Evolution/History of Telenursing
Upon completion of this chapter, the nurse will:
1. Realize that providing telephonic patient/client* care is not a new fad
2. Summarize the evolution of telemedicine and telenursing
3. Examine the basic nursing requirements to provide telephonic patient/client care
HISTORY OF TELEMEDICINE
Providing care to patients/clients through the use of communication equipment is not really new. It is only becoming more popular or used because of advancements in the telecommunication industry. It is thought that telemedicine was first used in the 1960s when the National Aeronautics and Space Administration (NASA) built health monitoring sensors into the astronauts’ spacesuits to monitor the health effects of space travel.
Also in the 1960s, telemedicine was used within the psychiatric mental health care population, but in this case primarily for health care providers to communicate and consult with each other. The first documented use of telemedicine to provide direct patient care occurred in 1967 at Boston’s Logan International Airport. A medical station was created, linking the airport with Massachusetts General Hospital, in order to provide care 24 hours a day.
During the decade that followed, NASA continued to play a role in telemedicine technology by employing satellites that transmitted information from Alaska (1971) or microwave technology to connect residents of an Arizona Indian Reservation with care providers (1972). Also in the 1970s, the U.S. Department of Health, Education, and Welfare sponsored several hospital projects to demonstrate the use of telemedicine. The very next year two telemedicine programs were established: one in Boston for nursing home residents and another at Jackson Memorial Hospital in Miami, Florida.
Telemedicine continued to evolve over the next decades, focusing primarily on remote or rural areas that lacked consistent health care providers or facilities. During this time, telecommunication equipment advances were made to include adjunctive equipment or devices to aid in monitoring patient conditions. Examples of this equipment include home monitoring devices for blood pressure, weight, heart rate, oxygen saturation and blood glucose levels, and effectiveness of pacemaker functioning.
Personal computers have played a large role in the use of telemedicine today. Integrated cameras and applications encourage and support real-time interactions between health care providers and patients. The only challenge might be the patient’s access to a device that can be used for these episodes of care.
IMPACT ON MEDICAL PRACTICE
Few people, if any, remember the days of physicians making “house calls.” These visits were made by the neighborhood general practitioner to the homes of patients who were too ill to come to the office to be seen. As these visits fell away they were replaced by ambulance calls and trips to emergency departments.
Today, nearly every street block in major cities has an urgent care center. Community care centers are strategically planted to provide care to individuals who have limited access to financial resources or transportation. Pharmacies are incorporating “care centers” to enhance one-stop health care shopping—go to the pharmacy for an acute illness, receive a prescription, and shop while waiting for it to be filled. The need for “general practitioners” for everyday common ills has decreased.
With telemedicine, however, the philosophy of the “house call” is resurrected, but with a twist. Instead of having the physician physically arrive at the home, the patient/client and physician can connect through telecommunication equipment. The patient can be “seen” by the physician, who can conduct an assessment, make a decision about treatment, and direct the patient to either use a prescription or follow up with a “live” visit in the brick-and-mortar office setting. These “virtual” visits are enhanced for patients who have monitoring equipment attached to the telecommunication device, as the physician can evaluate additional data to support clinical diagnoses and decision making about treatment.
Even though this cutting-edge technology exists, telemedicine is not embraced by all in the medical field. Reasons for reluctance to use telemedicine include:
The need to physically “touch” a patient prior to diagnosing an illness
The need to use traditional tools; for example, stethoscopes, otoscopes, ophthalmoscopes, and reflex hammers
The fear of making a wrong diagnosis because of technological limitations
The belief that medicine is not provided with a “cookbook” and should not be approached as such
But perhaps the greatest reluctance or fear of using technology to provide medical care is the impact it will have on the physician’s income.
Once upon a time, physicians were paid for their services with cash. Then health insurance policies were created to pool financial resources. Over time, the cost of health care spiraled upward, and it became clear to the insurance industry that there just was not enough money to cover all of the costs of providing care.
In the 1980s, the insurance industry had the idea to designate a specific amount of money to pay for the care of a specific disease or diagnosis. Diagnostic-related groupings (DRGs) were born and regulated by the Centers for Medicare and Medicaid Services (CMS). To ensure that a patient’s care did not exceed the amount of money that was allocated for a particular diagnosis or disease, health care organizations created tools and various care delivery systems to keep the patient’s care “on track.” Popular care terms during this time included primary nursing, case management, standardized care plans, and critical pathways.
But all patients do not fit into the confines of a set care map or standardized treatment plan. Patients needed longer hospitalizations and more frequent office visits. The amount of money that the average family physician received for patient care began a slow and steady decline.
Enter telemedicine. With this approach, the physician can be in one location and the patient/client in another. The patient does not have to travel to see a physician for a common ill or routine checkup for a known health problem. With this approach, the physician does not need to have large numbers of staff to collect data and maintain the office billing functions. However, the fear of losing even more income inched closer to reality.
Realizing the importance of telemedicine and the need to provide as much care as possible to the population within the United States, the CMS created guidelines for telemedicine reimbursement. Knowing that telemedicine care would be considered a covered benefit and payable through health insurance should help allay the physicians’ fears, right?
AMERICAN TELEMEDICINE ASSOCIATION
In January 2013, the American Telemedicine Association published a document outlining Medicare reimbursement for telemedicine or telehealth services. Reimbursement would be provided for:
Remote patient/client face-to-face services through live video conferencing
Non–face-to-face services conducted through live video conferencing or store-and-forward telecommunication services
Home telehealth services
Remote Face-to-Face Services
The CMS defines telehealth services to include those services that require a face-to-face meeting with the patient/client. Reimbursement is limited to the type of service, geographic location, organization delivering the service, and health care provider.
The service must be outside of a Medicare-defined statistical area; however, the health care provider can be located anywhere. Services that can be reimbursed include office visits, consultations, psychotherapy, and pharmacological management. The health care providers eligible to file for reimbursement include:
Clinical nurse specialist
Clinical social worker
Registered dietitian or nutrition professional
And the originating sites under the Medicare rules are to be:
Physician’s office or practitioner
Federally qualified health center
Skilled nursing facility
Hospital-based dialysis center
Community mental health center