Aspects of Nursing Education: The Types Of Skills And Knowledge Required To Meet The Changing Needs Of The Labour Force Involved In Nursing - Literature Review
Telemedicine/Telehealth
Telemedicine is an evolving feature of health care service provision in the 21st Century. The simplest definition of telemedicine is the practice of medicine at a distance (de Lusignan, Meredith, Wells, Leatham & Johnson, 1999 UK) whereby medical information and consultations are provided through the use of telecommunication technologies (Mair & Whitten, 2000 UK; Currell, Urquhart, Wainright & Lewis 2001 UK; Stanberry, 2001 UK). Telemedicine practice generally involves exchange of information between medical professionals or between the client and medical professionals. The telemedicine episode may or may not be augmented with additional information supplied by remote monitoring technologies or visual links such as videoconferencing. "e-health", or the use of personal computers (PC's), internet (www), and email mediated communication is an emerging component of telemedicine (Schlachta-Fairchild, 2001 USA). The telemedicine consultation may be conducted in real time (synchronous), or is time delayed (store-and-forward). The term "telehealth" refers to the provision of all health care services, from client education to direct health care delivery via telecommunication technologies (McNeal, 1998).
Telemedicine was introduced in the late 1950's in an effort to increase access and quality of care in rural and remote areas or in areas where health services were limited (Heterington, 1998 USA). In the intervening period, there has been a proliferation of technology. Sophisticated innovations in the form of information distribution, management and analysis systems, videoconferencing, artificial intelligence and automated decision making systems are now readily available as tools to assist health care service development (Buus-Frank, 1999 USA). The recent imperative for service delivery to be patient focussed, community based, accessible and cost effective has led to such technologies being embraced as alternatives to traditional methods of service delivery beyond the original application to rural communities (Anastasia & Blevins, 1997 USA). A literature review by Heterington in 1998 found that radiology (72 articles) was the medical specialty that most utilised telemedicine, followed by pathology (35 articles) and internal medicine (26 articles). This review, only 5 years later, identifies a much wider range of applications with only passing references to radiology. While the use in rural and remote services continues to expand, the literature reveals that telemedicine is now being used to deliver home-care health services and telephone triage services to urban populations. The literature reports that services traditionally conducted by acute hospitals on an outpatient or clinic basis can now be delivered in the community or traditional face-to-face services may be augmented by telemedicine services. Breslow (2001 USA) provides evidence that telemedicine applications can also be utilised within acute healthcare services for remote monitoring by ICU physicians at home. The literature relating to telemedicine describes these specific applications and reports on research relating to benefits and disadvantages of these applications, the feasibility and reliability of telemedicine services, and satisfaction with services provided in these ways. The impact on roles and activities of nurses and other health professionals is also explored.
A Cochrane systematic review (NHMRC level I) by Currell, Urquhart, Wainright & Lewis (2001 UK) was conducted to assess the effects of telemedicine as an alternative to face-to-face patient care. Seven well-conducted, randomised control trials were identified. The studies were concerned with telemedicine in the emergency department and the provision of home care or patient self-monitoring of chronic disease. The studies collectively involved 800 people, but in most cases numbers in individual trials were small. On the positive side, none of the studies revealed any detrimental effects from the use of telemedicine services, the use of telemedicine was proved to be feasible, technological interventions were found to be largely reliable and were well accepted by patients. On the negative side, the studies did not show equivocal clinical benefits nor did the findings constitute evidence of the safety of telemedicine. Despite many claims that telemedicine is cost effective, the studies provided variable and inconclusive results relating to the cost effectiveness of telemedicine systems. The authors conclude that policy makers should be cautious about recommending increased use and investment in unevaluated technologies. They claim that the trials reviewed prove the feasibility of conducting randomised control studies and draw attention to the need for further research of this nature.
