Telehealth: Issues For Nursing
Introduction
The growing use of and interest in the use of telecommunications technologies in the delivery of health care services has led to far-ranging discussions on telehealth (or "telemedicine") and its potential role in the health care system. The American Nurses Association (ANA) is committed to the use of telemedicine/telehealth in a manner that enhances access to quality, affordable health care services.
As part of its participation in the national dialogue on telemedicine/telehealth, ANA on August 29, 1996, submitted preliminary comments to a Joint Working Group (JWG) convened by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services. ANA continues to develop a more detailed and comprehensive analysis of the broad range of issues relevant to the continued growth and development of telehealth. The following is adapted from ANA's initial comments to HRSA.
Because the use of telecommunications technologies in providing health care services is broader than the discipline or practice of medicine, ANA generally refers to "telemedicine" as "telehealth" -- a much more inclusive and accurate term, and preferable to one predicated on solely a medical model.
ANA offers the following background comments specific to licensure and regulatory issues which may be viewed as barriers to the effective use of telecommunications technology.
The application of telecommunications technology in health care is evidenced through a variety of telehealth practices including telemedicine, telenursing and teleradiology. The mechanisms of telecommunication used include telephones, computers, interactive video and teleconferencing. While the application of this new technology offers the possibility of significant benefits to the health of individuals, it is important to anticipate and prepare for the concerns and problems attendant to this technologic advancement.
ANA strongly believes that the strength and promise of telehealth lie in providing increased access to health care services by augmenting existing services, not in replacing them. Telehealth technologies should not be used to replace needed access to in-person health care services. The potential for abuse of these technologies by providing "cheaper" substitutes for in-person care needed in homes, communities, schools, nursing homes, hospitals and other settings requires the development and enforcement of standards that ensure these technologies will be used appropriately.
Regulatory Issues
Telecommunications has the potential to expand access to health care services across state borders and even internationally. This has major implications for a health care regulatory system that is state-based with its primary responsibility being the protection of the public. How can such a regulatory system effectively adapt to the increased utilization of telecommunications in health care while safeguarding the safety and welfare of the citizens it serves?
The advantages of a state-based licensure system are that it is administered at the state level and can be tailored to the needs, standards and expectations of the population the licensed provider services. In addition, given a discreet jurisdiction, disciplinary actions of providers can be closely monitored. For many professions, including nursing, one of the chief difficulties presented by this system is that each state has developed its own specific scope of practice and standards based on that locality resulting in a patchwork of scopes, standards and requirements from state to state.
There have been various proposals made to amend the current state-based system to adapt to the increasing demands of telehealth. Of these, California State Senate Bill 1665 has advanced the farthest. It addresses some of the issues related to telehealth -- for instance, by allowing for consultation services from an out-of-state practitioner -- but leaves open many other issues related to provision of care other than consultation, including primary health services.
The issue of cross-state practice becomes even more complex as they pertain to nursing. Because laws and regulations governing nursing practice differ from state to state, it is often not clear which laws apply to nurses providing telehealth services across state boundaries. Do the laws of one state requiring practice under a protocol or agreement with a physician, for instance, pertain if a nurse is providing consultation to a practitioner and patient in a state where no such requirements exists? This could limit the consumer's access to care as well as increase health care costs by requiring a consulting physician to be involved in the care.
The use of new technologies has also allowed the increased use of protocols for triage, consultation and advice by telephone or computer. The use of protocols, standardized guidelines or computerized algorithms cannot be allowed to substitute for the independent assessment and judgment of registered nurses, who extend the assessment process to obtain contextual and situational information and will determine whether a particular guideline fits a specific patient's condition and needs.
Privacy, Confidentiality, and Security
The increasing uses of telecommunications technology in the delivery of health care raises new questions about issues of privacy, confidentiality and security of health information. Nurses have a longstanding commitment to promoting and maintaining patient privacy and confidentiality. There is concern on behalf of the nursing community that existing laws, regulation, policies and protocols do not provide sufficient protection of health-related information. Adequate privacy and security protection measures for health information should be an integral part of the development of telecommunications technology in health care. The following are fundamental measures that need to accompany the initiation of this technology in patient care:
previously established confidentiality and privacy protections of health information must be maintained as well as scrutinized to establish if they are sufficient for this new technology
patients who are the recipients of telehealth interventions should be informed of the potential risks (e.g., limitations to securing transmissions over the airwaves or by direct line) and benefits
patient access to information generated through telehealth is guaranteed
dissemination of patient data or identifiable patient images (e.g., voice) will be controlled by the explicit consent of the patient
patients are informed if other individuals outside the health team (e.g., technical staff, observers) are involved
individuals who violate established privacy, confidentiality and security regulations and misuse information will be subject to enforceable penalties
Vital to the responsible use of emerging telecommunication technologies within health care is the development of policy, standards and regulations. The need for well-established safeguards and monitoring mechanisms cannot be overemphasized. Nurses, by virtue of their distinct relationships with patients and their role in the delivery of health care, can provide significant leadership and are essential participants in discussion and decision making around these issues.
10/9/96
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THIS INFORMATION COPYRIGHT 1997 AMERICAN NURSES ASSOCIATION