Background

Tele is a prefix meaning “at a distance,” and it is used in terms such as telescope, or telemetry. The prefix tele, when combined with the term scope, has the single clear following meaning: an instrument to view phenomena at a distance.¹ However, in health care, as in other arenas, the prefix tele often takes on several meanings. For example, the term telemetry is described as a process,² data,³ and an electronic device⁴ related to the task of remote measuring and reporting of information of interest. There is inconsistent and emerging nomenclature related to tele in health care.

The inconsistent use of language associated with the delivery and management of health care at a distance has made it even more difficult to distinguish the ontology of terms and describe their related safety and quality issues. Specifically, previous literature has used the terms telehealth, telemedicine, and telenursing somewhat interchangeably, and the few articles reporting safety concerns were difficult to cluster for further analysis.

Telenursing is the use of “technology to deliver nursing care and conduct nursing practice”⁵ (p.558). Although the use of technology changes the delivery medium of nursing care and may necessitate competencies related to its use to deliver nursing care, the nursing process and scope of practice does not differ with telenursing. Nurses engaged in telenursing practice continue to assess, plan, intervene, and evaluate the outcomes of nursing care, but they do so using technologies such as the Internet, computers, telephones, digital assessment tools, and telemonitoring equipment. Bearing in mind that health services now provided via teletechnologies have expanded, the term telehealth is used to capture the breadth of services. For the purposes of this review, the Health Resources and Services Administration defines telehealth as “the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration.”⁶ Telemedicine, the original term, is defined as the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, visual, and data communications.⁷ The American Nurses Association has defined telenursing as a subset of telehealth in which the focus is on the specific profession’s practice (i.e., nursing).⁸

The delivery of telehealth care is not limited to physicians and nurses; it includes other health disciplines such as radiology, pharmacy, and psychology. These disciplines also deliver care using electronic information and telecommunications technologies and are accordingly called teleradiology, telepharmacy, telepsychology, and so forth. Although they are not the focus of this review, these disciplines are selectively included here for two reasons: (1) the safety issues associated with care delivered using electronic and telecommunications technologies are more similar than they are different among the various health disciplines, and (2) the dearth of research on safety and quality in the telenursing literature led the authors to include important research in other health disciplines. By including the research findings on safety and quality from varied health disciplines, the body of telenursing knowledge is expected to expand.

Research Evidence

Although the summary for the AHRQ evidence report, Telemedicine for the Medicare Population,⁹ specifically mentions safety related to telemedicine and how evidence could be presented and researched, it is ironic to note that in all the evidence tables of all the AHRQ reports there are no studies that mention safety or specifically research patient safety in telehealth. Indirect evidence such as monitoring, prevention of acute care events or complications, testing the technology for comparison with in-person care, and outcomes research all allude to safety but do not address it specifically. It is clear that there is a gap in the literature and research evidence for telehealth specifically related to safety. However, telenurses and other health care professionals are continually struggling to increase the safety of their patients, increase the quality of health care, and decrease adverse events, although the evidence of the impact of these concepts is not apparent in the research.

The four themes that emerged upon review of the literature offer insight into the field of telehealth and the practice of telenursing. Although not noted or researched specifically, patient safety is an important part of the diagnosis, monitoring, outcomes, and technical tools used in telehealth practice.

Diagnosis and Teleconsultation

A great deal of research has been done on the use of telehealth for diagnosing disease. It has been shown that diagnosis of disease using telehealth is successful (Evidence Table 1). For example, Schwabb and colleagues¹⁰ found that the remote interpretation and diagnosis with electrocardiogram results was just as good as interpretation in person. Additionally, telehealth has successfully been used as a tool for diagnosing acute leukemia.¹¹

Evidence Table 1

Diagnosis and Consultations Using Telehealth

In addition to diagnosis, educational sessions for providers, as well as patient education and psychosocial counseling, have been researched. Telehealth has been shown to be a successful endeavor for education and counseling through two-way audio and video technology.^12–14 Providers of care also have seen great benefits from consultations through telehealth equipment. Similar to education and counseling, two-way audio and video technology has been researched and shown to be beneficial for consults between providers.¹⁵ For instance, home health nurses may use telehealth equipment to consult with specialists, or physicians may consult with each other regarding a particular patient.

