Telehealth in the Year 2010
Veronica Thurmond RN, MS
The rapid changes in technology and communication have had a great impact on the delivery of health care in the United States. Such changes have spurred the growth of an arena in health care known as telehealth. "Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration" (Office for the Advancement of Telehealth, 2001, p. 1). The proliferation of telehealth initiatives has improved access to quality health care for many people in the United States, especially for those who have limited resources or debilitating physical conditions. In addition, those who are in rural or remote regions, where geography is a major barrier to care, have benefited from telehealth programs (Angood, Satava, Doarn, & Merrell, 2000; Dimmick, Mustaleski, Burgiss, & Welsh, 2000; Satava, Angood, Harnett, Macedonia, & Merrell, 2000).
Improvements in technology and communications have spawned many innovative programs that involve the use of telehealth (Agrell, Dahlberg, & Jerant, 2000; Allen, Roman, Cox, & Cardwell, 1996; Gray et al., 2000; Loane et al., 1998). The purposes of this paper are to describe some of the driving forces that have shaped many telehealth initiatives, present scenarios for a probable and preferred future for telehealth, and discuss the strategies needed to bring about the preferred future.
What is Telehealth?
The lexical definition of telehealth includes the use of technology in a wide area of healthcare. This definition encompasses a broad concept which includes research, education, and the actual clinical applications of health care (Office for the Advancement of Telehealth, 2001). The term telemedicine is a subset of telehealth, and has been used by many authors to indicate a similar definition (Fishman, 1997; Grigsby, Kaehny, Sandberg, Schlenker, & Shaughnessy, 1995; Whitten & Collins, 1997).
However, the definition of telemedicine is more narrow and involves the "use of telecommunications technology for medical diagnosis, monitoring, and therapeutic purposes when distance separates the user" (Agency for Healthcare Research and Quality, 2001, p. 1). Telemedicine implies physician services (Goldberg, 1997) and concentrates on the clinical applications of telehealth. Because of the expanding use of telecommunications outside the clinical area, the term telehealth more accurately describes this area of health care (Bashshur, Reardon, & Shannon, 2000; Connors, 1997).
Driving Forces in Telehealth
People in the United States are living longer. Those age 65 and older comprised 34.5 million of the population in 1999, and are expected to reach 70 million by the year 2030. The older population group increased by 10.90% since 1990 (Administration on Aging, 2000). The aging population of the United States poses unique challenges as Americans continue to live longer. Although older Americans are healthier than in the past, there are still millions who have some chronic illness (U.S. Department of Health and Human Services, 2000). Those chronic illnesses that limit mobility could be a barrier for accessing health care for many elderly Americans.
Initially telemedicine programs developed because of the need to bridge the gap separating provider and patients (Bashshur et al., 2000). This gap existed due to issues of access – such as geography, financial status, culture norm, psychological status (Bashshur et al., 2000), or physical limitation. The remoteness of rural areas poses special challenges for healthcare. Twenty-five percent of the American population live in rural regions where there are 40% higher incidences of injury-related deaths, compared to urban populations (U.S. Department of Health and Human Services, 2000).
Individuals' health status can also affect their ability to access healthcare. In a report issued by the U.S. Census Bureau in 2001, there were 33 million Americans with a severe disability in 1997. This number comprised 12.3% of the population (U.S. Census Bureau, 2001). This issue of disability has significant ramifications in terms of how these individuals arrive at their health care institutions, and what is the costs associated with these endeavors.
Beginning in January 1999, the Balanced Budget Act of 1997 (BBA) required that the Health Care Finance Administration (HFCA) reimburse for certain telemedicine services. However, the BBA for telemedicine applies only to patients who live in Rural Health Professional Shortage Areas (HPSAs); thus, limiting the number of consultations for reimbursement (Office for the Advancement of Telehealth, 2000). The BBA severely restricts the use of telemedicine in situations commonly being applied outside the guidelines of Medicare. Consequently, from January 1999 to September 2000, HFCA reimbursement totaled $20,000; this total comprised 301 claims (Office for the Advancement of Telehealth, 2001).
The issue of reimbursement has been a barrier to telehealth and telemedicine services. The four areas that were found problematic in the 2001 Telemedicine Report to Congress included: (1) health professional shortage area (HPSA) limitations, (2) fee-sharing requirement, (3) eligible presenters, (4) and eligible current procedural terminology. Hopefully, the passing of the Medicare, Medicaid and State Children's Health Insurance Program (SCHIP) Benefits improvement and Protection Act of 2000 will expand eligibility coverage (Office for the Advancement of Telehealth, 2001).
