Vol. 9 Issue 25
The Learning Scope
Information and communication technologies show potential to improve disease management
This offering expires in 2 years: November 19, 2009
The goal of this continuing education offering is to provide nurses with essential knowledge about telehealth. After reading this article, you will be able to:
1. Explain the definitions of telehealth and technology types used in telehealth.
2. Discuss the application of telehealth technologies in chronic disease management.
3. Identify the issues in using telehealth.
You can earn 1 contact hour of continuing education credit in three ways: 1) For immediate results and certificate, go to www.advanceweb.com/nurses. Grade and certificate are available immediately after taking the online test. 2) Send this answer sheet (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.
Merion Publications Inc. is an approved provider of continuing nursing education by the PA State Nurses Association (No. 008-0-07), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Publications Inc. is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).
Remarkable advances in modern healthcare during the past century have improved longevity. However, more than 90 million Americans live with chronic illnesses, and their medical costs account for more than 75 percent of national medical care costs.1,2 The most prevalent chronic illnesses include cardiovascular disease (primarily heart disease and stroke), cancer and diabetes. Physical, psychosocial and financial consequences from the prolonged course of illnesses may result in decreased quality of life for millions of Americans.1,2
However, effective disease management can prevent exacerbation of symptoms and improve individuals' quality of life, lessening the societal burden of lost productivity and increased healthcare costs.3-5
Recent advances in information and communication technology (ICT) have transformed healthcare dramatically and offer a great potential to improve the disease management process.6-8 In fact, various technologies (e.g., telemonitoring devices and video consultation) already have been used for tele-disease management, and healthcare professionals and organizations are making great efforts to improve the efficiency and outcomes of the technologies.9-11
Nurses always have been at the forefront in managing chronic illnesses using telehealth. Examples of this include home telehealth and tele-heart failure management programs coordinated by nurses.12,13
As the population ages, it is likely more telehealth technologies will be used to manage chronic illnesses, and nurses' role in this field will be invaluable. Telehealth also will become important to clinicians who take care of acutely ill patients, because caring for an individual occurs in a continuum, not at one point in time. Integration of telehealth technologies with hospital information systems is ideal because it allows data exchange between systems and improves efficiency of care.
Although telehealth is becoming more important, many nurses may have not had an opportunity to learn about it. The main aim of this article is to provide nurses with general knowledge about telehealth.
History & Definitions
Telehealth may seem to be a modern technology with a short history; however, the origins of telehealth date back to the early 20th century, when the first tele-electrocardiograph was developed by Willem Einthoven.7,14 Using a string galvanometer and telephone wires, he recorded the electrical cardiac signals of patients in a hospital 1.5 km away from his lab.7,14
Telehealth technologies have advanced rapidly since the late 1960s, when Murphy and Bird established an audiovisual microwave circuit between Massachusetts General Hospital in Boston and Logan Airport and conducted medical consultations for airport employees and travelers.7,15 Since then, with the rapid advancement of ICT, telehealth has made significant progress.
The scope and practice of care delivered remotely varies a great deal among different settings, and different terminologies have been used to describe such practice. The most frequently used terminologies are telemedicine, telehealth, eHealth and telemonitoring.6,8,16,17
Telemedicine: Has the longest history and is defined as the provision of healthcare services and education over a distance using telecommunication technology.18 Examples include medical image transmission and interaction via phones.
