Limited health resources and providers in some American commu­ni­ties exacer­bates health dispar­i­ties (Williams, 2007). Progres­sive devel­op­ment and sophis­ti­ca­tion of commu­ni­ca­tion and technology, coupled with demand for novel approaches to care, positions nurses to collab­o­rate and address health dispar­i­ties in these commu­ni­ties through deploy­ment of telehealth technology. Telemed­i­cine, meaning healing at a distance” (Strehle & Shabde, 2006, p. 956), is increas­ingly viewed as a mecha­nism to deliver more efficient and patient-centered health­care services to individ­uals who face barriers to access care.

Delivery of health­care by means of Infor­ma­tion and Commu­ni­ca­tion Technology (ICT) sources is varied, and refer­ences to this are commonly used inter­change­ably. Terms used to describe these services, such as telemed­i­cine, e‑health, telehealth, and even mobile health, can be confusing until the construct and meaning of telemed­i­cine is more clearly understood. 

The Insti­tute of Medicine (IOM) simply describes telemed­i­cine as “…the use of electronic infor­ma­tion and commu­ni­ca­tions technolo­gies to provide and support health care when distance separates the partic­i­pants” (IOM, 1996, p. 1). Telehealth offers the oppor­tu­nity to deliver care to a diverse array of under­served popula­tions, including those in rural (National Confer­ence of State Legis­la­tures, 2016), urban, and suburban commu­ni­ties. Modal­i­ties and sophis­ti­ca­tion of telehealth technology have evolved over time, and uses of telehealth in the United States will likely continue to change with the demographics and health­care needs of the country. 


Emergence of telehealth in America #

Begin­ning with the inven­tion of telephonic capability, the concepts and benefit of telemed­i­cine were conceived in 1905 by a Dutch physi­ol­o­gist who utilized the telephone for trans­mis­sion and monitoring of cardiac sounds and rhythms (Bashshur, Shannon, Krupinski, & Grigsby, 2013; Strehle & Shabde, 2006). The theoret­ical use of the televi­sion for delivery of bi-direc­tional medical care first surfaced in 1924 on the cover of Radio News (IOM, 1996). This was repre­sented in a novel depic­tion of a doctor, on the screen of a radio, assessing the health of a listener child, through the screen. 

The 1940s brought trans­mis­sion of radiog­raphy over telephone circuits between cities in Pennsyl­vania separated by 20 miles (Gershon-Cohen & Cooley, 1950). Given the poten­tial need for health­care delivery at a distance, as Ameri­cans began traveling to outer space, it was not surprising that the National Aeronau­tics and Space Admin­is­tra­tion (NASA) utilized some of the first closed circuit televi­sions for telemed­i­cine (LeRouge & Garfield, 2013). Soon there­after, Lockheed Missiles and Space Company and the Kaiser Founda­tion Inter­na­tional partnered to pioneer a remote monitoring system (Gruessner, 2015), known as Space Technology Applied to Rural Papago Advanced Health Care, to provide care for the Papago Indian Reser­va­tion in Arizona (Cushing, 2015), a medically under­served rural area. While these first approaches were exper­i­mental, and not solely tested in the tradi­tional medical setting, current advance­ments in technology now drive new oppor­tu­ni­ties for nurses to deploy telehealth technology in the future (Fong et al., 2011). 

Today, patients may be a ferry or car ride away, or many miles from the nearest major medical center, critical access hospital, or primary care provider. All scenarios can result in health­care delivery service gaps and barriers to access urgent or non-urgent health­care; contributing to risk for disease and death. Video confer­encing and other telehealth methods promote the oppor­tu­nity to ensure timely care that is efficient, safe, and patient-centered. These outcomes cannot be accom­plished without a cadre of nurses and other health­care professionals. 

