Editor's note: This special Job Watch article is a reflection of a desire by many nurses to enter or advance within specialty areas. You helped guide the theme through your enthusiastic reception of information we've published throughout the past year. Use our online exclusive articles and related content in our print editions to help guide your career to the next level.
Geriatric patients are not particularly known for being techies. However, it seems this commonly held assumption might need to be reconsidered.
"One of the patients in our telemedicine program is 98 years old. She absolutely loves logging on the system, seeing the live video feed, and having a nurse come up on the video screen right there in her living room," said Cindy Moore, CNP, Director of Home Care at Presbyterian Healthcare Services in Albuquerque, NM.
Recent technological advancements have allowed geriatric patients to obtain a new level of independence.
By utilizing video feeds between the patient's home and the healthcare provider, telemedicine allows elderly patients to have independence without sacrificing safety.
"Telemedicine is very appealing for an elderly patient population because they tend to be homebound; it can be exhausting for them to make even a routine office visit. Or, it can be financially draining if the patient has to take a taxi or ask a relative to take off work," said Jeanette Daly, PhD, RN, associate research scientist, University of Iowa's Department of Family Medicine.
Growing out of the advent of internet connectivity, telemedicine allows for remote patient care and home-based monitoring of indicators such as blood pressure, weight, and blood sugar. In its short existence, telemedicine has undergone numerous changes and improvements.
More than a decade ago, Daly and other researchers at the University of Iowa worked on a telemedicine pilot project. At the time, they were among the vanguard of telemedicine implementation; although their work was not the beginning of telemedicine, it was certainly unique.
"We did work on a telemedicine pilot project back in 2001. At that time we were hosting a visiting professor, Dr. Jung-Yung Park from Seoul, South Korea. He wanted to get telemedicine technology into nursing homes. He pitched the idea to various companies and was able to secure a grant for a telemedicine pilot project," said Daly.
Daly and her team of researchers had a difficult task: Build a portable telemedicine unit from the ground up. Countless roadblocks had to be circumvented in their endeavor.
"We had to spend a lot of time on each of the different pieces for the cart. Whether it was a camera for viewing a laceration or a probe to be put in someone's mouth, everything had to be FDA approved," Daly said.
Their frustrations did not end once the unit was constructed with FDA approved instruments; problems with implementation still abounded for the team.
"Despite our best efforts, there were many failures with the pilot project. Sometimes the doctor would be ready on one end but the nursing home's server was down," Daly said.
As pioneers in portable telemedicine units, Daly and her team were forced to engage complications head on. Nevertheless, their efforts paid valuable dividends toward the future of geriatric telemedicine.
"Actually working with the telemedicine unit should not be at all complicated; what is complicated is trying to build a unit from scratch," said Daly.
Modern Geriatric Telemedicine
Fast-forward a decade. Now, geriatric patients carry smartphones with apps that allow them to chart their blood pressure and send it to their primary care physician.
"Awhile back, we hosted a community health fair and an elderly man showed me a smartphone app that let him track his blood pressure. I was stunned," said Moore.
Though blood pressure monitoring apps are novel, Presbyterian has utilized technology in a far more comprehensive manner.
As a part of the hospital's home care department, telemedicine has provided geriatric patients greater independence through continuous disease management.
"Our telemedicine units allow the patient to monitor their blood pressure, weight, and blood sugar all from within the home," Moore said.
"This promotes independence by helping patients develop a treatment routine and teaching them to recognize early changes in their condition."
When patients enroll in the program, a telemedicine unit is installed in the patient's home and the patient is instructed in its usage.
The next step is a hearty dose of practice; although the unit is specifically designed with elderly patients in mind, some processes still need to be explained.
"Once everything is installed in the patient's home, we have them submit data for a week prior to their next nurse's visit. This allows the nurse to clarify any equipment usage questions for the patient," said Moore.
Always having a nurse on-call gives geriatric patients peace of mind and decreases the amount of unnecessary emergency room visits.
"This provides elderly patients access to a nurse in between their scheduled visits. Patients can contact the remote nurse with questions regarding medication usage or symptoms they may be experiencing," said Moore.
Different Users in Mind
The prototype unit designed by Daly and her team was to be used by a nurse in a nursing home setting. As a result, the instrumentations were designed with a nurse in mind.
"Everything on our cart was designed assuming that it would be a nurse who was using it. If the elderly patient was going to be the unit's primary user, then adaptations to the keyboard and telephone adaptor would certainly need to be made," said Daly.
The telemedicine units that Presbyterian utilizes take into account the fact that the elderly patient will be the primary user.
The instrumentation is as simple and intuitive as possible. Nevertheless, some ailments can bar patients from effectively using the technology.
"Since the patient is the one who has to manage the equipment, this technology is not effective for dementia patients unless a caregiver can help in the monitoring," said Moore.
Another major difference between the prototype units of old and those that are currently used is the role of the nurse.
"With our pilot project unit, the nurse had to function as the doctor's hands; since the doctor was not in the same room as the patient, the nurse had to do things like repositioning the stethoscope or adjusting the blood pressure cuff," Dalysaid.
Rather than being next to the patient serving as the doctor's hands, nurses serving in Presbyterian's telemedicine program have only the power of words to assist patients.
"Nurses must function at a higher level because of this technology; they need to be very innovative in coaching the patient in their own management," Moore said.
"If the patient hasn't taken their blood sugar, the nurse must be inventive in explaining why daily care is important."
With increased patient independence comes increased opportunity for non-compliance. However, nurses must again rely on education to stress the need for consistent monitoring.
"We do not have a 'three strikes and you're out' approach toward patient non-compliance. If a patient repeatedly fails to monitor their blood sugar, we just encourage them by reiterating the importance of developing these habits to help control their disease," Moore said.
Telemedicine technology has undoubtedly shifted in the past decade. This shift in technology has changed patient independence and where the nexus of care is located.
"Medicine will eventually be centered in the home again; things will come back full circle to the day when most care was provided in the home. Telemedicine is helping care to be rendered from a distance," Moore said.
Many of the most common chronic diseases such as diabetes, chronic obstructive pulmonary disease, or heart failure can be managed through this sort of remote monitoring.
"The patient data is documented directly into their electronic medical record and we can send that data to their primary care physician or run reports as needed," Moore said.
"It is vital that nurses are aware of these telemedicine resources available for disease management in the home."
A. Trevor Sutton is a frequent contributor to ADVANCE.