Telehealth to the Rescue During COVID-19 Health Crisis
The global emergency health crisis, known as COVID-19, has placed pressure on the healthcare industry to rapidly revise the traditional practice of patient care delivery. "Coronavirus disease spreads primarily through contact with an infected person when they cough or sneeze. It also spreads when a person touches a surface or object that has the virus on it, then touches their eyes, nose, or mouth," according to the World Health Organization. This highly contagious disease dramatically shifts the delivery of patient care commanding revisions to federal regulations, and healthcare organizations' swift implementation of telehealth modalities.
To contain the spread of COVID-19, organizations are following federal recommendations to limit non-urgent ambulatory care and specialty in-person medical appointments for the safety of patients and staff. If there were no other safe alternatives available to deliver patient care, regardless of whether the organization is a large medical center or a small private practice, this recommendation would strongly affect the continuity of patient care and place a financial burden on the organization. This is where the implementation of telehealth comes into play.
The Center for Disease Control (CDC) supports and recommends telehealth implementation, stating that "Shifting practices to triaging and assessing ill patients (including those affected by COVID-19 and patients with other conditions) remotely using nurse advice lines, provider "visits" by telephone, text monitoring systems, video conferences, or other telehealth and telemedicine methods can reduce exposure of ill persons with staff and minimize surge on facilities."
Telehealth delivery methods are ways that patients, caregivers, and providers communicate medical care needs and can occur either synchronously or asynchronously.
1. Synchronous, also known as "real-time" communication, allows two-way communication between a patient, caregiver, and provider utilizing audiovisual telecommunication technology such as a smartphone, laptop, or desktop. These devices must have a camera and speaker capabilities for successful video communication. Synchronous encounters are considered the same as a traditional in-person encounter.
2. Asynchronous communication does not occur in "real time". There are various types of asynchronous telehealth communication.
- Mobile Health or mHealth is the provision of health care services and personal health data via a mobile device.
- Remote Patient Monitoring uses digital technology to collect patients' vital signs and answer a series of questions that are tailored to their medical diagnosis and care needs. This also allows patients to transmit their medical data to a secured medical platform for review and interpretation by a healthcare provider.
- Store and Forward allow the electronic transmission of medical information such as digital images, documents, and pre-recorded videos through secure email communication.
In order for healthcare organizations and private providers to successfully transition to video conferencing, regulations and policies needed to be revised to enable reimbursement for telehealth services. Prior to COVID19, no two states had the same policy and approach on reimbursement for telehealth delivery. These differences made it challenging for providers to provide care across state lines and non-rural areas. "The Center for Connected Health Policy's bi-annual analysis of state telehealth Medicaid policies found that although states occasionally use similar language in their policies, no two states are alike in how telehealth is actually defined and regulated".
Many companies have moved toward hiring telehealth nurses to meet their staffing needs - meaning the nurse can essentially work from anywhere. Given the virtual nature of telehealth, the nurse must have access to high-speed internet, specialized software programs accessing the employer’s network, and possibly telephone service. Time zone differences between the nurse’s current living country and the telehealth employer is a significant consideration as well.
Appropriate internet speeds can be a challenge living overseas. Many countries are still working with broadband or dial-up connections that can be too unreliable for telehealth work. Consistent access to internet can also be a challenge if power supplies are variable. According to statics published by Internet World Stats, only 54% of the world has access to online web systems.
Companies hiring nurses for at-home telehealth positions require the nurse to have an active and unrestricted license in the state where the company resides or affiliates. Many states participate in the Nurse Licensure Compact, which allows the nurse to provide care in all participating states without obtaining additional licensing.
While Telehealth nursing for American nurses living abroad is technologically possible, individual employers would consider such a hire on a case-by-case basis. Telehealth and at-home nursing services are a relatively new working environment for most companies with varying degrees of employee oversight and interaction requirements.
Telephone triage nurses have a challenging job. Nurses are trained to assess from the second they lay eyes on a patient. A significant part of a head to toe assessment is the initial presentation - what the patient looks like at first glance. Are they alert? What is their skin tone? Do they appear in distress?
Nurses, especially experienced ones, often operate off “gut feelings “ - the nagging feeling that something isn’t right. This presents a challenge when assessing over the phone. When a patient calls and speaks to a triage nurse, the nurse first asks what the main complaint is. From there, he or she asks questions about the complaint while listening to cues from the patient that may point to other health issues. For example, if a patient calls in with a complaint of fatigue, the nurse might pick up on shortness of breath or a cough which could be indicative of a breathing or cardiac issue. This assessment leads the nurse towards a more specific line of questioning.
Many organizations have triage protocols in place to ensure no significant assessment piece is missed. The protocols are developed and refined by clinical staff and are reviewed regularly to ensure they are appropriate and follow current evidence-based practices.
Telephone triage nurses, or telehealth nurses, are nurses who assist and advise patients over the phone. They are extremely helpful in reducing patient care loads for physicians while helping patients avoid potentially high co-pays for doctor or emergency room visits. More importantly, they can decide which service is appropriate for their needs.
While telephone triage nurses have access to electronic medical records, the difficulty lies in not being able to visualize the patient. Nurses are trained to assess patients from the moment they lay eyes on them. Much of a nurse's assessment comes from non-verbal cues. For example, a patient may say he is feeling tired lately, and light headed. A nurse can check for mottling or cyanosis, and deduce there may be a respiratory or cardiac issue going on. This can be challenging over the phone. A nurse may ask questions, but the patient may not know what to look for.
Many organizations develop protocols for telephone triage nurses to follow which will help collect pertinent data and determine the best service for them- such as home care advice, a doctor visit, or a trip to the emergency room.
While protocols are helpful, nothing beats a nurse's sharp assessment skills and clinical experience. Telephone triage nurses learn to hone listening skills and pick up on other cues and incorporate that into their assessment. For example, let's say a patient calls for the previously mentioned complaint of fatigue and lightheadedness. While asking pertinent questions, the nurse listens for shortness of breath, difficulty completing sentences, slurred speech and mental status changes. The patient may answer all the questions in which home care advice might be indicated, but a nurse's clinical judgment can override a protocol to recommend an ER visit.
Telephone triage can be challenging, but a strong nurse’s critical thinking and decision-making can overcome the challenges of not being able to lay eyes on a patient.
However, the Center for Medicare and Medicaid Services (CMS) has since broadened the regulations to permit telehealth reimbursements under the 1135 Waiver Authority and Coronavirus Preparedness and Response Supplemental Appropriation Act. "Under this new waiver, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient's places of residence starting March 6, 2020."
In the course of several weeks, COVID-19 arose and dramatically shifted the delivery of health care from traditional face-to-face encounters to virtual visits. Organizations and private practices are taking advantage of the change in federal policy and transitioning in-person medical appointments to virtual appointments.
Patients are now encouraged to call their providers before coming in for unscheduled appointments. Telehealth modalities are being leveraged to keep people with a positive COVID-19 result or suspected exposure at home under observation. These patients are being monitored and educated on how to self-quarantine and protect both themselves and others in their homes from the spread of the disease. Dr. Christopher Crow, President of Catalyst Health Network in Plano, Texas, told the Dallas Morning News, "We're seeing a 180-degree change in how primary care medicine has been practiced in just a week or two. We're doing 10,000 to 12,000 virtual visits a day on our network, and that number could double by next week"
The COVID-19 health pandemic has shined a light on the convenience of telehealth appointments in lieu of in-person visits. It would be detrimental to return to "business as usual" and the traditional care model once this resolves, limiting access to health care and discontinuing telehealth in the process.
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