Providers are increas­ingly looking to telehealth as a viable care delivery model for the future, and the adoption of certain telehealth technology and delivery of services is on the rise (HimSS Analytics, 2016). Concur­rently, growth in technology and changes in consumer behavior are gener­ating younger, techno­log­i­cally savvy patients, who repre­sent diverse popula­tions (Powell, Chen, & Thammachart, 2017). These patients demand efficient ambula­tory care at the tap of a finger, driving advances in mobile health technology to provide health educa­tion and services via mobile devices (National Confer­ence of State Legis­la­tures, 2016). As one of the most widespread profes­sionals with high level skills, nurses across America are called to action to deter­mine how to leverage infor­matics and technology in the trans­for­ma­tion of care delivery to improve the nation’s health with high quality, cost efficient, and conve­nient care (Sensmeier, 2011). 


Modalities of telehealth services #

More recent techno­logic advance­ments and wireless commu­ni­ca­tions have catapulted telehealth services and the possi­bil­i­ties for nurses to partic­i­pate in delivery of remote care (Fong et al., 2011; LeRouge & Garfield, 2013). Under­standing the modal­i­ties and options for telehealth is impor­tant to deter­mine precise means of imple­men­ta­tion. Telehealth services are conducted in a variety of ways depending on the location of the patient (end user), intended delivery of services, and various means for inter­ac­tion with patients and health­care providers (Fong et al., 2011). Direct and indirect telehealth services commonly deployed include synchro­nous, asynchro­nous, mobile health and ehealth, and remote monitoring. This section provides a brief overview of each of these services with select examples and liter­a­ture support, and describes educa­tion of health­care providers through Project ECHO (Exten­sion for Commu­nity Health­care Outcomes) and eConsult. 

Synchronous telehealth

Synchro­nous telehealth commu­ni­ca­tion is defined by a live, face-to-face inter­ac­tion between a patient and health­care profes­sional or between health­care profes­sionals, in consul­ta­tion, via audio-video confer­encing. In this tradi­tional health­care setting, patients check in to a clinic in their area equipped with a video cart that allows for bi-direc­tional inter­ac­tion between the patient and health­care provider and a camera with zoom capability (Ferguson, 2006; Verho­even, Tanja-Dijkstra, Nijland, Eysen­bach, & van Gemert-Pijnen, 2010). The cart may be equipped with Bluetooth enabled digital and periph­eral equip­ment (e.g., stetho­scope, otoscope, or ophthal­mo­scope with camera capability) to use for more sophis­ti­cated physical exami­na­tion and evalu­a­tion (Fong et al., 2011). Synchro­nous visits are typically facil­i­tated at the origi­nating site (where the patient is located), commonly by a nurse trained as a telep­re­senter. The telep­re­senter uses the equip­ment to examine the patient for a provider offering health­care services from a distant site (Wechsler, 2015). Synchro­nous visits enable assess­ment, diagnosis, and treat­ment in hospital or clinic settings, and facil­i­tate nurse to patient education. 

Critical access hospi­tals with limited resources can benefit from prompt, synchro­nous consul­ta­tion by a neurol­o­gist, in the event a stroke is clini­cally suspected and timely treat­ment with throm­bol­ysis is critical. Telestroke services are those wherein synchro­nous assess­ment of the patient by a neurol­o­gist occurs. Telestroke services have increased prompt access to special­ized care with improved rates of evidence based care and inter­ven­tions (Cutting, Conners, Lee, Song, & Prabhakaran, 2014). 

Synchro­nous telehealth models improve conve­nience, access, and efficiency of care by offering walk-in telehealth services. Synchro­nous telehealth models improve conve­nience, access, and efficiency of care by offering walk-in telehealth services. One study (Neufeld & Case, 2013) compared the same services at walk-in telehealth clinics and sched­uled, in-person mental health medica­tion visits (staffed by nurse practi­tioners and medical doctors). The in-person clinics had noted signif­i­cant no-show rates and incurred the expense of long distance travel by staff. This study demon­strated that the walk-in telehealth clinics provided signif­i­cantly shorter wait times and more open access for initial and routine follow-up psychi­atric visits, with more reliable utiliza­tion of the clinic time (Neufeld & Case, 2013). 