Technology and Communication
Telemedicine existed as early as 1877, when a group of physicians used the plain old telephone system (POTS) to facilitate communication with the local drug store (Lee, Mun, Jha, Levine, & Ro, 2000). Telemedicine efforts in the 1970s encountered problems because of lack of adequate infrastructure, and simply because the cost to transmit video or audio signals was too expensive. The prohibitive cost resulted in agencies withdrawing funding support from initial demonstration projects (Lee et al., 2000). The cost of technology has decreased, while its quality has improved substantially, during the last five years. These telehealth technology include the personal computer, video monitors, and digital cameras (Visco et al., 2001). In the 1990s, several factors revived the interest in telehealth. These factors included the development of the Internet, high speed telecommunications, interactive video teleconferencing, and the focus on integrative healthcare (Lee et al., 2000).
The use of technology in telehealth today can range from the simple to the mind boggling. The use of the telephone for consultation and the Internet for health references involve simpler technologies. However, performing robotic surgery in the virtual operating room involves more complex equipment and skills (Goldberg, 1997). Today, technology equipment used in the delivery of telehealth care services may include the telephone, the Internet, a video system (Connors, 1997), the facsimile, a scanner (Perednia & Allen, 1995), electronic telestethoscope, or fetal heart rate monitor.
Home Health Care
Telehealth technology is well suited for use in the home environment. Researchers have studied the use of technology to provide telecare to the client's home. (Agrell et al., 2000; Allen et al., 1999; Gray et al., 2000; Valero, Arredondo, del Nogal, Rodriguez, & Frias, 2000). This home service could decrease the client's need to travel to a health care facility for routine home care, as well as allow providers to consult with clients without having to physically be in the same location. Consequently, this approach could save client and provider time and money associated with travel. More importantly, for those who have limited resources or delimiting health status, telehealth care may be an excellent alternative to how we handle future health care scenarios.
A scenario is "simply a series of events that we imagine happening in the future" (Cornish, 1977, p. 111). Schwartz (1991) described scenarios as tools that assist in taking a long view of situations, composed of stories of potentialities. Scenarios help develop an awareness for possible problems with courses of actions, and opens one's eyes to the opportunities in the future (Cornish, 1977). Scenarios could be used to help see the possibilities and threats of the future (Bezold, Hancock, & Sullivan, 1999).
Two scenarios for telehealth will be described. The first scenario is the probable future; this future has also been referred to as 'business as usual' (Bezold et al., 1999). The probably future is based on current situations and incorporating the trends of the future (Hancock & Bezold, 1994). The second scenario is the preferable future for telehealth. The preferable future requires creating a scenario for what does not currently exist. This future is what we hope will happen (Bezold et al., 1999).
Probable Future of Telehealth in 2010
Policies, Licensure and Reimbursement
Guidelines regulating telehealth issues are driven mostly by physician services. Passage of an amended version of the Quality Health Care Coalition Act of 1999 provides physicians exemptions from antitrust laws. The passage of this law allows physicians to rally against insurance companies for pricing and results in strong competition between insurers and physicians ("Consumers will pay if the Campbell Bill passes," 2000; Fisher, 1999). The passage of the bill stunts the growth of managed care programs. Physicians collude against nurse practioners – barring them from practicing in the manage care situations (Rau, 2000). Lack of collaboration among the organized groups weakens the impetus for telehealth progress.
Telehealth initiatives are still in place, but growth has been difficult for a variety of reasons. First, results of research are questionable because of methodological problems with the studies (Bashshur et al., 2000; Mair & Whitten, 2000). The majority of research focuses on the technology used in telemedicine. Unfortunately, these studies continue to use retrospective, rather than prospective designs (Bashshur et al., 2000). Non-definitive data hampers attempts for further telehealth funding (Perednia & Allen, 1995). There are few comprehensives studies that actually quantify the cost-benefit of telemedicine (Kun, 2001). This lack of documentary evidence stifles the progress in developing telehealth programs and changes in health policy (Bashshur et al., 2000). Consequently, research results do not substantiate program development or policy changes.
