By Curtis Pond
April 17, 2000
Photo: Margie Paschke/William Jacoby

During a routine examination, there is nothing unusual about Bonnie Britton, MSN, RN, checking a heart patient’s blood pressure, measuring abdominal girth, or inspecting the feet for signs of edema. What could be construed as a little odd, however, is Britton conducting her examination some 250 miles from the patient’s bedside.

Britton’s assistant is a 14-pound device equipped with a detachable camera, video screen, blood pressure cuff, digital readout, and stethoscope that is placed in the patient’s home. The box relays the patient’s vitals to Britton, who then can decide if the patient needs further medical attention.

"The patients love the device," said Britton, who worked as a cardiology nurse for 17 years before starting University Home Care in Greenville, N.C. "It keeps people out of the hospital and saves money for the patient and the hospital. And all the patient has to do is push a button. The hardest part is teaching the patient how to put on the blood pressure cuff."

Receiving and exchanging medical information through wires and tubes is not a new role for nurses. Telephone triage, a staple in nursing, is considered the forerunner of telemedicine—the use of wire, radio, visual, and other information technologies to provide clinical care to patients from a distance. Telehealth is the broader application of telemedicine, and is generally the term preferred by nurses because telehealth focuses on the individual’s long-term wellness and health. This technological shift in health care has moved some patients from the exam room to the desktop as healthcare providers treat patients who have limited access to hospitals and clinics.

The promise of telehealth is to save time and money by reducing hospital visits and increasing productivity. A telehealth home care study in California projected that nurses could see almost four times as many patients a day by computer, and that the average computer consultation lasted just 18 minutes, compared to 45 minutes in person.

Britton said a recent project that her facility participated in, involving a combination of home visits and telehealth home care consultations, eliminated 187 hospital days for 10 patients with pregnancy-induced hypertension.

Setting the course

Nurses have carved a niche in telehealth because of their role in treating inmates and rural populations—common targets for telehealth technologies. Nurses also have played an active role in telehealth largely because they are responsible for coordinating connections between remote sites.

"Nurses are forced to deal with technology because they are responsible for keeping the technology [in the exam room] operational," said Carol J. Bickford, MS, RN, senior policy fellow for the American Nurses Association. "They are accustomed to nothing being the same."

Bill Grigsby, PhD, of the Association of Telehealth Service Providers (ATSP) in Portland, Ore., said nurses also are active in using telehealth technologies in forensic examinations.

"There are many SANE [Sexual Assault Nurse Examiner] clinics that are using audiographic technology to get second opinions from forensic experts on sexual assault cases, especially those involving children," he said.

The Violence Intervention Program at the University of Southern California Medical Center in Los Angeles reported in an ATSP study that telehealth consultations on child sexual and physical abuse cases produced "quicker turnaround time for cases and increased the likelihood of accurate assessment." Other medical centers that participated in the study said telehealth consultations decreased travel time for patients and reduced the need for re-examination.

Although the benefits of telehealth are numerous, the technology has many obstacles.

Making telehealth consultations routine has been hampered by the issues of reimbursement billing and licensing of healthcare providers treating patients across state borders.

The rules of telehealth have become more complicated than the technology itself.

"The government should be developing standards to say what is illegal and legal in telemedicine," said Virginia K. Saba, PhD, RN, nursing informatics instructor at Georgetown University.

Keeping quiet

But the government isn’t saying much, or at least not what nurses and other healthcare providers want to hear.

Often, telehealth programs are funded through government or private grants. Insurance companies and HMOs provide reimbursement for some telehealth procedures, mainly live interactions, depending on the particular plan.

The Health Care Financing Administration (HCFA) began reimbursing physicians and other mid-level providers in April 1999 for certain Medicare telehealth procedures for patients living in rural areas labeled Health Professional Shortage Areas (HPSA).

So far, healthcare providers have been less than happy with the results.