Another area of success is conti­nuity of care in the transi­tion of chron­i­cally ill patients from hospital to home during an acute phase of illness, including synchro­nous visits with nurses upon discharge. In a mixed methods study (Day, Millner, & Johnson, 2016), patients received various devices for self-monitoring and video-confer­encing. This study observed use of telehealth equip­ment by nurses to monitor self-care, coaching, and super­vi­sion of patients during an acute exacer­ba­tion of a chronic illness. In telehealth inter­ac­tions with nurses and remote monitoring, patients became more involved in self-care; under­stood the time to report symptoms or a change in health (sooner rather than later); and reported a perceived mastery of their self-care. Compe­tent and effec­tive utiliza­tion of telehealth technology and equip­ment by nurses in provi­sion of health­care can positively impact patients (Day et al., 2016). 

Mobile health or eHealth

Mobile health or eHealth is another example of synchro­nous telehealth wherein health­care visits are initi­ated and conducted on patient personal computers and mobile devices or smart phones, from the patient’s preferred location, instead of the tradi­tional clinical setting. This form of synchro­nous consul­ta­tion with health­care providers, including nurse practi­tioners, is conve­nient for delivery of urgent care services and growing in popularity. Psychi­atric care via a smart­phone (telepsy­chi­atry) highlights the benefits of health­care delivery to high-risk patients in serious need of psychi­atric services. The conve­nience of mobile health­care breaks the barriers of trans­porta­tion issues and need for caregiver accom­pa­ni­ment, and transcends symptoms and condi­tions like agora­phobia, factors which often isolate patients and prevent access to psychi­atric care (Powell et al., 2017). 

Asynchronous telehealth

Asynchro­nous telehealth commu­ni­ca­tion repre­sents contact that is not face-to-face, but in real time, by way of email, internet, text messaging (Verho­even et al., 2010) or as store and forward’ wherein infor­ma­tion is sent and picked up or responded to at a later date. Most commonly supporting medical care in a non-urgent setting, this modality has been utilized for years in the radiology space where radio­logic films are uploaded for review at a later date (Agrawal, Erickson, & Kahn, 2016). Another example of this utility is the assess­ment of derma­to­logic condi­tions by way of uploaded digital photos or other patient data (Ferguson, 2006; Wade, Karnon, Elshaug, & Hiller, 2010). 

Remote telemonitoring

Remote telemon­i­toring is a well-estab­lished means to monitor various condi­tions and associ­ated data, including cardiac monitoring for those who suffer heart failure, or general monitoring of chronic diseases. In a study of over 3000 patients in the United Kingdom, researchers demon­strated that patients with diabetes mellitus, heart failure, or COPD had a nearly 50% reduc­tion in one year mortality and 18% fewer hospi­tal­iza­tions when using a simple home monitoring device, compared to those who did not (Steventon et al., 2012). 

An example of telemon­i­toring in the acute care setting is the recording of vital signs, contin­uous electro­car­dio­gram tracing, and hemody­namic values in the Inten­sive Care Unit (Fuhrman & Lilly, 2015) and trans­mit­ting this clinical infor­ma­tion to the teleICU. Critical care medicine experts then inter­pret the data in real time and assist the originating/​remote site with clinical decision making. This type of monitoring is utilized in health systems to promote efficiency and quality (e.g., reduce waste, deliver evidence based standards of care) and decrease redun­dancy, such as costly positioning of equip­ment and profes­sionals in commu­nity or critical access hospi­tals. In one study across 15 states that included 100,000 patients, researchers found that patients in the teleICU group had a 16% and 26% lower risk of hospital and ICU mortality, respec­tively (Lilly et al., 2014). 

Project ECHO and eConsults

In contrast to the above programs, which provide direct consul­ta­tions to patients, Project ECHO increases knowl­edge amongst primary care nurse practi­tioners, physi­cian assis­tants, and primary care physi­cians through synchro­nous, audio-video confer­encing for profes­sional educa­tion from academic centers and special­ists to primary care providers (PCP) in remote areas. This initia­tive, devel­oped by Dr. Sanjeev Arora at the Univer­sity of New Mexico School of Medicine, illus­trates how technology can be used to train nurses at all practice levels in core specialty knowl­edge (Arora et al., 2007). Partic­i­pants reported less profes­sional isola­tion, greater job satis­fac­tion, and more confi­dence in managing complex chronic diseases (e.g., hepatitis C; Arora et al., 2010). Through Project ECHO not only do patients receive expert assess­ment and care, but nurses can also receive bonus training in remote locations where educa­tional resources may be limited. 

