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Telemedicine: Virtual visits with patients
Sarah E. Fletcher, MSN, BS, RN-BC
This course is 1.5 contact hours
Course must be completed by March 15, 2019
Goal and objectives: The goal of this program is to provide healthcare providers with information about telemedicine, including types of telemedicine, clinical usage, and supporting technologies. After studying the information presented here, you will be able to:
  1. Describe two kinds of telemedicine
  2. Discuss ways in which telemedicine supports interprofessional or interdisciplinary care
  3. Identify three technologies involved with telemedicine practice
Nurse.com educational activities are provided by OnCourse Learning. For further information and accreditation statements, please visit Nurse.com/Accreditation. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity. OnCourse Learning guarantees this educational activity is free from bias. See “How to Earn Continuing Education” to learn how to earn CE credit for this module or visit http://ce.nurse.com/instructions.aspx.
Not too long ago, going to see a physician may have been an all-day excursion for people in remote areas. Today, it may be just a matter of turning on a computer or TV to connect with a provider. Although caring for people from a distance is not a new practice, telemedicine has revolutionized the potential for delivering care.
Telemedicine is any kind of interactive healthcare work done from a distance. It is a growing facet of the modern healthcare landscape with more than half of U.S. hospitals supporting some form of telemedicine.1 This can be the sharing of electronic data, video conferencing, or a simple phone call. Telemedicine is a supplement to face-to-face visits rather than a replacement for them.2

Although certain specialties or allied health clinicians may work exclusively via video conference and other virtual tools, the patient must still be assessed regularly in person by a provider. According to the U.S. Health Resources & Services Administration, telemedicine and telehealth are considered different in that telemedicine includes only clinical interactions and telehealth also includes meetings, continuing education for clinicians, and clinical training.3 Telemedicine can be what is called store and forward, meaning that information is uploaded by an individual and accessed asynchronously by another individual. An example of this is information uploaded by patients’ specialists that is later accessed by patients’ primary care providers.4 Remote monitoring is information uploaded and provided by the patient, or from the patient’s device, which a provider or clinician later accesses and analyzes. This includes home health monitoring with remote devices and is most commonly used for managing chronic diseases, such as diabetes or heart disease.4 Real-time interactive telemedicine is any technology that allows the provider and patient to interact together synchronously, or in real time. Video conferencing is an example of this and has been used for psychotherapy, physical exams, and other purposes.4 It also can include any clinician interactions, such as consulting with a specialist provider, dietitian, nurse, or other clinician. Telemedicine can be used for virtual case conferences, allowing clinicians at different clinics to collaborate on patient care, privately and with the patient.5 An emerging form of telemedicine is mobile health. Many new options are available for connecting with smart phones and devices connected to smart phones. There are a number of regulatory concerns with how these new devices are managed, and regulations are still being established.6 Some examples of these devices are fitness trackers, cardiac monitors the size of a Band-Aid, and continual blood glucose monitors with the use of nanofibers.7 More mobile health data are being used to diagnose and treat patients despite the challenges of data management and privacy.8
Telemedicine communication technology
Telemedicine relies on a number of different technologies. The most straight-forward are telephone technologies and the internet, which followed two-way radios and other older technologies.12 Internet coverage is not universal in the United States, especially in rural areas, where telemedicine may be a major supplement to face-to-face healthcare visits. Initiatives are underway to increase internet access to these areas, including improved wireless access, expanded broadband internet, and satellite internet.13 The primary benefit of satellite internet is that you simply need a receiver on the ground and your signal is received by geosynchronous satellites, although there is a trend toward satellites in low-Earth orbit with the aim to reduce latency (delay in signal) and make the technology more viable for real-time communication.14 This makes it relatively easily available to remote areas and less expensive compared with laying fiber-optic cables.