"We’re classified as a medically underserved area, not rural, so we don’t get the same reimbursement as HPSAs," said Vicki Pendleton, RN, who works at a medical center in Johnstown, Penn., that uses telehealth in the field of dermatology.

HCFA’s reimbursement policy also is filled with narrow guidelines that have kept healthcare providers from experiencing the benefits of telehealth.

For instance, under HCFA guidelines, healthcare providers are able to bill as long as the telehealth consultation is a live video transmission between physician, patient and a specialist, if needed. Healthcare providers are unable to take advantage of store-and-forward consultations, which allow a provider to record an examination with audio and visual images, then forward the results to a specialist who uses e-mail to examine the patient. Because this is the preferred telehealth method, providers pay out of pocket for many telehealth consultations.

Even when providers are able to bill for a telehealth consultation, they still stumble into pitfalls, such as having to split fees with the physician to whom they referred the patient.

"Reimbursement is an accounting nightmare," said Holly Russo, health telecommunications policy analyst for the U.S. Department of Commerce. "You’ve got 75 percent of pay going one way and 25 percent going another."

But that is just the tip of the iceberg, according to Bickford. "How do you get reimbursed on a telephone call or e-mail where there is advice given?" she said. "Without guidelines, the door is open for fraud and abuse."

Bickford also is concerned about system disparities that do not allow nurse practitioners and advanced practice nurses to bill the same as physicians.

"These issues of reimbursement have been around for a long time. They’re not specific to telehealth," Bickford points out. "Nurse practitioners and advanced practice nurses, who may be experts, are considered non-physician providers. But [they] are who you see when your back hurts, not the doctor."

Moving forward

While billing restrictions have prevented some healthcare providers from jumping on the telehealth bandwagon, nurses have not been deterred from taking a leadership role in developing telehealth guidelines, especially in licensure.

"We’re ahead of physicians in licensure in response to telephone triage," said Loretta Schlachta, MSPH, RN, who is conducting her dissertation research on telehealth and nursing. Schlachta said telephone triage opened the door a long time ago to how nurses would give advice in areas they are not licensed to practice.

Carolyn Hutcherson, RN, consultant for the Center for Telemedicine Law in Washington said the nursing community is currently bonded by an endorsement policy, which recognizes that nurses across the country have met similar requirements to practice nursing.

"So North Carolina will recognize a nurse from Texas and issue a license by endorsement," she said.

"All nurses have been taking the same exams since the 1950s," said Hutcherson, "so it’s been easier for a nurse to go from state to state. This isn’t the same for all medical professions. Some have to do additional requirements to practice some place else."

Hutcherson said nurses are moving toward a reciprocity policy that will further allow them to grow in the field of telehealth. A reciprocity policy is what a driver’s license is, something accepted automatically from state to state.

In 1998, the National Council of State Boards of Nursing hammered out the Interstate Nurse Licensure Compact—an 11-point declaration that acts as a guide for nurses giving medical advice across state borders. Nine states have adopted similar legislation, while two have enacted legislation directly related to the compact.

In comparison, about 20 states have adopted restrictive licensure laws that limit physicians from practicing across state borders, according to the Health Resources and Services Administration’s Office for the Advancement of Telehealth. States that have adopted language against multi-state licensure generally point to liability as the reason physicians or nurses should practice only in states where they are licensed.

"I have never heard of any problems related to telemedicine, such as technical glitches that have caused harm to a patient," Schlachta said. "The only bad thing I have seen is when you take patients off the technology. They want it, and when you take it away, they miss it."

And never far from the surface of telehealth is the reality that most households and facilities do not have the modem speed to benefit from regular telehealth consultations.

Telehealth’s proponents hope that as the Internet changes the structure of the home, video and other multimedia technologies will become as common as a sofa.

"Right now we need things more simple," Russo said. "We need things built into everyday items, so telehealth is not a separate piece of equipment in the home."