eConsults are similar to Project ECHO in that the consul­ta­tive exchanges are between PCPs and special­ists. However, it differs in that consul­ta­tions are asynchro­nous and not part of a larger confer­ence. In this model, the PCP sends a profes­sional consult request regarding a patient with a specialty problem, and, at a later date, the specialist returns expert infor­ma­tion to the PCP (Davis et al., 2015). This is especially helpful to ensure timely care for patients who would other­wise have long wait times to see a specialist, or perhaps where it is impos­sible to see a specialist, depending on geographic location. In summary, both Project ECHO and eConsults help PCPs develop core specialty knowl­edge crucial to care delivery in the present and along the patient care continuum, and improve conve­nience and access to patients who require specialty care. 


Quality, means, and cost of healthcare delivery #

Health­care value has been defined as the health outcomes achieved, divided by each dollar spent (Porter, 2010). In the current era of value-based care, inten­tional design of high quality clinical care delivery models are targeted to achieve better patient outcomes. Provi­sion of high-value care is a major priority for all stake­holders, including consumers who are patients; purchasers repre­sented by employers and individ­uals; and health­care systems as suppliers of health­care. The IOM has identi­fied the neces­sity and utility of technology to achieve better outcomes, stating “…infor­ma­tion technology must play a central role in the redesign of the health care system if a substan­tial improve­ment in quality is to be achieved” (IOM, 2001, p. 16). 

There are many conver­sa­tions and mandates around deliv­ering high quality care, but under­standing what consti­tutes quality, and what is meant by high quality’, is essen­tial to making effec­tive changes in care delivery. Nine years before the Patient Protec­tion Afford­able Care Act ([ACA], 2010) was passed, The Insti­tute of Medicine and Committee on Quality of Health Care in America (IOM, 2001), outlined a roadmap that succinctly listed essen­tial achieve­ments and quality aims to strive for in order to improve the health of Ameri­cans. The recom­mended initia­tives (pp. 39 – 40) described care that is: 

  1. Effec­tive – ensuring that care deliv­ered is evidence based with proven efficacy 
  2. Efficient – minimizing waste of resources (equip­ment, supplies, ideas, and energy) 
  3. Safe – preven­tion of harm or injury from the health­care delivered 
  4. Timely – harmful delays in care delivery are avoided 
  5. Patient centered – patient’s needs, prefer­ences, and values are respected and upheld 
  6. Equitable – no variance in the quality of care deliv­ered to all 

In the current health­care climate, and within health­care organi­za­tions, signif­i­cant atten­tion is placed on these quality aims. The Agency for Health­care Research and Quality (AHRQ) cites the impor­tance of these six domains of health­care quality, and promotes the frame­work as a way for consumers to under­stand the meaning of quality (AHRQ, 2016). The American Hospital Associ­a­tion built the quality aims into its policy and advocacy agenda (American Hospital Associ­a­tion, 2017). If quality aims are actively integrated into direct clinical care, they possess the poten­tial to greatly contribute to the timely delivery of safe and quality care, at good value, in a patient-centered way with the intent to mitigate health dispar­i­ties, wherein all stake­holders win. Telehealth offers the oppor­tu­nity to support achieve­ment of quality aims, addressing barriers to care through innov­a­tive means and lever­aging the prolif­er­a­tion of technology in an increas­ingly mobile-friendly and technology-centric population. 


Need for telehealth services #

With the overar­ching goal to meet health­care demands of Ameri­cans, it is essen­tial to under­stand who is in need, and could benefit from health­care via telehealth. In 2017, the United States (U.S.) popula­tion is estimated at over 300 million, (Index Mundi, 2017b; U.S. Census Bureau, 2017) and is increas­ingly repre­sented by minority popula­tions and older adults (Index Mundi, 2017a). Diver­sity will continue to grow, with a projected minority popula­tion to exceed 50% of the total U.S. popula­tion by 2043 (La Veist, 2005; U.S. Census Bureau, 2017). More than ever health­care providers will be required to offer cultur­ally sensi­tive and patient centered care with consid­er­a­tion for ethnic, social, and cultural backgrounds. Concur­rent with the surge in minority popula­tions, the country is aging rapidly with 53.8 million current Medicare benefi­cia­ries (National Committee to Preserve Social Security and Medicare, 2017). This number will continue to trend upward and likely demand devel­op­ment of innov­a­tive solutions for care, especially for patients with chronic conditions. 