One main challenge is that satellite internet can be affected by the weather and landscape, because the signal has to penetrate cloud cover, or the receiver needs to be placed on high ground in mountainous and/or tree-covered areas. Satellites also have a finite bandwidth, although this is increasing year by year.13 Anyone with a cell phone is familiar with dropped calls and dead zones, which are so ubiquitous as to lead to extensive recommendations from the Federal Communications Commission regarding coverage areas.15 One aspect of this is the concern that cellular networks are often overloaded during widespread emergencies, which severely limits their benefit for telemedicine uses during a disaster.15 Even when the network is functional, wireless signals require a line of sight to function, resulting in urban or mountainous areas having limited functionality due to terrain.13 Broadband wired internet is another aspect of communication. To complete certain telemedicine tasks, such as video conferencing or surgery, a stable broadband connection with minimal latency is required to ensure smooth communication.16 (Level C) The biggest challenge with wired broadband is the “last mile,” the wired connection from the regional or neighborhood trunk line to the walls of a home.

Specifically, the concern is who places and owns that particular stretch of cable. How the last mile is managed from a regulatory perspective can make a significant difference in broadband accessibility to the populous of a country, and the United States has been slipping in the broadband speed ranking worldwide.17 The FCC has a National Broadband Plan designed to expand access to this service.18 Regardless of how the provider and patient are connected, they can use such connections for virtual office visits. This includes video conferencing for two-way visual interaction. The provider can see the patient, including his or her surroundings and physical well-being, and the patient can see the provider’s expressions or any shared educational materials.16
Body-area networks
Body- (or personal-) area networks are an extremely beneficial piece of technology for telemedicine, especially for remote monitoring. As its name indicates, a BAN is a network local to the patient’s body as wearable patches and implants.

Devices may be wired together or may communicate wirelessly.19 It may be self-contained, which is known as an intra-BAN, or connected to the internet, known as an extra-BAN. A number of challenges exist with BANs, including wired connections kinking or becoming disconnected, wireless BANs experiencing interference from other wireless signals, and artifact due to movement or sleep.19 BANs are interconnected devices. An example of an intra-BAN is a cardiac or sleep apnea sensor connected to a small base station that records data in the patient’s home or daily life that a specialist later accesses and analyzes.7,19 Many people are beginning to use fitness trackers that connect to their cell phones and post to a central website. This is an example of an extra-BAN configuration, although it is not necessarily used as part of provider-monitored healthcare.7

Real-time monitoring is extra-BAN, as it requires an internet connection for the clinicians to monitor vitals, such as weight, blood pressure, and pulse-oximeter. Studies such as sleep apnea assessments would be intra-BAN because data are stored internally and retrieved later. In certain scenarios, some portion of the network may consist of implanted devices.19
Regulations and standards
Currently, a number of standards exist for BANs, none of which have become a universal standard.19,20 This makes it particularly challenging for interoperability. Different devices used to monitor the same clinical condition may not use the same technology for communication and data sharing. This greatly increases the risk of crossover when individuals with BANs come into close proximity.19 The Institute of Electrical and Electronics Engineers has instituted a work group for wireless PANs (BANs) to work on a new standard. Until such a standard is fully implemented, several common standards are competing for use, such as Bluetooth and ZigBee.21 As these are noncompatible standards, interoperability between devices can be a challenge. Reimbursement for telemedicine varies across the country, with more than half of states having little to no reimbursement for telemedicine encounters.22 Insurance requirements vary by state, which can lead to limited adoption by clinicians and providers. The use of telemedicine varies by state and is based on the state’s definition of the patient’s location when the care is delivered.

The state’s definition of an approved patient location can vary significantly — from being restricted to a hospital or clinic to including the patient’s home, school, or skilled nursing facility.23 (Level A) Until such limiting regulations are removed, which are currently left up to the state,24 it will be difficult to achieve full acceptance of telemedicine in healthcare.
How to earn continuing education
THIS COURSE IS 1.5 CONTACT HOURS
1.
Read the Continuing Education article.
2.
This continuing education course is FREE ONLINE until October 26, 2018, courtesy of Nurse.com. To take the test for FREE, go to https://www.nurse.com/ce/telemedicine. After that date, you can take the course for $15 at the same link. If you have a CE Direct login and password (generally provided by your employer), please login as you normally would at https://cedirect.continuingeducation.com and complete the course on that system.
3.
If the course you have chosen to take includes a clinical vignette, you will be asked to review the vignette and answer 3 or 4 questions. You must answer all questions correctly to proceed. If you answer a question incorrectly, we will provide a clue to the correct answer.
4.
Once you successfully complete the short test associated with the clinical vignette (if there is one), proceed to the course posttest. To earn contact hours, you must achieve a score of 75%. You may retake the test as many times as necessary to pass the test.
5.
All users must complete the evaluation process to complete the course. You will be able to view a certificate on screen and print or save it for your records.
In support of improving patient care, OnCourse Learning is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