Mair and Whitten (2000 UK) conducted a systematic literature review of all literature relating to patient satisfaction with telemedicine (NHMRC level II). They reviewed 32 papers including the same randomised control relating to telemedicine in the emergency department as included by Currell, Urquhart, Wainwright, & Lewis (2001 UK). Two trials where participants were randomly selected were identified and a case-control study was also included. The remaining 28 studies were classified as providing low levels of evidence. A large proportion of the studies reviewed was concerned with telemedicine in psychiatry and dermatology. The majority of studies used simple survey instruments and found that patients were satisfied with telemedicine services. Elements contributing to satisfaction included: tele-consultations being an acceptable replacement to face-to-face consultations, that telemedicine increased accessibility to specialist expertise, and that travel and waiting times were decreased. Findings relating to dissatisfaction included concerns relating to communicating through a technological medium. Mair and Whitten caution about generalising these results however, as the results from much of the published research are largely influenced by the specialised applications of telemedicine practice. Further, they identified a high degree of methodological deficiency in the published literature. Like Currell, et al these authors consequently highlight the need for more scientifically robust studies.
While there is much literature on every possible application of telemedicine, this review focuses on detailing literature where the introduction of a telemedicine service directly impacts on the role of the nurse.
Literature relating to the use of telemedicine to overcome the challenges of distance for delivery of healthcare services to citizens of rural and remote communities includes reports on research in the form of case studies. A case series (NHMRC level II) by Boulanger, Kearney, Ochoa, Tsuei and Sands (2001 USA) found that there was a high degree of satisfaction with telemedicine-based follow-up of rural trauma patients discharged to remote areas of Kentucky. These patients attended a Tele-Trauma Clinic at a regional Medical centre, travelling between 1-80 miles for the consultation rather than between 100-240 miles to the Level 1 Trauma Centre where follow-up appointments were previously conducted. A nurse facilitated any necessary radiological studies and recorded the patient's vital signs prior to the two-way real-time telemedicine link-up. The remote physician conducted an interview and examined the patient with the assistance of the Clinic Nurse, an electronic stethoscope and a close-up viewing instrument. The findings were derived from surveying all consulting physicians and all patients involved in the Tele-Trauma Clinic link-up. Despite the new skills required and the new role adopted, the Clinic Nurse was not surveyed. Nor was there a comparison between this service and the usual face-to-face follow-up. The decision to continue and expand this service was reached through positive responses particularly to the questions: "overall, I was very satisfied with today's consultation", " telemedicine makes it easier to get medical care" and negative responses to the question "would you have preferred to see the consultant in person?"
Dimmick, Mustaleski, Burgiss and Welsh (2000 USA) report initial findings from a case study of a federally funded tele-home care demonstration project in rural Tennessee. The study involved the use of video camera, video monitor, speakerphone and an electronic interface to the standard home telephone line. Using this equipment the patient is linked to a home health nurse for one or two scheduled consultations per week and additional contacts if required. Data was collected over a 12-month period from the 14 patient participants. All patients had chronic diseases and the types of services provided included pain control, physical, wound, and vital sign assessment, glucose and patient controlled analgaesia monitoring and medication management. The data collected set included 444 telemedicine encounter sheets, monthly satisfaction questionnaires administered by the nurse over the telemedicine system, telephone interviews by an independent caller and in-depth interviews by the researcher. Patients reported satisfaction relating to the benefits of easy access to nursing services, the ability to maintain their own health status at home, a perception of personalised care and the fact that they didn't have to drive on dangerous rural roads. Participating patients found the tele-home system user-friendly and as most also received an in-home visit their claim that the quality was the same or better was valid. Family caregivers were also surveyed and reported that tele-home care afforded greater confidence in caring for chronically ill relatives at home by knowing they could easily access help. Providers reported that tele-home health provided a reliable, low cost, long term patient management system that increased productivity and was a viable alternative to in-home visits to provide monitoring, management and incremental health education.
The introduction of a nurse-led telemedicine service to elderly (> 65years) residents of a rural Scottish village was the subject of a two part report by Macduff, West and Harvey (2001a, 2001b UK). Using similar equipment to that used in the study reported by Dimmick, Mustaleski, Burgiss, & Welsh (2000 USA), 20 patients were video-linked from the community nursing clinic to the GP's rooms. The community nurses' used a referral protocol to determine the need for a video-link GP consultation, provided the GP with a succinct assessment prior to the consultation. The nurse was then available to provide support during the consultation at the patient's request and following the consultation carried out any treatment that the GP advised. The patient questionnaire revealed satisfaction with the service, particularly relating to convenience and the role of the nurse in interpreting and explaining points that they had not understood during the GP consultation. Although a relatively small development in terms of numbers this new service resulted in a significant expansion of the community nurses' role, both in the provision of technical assistance and provision of assessment, monitoring, advisory and prescribing services. The numbers of patients treated solely by the community health nurse increased significantly with only a few patients needed referral to a face-to-face GP consultation. The participating GP's reported satisfaction with the service, both in terms of patient outcomes and the decrease in their own workload.