Second, funding for telehealth programs slowly progresses because of the difficulty of articulating physicians and APNs services (Jenkins & White, 2001). Both physicians and Advanced Practice Nurses (APNs) continue to have difficulty with reimbursement issues regarding telehealth services. Eligibility requirements remain restrictive and Medicare continues limited reimbursement (Office for the Advancement of Telehealth, 2001).
The difficulty with receiving reimbursement for services cause some telehealth programs to stagnate, while others are in danger of being closed down. Finally, licensure issues continue to be debated (Fishman, 1997). Licensing bodies refuse to unite and do not allow providers to maintain one license for the entire 50 states. Therefore, providers shy away from consultation services from several sites because of the prohibitive cost of multiple state licensure.
Serious ethical issues arise concerning patients preferences to health care services. Patients are resentful of being "forced" to use telehealth technology – such as video teleconferencing – for their health care. This resentment persists because providers appear distant and inhuman. Patients miss the "personal touch" and are uncomfortable with the lack of privacy with telehealth encounters (Mair, Whitten, May, & Doolittle, 2000). Physicians and nurses have not done an adequate job of trying to "connect" with patients. Also, patients are not given the option of a traditional face-to-face consultation.
Telehealth videoconferencing is the norm, but patients wanted it simply as an adjunct to their previous program care (Mair et al., 2000). Patients are concerned about issues of privacy and confidentiality (Jenkins & White, 2001; Mair & Whitten, 2000). The hardware used in telehealth poses serious threats to patient information (Jenkins & White, 2001); unfortunately some funding issues align with patient concerns regarding privacy.
Preferable Future of Telehealth in 2010
Regulatory guidelines and funding issues are established as a multidisciplinary approach between many health care disciplines and the federal government. Since telehealth programs have an impact on a wide array of health care issues – from social services to clinical care – a collaboration between many disciplines exists to bring about effective change. Funding for telehealth programs increases because well-designed research has shown that many patient situations can be effectively diagnosed or treated via interactive video teleconferencing.
Provider and institutions increasingly seek funding from private corporations and telecommunications companies (Brown, 2000). Such actions fill the void left by sluggish legislature that inadequately addresses the issues of telehealth care.
Physicians move away from the HMO settings, and once again establish private practices to care for patients. Physicians are able to consult with patients at remote sites, using desktop personal computers or mobile laptops (Perednia & Allen, 1995). They continue to work in health care intuitional settings; however this is not their primary practice site. Their practices are equipped with current, state-of-the art telemedicine technology. This new office setting is possible because the proliferation and advancement in technology means lower prices for the consumers.
The cost for telehealth equipment is no longer prohibitive. Institutions contract with provider specialists and generalists for services. Local physicians contract to provide in-home care in cases when necessary. Because telehealth is still considered a toddler, physicians are still forced to divide their time between the traditional health care setting and telehealth programs. However, much of the routine care is provided via telehealth. Physicians can monitor patients from home.
Physicians effectively collaborate with nurses in telehealth clinics, especially in rural and under-served areas. Research has found that this collaboration between telehealth clinics and nurses provide the greatest quality, expeditious health care to those who need it the most. Health care facilities decrease costs associated with staffing, because not as many staff physicians or nurses need to remain in house.
Telehealth clinics abound in all areas of the United States, especially rural and underserved regions. Along with the technological advances, quality of equipment improves while the cost decreases (Kun, 2001). Consequently, these telehealth clinics are fully equipped with the latest in telehealth technology. Nurses with bachelors of science degrees in nursing (BSN) are in charge of telemedicine sites (Karp et al., 2000). Advanced practice nurses (APNs) manage the clinic and coordinate teleconsultations with physicians as needed. When in-person consultation with physicians are not required, APNs interact both with patients and physicians via interactive video teleconferencing. Furthermore, this interaction can occur any place a portable laptop can be used (Rau, 2000).
The entrepreneurial spirit in nursing really comes alive. Nurses establish their own businesses and provide telehealth monitoring from their homes to their clients homes. Nursing case management businesses continue to thrive. Physicians support nurses in managed care settings, and this model of care proves invaluable for patients with chronic illnesses. Nurses contract with families directly to provide 24-hour nursing services via telehealth technology. Some areas where nurse practioners focus include: postoperative assessment, wound care, chronic heart conditions, and other chronic illnesses which does not necessitate acute emergency care.