Telehealth: A more encompassing term that includes the integration of telecommunication systems into the practice of promoting health, while telemedicine is more focused on curative medicine.8
eHealth: Recent term that incorporates all forms of electronic healthcare delivered over the Internet, including informational, educational and commercial services.8,19,20
Telemonitoring: A type of telecommunication technology that uses monitoring devices (e.g., Web camera, scale).8
Telehealth uses various technologies, such as the telephone, video, Web-based communication and telemonitoring devices (e.g., scale, blood pressure unit, glucometer, ECG). It also can use both real-time technology (e.g., interactive video consultation) and "store-and-forward" technology (e.g., consultation of pathology film transmitted to another location).6,8
Based on their use in telehealth, these technologies can be categorized into four groups: 1) technologies that support patient education and self-care; 2) technologies that facilitate patient/provider and provider/provider communication; 3) technologies that allow data sharing between providers and electronic data storage; and 4) technologies that combine all of the above.6
Application of Telehealth Technologies
The current disease management approach emphasizes the importance of empowering patients to manage their own chronic diseases and prevent complications through adherence to medication regimens, regular monitoring of vital signs, a healthy diet, exercise and other lifestyle choices.5 Many prior findings demonstrated the effectiveness of disease management programs on the frequency of hospitalization, quality of life and functional status of the individual.21,22 As healthcare technologies advance, many studies have examined the effects of technology-based chronic management programs (e.g., heart failure, diabetes, pulmonary conditions).12,23,24
Although findings are inconclusive, many studies of telemanagement programs show decreased hospitalization rates and improved quality of life and functional status.9,10,21,22,25-32
Various technologies can be used to manage chronic illnesses, including:
systems that monitor physiological measures;
systems that electronically "check" on the patient (e.g., online symptom survey);
sensor systems that monitor the patient's movement (e.g., falling, lack of movement);33 and
telephone systems (e.g., cell phone, regular telephone).
In this article, we explore the application of different telehealth programs on chronic disease management of heart failure (HF). This is selected because cardiovascular disease is a leading chronic illness and various telemanagement programs have been used in this field.1
Many earlier programs used telephone-based telemanagement programs to manage chronic illness after hospital discharge.
In a two-group randomized controlled trial (RCT) (N = 358), Riegel and associates assessed the effect of telephonic case management on resource use of patients with HF (e.g., hospitalization rates and days, readmission rates and days).18 Participants in the intervention group received a telephone follow-up within 5 days after hospital discharge and thereafter at a frequency guided by a decision support program and the case manager's judgment based on patient symptoms, knowledge and needs.
Findings showed HF hospitalization rates and days, as well as readmissions and inpatient costs, were significantly lower in the telemanagement group. Furthermore, patient satisfaction with care was higher in the telemanagement group.
Televideo programs have been used in several studies.34,35 In their study, Jerant and colleagues compared the effects of three post hospitalization nursing models for patients with HF (N = 37): video-based home telecare, telephone calls and usual care.35,36
Participants in the video-based home telecare group used a telecare unit equipped for videoconferencing with the nurse in the hospital. The unit used a regular telephone line. A camera on the unit allowed nurses to observe the patient's facial expressions, respiratory effort and lower extremity edema, as well as objects such as digital scale displays. The voice was transmitted simultaneously via a microphone. During the videoconference, the nurse had the patient or caregiver place an electronic stethoscope to the heart and lung auscultation points.
The findings showed HF-related readmissions and emergency department visits were significantly lower in both the video-based home telecare group and the telephone group compared to the usual-care group.35,36 There was, however, no significant difference between the two intervention groups.
In a large RCT, Cleland and colleagues compared outcomes of home telemonitoring (HTM) intervention with those of a nurse telephone support (NTS) intervention and usual care for patients with HF.37 A total of 426 patients with HF who were ready for discharge or recently discharged participated. The participants in the HTM group were instructed to assess weight, BP, pulse and heart rhythm twice daily using the wireless telemonitoring devices. The measurements were transmitted via phone line to the HF nurses.
Findings showed the usual-care group had higher 1-year mortality (45 percent) than the NTS (27 percent) or HTM (29 percent) groups (p = 0.03). The admission and mortality rates were similar among patients randomly assigned to NTS or HTM, but the mean days for hospitalization were reduced by 6 days with HTM.37
Subjective Symptom Questions
In a two-group RCT (N = 188), Weintraub and associates compared the HF disease management program with automated home monitoring (AHM) and the usual HF disease management program.38 For the participants in the AHM group, in addition to the objective data (weight, BP and pulse), collected daily using telemonitoring devices, participants also answered questions about clinical status and medication compliance using an interactive device. Preliminary findings over 90 days showed significantly lower hospitalizations (72 percent) for the AHM group.