The final study relating to rural telemedicine services is reported in the paper by Harris and Campbell (2000). This American study evaluated the utilization of computer-based telemedicine in three rural counties in Missouri. The ten general practice clinics that participated in the study each received a computer with a network card so that they could connect to the world-wide-web (www), email, access community specific information and contact a medical librarian. The study revealed low utilisation of email, but higher utilisation of the www by physicians. With one exception the study revealed that when compared to the utilisation by nursing staff at the clinics, physician acceptance of this technology was low. A closer analysis by the researcher revealed that the nurse often used email at the physician's request. The researcher's concluded that a physician's willingness to use nurse practitioners in their practices may increase their willingness to use telemedicine as an extension to their practice. This change in service would therefore have implications on the role of the nurse practitioner in a GP practice.
The randomized control trial (NHMRC level II) by Brennan, Kealy, Gerardi, Shih, Allegra, Sannipoli and Lutz (1999 USA) was included in both systematic reviews described earlier. This study evaluated the use of standard teleconferencing equipment and peripherals (otoscope, stethoscope, and dermoscope) by emergency physicians to take a medical history and perform a physical examination on patients in a remote Emergency Department (ED). An ED telemedicine trained nurse assisted at the remote site. Patients with any of 18 pre-determined minor conditions were randomised to be seen by either the telemedicine nurse or to conventional physician care at the remote site. After the local telemedicine nurse and the remote telemedicine physician evaluated 50 patients, the nurse and physician recorded their experiences using a satisfaction scale. Patient interaction, nurse interaction, video quality, ability to hear and see patients, comfort level in making diagnoses, audio quality and usefulness of peripherals were rated by remote physicians using a scale of 1: not very satisfied, to 5: very satisfied. The mean survey responses ranged between 3.7 for usefulness of peripherals to 4.8 for nurse and patient interaction. Nurses rated patient interaction, physician interaction, video quality, perceived ability of physician to hear and see patients, perceived comfort level of physician in making diagnoses, audio quality, and ease of use. Their mean responses ranged from 5.0 for video quality and physician interaction to 3.7 for perceived ability of physician to hear and see patients. The researchers consequently concluded that physicians and nurses were satisfied with the use of telemedicine to diagnose and treat selected groups of ED patients.
Four papers report a longitudinal study (NHMRC level IV) of a telemedicine link between a nurse-led minor treatment centre in London and an ED in Belfast (Darkins, Dearden, Rocke, Martin, Sibson & Wootton, 1996 UK; Tachakra, Wiley, Dawood, Sivakumar, Dutton & Hayes, 1998 UK; Tachakra, Loan & Uche, 2000 UK; and Tachakra, Dutton, Newson, Hayes, Sivakumar, Jaye and Bak, 2000 UK). Standard videoconferencing equipment was used by the emergency nurse practitioners to access ED physicians as an alternative to referring patients to a local ED or a local GP. In the first twelve months of operation, only 0.5% of patients were seen using the telemedicine link. This was fewer than expected but was deemed to be a cost effective alternative to employing a physician at the clinic. One could argue that it would be just as cost effective to refer the patients to local physician services. The 1998 paper revealed that the number had increased to 2.9%, the most common reason (39%) for the use of telemedicine link being to discuss an X-Ray. The accuracy of the telemedicine assisted X-ray interpretation was subsequently checked by a review panel and found that the nurse practitioners working diagnosis was improved with the help of the telemedicine consultation from a sensitivity of 90% to 97% and a specificity of 96% to 99%. By late 1999, the number of tele-consultations had increased again to 5.9% of all consultations. When the researchers examined the hospital records of those who had required admission to determine the reliability of telemedicine diagnoses, 98% of diagnoses were considered correct. The fourth study conducted four months later noted that consultation rates increased when a number of local consultant run clinics were closed and fell when nurse practitioners gained more experience in interpretation of X-Rays. These studies perhaps illustrate the efficiencies of nurse-led clinics better than those of telemedicine.