Telehealth changes the face of home health care. Around the clock coverage is the norm for all home care nursing and hospice nursing. The technological equipment in the clinic allow nurses to have instant, real-time access to specialists and general practioners. Issues with access to health care decline because physicians and APNs routinely conduct physical examinations and assessment through interactive video teleconferencing. More APNs work independently in the telehealth clinics. Finally, nurses are extremely involved in helping to establish guidelines and policies for telehealth programs.
Patients have the option of a traditional face-to-face consultations, or one via telehealth video. Many homes and businesses are equipped with telehealth technology that allow patients to consult with their providers via video teleconferencing. For routine clinical care, telehealth combines quality with convenience. Patients save needless trips into health care facilities, because televideo allows physicians and nurses to view wound sites, perform physical exams, and answer health care questions. Also, patients access local clinic hubs for preoperative evaluations, without having to enter the health care facility until the time of surgery (Ricci, Knight, Nutter, & Callas, 1998).
Upon completion of a telehealth examination, patients are referred to appropriate locations for diagnostic testing or prescription pickup. Patients save money by not having to take time from work, travel or arrange for childcare. The technologies available in the home healthcare arena increase the types of healthcare services patients receive.
Barriers to the Preferred Future
The major barriers to seamlessly incorporating telehealth into the health care system include proper funding, appropriate licensure, technological advancement, and issues of confidentiality (Brown, 2000; Office for the Advancement of Telehealth, 2001). Also, providers, administrators, and patients might be hesitant to embrace telehealth care because of their lack of familiarity with the technology involved. This perceptions will ease with time and with future generations.
The collaboration between patients, providers, and funding agency is the ultimate key to ensuring that this medium improves quality of health care. The three groups are an integral part of deciding whether or not electronic and telecommunications technology will survive in the health care system. Steps must be taken to ensure that the strategies discussed in the following section is implemented. If not, there is the potential that telehealth programs could wither and falter as they did in the past.
Strategies to Achieve the Preferable Future
Collaboration Among Disciplines
Because telehealth involves many aspects of patient care, the various disciplines who use telehealth technology will need to band together and provide one strong voice at the funding table. This collaboration is important because it will allow the financial stakeholders to understand that telehealth interventions are not a thing of the future, but of the present. This collaboration is needed to present the broad picture of how telehealth technology affects patients on a daily basis.
The planning process is important to ensure that equipment and technology match (Burmahl, 2000). Individual and institutional stakeholders need to develop a plan to minimize waste and duplicated efforts, and to effectively utilize the resources. These steps should be taken to establish an effective plan (Perednia & Allen, 1995): 1) clearly define goal early; 2) include data collection, evaluation and accountability as part of the technology management tools; 3) adhere to communication standards for access; 4) use licensing and reimbursement policies that that focus on desired outcomes; 5) reevaluate goals and accomplishments periodically. Part of the plan should consider how the staff will accept the telehealth programs. Consequently, educating and training staff members should be a priority in the overall plan (Burmahl, 2000). This is important because without the buy-in from those who will implement the telehealth programs, the planning will simply be a wasted effort.
Connecting with the Patients
Some patients may not fully appreciate the convenience of a video teleconference to discuss their health concerns. This could be especially true in situations where patients have never met the providers. Also some patients may feel somewhat uneasy when nurses act as proxies for physicians during physical examinations (Mair et al., 2000). This unease will lessen as telehealth via video becomes more commonplace. However, providers need to find ways to connect with patients when consulting through an interactive video medium. Patients also need to be educated and properly trained on the use of telehealth equipment. Attending to patients' learning will help in decreasing some level of frustration and encourage patients to view the technology in a more favorable light.
Providers must be motivated to learn and research about the technology that can enhance the quality of patient care. The technology development will continue to move at a rapid pace, and providers must become more technologically competent to make use of the latest development. Also, providers must not be lured into jumping on the latest technological development – without researching its potential impact on the patient. The drive to use the latest technological tool should be dictated on the degree that it improves health care, as well patient's acceptance of the technology.
Issues limiting reimbursements must be resolved before telehealth can be incorporated into the mainstream of health care (Goldberg, 1997). Funding agencies must lessen the restrictions on what services are considered reimbursable. Discussions between funding agencies, providers, and patients will have to occur to determine what types of telehealth services are needed to provide quality health care. Dialogue about the realistic issues of telehealth services as an extension to in-person care is imperative. All parties will find that more and more services can be provided through electronic means, or through the use of telecommunications technology.
