by June Kaminski, RN MSN PhD(c)
Telehealth and other digital technologies are becoming cornerstones of Canada’s, the US and global healthcare system’s move to value-based, client-centred, collaborative care. Telehealth is one kind of virtual care that is beginning to make a real difference in client-centred care and in supporting health literacy. “Telehealth connects patients to vital health care services through videoconferencing, remote monitoring, electronic consults and wireless communications. By increasing access to physicians and specialists, telehealth helps ensure patients receive the right care, at the right place, at the right time” (American Hospital Association, 2019a, p. 1).
Telehealth is swiftly growing to meet the needs of both clients and providers. The COVID-19 pandemic of 2020 and 2021 has catalyzed this growth at astonishing rates and sparked federal and state governments to provide financial incentives and other resources to support this surge. “Hospitals and health systems that are working now to increase the maturity of their telehealth capabilities will be well-positioned to meet patient demands for digital tools that allow them to conveniently engage in care. Hospitals that don’t address these expectations increasingly will be challenged by new market entrants and other disruptors that seek to attract new health care consumers and encroach on existing patient-provider relationships” (American Hospital Association, 2019b, p. 3). These trends are even more pronounced as each year goes by, especially after clients have lived through a pandemic.
Telehealth is particularly valuable when clients live a distance from health services or access issues prevent routine care. “Telehealth helps increase health care value and affordability. Virtual care technology saves patients time and money, reduces patient transfers, emergency department and urgent care center visits, and delivers savings to payers. In addition, telehealth helps address physician burnout by reducing clinicians’ drive times and allowing more time for patients” (American Hospital Association, 2019a, p. 1). There are many benefits and barriers that currently impact telehealth availability which require planning, collaboration, support, and expertise to harness the pros and mitigate any risks and barriers.
Telehealth for Improved Access
Improved access to care is one of the key benefits and goals of telehealth. Travel time and expenses are avoided in both rural and urban regions, since expenses from childcare, missing work, and transportation needs are avoided. If the technologies required are available, access to care can be enhanced for all people, including vulnerable populations. It is important that infrastructure is established to support all clients and providers to ensure access from client homes or nearby clinics, offices, and care centres. “The health care field must work to ensure that all individuals have access to affordable and equitable health, behavioural, and social services; provide increased value to individuals; embrace the diversity of individuals and serve as partners in their health, including connecting with them in ways that make sense in the digital age; focus on well-being and partnerships with community organizations; and coordinate and integrate care” (Bhatt & Bathija, 2018, p. 1271).
A key focus of many telehealth initiatives is rural and remote area health care. Many rural communities have limited access to specialty care and some even to primary care. Many rural clients must travel great distances to access care especially if they have chronic health or behavioural health needs. Although telehealth can offer many services to rural communities, there are several barriers that can impede telehealth implementation.
Some of these barriers include:
- Limited Access to High Speed Internet
- Limited Access to Smartphones
- Credentialing and Licensing Requirements for Telehealth
- Reimbursement issues
- Sustainability issues
- Malpractice policies may exclude telehealth
- Transportation issues may still exist if client must go to a clinic or office for consult
- Interoperability issues
- Mistrust of Technology and Healthcare
- Concerns about Security of information
- Lack of Provider Buy-in or Utilization (Rural Health Information Hub, 2019, p.1).
Despite these barriers, many rural and remote communities are beginning to incorporate telehealth into their services which improves quality of care and reduces access issues.
Telehealth to promote Continuity of Care
Virtual care which includes telehealth is one of the most popular methods of using digital technology to provide client-centred care. More and more practices are adding virtual care to their roster of services, so nurses may well be involved in using this technology. This rise in usage is partly based on patient demand but also on health insurance coverage.
In 2020 even more reimbursement sanctions were put in place to accommodate the surge for telehealth in the time of the COVID-19 pandemic. One of the strongest pulls for telehealth, from a government and professional perspective is the needs of people living with one or multiple chronic illnesses who require consistent continuous care to manage their symptoms. As well, developmental lifespan care that follows a child from birth to adulthood, a normal pregnancy from conception to birth, or adult health from young to old all require optimal continuity of care in a variety of settings. Telehealth can be harnessed to support this ongoing supportive care and nurses can be central players in this care.