Changing national demographics and geographic disper­sion of popula­tions gener­ates signif­i­cant oppor­tu­ni­ties for telehealth technology. Occupying 3.8 million square miles, America is one of the largest countries in the world (Nation­master, 2017), and 72% is catego­rized as rural terri­tory (U.S. Depart­ment of Agricul­ture, 2017a). This percentage repre­sents 42 million people in rural America (U.S. Depart­ment of Agricul­ture, n.d.) with consid­er­ably higher rates of unemploy­ment and poverty compared to their urban counter­parts, and with 25% of families (with children) in deep poverty (U.S. Depart­ment of Agricul­ture, 2017b). 

Deter­mi­nants of health, including level of educa­tion, socioe­co­nomic status, and geographic isola­tion in relation to health­care services, may keep many Ameri­cans at risk for subop­timal health outcomes (Healthy​People​.gov, 2017). With challenges to connect with health­care resources, these popula­tions, especially those in rural and medically under­served areas, remain at higher risk for health dispar­i­ties and poorer health outcomes (Marmot & Wilkinson, 2006; Williams, 2007). Telehealth may offer a new oppor­tu­nity to provide essen­tial health­care services to these under­served communities. 


Policy considerations #

Given the poten­tial of telehealth, especially with rapidly devel­oping ICT and estab­lished need for services, policy consid­er­a­tions are impor­tant to continue the evolu­tion of quality, acces­sible services. Just as impor­tant is the need for nurses to become informed and support initia­tives in telehealth in this era of health care reform. This section will discuss telehealth policy consid­er­a­tions such as the demand for providers; the role and contri­bu­tion of nurses; challenges and feasi­bility of delivery and reimburse­ment; and future considerations. 

Policy impact on demand for providers

With the intent to create a healthier popula­tion, the ACA (2010) estab­lished provi­sions that incen­tivize patients to access primary care and preven­tive health services (Davis, Abrams, & Strem­ikis, 2011). Calling for the elimi­na­tion of out-of-pocket costs for preven­tive services such as cancer screen­ings and annual wellness physi­cals, the legis­la­tion placed new pressures on an already stressed primary care network across the country. Coupled with increasing numbers of insured individ­uals, this has resulted in a greater demand for primary care providers (Heisler, 2013). 

Many rural areas especially lack reason­able numbers of and appro­priate ratios of health profes­sionals (e.g., primary and dental care, mental health) to persons offer reliable access to safe and quality health­care. Such areas are identi­fied as Health Profes­sional Shortage Areas (HPSAs) (Heisler, 2013). This shortage of health­care profes­sionals signif­i­cantly deter­mines access to health­care, or lack thereof, and thus the health of commu­ni­ties. Profes­sional isola­tion for health­care providers in these remote HPSAs also poses a serious challenge. Telehealth provides a unique oppor­tu­nity to address these short­ages and effec­tively provide care to patients and support to providers, primarily nurses and doctors, in areas of provider and resource constraints. This shortage of primary care providers is well documented, and the delib­erate inclu­sion of nurses as a solution is a natural conclu­sion to continued calls for innova­tion to meet health needs of all patients. 

Nurses as critical partners in telehealth services

Nurses are educa­tion­ally and profes­sion­ally prepared to provide a broad scope of skills and services across the continuum of health­care (Bleich, 2011). The nursing workforce has doubled since 1980, and is now the largest contin­gency in the U.S. health­care workforce (Committee on the Robert Wood Johnson Founda­tion Initia­tive, 2011) with 3.6 million regis­tered nurses (McMenamin, 2016). This number includes 208,000 nurse practi­tioners, who are board certi­fied to deliver specialty services and primary care (American Associ­a­tion of Nurse Practi­tioners, 2017) with a similar scope of practice as primary care physi­cians (Bleich, 2011). 

