Informatics And Telehealth In Rural Medicines

Informatics And Telehealth In Rural Medicines. BRIEF REPORT Nurse Practitioners in Telehealth: Bridging the Gaps in Healthcare Delivery Kristi Henderson, DNP, FNP, Tearsanee Carlisle Davis, DNP, FNP, Mary Smith, DNP, FNP, and Melissa King, MSN, FNP ABSTRACT There is no denying that many changes must be made in the health care delivery system in order to meet the needs of all people and improve the health of our nation. Because of advances in technology over the past 2 decades, telehealth has greatly improved patient access to health care and equipped providers with innovative tools to provide quality health care to a larger population. The health care climate demands an innovative approach to health care delivery with an attention to scalable and sustainable models. Telehealth, and the use of nurse practitioners, will be an integral part of these new models. Keywords: connected care, nurse practitioners, telehealth, telemedicine Ó 2014 Elsevier, Inc. All rights reserved. T here is no denying that many changes must be made in the health care delivery system in order to meet the needs of all people and improve the health of our nation. Because of advances in technology over the past 2 decades, telehealth has greatly improved patient access to health care and has equipped providers with innovative tools to provide quality health care to a larger population.1 No longer does geographic location limit the health care services one can access. The health care climate demands an innovative approach to health care delivery with an attention to scalable and sustainable models. Telehealth, and the use of nurse practitioners (NPs), will be an integral part of these new models, which provide a scalable approach to coordinated and collaborative care. However, the widespread adoption and integration of telehealth can be difficult. Telehealth is a broad term that includes videoconferencing, exchange of medical information via electronic communications, remote patient monitoring, population health management, and mobile health technologies.2 Our academic medical center (AMC) has answered the call to minimize health care disparities related to geographic barriers to gain access to health care by using technology to bring collaboration among multiple disciplines in a virtual environment. Our AMC operates a system-wide center for telehealth that began as a pilot project nearly 11 years ago. The first program that launched www.npjournal.org in 2003 was the telemergency program. This program uses NPs as the distant site providers and allows for direct connection to board-certified emergency physicians at our level I trauma center for a higher level of care using telecommunication equipment.3 In some rural areas, the closest, fully staffed emergency room was 40 miles away, and some rural emergency rooms were staffed with physicians or NPs with little or no formal emergency medicine training. As a result, the AMC frequently received poorly managed critical care patients in transfer to their emergency department, and some patients did not make it that far. Informatics And Telehealth In Rural Medicines TedEx Video Analysis

Informatics And Telehealth In Rural Medicines. The tele-emergency program trains NPs through an intense didactic and clinical continuing education program that is in addition to the education received as a part of the NP’s formal degree-granting education and certification required for practice. The content is focused on the clinical knowledge and diagnostic procedure skills necessary to work in an emergency department and incorporates appropriate use of the telemedicine equipment, which allows them to collaborate with board-certified emergency medicine physicians. This curriculum focuses on topics such as the approach to the emergency patient, cardiac emergencies, psychiatric emergencies, toxicologic emergencies, obstetrical emergencies and delivery, and pediatric and orthopedic emergencies. This content is taught through a combination of inperson classes, online modules, simulation laboratory The Journal for Nurse Practitioners – JNP 845 sessions, and clinical rotations. Once the NP completes this 3- to 6-month training, they may go on to staff rural emergency departments that are a part of the AMC’s telehealth network. This program provides a sustainable model for the utilization of NPs to positively impact rural communities through telemedicine. In this program, the NP uses bidirectional audioconferencing and videoconferencing for collaboration with emergency medicine physicians at the academic medical center (Figure 1). The rural hospital emergency departments are outfitted with telemedicine equipment that is either mounted in the emergency department’s examination room or contained on a telemedicine cart that allows for mobility between examination rooms in the emergency department and the inpatient hospital rooms. In either scenario, a video monitor, camera, and microphone allow for videoconferencing between 2 geographically distant sites. The NP can easily consult with the AMC’s department of emergency medicine’s physicians or a stroke neurologist with a push of a button. Any of the AMC’s resources and specialties can be consulted as the emergency physician deems necessary. This virtual care team provides a treatment recommendation to the NP at the rural hospital. Should the patient require a transfer to a facility offering expanded services, the care that was delivered through telemedicine results in an improved transition of care from the rural hospital to the academic medical center. A study by Henderson et al4 compared patient outcomes of cardiac arrest patients in 8 rural hospitals using the telemergency program to that of our AMC. The survival of cardiopulmonary arrest patients in rural emergency departments has historically been significantly lower than that in the Figure 1. AMC telemedicine workstation. 846 The Journal for Nurse Practitioners – JNP urban emergency department setting. In this study, rural emergency departments using resuscitation guided by telemedicine consultation with emergency specialists were found to have survival rates that were not significantly different from those in our AMC. This finding suggests that telemedicine may improve the quality of emergency care delivery in the rural setting.4 Although the impact on access to care and quality of care is critical, in order for a telehealth program to be adopted and integrated, there must be a solid business plan that shows a positive return on investment. The economic evaluation of a telehealth program to determine the benefit-cost analysis should consider the broad range of impact a program has on the health of individuals; the workforce and populations, and the impact on new jobs, economic development, and the cost of health care.5 The financial impact of a telehealth program on a hospital or other clinical entity can be assessed in a number of ways such as the ability to retain patients admitted in the community hospital (avoiding unnecessary transfers of patients), a reduction in medical staffing costs (shared resources), an added medical service line, a decrease in the length of hospital admission, and/or the prevention of a financial penalty from hospital readmissions. The literature is growing to show the positive financial impact and the win-win scenario found in a telehealth program.5-10 In some cases, telemedicine has prevented the unnecessary transfer of a patient to the AMC when the condition could have been managed at the local hospital with support via telemedicine. This results in benefits for both the patient and the rural hospital. If the patient is stabilized and can stay at their local hospital, they are closer to home and family and are able to receive the care they need in a familiar environment. If the rural hospital is able to keep the patient, it keeps the revenue in the community and expands that hospital’s ability to support the community. In an analysis of the first 8 tele-emergency hospitals, a comparison was done between the operational cost and the hospital census pre- and postimplementation of the telemergency program. Informatics And Telehealth In Rural Medicines TedEx Video Analysis

