient out with guards to go see a psychiatrist, it gets to be very expensive and this allows them to be able to receive better more frequent services within the prison settings. And then we also see where there are nurses who are wound care specialists. And they use telehealth to be able to provide consultations about, you know, staging pressure ulcers or what's the best kind of treatment for pressure ulcers. ICU monitors is another issue where we have what we call eICUs. So we'll have ICUs that can be monitored from a central location. And you can have 15, 18, 30, 100 ICUs across the country where nurses who are very experienced in the central location can actually provide monitoring for ICUs. And then, also, we see telehealth used for health promotion. So helping people with obesity, for instance, to be able to do a better job of complying with diets or exercise. So as we look at what is the role then of a telehealth nurse? Well one is called a presenter, and a presenter is someone who actually sets up the equipment, lines up the appointment, tests the equipment schedules the patients, brings them in, does an initial assessment, and then presents them over telehealth to a specialist on the other end. Another type of role is the nurse case manager. So we're seeing an increasing number of nurses working in roles in order to be able to help manage chronic diseases like diabetes or support health promotion. Public health nurses are also using telehealth. So you'll find that Text4bbies or Text2Quit smoking are two examples of telehealth. So telehealth isn't always video, it can be other kinds of technologies. Health coaching is another role and then the Tele-ICU nursing that I mentioned earlier. And then also because of the fact that the roles for telehealth are expanding so much, we actually see coordinators who are specializing in coordinating a group of telehealth nurses. So this is really an upcoming role that you'll be seeing in the future. Now, an example of what does a nurse presenter do? Well, the first thing that they have to do is actually plan the program. So one of the examples is what room do you actually put a telehealth equipment in? And it needs to be in a quiet area where you're not hearing the paging overhead, for example. and it needs, you need to look at the scheduling coordination, not just in the local place, but also with the specialist who's on the other end so you're doing dual scheduling. evaluating and preparing the equipment, making sure it's located in the right place so it's easily accessible without blocking the monitoring of the patient. Assessing the patient, presenting, what are the findings? And then facilitating remote exams. You're going to see various kinds of equipment like derm camera, where you can get a camera right up next to a person's hand, and be able to see the texture of the skin, the color, and so on. as well as things like listening to heart sounds, you know, looking in their ears, looking in their throats. So there's various types of equipment that's used for the specialist on the other end to be able to actually see what the nurse on the end with the patient is seeing. And then documentation afterwards and scheduling the follow up care with the patient. Now, there are different kinds of telehealth. So, one is called real time, in which it might be just the use of a telephone as an example. Or you might have web consults, where it's two-way audio and visual, so that there's an interaction that's going on. And you might find that you're either using peripheral devices like I mentioned a stethoscope or no peripheral devices. So there are different levels of technicality in the equipment. There also is something called store and forward. So what that means is that you may have images such as x-rays or audio or video types of images that can be stored. And then, they can be forwarded to somebody for specialty consultation as well. Or you might see a combination of those where an x-ray was done ahead of time, but then, you've got a real time person there and you also are looking at store and forward images from previous times. So one of the things that is really interesting is the variety of different equipment that is used in telehealth. So phone lines, obviously and internet are critical in, in order to be able to do telehealth. you know, looking at phones and computers, and the computers can be either with camera or without camera and microphones. cellphones are being used, life lines, sensor technology and various kinds of peripheral devices. So those are listed on the right hand of the slide here, and so you can see that there are different kinds of peripheral devices, like blood pressure scales, glucose monitoring cardiac monitoring dermascope, otoscopes, and pedometers. The thing that's important about that is the information is collected locally and it's transmitted remotely so that the person on the other end can actually, it's like they're in the room with you when you're using the equipment. So here's some examples of that. On the left upper hand corner, you'll see that there is a General Exam Camera. I saw the use of it the other day where they got right down and you could see every, it's like watching the fairies dancing on the head of a pin, you know, you can see such good clarity. the PhysioGlove is actually EKG monitoring. So you just simply just put it on the person's chest and be able to get EKG per that is remotely communicated. And with the Electronic Stethoscope, the person on the other end can hear every single heart and breath sound through the equipment. You'll also see Spirometers for measuring people's ability to breathe. The Ophthalmoscope for looking at their eyes, and then the ENT/Otoscope as well for looking in ears. Additional equipment that you'll see are Portable Ultrasound or Nasopharyngoscopes, so being able to look inside someone's nose to be able to do an examination. Now, I'm going to switch from equipment to talking a bit about some of the types of technology. So, as I mentioned earlier on, you can be very simple, like a phone or even email consults, provided that you're doing it securely, and that's the whole nature of this. Or you can have a [UNKNOWN] complex, as looking at an eICU. An example of that is that Baptist Hospital has eight ICUs for a total of 142 beds that are remote, remotely monitored from a single location. So there are four