OnCourse Learning is also an approved provider by the Florida Board of Nursing, the District of Columbia Board of Nursing, and the South Carolina Board of Nursing (provider # 50-1489). OnCourse Learning’s continuing education courses are accepted by the Georgia Board of Nursing. OnCourse Learning is approved by the California Board of Registered Nursing, provider # CEP16588.
ONLINE
You can take this test online or select from the list of courses available. Prices subject to change.
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EDITOR’S NOTE: OnCourse Learning guarantees this educational activity is free from bias.

Go online to read the full continuing education module and take the test.
Sarah E. Fletcher, MSN, BS, RN-BC, is a certified nurse informaticist and an informatics consultant with almost 10 years’ experience in nursing informatics. She obtained a degree in computer science from the University of South Dakota and spent more than 10 years providing technical support and training at the University of South Dakota help desk and Gateway Inc., and as a consultant. In 2004, she obtained a degree in nursing from the University of South Dakota. Contributing author: Dale Ames Kline, MS, RD, LD, is the director of food, nutrition, and dietetics for OnCourse Learning.
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One of the original examples of technology supporting healthcare monitoring from a distance was the use of telephones by physicians calling to check on patients or to consult with their colleagues. Over time, this has evolved into e-mails, video conferencing, all sorts of devices for remote monitoring, and even remote surgeries.25 Remote monitoring often is what people think of when telemedicine is discussed. Patients are at home or otherwise going about their day while wearing some kind of monitor, such as for cardiac function, blood glucose, sleep apnea, or any other clinical values. This often is used in rural areas, where distance and travel concerns impact the ability of patients to regularly or safely visit their provider and specialists.26 Patients in urban areas also benefit from remote monitoring, where similar travel constraints may exist with traffic and public transportation.26 Cardiologists may need to monitor a patient’s cardiac rhythm for a period of time to assess for intermittent dysrhythmias, or a sleep study may occur in the patient’s home.7,27

These can record a patient’s heart rhythm continuously, which a specialist later analyzes. New devices are being developed to continually monitor diabetic blood glucose and the oxygenation of a patient with asthma. Many of these devices are designed to contact emergency services if abnormal results are detected.19
Interprofessional communication and collaboration
Patient care is a team approach, and telemedicine is no exception. In fact, it can increase the team communication, as clinicians can video conference or teleconference with a patient as a group, or do so individually followed by clinical huddles.9 (Level B) One of the oldest uses of telemedicine is a clinician’s picking up the phone to speak to another clinician regarding a patient’s care, although this is not considered telemedicine by everyone. More recent examples of telemedicine for interprofessional communication include video conferencing, texting, and forums or chat rooms for professionals. For example, when a patient has multiple comorbidities, such as diabetes, obesity, congestive heart failure, and end-stage renal disease, the primary care provider can collaborate remotely with nephrologists, dietitians, case managers, and other care providers involved in the patient’s care. Care team discussions can occur even if the provider and other clinicians work at disparate locations. One concern with using telemedicine for clinical discussions and consults is privacy, especially with the transmission of protected health information.8 Standard e-mail and texting accounts are not encrypted, meaning that anyone with a modicum of hacking skills can access any PHI transmitted.

Encryption on websites and forums is set up by the host of the site, and all privacy policies should be reviewed before posting PHI.10 Devices must be configured to support Health Insurance Portability and Accountability Act regulations when transmission occurs between providers and other clinicians. With that in mind, telemedicine technologies allow the clinical team to span the globe rather than be limited to an office. It even is possible to crowdsource diagnoses.11 (Level B) Due to the availability of global telecommunications and information, any clinician can reach out to any other clinician regarding the diagnosis and management of rare illnesses.