There is an unending need for health­care profes­sionals, including nurses, to initiate appro­priate and timely use of telehealth services to ensure Ameri­cans receive the care they need. Providers must collab­o­rate to strengthen the infra­struc­ture of clinical practice; delegate tasks to broaden the spectrum of caregivers; and develop care delivery pathways and models in telehealth to address quality and reimburse­ment require­ments. Collab­o­ra­tive practice is key to building effec­tive health­care teams (Joel, 2013); improving delivery and experi­ence for patients via telehealth technology services; and optimizing efficien­cies of healthcare. 

Nurses are often the only consis­tent, front­line health­care providers present in commu­ni­ties; criti­cally positioning them to support all aspects of the telehealth continuum, with the greatest impact on patient care. As clini­cians, educa­tors, researchers, advocates of policy, and as trans­for­ma­tional leaders, nurses need to practice at the fullest extent of their educa­tion and training in order to derive their profes­sional poten­tial for all involved. Nursing practice, at its full scope, must include continued reform to develop and deliver telehealth services. 


The intersection of telehealth and healthcare reform #

The 2009 American Recovery and Reinvest­ment Act included billions in funding to update health­care IT systems, research, and facil­i­ties (LeRouge & Garfield, 2013). The National Broad­band Plan, in 2010, identi­fied and directed funds for further devel­op­ment and use of infor­ma­tion technology by expanding the infra­struc­ture for high speed internet access aiding in the estab­lish­ment of telemed­i­cine and remote monitoring (Federal Commu­ni­ca­tions Commis­sion, 2010; The White House: Presi­dent Barack Obama, 2016). In 2010, the ACA became a driver of health­care delivery and payment reform, and aspects of the legis­la­tion focused on improving care quality, value, trans­parency, and health infor­ma­tion technology. 

Telehealth is a means to achieve many aims of health­care reform, partic­u­larly goals to improve value and deliver afford­able care with high quality outcomes, while reversing rising health­care costs (Rosen­feld, 2015). In the Account­able Care Organi­za­tion (ACO) model, a product of the ACA, health systems are respon­sible for the care of a defined popula­tion, which requires seamless cooper­a­tion of multiple facil­i­ties and providers across the care continuum. The ACO model creates an ideal testing environ­ment for novel models of care delivery like telemed­i­cine, focused on better coordi­na­tion and efficiency (National Advisory Committee on Rural Health and Human Services, 2015). 

In the Centers for Medicare and Medicaid Services (CMS) Compre­hen­sive Care for Joint Replace­ment (CCJR) program, hospi­tals are finan­cially respon­sible for quality and cost of the entire care episode for Medicare benefi­cia­ries receiving hip and knee replace­ments, including 90 days post discharge. As part of the CCJR program, CMS waived certain geographic reimburse­ment require­ments for telehealth, encour­aging the use of telehealth to care for patients during the episode of care, especially as they transi­tion out of the hospital (CMS, 2017; mHealth Intel­li­gence, 2016). 

Now, value-based programs including the Medicare Access and Chip Reautho­riza­tion Act (MACRA), which will replace Meaningful Use in 2017, and the Delivery System Reform Incen­tive Payment Program, openly invite expan­sion of virtual services as a means to provide timely and cost-effec­tive care (Becker’s Health IT & CIO Review, 2016). The new payment tracks under MACRA will affect over 700,000 clini­cians in 2017, including payments for nurse practi­tioners, clinical nurse special­ists, and certi­fied regis­tered nurses (Advisory Board, 2017). 


Challenges and feasibility of delivery and reimbursement #

Increas­ingly, health­care providers are driving innova­tion with intent to deliver care, promote wellness, and keep people healthier in new and cost effec­tive ways, such as telehealth. However, there remain many evolving and unresolved challenges of telehealth, such as the deter­mi­na­tion of permis­sible practice environ­ments; ethical consid­er­a­tions; licensing and creden­tialing; and inter­state compact agree­ment statutes. Patient privacy and infor­ma­tion security are other concerns. For example, telehealth provi­sion must adhere to Health Insur­ance Porta­bility and Account­ability Act (Public Welfare, n.d.) require­ments and always ensure patient privacy. This may require extra steps for providers (e.g., entering a business associate agree­ment) to ensure protec­tion of patient health infor­ma­tion (Center for Connected Heath Policy, 2017b). Services rendered electron­i­cally may be vulner­able to hackers and other security breaches, requiring the utiliza­tion of software encryp­tion features and advanced proto­cols for security (Telehealth Resource Centers, 2017b). 