A fifth paper reported in this series reported on the nature of calls to the service. (Tachakra, Hollingdale & Uche, 2001 UK). This paper reports that two hundred of the 1854 teleconsultations from mid 1996 to 2000 were with the orthopaedic service. Of these, 193 needed teleradiology with 190 showing an abnormality. The emergency nurse practitioners and orthopaedic registrars diagnosed all cases correctly. Where patients required hospital admission the emergency nurse practitioner consulted with the orthopaedic resident telemedically and organised direct ward admission, thus avoiding the transfer of the patient to a second accident and emergency department for assessment.
In the UK there is particular recognition of the role of the emergency nurse in determining the level of first line services required. 'NHS direct' is an UK government initiative to provide a 24-hour telephone advice line staffed by nurses. It is already established in England and will be operational in Wales and Scotland by 2000. The function of the telephone consultation is to recommend home care or referral to appropriate healthcare services through a triage system that identifies the nature and potential urgency of the clinical problem. Nurses answering the calls are supported by computerised decision making software, advice and information databases, and electronic communication links with primary care services, hospital accident and emergency (A&E) departments, the ambulance service and other agencies. The narrative paper by McLellan (1999 UK) reports that at the time of writing, 95% of calls were about symptoms, with 45-50% of all calls being about children. Accordingly, the most frequent users of the call system are parents of young children. McLellan identifies that the call service has the potential to improve and develop child health services in the UK, but cautions that this will directly relate to the quality of the advice. He highlights the need to recruit paediatric nurses to the call service or provide specific paediatric/child health education to call centre nurses without paediatric qualifications. Additional knowledge required by call centre nurses includes use of telephone systems and the use of clinical decision support software. Call centre nurses' also require specific knowledge relating to remote decision making, eliciting pertinent information from the caller, evidence based practices and knowledge of local health care service practices and procedures.
Schwartz, Genovese, Devitt & Gottlieb (2000 USA) report that in the USA there are many commercial telephone call centres and most hospitals have some form of telephone triage system. These authors showcase a national Veterans Affair telephone care program that is conducted by an all-RN staff with advanced practice or critical care skills that can work independently and make critical judgements. The use of computer networks by the service facilitates immediate access to patient's medical records. This same network facilitates immediate recording of progress notes with notification to the primary care provider by telephone or e-mail. Continuity of care is ensured through access to laboratory results so that the telephone triage nurse can determine whether care at home has been successful or whether the veteran needs to attend a healthcare service. Telephone triage nurses also make follow-up calls should the patient be referred to a healthcare service and follow-up veterans following ambulatory surgery. Clinical decision-making support is afforded through protocols classified by symptom. Other protocols used are specifically for follow-up of surgical patients. Information provided by the authors identifies that 74% of calls are classified as clinical (including symptom-related calls, patient education and coordination of care), 10.6% are administrative calls, and 14.4% are general calls. Patient satisfaction surveys conducted by Veteran Affairs rated the program as excellent, with patients most appreciating receiving immediate assistance from a knowledgeable nurse. The authors report that the implications for nursing in the future are extensive, not the least being that nurses in one state are advising and caring for patients in another state where they may not be licensed to practice.
The papers outlined so far refer to telemedicine services that primarily aim to provide immediate access to the health care system and recommend interventions for acute care from a remote site. In line with the shift of services from hospitals to the community, patients who were hospitalized in the past may successfully be treated in the comfort of their own homes. The technological advances associated with telemedicine therefore have great potential for improving delivery of such home health care (Hepburn-Smith, 1999 USA). Now, virtually any home with a touch-tone phone can receive interactive visits by health professionals. While standard teleconferencing equipment enables real time images to be sent over standard phone lines, home telehealth care systems also have the capacity to capture vital sign information and communicate it to a health professional at a remote site. Devices include the telestethoscope that transmits heart and lung sounds, pulse oximetry that transmits oxygen saturation and heart rate readings, ECG that transmits 12 lead ECG recordings, and automated blood pressure cuffs that transmit temperature pulse and blood pressure readings. Home telehealth systems also have the capacity to deliver medications through infusion devices with remote programming capabilities, and transtelephonic defibrillation can restore normal conduction should a cardiac arrhythmia arise. Portable X-Rays can also be obtained in the home and electronically transmitted (teleradiology) (McNeal, 1998 USA. A nurse at a central station that is connected to one or more patient station generally monitors Telehealth systems (Warner, 1996 USA).