Some examples of how telehealth is improving continuity of care include:
- Patients on treatment protocols who need close follow up care and multiple visits to ensure compliance and manage medication
- Care for chronic and complex conditions, including virtual consults on lab results, symptom triage, lifestyle management, and remote patient monitoring (RPM) check-ins
- Post-operative wound care
- Group education consults with pre-diabetic and diabetic patients on health eating, exercise and wellness tips
- Address shortages in local or on-site mental health services in rural or underserved populations by connecting patients to a specialist
- For routine follow-ups with anxiety, depression and ADHD patients who are adjusting to new medications
- Routine virtual psychotherapy appointments
- Urgent care for established patients with low-risk, infectious diseases, such as conjunctivitis or urinary tract infection (American Medical Association, 2019c, p. 11).
Telehealth offers clients and health care providers many benefits if access is facilitated, and privacy and security considerations are managed well.
Key elements that are needed to effectively use telehealth in a variety of settings include:
- Integration with existing electronic health record (EHR).
- Integration with staff workflow.
- Base development on client, family and community needs.
- Use telehealth services to coordinate care across health care settings.
- Incorporate telehealth services into value-based care and reimbursement models.
- Use telehealth services to help direct clients to the appropriate level of care.
- Set key performance indicators (KPIs) for telehealth such as client satisfaction, reduced readmissions, improved diagnosis times, and so on. (American Hospital Association, 2019c, p. 15).
Telehealth for Improved Resource Use
Telehealth provides several benefits to both clients and health providers such as access, but just as importantly, saves time and money. “Going to the doctor takes up a big chunk of the day. You must make an appointment in advance during business hours, drive or take public transit (sometimes from far away), sit in the waiting room, get all your vitals taken, and finally see the doctor. It’s an inefficient and inconvenient system that can cause people to miss work or school. With telehealth, patients spend a lot less time on the road and in waiting rooms, resulting in time saved overall and a more efficient experience. For patients who have to miss work for doctor’s appointments, the cost savings can be substantial” (Health Technology Net, 2020, p. 1).
Some researchers contest the fact that telehealth saves costs since in some cases, people actually attend more frequent eVisits because it is so convenient. Others argue that this fact alone reflects a projected cost saving since better care should theoretically reduce compounded problems down the road and help people to stay healthier, thus reducing emergency room visits, hospitalizations and medication/treatment costs over time.
“Telehealth can save Canadians millions of dollars in personal travel costs and time off work to attend a doctor visit. It can also decrease hospitalizations and length of stay in hospitals, thereby reducing costs on the system. In a 2010 research review, telehealth services were shown to be more cost-effective for home care and access to on-call hospital specialists.” (Khalid, 2020, p. 2).
Another potential benefit of telehealth is better utilization of existing and future personnel. Some researchers even predict it could help alleviate nursing and physician shortages. “Telehealth nursing can be practised almost anywhere, and it enables nurses to connect with patients without lost time spent travelling, registering, and waiting like there would be with traditional appointments and visits.
There are several additional ways telehealth is helping to ease the burden of the nursing shortage:
- Nurses can support and educate parents in a specific approach with very clear outcomes with the use of telehealth platforms
- Telehealth nurses can learn about state-of-the-art therapies in medicine without being pigeon-holed into one small area of traditional nursing; they aren’t bound to one department day after day.
- Telehealth nursing allows providers to build relationships with patients over the course of the entire disease process.
- Nurses in telehealth have meaningful contact with patients due to the lack of intrusions, interruptions, and distractions that plague traditional office visits.
- Telehealth nurses can spend more time with patients that would otherwise be spent travelling, charting, or running from one patient to another on-site.
- Nurses are more accessible to patients with telehealth, creating the opportunity for an adequate amount of care performed with fewer nurses (InTouch Health, n.d. p. 1).
Optimal Telehealth Implementation
Telehealth introduces several benefits that make it worthwhile to both clients and providers. It also introduces unique risks and barriers such as privacy issues, access to technology, and proper implementation considerations. No matter how mobile and digital technologies are used in health care, whether by EHR, EMR, telehealth, social media, email, instant messaging (IM), or text messaging, security compliant platforms must be used that have strong encryption capabilities to protect protected health information (PHI) of clients. As well, privacy and security plans as well as data backup, disaster planning, and emergency plans must be established when using computers, mobile devices, and remote monitoring equipment for telehealth care. Privacy and security should be part of the key telehealth implementation plan. Most established vendors will address privacy and security of equipment, but human security practices should also be part of the implementation plan.