For telehealth care to fully be implemented, licensure and credentialing issues must be resolved. Currently, before practicing in any state, physicians are required to be licensed in that state (Charles, 2000). At the opposite end of the spectrum, the National Council of State Boards of Nursing allows nurses to be licensed in one state and practice in another state. However, nurses must adhere to the laws and regulations in the state in which they are practicing (Goldberg, 1997).
Individual state mandates for licensure must change to either a regional or national focus. Simply decreasing the cost for state licenses will not obviate the problem. A system must be established that easily allows providers to consult and treat patients in various parts of the United States, without having to endure a costly and lengthy process for licensure. Both HFCA and Medicare are examining state licensure issues in populations that are indigent and medically underserved (Charles, 2000).
Equipment to enhance communication between provider and client needs to continue to decrease in price and increase in quality. The explosion of smaller, more portable compatible telecommunications equipment needs to continue to proliferate on the market (Rau, 2000). Technical standards need to be developed for telehealth care (Office for the Advancement of Telehealth, 2000). These standards would facilitate issues of equipment compatibility, as well as address concerns of privacy and confidentiality. These standards must be fluid enough to adapt to the ongoing, rapid changes in telehealth care (Office for the Advancement of Telehealth, 2000).
Agencies providing care will need to provide some means to protect patient electronic files with at least the same rigor used to protect chart records (Warner, 1998). Also providers must be attuned to patients' desire for privacy during telehealth consultations. Privacy might be limited when such technology is involved (Mair et al., 2000); consequently, the provider should ask during every telehealth encounter if the patient has any questions that might require more privacy than currently provided.
Although telehealth has tentatively been shown to be advantageous for health care (Loane et al., 1998; Mair et al., 2000; Pacht et al., 1998; Stevens, Doidge, Goldbloom, Voore, & Farewell, 1999), routine use of telehealth technology could have some significant unintended consequences. First, future blue prints for homes, schools, and businesses will include specifications on designs and wiring to accommodate telehealth equipment. The inclusion of telehealth technology in such buildings will result in increase use of the health care system. Telehealth ready schools would help to alleviate some of the issues regarding school nurse shortages. Corporations would have telehealth stations available for employees to seek medical attention when they feel ill during the duty day. This immediate access to health care would keep workers healthier, happier, and more productive.
Telehealth hubs would be located in key locations in all cities. These hubs would allow patients to access their providers more easily. Patients would be able to access their providers more frequently and, therefore, establish a stronger rapport than they are able to do so at this point in time. Such ready access to health care will result in a healthier population.
The negative side of this proliferation and ready access of providers via telehealth technology is lost of some of the human connection that occurs only during in-person encounters. Essentially, the need for convenience and a healthier population can result in a feeling of being disconnected from those who provide health care. Older patients might perceive their providers as non-caring. Those who grow up with telehealth will not miss this connection, because telehealth technology is not an new medium to them. As a result of the immediate access, more providers will be needed to tend to increase demands for care. Provider shortages in all disciplines of health care could become a significant issue.
Another unintended consequence is the potential for increase in litigation associated with telehealth claims. Since all patient information is available in electronic format, this medium would be very susceptible to computer hackers. Unfortunately, hackers could make a great deal of money by selling confidential, private patient information to key corporations or insurance companies. Also, ensuring secure privacy during a telehealth consult could prove problematic.
Finally, a severe unintended consequence could be the delays in health care because of natural disasters or interruption in power supplies. If most of health care relies on the use of electronic communication, there could be devastating effects during those times when energy supplies become an issue. This interruption to power could be due to a variety of reasons. Unfortunately, the impact would be that patients would not be able to use telehealth equipment for health care. Lack of access to health care could have some tremendous consequences themselves. This would be an even greater problem if telehealth becomes the primary mode of caring for patients. Effective telehealth planning would need to include how to deal with such matters should they occur in the future.
Telehealth programs are on the rise (Connors, 1997). These programs can overcome the challenges associated with access and cost. As a result, patients will have another way to receive health care that might be more amenable to their lifestyle. Telehealth will simply be another way of accessing the health care system and will be commonplace (Brown, 2000). However, before telehealth can become fully integrated as a routine part of health care, discussions concerning reimbursement, licensing, and appropriate technology must be ongoing. Careful planning, which includes discussion of future scenarios, could help highlight potential problems. The implementation of telehealth technology to meet the demands for health care is not the end point, but merely one of the landmarks for enhancing the quality of patient health care.
Disclaimer: The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Army, the Departments of defense, or the U.S. Government.