Informatics And Telehealth In Rural Medicines. The program analysis revealed a decrease in provider staffing costs of 25% in the tele-emergency model and showed an increase in the distant hospital patient admissions of 20%.11 Although this report has Volume 10, Issue 10, November/December 2014 been submitted for peer review and publication, the findings have already led to telemedicine program expansion and increased adoption. With avoided transfers, the AMC is then able to focus on the more critically ill patients who need the level of care only they can provide. The success of this initial telehealth program and the increase of supporting literature created the impetus for us to replicate this model in other specialties. Over the past 10 years, the institution has expanded this initial program to a statewide telehealth network and achieved the designation as a center for telehealth in July 2013. The center is led by a chief telehealth and innovation officer who is a doctorally prepared nurse. The mission of the center for telehealth is to fill the gaps in health care and to improve the quality and accessibility of health services in order to decrease health disparities, manage chronic diseases, and improve the quality of life. Our center for telehealth supports the institution’s commitment to provide health care statewide and matches the state’s need and demand for telemedicine services. To date, over 30 different specialties are being offered via telemedicine to over 100 unique nonaffiliated sites across our state, many of which are manned by NPs. The center is now receiving requests nationally and internationally to extend these telehealth services outside the state. Currently, the AMC’s telehealth program does not extend outside of the state. TELEHEALTH TODAY Telehealth is being delivered in a variety of inpatient and outpatient settings in our state, providing services such as telestroke, teledermatology, telepediatrics, telepsychiatry, teleneonatology, and telecardiology care to underserved areas. A primary focus of telehealth programs is to fill the need for health care providers, thereby improving access to care for anyone, regardless of their location. In October 2013, our AMC hired its first telehealth NP dedicated to the delivery of health care through telehealth technology for corporations and schools (Figure 2). The program uses e-clinics to deliver care to students in their school clinics and to employees in their workplace. Because of this program, employees are able to seek care for minor illnesses without leaving www.npjournal.org Figure 2. Corporate Telehealth workstation. work. Employers benefit from this service because it limits the loss of productivity and reduces health care costs. The program has seen great success in the pilot phase and has hired 2 additional NPs to meet the demands of Mississippi corporations. The school telehealth program is similar in that students are allowed to receive episodic care for minor illnesses via telehealth, which allows parents to stay at work when they choose to do so. In this program, the school nurse serves as the facilitator who connects to the telehealth system for an NP teleconsult at which time the patient is assessed, diagnosed, and treated. If there are needs that require in-person examination or follow-up, the NP coordinates these appointments with a local provider in the patient’s community. The benefit is that students who may not have a primary care provider have access to care when they need it and receive assistance in securing a medical home for ongoing needs. NPs working in these 2 programs have a family medicine and/or urgent care background and are knowledgeable about resources in the community.Informatics And Telehealth In Rural Medicines TedEx Video Analysis