Engaging in telehealth, in practice, also depends on identi­fying specific services that can be rendered; practical devel­op­ment and imple­men­ta­tion; and deter­mi­na­tion of the feasi­bility of reimburse­ment. Reimburse­ment for telehealth services varies amongst Medicare, Medicaid, and private payers (Center for Connected Heath Policy, 2017a; Robert Wood Johnson Founda­tion, 2016). In 1997, Medicare was one of the first payers to acknowl­edge and promote reimburse­ment for telehealth services as part of the Balanced Budget Act (Telehealth Resource Centers, 2017a). However, Medicare has coverage restric­tions for telehealth services, and tradi­tion­ally only reimburses synchro­nous telehealth services for desig­nated rural and under­served areas. 

Expan­sion of reimburse­ment for other telehealth services has been slower amid concerns it will incen­tivize an increase in unnec­es­sary utiliza­tion and drive Medicare expenses up (Galewitz, 2016). In 2000, The Benefits Improve­ment and Protec­tion Act expanded Medicare coverage for telehealth, and today CMS only reimburses for a select number of services, and restricts payments to specific areas (Telehealth Resource Centers, 2017a). Although Medicare has covered some itera­tion of telehealth services for two decades (National Advisory Committee on Rural Health and Human Services, 2015), fewer than 1% of Medicare benefi­cia­ries use it (Galewitz, 2016). Nurses have a critical oppor­tu­nity to promote accep­tance and adoption of telehealth services, advocate for nonre­stric­tive telehealth benefits, and educate patients on the care avail­able through telehealth. 

Medicaid reimburse­ment for telehealth is admin­is­tered by respec­tive states, and as of January 2016, 48 states provide some form of Medicaid reimburse­ment for live video telehealth services with drasti­cally fewer states providing Medicaid coverage for store-and-forward and remote monitoring (Center for Connected Heath Policy, 2015). Medicaid reimburse­ment for live video is more preva­lent in most states, rather than reimburse­ment for store-and-forward and remote patient monitoring (Telehealth Resource Centers, 2017c). 

Individual states are able to estab­lish require­ments for private payers, mandating coverage for telehealth services (National Confer­ence of State Legis­la­tures, 2016). As of 2016, 32 states had a private payer legisla­tive policy in place (National Confer­ence of State Legis­la­tures, 2016). A study reviewing hospital adoption of telehealth (Adler-Milstein, Kvedar, Bates, 2017) found that uptake of telehealth is directly impacted by state policies on reimburse­ment and licen­sure. States with private payer reimburse­ment for telehealth, and partic­u­larly policies requiring payment parity, were associ­ated with a greater number of hospi­tals choosing to adopt telehealth technolo­gies (Adler-Milstein et al., 2017). Such policies drive reimburse­ment for telehealth services, including payment parity, where legisla­tive policy require payers to reimburse at the same rate for the same services provided in person or via telehealth (Center for Connected Heath Policy, 2015). Payment parity encour­ages health­care systems and providers to deliver telehealth services, and allows providers to make neces­sary invest­ments in infra­struc­ture to support new approaches in care delivery. 

Nurses as key contributors and informants

As noted previ­ously, the 2010 landmark IOM report strongly recom­mended an increased role for nurses in the trans­for­ma­tion of health­care. This report outlined a future in which nurses work at the top of their license and training, achieve higher levels educa­tion through improved educa­tion systems, and work as partners with other health­care profes­sionals, including physi­cians. The report called for effec­tive workforce planning and better data collec­tion and infor­ma­tion infra­struc­ture (Bleich, 2011). Fostering essen­tial interest and uptake of telehealth services by health­care profes­sionals, including nurses, demands integra­tion of telehealth curriculum and practical training into academic programs (Ferguson, 2006). Such curriculum will enhance nurses’ ability to demon­strate profi­ciency to conduct telehealth visits and advocate for such services through health policy. 