The literature relating to telehealth emanates from the United States. Two research articles explore the feasibility of implementing home telehealth. The first by Shaul (2000) reports on a pilot pseudo-randomised control trial (NHMRC level II) specifically investigated the feasibility of using telehome health for elderly patients (( 65 years) with one or more chronic illnesses. Patients who did not meet these criteria, who were already receiving home health care services, or did not have access to a telephone, or could not use or have access to anyone, who could use a telephone were excluded from the trial. Patients who met the inclusion criteria were alternately assigned to either the intervention or control group. The control group patients received the usual care by visiting the physician's office, self-care, informal care or a combination of the three. The intervention group received the telehealth equipment, instruction on its use and 15-20 minute telehealth consultations two or three times per week by a RN experienced in home care. The telehealth nurse also allocated additional time each week to coordinating referrals to other providers, obtaining new medication orders and addressing social support needs. Functional status, frequency and severity of acute exacerbation of the chronic illness, and quality of life of the two groups were compared through the completion of questionnaires. A satisfaction survey was also administered to the intervention group. Preliminary data from the first 8 months revealed that those patients in the intervention group maintained baseline physical status and incurred fewer hospitalizations compared to those in the control group. This group of patients rated the quality and satisfaction of the telehealth consultation as equal to or better than a home visit. Most found the equipment easy to use after instruction during the set-up visit, although patients with memory problems or impaired cognitive function required prompting at each telehealth consultation. The telehealth nurse spent an additional 30 minutes per week on coordinating follow-up care.
The case study by Rooney, Studenski, and Roman (1997) specifically focussed on the feasibility of implementing a home telehealth care program as a lower cost alternative to traditional in-home care. Patients were selected from multiple referral sources and included in the study if they had two or more chronic diagnoses, four or more active medications, were under the care of a physician who approved the program and were willing to consent to participate. Patients with a terminal illness, severe mental health condition, who were substances abusers, who required daily skilled invasive nursing procedures, or who were unable to operate the equipment (or have access to a carer who could) were excluded from the trial. All participating patients received an interactive two-way televideo with standard computerised assessment tools (including glucose monitoring for diabetic patients) and access to the telehealth call centre as determined by an individualised care plan. 46 patients participated and received a mean of 4.0 telehealth encounters per week. Telehealth nurses participated in a mean of 7.3 telehealth consultations per day with a mean duration of 12.25 minutes. 35 patients expressed an overall positive reaction to the system, nine were neutral and two patients withdrew from the program because they felt the equipment was too intrusive. Few problems were encountered with the equipment, but those that did arise could be overcome with the development of a single multifunction device. The researchers reported that the program was cost effective based on the elimination of travel costs incurred at an average of $7 per visit and lost productivity of $9 per in-home visit. They concluded that telehome care can provide nursing services in the home effectively and in a cot-effective way that can complement traditional in-home care.
Higher-level evidence for both the cost-effectiveness and feasibility of telehealth nursing services is reported in a paper by Johnstone, Wheeler and Deuser (1997 USA). This study (NHMRC level II) randomised 100 patients to the intervention group and 100 to the control group. The control group received in-person and telephone visits from the home health nurse, while the intervention group received in-person and televideo visits. Preliminary findings found high patient satisfaction and cost savings of 33-50% in the intervention group due to the decreased number of home-visits required.
All three papers raise important considerations relating to the implementation of a home telehealth nursing service. The researchers noted that in order to cope with the role change precipitated by this change in service it was essential that nurses already possessed specific skills and knowledge. They recommended that the telehealth nurse possess excellent assessment and case management skills, be comfortable in assessing patients from a remote site and be accepting of new service delivery methods. Kinsella (2000 USA) adds that while it is simple to assume that the routine in-home visit is easily replicated by a telehealth visit, there are fundamental differences that the nurse needs to learn how to overcome. These differences include such impediments as time delays, lack of audio/visual clarity, and the need for repetition. Kinsella also recommends that nurses need to develop presentation skills appropriate to the telehealth technology and seize the opportunity to assist in the design and planning of the telehealth tools. The researchers also recommended that equipment should be chosen carefully. Papers by Douglas (1997 USA) and McNeal (1998 USA) describe a four-feet tall home-based computerized "nurse" called HANC. Short for home-assisted nursing care, HANC provides an integrated videoconferencing and monitoring system that would overcome the problems encountered in the study by Rooney, Studenski, & Roman (1997 USA).