Planning telehealth requires concrete steps to ensure success, protect clients and data, and support staff. Ideally, when an organization embraces telehealth, a careful plan is collaboratively established, and a dedicated team work together to set it up.
In the publication, Telehealth Implementation Playbook the American Medical Association outlined twelve steps that are essential to optimal telehealth planning. These steps are organized into two stages: “pre-game” and “game-time.”
Step 1: Identifying a Need – Ground your digital health implementation in a true need, engage end users to generate buy-in
Step 2: Forming Teams – Keep the end user in mind, carefully consider who needs to be at the table.
Step 3: Defining Success – Envisioning success brings clarity to the goal you are trying to achieve, align your goals to the Quadruple Aim of Healthcare.
Step 4: Evaluating the Vendor – Evaluate vendors across six key variables to find your best partner (business, information technology, security, usability, customer service, clinical validation).
Step 5: Making the Case – Compile the content you have gathered into a leadership team proposal.
Step 6: Contracting – Lay the groundwork for a successful long-term vendor relationship.
Step 7: Designing the Workflow – Document an updated workflow for telehealth visits, ensure your workflow addresses the entire telehealth lifecycle.
Step 8: Preparing the Care Team – Start with your most enthusiastic clinicians and staff, many vendors provide resources for staff training and support.
Step 9: Partnering with the Patient – Strategically engage patients to maximize the impact of telehealth which relies on patient interest and engagement.
Step 10: Implementing – Launch your telehealth program and execute your plan.
Step 11: Evaluating success – Determine the success of implementing telehealth by revisiting your goals, validate your program’s success to secure its future.
Step 12: Scaling – As you scale, focus on growing smart, not faster; Don’t allow your initial implementation to die or lose momentum.
Well planned telehealth implementation can make a real difference to Canadian clients, families, and communities especially as we move towards primary care. Structures set in place during the pandemic can be reinforced and optimized to continue to serve the public once life goes back to normal. Nurses can be key players in this initiative and are encouraged to explore the possibilities within their own practice area. “Given the theoretical framework of nursing in holistic, person-centred care, nurses should continue to lead the development and growth of telehealth. It is critical, however, that nurses become engaged with digitally connected health-care environments to provide optimal health and wellness to their patients. Nursing leaders must also actively support emerging technologies, as a critical skill for effective nurse leadership in the future includes “technology skills which facilitate mobility and portability of relationships, interactions and operational processes.” (Canadian Nurses Association, 2017, p. 1-2).
American Hospital Association. (2019a). Fact Sheet: Telehealth. https://www.aha.org/system/files/2019-02/fact-sheet-telehealth-2-4-19.pdf
American Hospital Association. (2019b). Telehealth A Path to Virtual Integrated Care. The Center for Health Innovation: Market Insights. https://www.aha.org/system/files/media/file/2019/02/MarketInsights_TeleHealthReport.pdf
American Medical Association. (2019c). Telehealth Implementation Playbook. https://www.ama-assn.org/system/files/2020-04/ama-telehealth-implementation-playbook.pdf
Bhatt, J. & Bathija, P. (2018). Ensuring Access to Quality Health Care in Vulnerable Communities, Academic Medicine, 93(9), 1271-1275. doi: 10.1097/ACM.0000000000002254
Canadian Nurses Association. (2017). Telehealth: Fact Sheet. https://www.cna-aiic.ca/-/media/cna/page-content/pdf-en/telehealth-fact-sheet.pdf
Health Techology Net. (2020, July 19). The cost savings of telemedicine. http://healthtechnologynet.com/2020/07/19/the-cost-savings-of-telemedicine/
InTouch Health. (n.d.). How Telehealth Can Ease the Nationwide Nursing Shortage. https://intouchhealth.com/nationwide-nursing-shortage-eased-with-telehealth-services/
Khalid, A. F. (2020, June 29). How to build a better Canada after COVID-19: Make telehealth the primary way we deliver health care. Brighter World. McMaster University. https://brighterworld.mcmaster.ca/articles/how-to-build-a-better-canada-after-covid-19-make-telehealth-the-primary-way-we-deliver-health-care/
Rural Health Information Hub. Rural Telehealth Toolkit. https://www.ruralhealthinfo.org/toolkits/telehealth
Kaminski, J. (2021). The Rise of Telehealth: COVID-19 and beyond. Editorial. Canadian Journal of Nursing Informatics, 16(1). https://cjni.net/journal/?p=8560