The Josiah Macy Jr. Founda­tion (2016) published recom­men­da­tions for the increased role of nurses in primary care. Given current stresses on the primary care system, new practice models that include nurses in critical roles are needed to meet demand and achieve the Insti­tute for Health­care Improve­ment (IHI) Triple Aim of improved patient experi­ence, health of popula­tions, and per capita cost of health­care (IHI, 2016; Josiah Macy JR Founda­tion, 2016). An advanced role for nurses, and redesign of primary care practices, can provide an oppor­tu­nity for nurses to partic­i­pate and actively lead telehealth integra­tion in the future. 

As telehealth continues to move from theory to practice, legis­la­tion that ensures compa­rable reimburse­ment and favor­able condi­tions for practice of telehealth services will be critical. This telehealth legis­la­tion remains a signif­i­cant need in health­care reform. Such health policy cannot occur unless health­care providers partner with local govern­ment officials, and actively drive telehealth initia­tives. Advocacy and aware­ness of critical legis­la­tion is also impor­tant, such as the Nurse Licen­sure Compact which allows nurses a multi­state license to practice (National Council of State Boards of Nursing, 2017) Without this legis­la­tion, telehealth becomes an expen­sive venture requiring licen­sure in each state where telehealth care is deliv­ered. As key infor­mants on the front line of clinical health­care, nurses should not under­es­ti­mate the power of their individual and collec­tive voices to advocate for changes to health policy in their practice states. 

The future for telehealth

In 2017, amid rising pressure of increasing health insur­ance costs, break­downs in state health insur­ance market­places, and working to fulfill a campaign promise, Repub­li­cans intro­duced legis­la­tion to move towards repeal and replace­ment of the ACA. The House of Repre­sen­ta­tives voted to pass the American Health Care Act in May of 2017. The bill now moves to the Senate. For now, the ACA remains in place, but the long-term future of this legis­la­tion remains unknown. The extent to which the law will be modified or overhauled, and how health­care coverage will be financed in the future, remains a highly polar­ized, partisan issue. 

Meanwhile, advance­ments in telehealth policy continue to emerge. In spring 2017, a bipar­tisan bill was intro­duced to the U.S. Senate to expand Medicare coverage of telehealth services. The bill is aimed at increasing access for rural patients, however, opponents raise concerns regarding the poten­tial for increased utiliza­tion, leading to greater overall Medicare costs (Arndt, 2017). Akin to the fate of health­care reform, the future of the bill is yet to be deter­mined in the polit­i­cally charged and polar­ized environ­ment of Washington DC. 


Conclusion #

Telehealth policy aligns with current reform efforts that increas­ingly focus on health­care value… It is certain that we need to meet care demands for our patients and raise the bar in delivery of quality and effec­tive health­care to the nation. Telehealth policy aligns with current reform efforts that increas­ingly focus on health­care value, a devia­tion from the tradi­tional fee-for-service model that incen­tivizes volume of services rendered. Video­con­fer­encing and other ICT advance­ments aid in moving toward a value-based future, and thus in achieving the IHI Triple Aim of better health, and better care, at lower costs (IHI, 2016).

Health­care reform is an ongoing process. As the market continues to expand, nurses can and will be excel­lent champions for telehealth. It is essen­tial for nurses to under­take the critical advocacy task of identi­fying an opening oppor­tu­ni­ties to reach patients in the commu­ni­ties they reside through telehealth. In doing so, nurses will close health­care delivery gaps and reduce health dispar­i­ties by stepping forward and utilizing the breadth of their skills to adapt, adopt, and imple­ment telehealth resources and services as commonly accepted, mainstream methods of care delivery.

Reprinted with permis­sion from the Online Journal of Issues in Nursing 

Citation: Fathi, J.T., Modin, H.E., Scott, J.D., (May 31, 2017) Nurses Advancing Telehealth Services in the Era of Health­care Reform” OJIN: The Online Journal of Issues in Nursing Vol. 22, No. 2, Manuscript 2. 

DOI: 10.3912/OJIN.Vol22No02Man02