Ades, Pashkow, Fletcher, Pina, Zohman & Nestor (2000 USA) report on a nurse-led home-based cardiac rehabilitation program evaluated using a controlled trial (NHMRC Level III-2). The study compared the effectiveness of home-based, telemedicine monitored cardiac rehabilitation with standard, on-site, supervised cardiac rehabilitation. All patients included in the study had experienced an acute coronary even within 3 months of entering the program. The intervention group consisted of patients who were unable to attend the on-site rehabilitation sessions due to geographical reasons or if work or schedule conflicts precluded their on-site participation. The control group consisted of patients who were able to attend the on-site sessions without geographical, work or schedule conflicts. Evaluation criteria consisted of exercise capacity, weight, quality of life and frequency of adverse effects. Drop-out rates were of no statistical difference between the control and intervention groups. Both groups demonstrated similar improvements in exercise capacity and quality of life scores. The weight of the home-based group slightly increased. There were no exercise-related complications in the home group and there were no exercise-related deaths, cardiac arrests or myocardial infarctions in either group. These findings support the introduction of a rehabilitation service for patients who would traditionally be considered of too high risk for home-based service, but who would not normally have attended on-site rehabilitation due to geographical, work and schedule factors. With well-established benefits of cardiac rehabilitation after a coronary event, this use of telemedicine and nursing services may significantly improve public health.
Another community nurse-led application of telemedicine reported in the literature relates to school health services. A qualitative study by Whitten, Kingsley, Cook, Swirczynski & Doolitle (2001 USA) evaluated a telehealth project (Tele-Kid Care) that brought healthcare directly into elementary schools using interactive video technology and peripheral devices to consult with a physician. The role of the school nurse was dramatically affected by this project. He/she school nurse was no longer just responsible for routine record keeping and providing basic vision and hearing screenings. Instead, the school nurse was responsible for making the telehealth referral, became directly involved in the interaction between the student and physician and followed up on the home care being received by the students after the telehealth consultation. Nurses routinely confirmed that medication was being administered, listened and responded to concerns of parents related to medications and other healthcare interventions and helped parents connect with other community resources.
A narrative paper describes the implementation of a multidisciplinary, multi-site telehealth service in response to an increasing number of children in schools with debilitating medically conditions, physical or mental disabilities, or complex medical needs (Green, Esperat, Seale, Chalambaga, Smith, Walker, Ellison, Berg & Robinson, 2000 USA). Initially designed to provide distance education between academic health science centre, the Nursing Department at University of Texas and school teachers and nurses, teleconferencing equipment was employed to also provide a telehealth service. Patients benefited from no longer having to commute long distances to numerous appointments with single healthcare professionals. As a result of this initiative, teachers and school nurses enjoyed greater collaboration with healthcare professionals and became more comfortable in providing care to the participating children.
Telemedicine technologies have also demonstrated effectiveness in Mental health service applications. A randomised control trial (NHMRC level II) demonstrates a high level of evidence for the use of telehealth care to augment traditional physician counselling and anti-depressant medication treatment of depression in the primary care setting (Hunkeler, Meresman, Hargreaves, Fireman, Berman, Kirsch, Groebe, Hurt, Braden, Getzell, Feigenbaum, Peng & Salzer, 2000 USA). In this research Hunkeler et al randomly assigned 302 patients to usual care (physician care) telehealth care (usual care + telehealth provided by trained primary care nurses) and telehealth care plus peer support (usual care + telehealth + peer support). Telehealth care incorporated emotional support and focused behavioral interventions for a determined number and duration of calls. The nurses' providing this service completed a 6 hour training workshop and received ongoing weekly supervision from the clinical director and a clinical psychologist. Knowledge required included management and assessment of depression, drug therapies, counseling, behavioral activation, education skills and provision of emotional support. Peer support incorporated telephone and in-person supportive contacts. Outcomes were measured using the Hamilton Depression Rating Scale, Beck Depression inventory, and SF-12 Mental and Physical Composite Scale assessments conducted at baseline, 6 weeks and 6 months. It is of great significance that the researchers found that the difference between usual care and care augmented by telehealth nurses is almost as large as that between drug and placebo trials. Trial results revealed that telehealth patients, with or without peer support more often experienced 50% improvement on the Hamilton Depression Rating Scale at 6 weeks, and 57% at 6 months compared to the control group at 37% and 38% respectively. Mental function also improved, as did patient satisfaction with treatment. The addition of peer support to telehealth did not improve these outcomes. Contrary to the researcher's hypothesis, telehealth care did not improve medication adherence.