nurses every shift, and one of the things to note is that this is not an entry level position. These are nurses with an average of 19 years of experience. And they are able to do real time vital signs and cardiac monitoring. They can and see the entire electronic health record. They can do alerts if there is a problem, so they can notify the nursing station, immediately be able to get help for the patient. And they can actually activate a camera and be able to speak to the person in the patient's room. So obviously, patients need to be oriented when their TV comes on and they see a person in front of them, you know, that that is really a nurse from a remote location who's monitoring them. As we look at the future and actually kind of the present, we're beginning to see that Mr. Smith's House is calling. The technology that we have in the community is beginning to help us be able to really support people to stay safely in the community, but also, to be able to gather information that a health care provider can help to be able to monitor what's going on for them. So there's caregiver alerts. So, an example is the lifeline that's been around for many years. There are also are voice prompts to remind people. an example of that is, especially with medication management, there are many devices now that remind people that it's time to take your medication. And in fact, if they don't take their medication number of the devices are set up to actually call whoever they designate as the person. And so, in 30 minutes, if you haven't taken your medication, I'm calling your doctor or I'm calling your nurse or I'm calling your daughter. So oftentimes, it's an informal caregiver who gets called. There are floor sensors. so what you'll find is that somebody who has problems with ambulation, is at risk for falling, you can actually pick up you know, their, their step, their gait, as they're walking and notice if there's anything different. And so it's it's kind of early stage yet, but there's a lot of work going on in assisted living situations. To use that as kind of early warning detectors, that when dates begin to change, or for people walking, that it might mean something else is going on. there are safety features that are, in homes, like you'll find in Alzheimer's units. There are different kinds of monitoring devices that are sensory. there are also video monitoring, vital sign monitoring and even smart beds. So an example of a smart bed is there is pad that fits underneath the sheet that will pick up early detection of moisture, wake the patient up so they get up and go to the bathroom before they actually are incontinent. And incontinence is a leading cause for people not to be able to remain at home. So this has become a really helpful kind of thing. Now, this one is more futuristic. When you look at all the robots, I haven't seen a robot that will go around and vacuum your floor that looks like this but we do actually have robots now that vacuum floors. On commercials, you may have seen these small round disks that go around and vacuum up floors. I haven't seen one who'd do the grocery shopping yet, but that'd actually be really great when that happens at some point in the future. As we think about telehealth, it's critical to also always pay attention to the ethical and to the legal issues. So if you take a look at, there's a couple of different scope and standards of practice. One is put out by the AAACN, so I'm not sure I remember what that stands for, but it's a telehealth association. There are standards and guidelines from nursing as well as from the telehealth groups. There are also some standards out in regards to devices in particular. It's really critical in telehealth. So the is the center for Telehealth and eHealth Law that will you, will be a good resource for trying to understand the legal issues around telehealth. And then there's the license to practice. So, the location of the patient is where you need to be licensed. Minnesota is not part of the compact states for instance. And a compact state means that if I have a license here and I'm part of a compact, I am licensed to practice in other states. So if a patient I want to monitor lives in Wisconsin, but I'm a nurse in Minnesota, I can not provide telehealth in Wisconsin. So it's really critical to understand where you're licensed to practice. There is a lot of research that is out and continues to rapidly unfold about the benefits, as well as the challenges with telehealth. So the benefits really are about health care access. Especially, in remote rural or urban areas. there is a beginning return on a dollar dollars that's beginning to be demonstrated now through a number of different grants. Certainly coordination of care is really key. especially when you think about home care or case management. Being able to make sure that somebody is center with the patient and then gets other people involved as is needed. And then we're seeing that the quality of care can greatly improve because of the followup that can occur with patients. There are some challenges though of telehealth. Certainly it's been slow to expand and mainly because of reimbursement, but the reimbursement issues are beginning to shift now that we're demonstrating the benefit and the financial return. We're beginning to see more payers willing to actually pay for telehealth visits. in rural area, the technical infrastructure continues to be a challenge. There are areas that do not have cable, for instance or fiber optic and they're still using what's called POTS lines, plain old telephone system lines. licensure and credentialing still needs to be attended to. And we need to continue to gather the evidence that telehealth really does make a difference. So in summary, what we've covered today is just a brief overview of what's telehealth? What settings is it being used in? What are some of the roles with telehealth? A little bit about equipment, as well as the technology that's used in telehealth. So now there's an exercise for you to do. So the exercise is, first of all, identify one situation in which you might think about using telehealth? Secondly, what concerns might you have in implementing it? And then third, what strategies would you use to be able to successfully implement telehealth, based on the topic that you chose? So, thank you very much. I really appreciate your time and attention.