COORDINATION OF CARE IN THE COMMUNITY Health care reform is placing a strong focus on the coordination and continuity of care among all populations but specifically for those populations with multiple chronic illnesses and risk factors, which leave them the most vulnerable.12 Risk factors such as polypharmacy, poor health literacy, and lack of supportive resources place a greater need for interprofessional collaboration and can all be The Journal for Nurse Practitioners – JNP 847 positively affected with the appropriate use of telehealth. Telehealth will play an instrumental role in the utilization of a collaborative approach that delivers quality care, enhances patient safety, and generates cost savings.13 Telemedicine is instrumental in preventing excessive health care costs through remote patient monitoring. Research studies are beginning to reveal the impact of remote patient monitoring on hospital readmissions, disease management, avoidance of emergency room visits, and patient satisfaction.10,14,15 A study by Pekmezaris et al10 studied the impact of remote patient monitoring on heart failure patients. The study indicates that remote patient monitoring has the potential to provide a cost-effective and convenient method to manage heart failure.10 Remote patient monitoring aids in containing healthcare costs by enabling nurses and other health care providers to intervene when there is a change in health status and eliminates the need for costly home care visits for monitoring only.16 Cost savings are seen with an efficient and coordinated delivery system that minimizes exacerbations of chronic illnesses, curtails adverse events, reduces hospitalizations, and reserves the use of emergency rooms for truly emergency care. The National Rural Health Association reports that rural areas have greater shortages of primary and specialty health care providers, a larger population of individuals who rely on Medicare and Medicaid, an increased prevalence of chronic disease, and geographic barriers that force travel over long distances in order to gain access to specialty health care services.17 Telehealth technology will allow for vulnerable populations in underserved areas to overcome some of these challenges by reducing geographic disparities and health care workforce shortages and increasing access to preventive services. An example of how telemedicine is bringing needed services to the rural community is telepsychiatry. There is a vast shortage of mental health providers in rural communities. Often, primary care providers are forced to treat patients suffering from mental illness without the expertise of mental health professionals. Telepsychiatry allows patients in rural communities to have access to the same level of care as those in 848 The Journal for Nurse Practitioners – JNP larger cities by using videoconferencing to conduct mental health evaluations and regular follow-up.18 The provision of subspecialty care to children with special health care needs who live in rural communities is also a benefit of using telehealth. Traditionally, parents would be taxed with the burden of traveling far distances to receive the care that their children needed. Marcin et al19 reported that pediatric subspecialty consultations can be provided to these children with high satisfaction for families and rural providers. The utilization of telehealth has the potential to meet the Institute for Healthcare Improvements’ triple aim for better health, better health care, and lower costs.5-10,13,15 Population health management and chronic disease management programs are also capitalizing on the use of technology.14 A program recently implemented by our AMC, the Mississippi Diabetes Telehealth Network, aims to bring a diabetes care team to an existing rural health clinic that currently does not offer any specialty care. Diabetics whose disease is currently uncontrolled are eligible for this program. Patients enrolled in the program are provided with a computer tablet that allows for realtime health sessions and coaching as well as remote monitoring of vital signs and glucose levels.Informatics And Telehealth In Rural Medicines TedEx Video Analysis

20 The community physician or NP in the rural health clinic will have access to endocrinologists, ophthalmologists, specialty NPs, nurses, diabetes educators, pharmacists, and nutritionists to bring a team approach to their health care. Until now, this type of approach was only accessible to those in urban areas. Because so much of diabetes management is related to behavior and life style changes, this program will also provide daily health sessions delivered through a computer tablet to include symptom and compliance assessment, education, and remote monitoring of the patient’s glucose level and vital signs. NPs who staff the rural health clinic will be able to refer patients to specialists located at the AMC for care that would otherwise not be accessible. It is expected that patient compliance to treatment will improve because their primary care provider, the NP, will be able to facilitate additional services via telemedicine. This is another example of how NPs are pivotal in the improving access to care in rural communities. Volume 10, Issue 10, November/December 2014 CRITICAL CARE SERVICES The use of technology can provide a cost-effective and efficient way to deliver health care, provide education, and manage chronic disease. The health care system is demanding more with fewer resources. Workforce shortages, the geographically disproportionate spread of health care providers, and the lack of access to care, whether caused by a lack of transportation or a lack of health care services in an area, create barriers that the current model of health care have been unable to overcome. In the current telee intensive care unit (ICU) program, critical care patients are monitored remotely 24 hours a day by experienced critical care nurses. This is in addition to the bedside critical care nurse. The preliminary data from our model suggest it to have a positive impact on safety and quality and allows for earlier intervention for changes in patient status. Initially, there was uncertainty as to whether it was cost-effective at our AMC, which resulted in the program being “turned off.” The result was an increase in safety and quality concerns that led to reinvigoration of the program. The program remains active and is expanding in our AMC. The literature reveals a similar picture of inconsistent outcomes of an ICU telemedicine program. The data are conflicting on the cost-benefit analysis, but numerous studies suggest that when telehealth services are implemented with well-defined patient inclusion criteria and protocols that it can be cost-effective.21-24 This has been true for our AMC. Plans are currently being drafted that will include adding acute care NPs to the ICU telemedicine model currently used in the AMC. The NP would be a part of the intensivist team and will ensure continuity of care in this population. The NP in the tele-ICU will be able to intervene much sooner and place orders that will prevent a delay in care and improve patient outcomes. Future studies are needed to determine the impact of the NP on this model. MOVING FORWARD Rural and community hospitals have threatened viability and survivability. The tele-ICU program and other telehealth services allow the smaller hospitals to keep their own patients in their facility safely and www.npjournal.org prove to be a quality and financial benefit to the community.15 Financial challenges have often been the reason that rural agencies have shied away from nontraditional models of care delivery. The center for telehealth not only creates and implements the programs, but doctorally prepared NPs work with community agencies to identify needs and create programs that produce a revenue stream that will ensure sustainability. Each site has different resources, and with that in mind, no 2 programs are identical. Based on the needs of the agency and the resources available, the center for telehealth devises a realistic plan, and NPs are a key component to this transformed health care delivery model. Technology will continue to change the way …