The acceptance of nurse provided telemedicine services in mental health is also supported by a retrospective review of all calls received by a telephone help service for younger people with dementia, their families and the professionals caring for them (Harvey, Roques, Fox & Rosser, 1998 UK).
Literature describing a randomized controlled trial (NHMRC level II) of child psychiatric assessments conducted using videoconferencing (Elford, White, Bowering, Ghandi, Maddiggan, St. John, House, Harnett, West & Battock, 2000 CAN) and a case series (NHMRC level IV) evaluating internet-mediated, protocol driven treatment of psychological dysfunction (Lange, Van de Ven, Schrieken, Bredeweg & Emmelkamp, 2000 NETH) were also retrieved. While these studies reported favorable outcomes, the change in service did not involve nurses.
The above papers have all reported 'real-time' video teleconferencing services. Another mode of providing services is through a 'store-and-forward' approach. A paper by Lewis, McCann, Hidalgo and Gorman (1997 USA) reports on the provision of a service that uses a telephone link-up to communicate and visualise a single still image captured by a digital camera. This technology was used to facilitate a vascular nursing teleconsultation service for wound assessment. Also present for the link-up the service replaces an outpatient clinic visit for rural patients who would otherwise have had to travel significant distances to attend.
A family nurse practitioner from the outreach clinic is also present at the teleconsultation to facilitate planning for a home-visit and the provision of appropriate wound care. A vascular surgeon is on call along with other healthcare providers such as a nutritionalist, reconstructive surgeon and dermatologist. The case study reported demonstrates how this remote method can successfully evaluate wound healing and plan appropriate home-care interventions. It also demonstrates the successful implementation of a nurse led clinic and the specialised skills required by nurses who provide wound management services.
A number of other studies relating to a change to the provision of outpatient/clinic services via telemedicine appear in the literature. Mease, Whitlock, Brown, Moore, Pavliscsak, Dingbaum, Lacefield, Buker and Xenakis (2000 USA) conducted a randomised control trial (NHMRC level II) examining the provision of diabetes control via telemedicine. The intervention group was supplied with videoconferencing and monitoring equipment and was reviewed by a nurse case manager (weekly consultations) in partnership with a primary care physician (monthly consultations). Each week the nurse case manager would review and record assessment data, exercise and nutrition goals and sense of well being. Based on this data the nurse would recommend nutritional and exercise alternatives and reinforce medication compliance. The nurse would also participate during the monthly physician sessions. The control group attended an on-site diabetic clinic for baseline measurements, was encourage attending diabetic education classes and primary practice clinics and was reviewed at the end of the three-month trial period. Despite some significant problems with the equipment the researchers reported better results in the intervention group to the control group in the outcome measures of reduced HBA1C levels and weight reduction. These parameters are considered to be the major indicators of diabetic morbidity. This was not a simple comparison of telemedicine versus traditional on-site clinics however, and any conclusions regarding the efficacy of treatment must include the contribution of the nursing consultations.
The results from a randomised control trial (NHMRC level II) that directly compared the same physician consultation service delivered either on-site or through telemedicine were not so successful. In this study Chua, Craig, Wootton & Patterson (2001 UK/AUS) found that telemedicine for new neurological outpatients was possible and feasible, but generates more investigations and is less well accepted than face-to-face examinations. Although a neurology registrar attended the remote clinic, he/she was not present for the teleconsultation.
More success has been reported from telemedicine services when the healthcare professional is present with the patient at the remote site. This was the case in the earlier study by Chen & Patterson (1996 USA) where a clinical nurse practitioner or certified physician assistant assisted in patient evaluations at the "far end". These researchers found greater acceptance by patients and were able to detect subtle neurological findings such as abnormal reflexes or retinal abnormalities.