A few studies focused on the effects of computer or Web-based educational intervention.30,39 Kashem and his colleagues tested an Internet-based telemedicine system that allowed communication between patients and their healthcare providers.30 Thirty-six patients who attended an HF center were randomized into the intervention or usual-care group. When using the Web program, the participant was required to enter the data for daily weight measured using a regular scale, steps assessed with a pedometer, and BP and heart rate obtained from a sphygmomanometer, as well as answer symptom questions. Total hospital days were lower in the intervention group (44 days) compared to the control group (133 days).
In another preliminary study (N = 12), Bennett and her colleagues developed and pilot-tested a Web TV-based education program tailored to each patient's medications.39 Findings suggested feasibility of the program for further studies.
Motion sensors often facilitate frail older adults' independent living rather than manage specific signs and symptoms of illnesses.40,41 This technology can be categorized as a telemonitoring device; by monitoring mobility using sensors, the clinicians can assess the health status of elderly individuals.41 One interesting example is "smart home" technology. So-called smart homes are equipped with motion sensors and other advanced technology applications that enhance residents' independence. The health of residents of the smart homes often is managed by a multidisciplinary healthcare team.40
In telehealth, as in all other healthcare settings, protection of privacy, confidentiality and security of personal health data are critical. The telehealth environment, however, introduces different challenges than the traditional face-to-face settings in obtaining consent and securing data. Appropriate procedures and measures must be implemented for the consent process and data security.42-44 Although HIPAA does not apply to all healthcare organizations, compliance with those regulations reinforces the privacy and security of the individuals' personal health data in the telehealth arena.19
One of the strengths of telehealth practice is overcoming geographic limitations. However, this aspect raises several legal issues in providing healthcare. For example, although a number of authorities have proposed options to address the issue, licensure and jurisdiction are still problematic in telehealth.45
A second issue arises in the area of reimbursement. Currently, Medicare reimburses the following three telemedicine/telehealth services:
1. remote patient face-to-face services seen via live video conferencing;
2. non-face-to-face services that can be conducted either through live videoconferencing or via "store-and-forward" telecommunication services; and
3. home telehealth services.17
In general, however, there is a lack of universal reimbursement policies among Medicaid and private payers.17 Based on a 2005 national survey of 64 organizations that provide billable telehealth services, 58 percent received reimbursement from private payers, up 5 percent from 2003.46,47 This shows private reimbursement is becoming more common for telehealth services.
Telehealth practice must meet various standards in both the healthcare field (e.g., specific practice standards) and the information and computer technology arena (e.g., wireless network security standard for IEEE 802.11a/b/g). A lack of universal standards has been identified as an issue in telehealth practice.42
However, several professional organizations, such as the American Telemedicine Association (ATA) Special Interest Groups, established specific standards and guidelines for telehealth practices.48 For instance, in 2002, the ATA home telehealth special interest group established Home Telehealth Clinical Guidelines to guide the development and deployment of home telehealth.49 These guidelines include:
definitions of terms used in telehome care;
generic guidelines applied to both interactive home telehealth and telemonitoring;
guidelines specific to the use of interactive home telehealth; and
guidelines specific to the use of telemonitoring.
The costs of establishing and maintaining telehealth services can be high. Various factors affect telehealth costs, including hardware and software, the communication method between the provider and patient, existing network structure and personnel costs.6,43 Although many prior findings showed the effectiveness of telehealth programs on various health outcomes, the cost-effectiveness of telehealth programs remains inconclusive.
The history of telehealth is relatively short compared to other clinical disciplines. However, further rapid advancement of telehealth is warranted due to several factors in current healthcare: the rapid advancement of ICT, national emphasis on interoperability of healthcare systems and the growing population of older adults who need chronic disease management.
More nurses will be involved in telehealth directly or indirectly because telemanagement practice will be integrated into the care delivery continuum and most telemanagement programs will be managed by nurses. Therefore, it is important nurses and nursing students learn about telehealth and maintain their competency.
References for this article can be accessed at www.advanceweb.com/nurses. Click on References on the left navigation bar under Education.
Eun-Shim Nahm is an assistant professor at the University of Maryland School of Nursing, Baltimore.