For example, if a provider has a patient with unclear or inconsistent symptoms and no clear diagnosis, the provider can access any number of other providers, including specialists, to narrow down and identify an accurate diagnosis.
Clinical uses
Emergency medicine was one of the first uses of concurrent telemedicine, as shown in the 1970s television show “Emergency!” In the show, EMTs had a large portable radio through which they could communicate with a physician at a hospital about care for a patient.36 This is evolving into remote assessment and mobile video conferencing, which allows providers to see trauma, illness, and injury rather than have it described to them.37,38 Continual live monitoring for patients is available for patients who are receiving care in nursing homes or critical access hospitals without dedicated critical care or specialty staff.39,40 The physicians or nurses monitoring the patient can be in any location, but are often located in another care facility.40 The room where the patient is located is specially designed with cameras and controls that allow the offsite eICU nurse to focus on the medicine bags or program in the IV pump. If the eICU nurse cannot control the pumps remotely, the onsite clinician will input the program by proxy. Onsite staff perform other care actions, such as turning the patient, changing dressings, or managing nutrition.40 Any specialty care can be managed from a distance, including consults, but one of the most exciting new options is telesurgery. With more and more surgical equipment being robotic and not requiring the surgeon to be in the room with the patient, the next logical step is to have the surgeon not be in the same building or room as the patient. This expands options for patients and surgeons, because the surgeon can perform multiple surgeries in a day on patients all over the country or world.41 Clinicians in smaller facilities or clinics may provide follow-up care to patients who have received robotic surgeries.
Clinician-to-clinician telemedicine
Management of chronic illnesses, such as heart failure, COPD, and diabetes, is a major benefit of telemedicine. As nearly half of American adults have a chronic illness, telemedicine can add another level of support for the care of these patients.28 Data from devices can be referenced by multiple providers, including if there are early indications of exacerbation.28

In treatment of patients with physical therapy, in-home treatments with telemedicine provided equivalent outcomes to standard outpatient therapies.29 In addition to the use of BANs, there are remote sensors available for the home for monitoring of gait issues or patients with fall risk.30 Patients may even monitor themselves and share those data with their provider. Fitness trackers are becoming ubiquitous and even more complex, tracking greater information — from pulse to sleep patterns. The data can be combined with a patient’s self-reported activity, diet, or other information to monitor for patterns, such as glucose spikes after certain foods. The number of smart phone apps is growing daily, and new devices are being developed to allow even greater monitoring, so the monitoring options will continue to grow.7 A growing trend in mental health is the option for video therapy sessions. This can be especially helpful for patients who live in remote areas or are agoraphobic or paranoid, or have other concerns that prevent them from traveling regularly to an office. Regardless of the type of remote visit, real-time communication allows patients to seek care from physicians, dietitians, nurses, and other clinicians in other time zones rather than being geographically limited.31

For example, if agoraphobic patients also have physical illnesses, such as diabetes, they can have remote therapy sessions with a therapist, endocrinologist, or dietitian via video conferencing from their homes. As with any technology, there always is a risk of lessened security, as few software and wireless technologies are securely encrypted.19,32 Communication with patients is not entirely via video conference nor telephone. Social media are also playing a part. There are online groups and forums for virtually any illness, and some, such as patientslikeme.com, that allow you to seek out similar patients. Often, these exist with little to no healthcare provider involvement. Those that do fall under the umbrella of telemedicine.33 The more common way for a patient to communicate with a provider electronically is via a patient portal.34 Patient portals are part of the Health Information Technology for Economic Clinical Health Act and Meaningful Use.35 The purpose is to pull a patient’s records together electronically so the patient can view and make appointments; review medical data and lab results; and communicate with his or her provider, health coaches, dietitians, and other clinical staff. Not all patient portals provide all of these services, but the goal is to do so.35
Due to the availability of global telecommunications and information, any clinician can reach out to any other clinician regarding the diagnosis and management of rare illnesses.
Telemedicine takes interactive healthcare to a new level
Earn 1.5 credit hours for free with this course
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