A Finnish study (Haukipuro, Ohinmaa, Winblad, Linden & Vuolio, 2000 SC) also reported success with remote outpatient consultations when a GP or experienced nurse attended the telemedicine session. In this randomised control trial (NHMRC level II) postoperative orthopaedic outpatients were seen either by orthopaedic specialists face-to-face at a central clinic, through telemedicine at the central clinic, or via a telemedicine link-up in a remote Primary Care Clinic. Although there were some difficulties in examining the telemedicine patients, telemedicine consultations were deemed feasible. In addition, both the patients and the specialists participating in the remote intervention and control group were equally satisfied with the service. These results may lead to cost-savings by the replacing the usual specialist visits to the regional clinics with teleconsultations. It is unclear how the on-site intervention group contributed to the results.
Of interest was a pilot cluster-randomised control trial (NHMRC level III-1) comparing telemedicine at GP clinics to face-to-face specialist surgical outpatient clinics (Harrison, Clayton and Wallace, 1999 UK). In this case satisfaction from remote participants exceeded that of patients participating in conventional outpatient visits. The greater satisfaction rates for the intervention group suggested that the time saving nature of teleconsultations is a significant factor in patient satisfaction with telemedicine services.
Other outpatient applications were the subject of successful telemedicine trials. A case study by Rosser, Prosst, Roda, Rosser, Murayama & Brem (2000 USA) found in-home post-operative nurse/intern follow-up for patients undergoing laparoscopic surgical procedures to be both time efficient and of high clinical accuracy. On average patient's rated their satisfaction with the experience as 4.8 of a maximum of 5. In a small study in the United Kingdom Murdoch, Bainbridge, Taylor, Smith, Burns, & Rendall (2000 UK) report on telemedicine to support the postoperative evaluation of patients who have had ophthalmic surgery. A trained ophthalmic nurse captured video slit lamp images of the patients at an outreach clinic. After some initial equipment difficulties staff were satisfied in the images received. Only one out of 24 patients found the teleconsultation unacceptable.
Harrison, Clayton & Wallace (1996 UK) report the results of teleconsultations at six GP practices for the specialties of dermatology; endocrinology; ear, nose, and throat; gastroenterology; gynaecology; oncology; orthopaedics; paediatrics; psychiatry; and urology (NHMRC level IV). These researchers found that 84% of patients would use the service again, 86% felt that the consultant could understand their problem and that they were able to say what they wanted. Only 8% were concerned about confidentiality. Of the specialists, all but the dermatologists were satisfied with the quality of the visual images transmitted during the consultation. These problems can most likely be resolved by the use of store-and-forward techniques. This technique was found to produce better results in a literature review that compared live tele-conferencing and store-and-forward methods (Eedy & Wootton, 2001 UK/AUS). It was also found to lead to correct diagnosis for 90% of patients in a randomised control trial (NHMRC level II) conducted by Zelickson and Homan (1997 USA). These researchers compared diagnosis from patient's history alone, to image alone, and image and history together. The store-and-forward techniques was used as the image component and the study was used to provide evidence that nursing home teledermatology consults could replace some on-site consultations. Taylor, Goldsmith, Murray, Harris & Barkley (2001 USA) compared store-and-forward technology to face-to-face consultations. In this study the patient participated in routine face-to-face consultations and the clinic nurse took images of their skin lesions. The consultant dermatologists subsequently reviewed the stored images with a third consultant grading the level of agreement. From this retrospective analysis (NHMRC level III-3) these authors found that there were high levels of agreement between the telemedicine diagnosis and the face-to-face consultations. The recommendations from this study were that instead of a standard consultation, the nurse could transmit the data and specialists could make a rapid inspection of the transmitted image to determine the necessity of an urgent follow-up appointment.
As can be seen by the papers reviewed, nurses have a pivotal role in the delivery of telemedicine services. They may lead the consultation and/or management or be present to assist with the examination, provide patient education and manipulate/trouble-shoot the telemedicine equipment. Accordingly, the skills and knowledge directly relate to use of the technology and require varying degrees of proficiency in patient assessment, management and education.
Any comments or queries should be sent to: highered@dest.gov.au
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