Monitoring and Surveillance

Compliance and adherence problems are among the many issues that are important to achieving patient safety. After a patient leaves a provider’s office or a hospital, the patient is responsible for his or her own health care at home. Patients often do not follow a treatment plan as directed by a physician or provider due to several factors, including: miscommunication or faulty understanding of the treatment plan, lack of access to facilities needed for the treatment plan, and a complex treatment regimen that the patient cannot comprehend without additional guidance.¹⁶ This can cause negative outcomes and creates safety issues for the patient. Therefore, inventive and efficient telehealth-based methods of caring for patients are increasingly being used to improve compliance or adherence to the prescribed regimen of care, as well as for symptom management. Telehealth is one strategy for monitoring and communicating with patients beyond the acute care setting. It has also had an impact upon health care utilization rates for acute care services (such as decreasing visits to the Emergency Department) in studies with limited sample sizes, although large randomized trials have not yet been reported (Evidence Table 2).

Evidence Table 2

Monitoring and Surveillance Related to Telehealth and Telenursing Practice

Adding to the problem of adherence in patients is a lack of access to quality health care, specialists, or nurses. With the current trend in outpatient care management, monitoring, and surveillance of patients, additional nurses are needed for the increasing number of home care patients and the increasing acuity of illnesses in these patients.¹⁷ Further, patients who live in rural areas or in medically underserved areas may not be receiving the expert care that is needed.^{18, 19} Traveling far distances to a treatment facility, time lost from work for treatment, and other responsibilities also contribute to the compliance issue.

To meet the patients’ needs, and with the additional burden on nursing because of the current nursing shortage, many home care agencies are looking for innovative ways to care for a large number of patients. Telehealth technology offers increased productivity for nurses by decreasing travel time to remote areas, thereby increasing the average daily census.²⁰ Especially in rural areas, where driving time to patients’ homes can take up the majority of a nurse’s day, new time-saving and patient safety initiatives are imperative, leading to further adoption of telehealth in home care. Audio and video technology can facilitate remote home health monitoring between patients and caregivers.^{17, 20} Often, peripheral devices placed in patients’ homes—such as thermometers, sphygmomanometers, and stethoscopes—are connected to the telehealth equipment so telenurses can monitor clinical signs remotely. Nurses are able to spend more time on direct patient care rather than indirect care, resulting in better use of their time and education. Hence, telehealth and telenursing address barriers to quality health care that are created by geographic location and costs associated with lost time.

Clinical and Health Services Outcomes

The majority of research completed on outcomes after implementing telehealth has been related to chronic conditions such as diabetes, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). Often, morbidity and mortality are measured outcomes for these patients, and telehealth use shows better outcomes in these areas (Evidence Table 3).

Evidence Table 3

Outcomes Related to Telehealth and Telenursing Practice

More specifically, telehealth technology has been shown to be a successful method of telehealth intervention, inducing communication that has helped patients’ HbA1c levels to decrease, as well as offering assistance to traumatic brain injury patients in transitioning from the hospital to the community.^{16, 21}

In addition to the more widely used telehealth technologies, there are a number of devices and applications with specific functionalities that are making a difference in patient health care and safety as related to health outcomes. Glucoboy and Digiscope are two examples of these new technologies. The former is a diabetic tool in a video game cartridge format. The cartridge is inserted into Nintendo’s Game Boy and has been shown to help children with the management of type 1 diabetes mellitus.²² The Digiscope is a telehealth technology that allows for screening of diabetic retinopathy in a primary care physician’s office rather than under the specialized care of an ophthalmologist.²³ These telehealth technologies have been shown to be practical alternatives to traditional care.

Technical Issues

Telehealth technology differs in every situation and can range from telephone calls postoperatively to preventing diabetic complications in children by using a popular video game system, to live, interactive voice and video patient education, to downloadable data devices used by patients with data interpreted by telenurses. Studies report various technology approaches used by various types of providers in different settings with diverse disease entities (Evidence Table 4).

Evidence Table 4

Technical and Ethical Issues Related to Telehealth/Telenursing

For instance, telephone technology has traditionally been used as a telehealth mechanism. While using a technology that is already in place in many patients’ homes, this technology can be used to deliver important aspects of health care, including education,²¹ psychosocial therapy,¹⁶ and emotional support.

One of the most common technology configurations for telehealth applications uses two-way audio and video, or teleconferencing equipment. This technology allows patients and caregivers to communicate effectively, while allowing caregivers the benefit of seeing the patient. Other technologies can be incorporated into the main audio and video equipment to transmit specific health care data such as blood pressure and heart rate. These technologies makes telenursing possible because data to support patient safety in home care can be retrieved from home telehealth devices if proper terminology and data standards are employed.²⁴

One innovative technology that has recently begun to be studied would allow patients to be monitored remotely with even less of a time burden placed on the nurse and the patient. Infrared technology offers perhaps the most continuous method of telehealth monitoring equipment. Infrared scanners have been shown to be effective in reporting deviations from a daily routine.²⁵ With this technology, the monitoring of elderly or dependent patients is done from a remote location; patients can be monitored at home, in a nursing home, or in the hospital. Safety of the patient can be assessed without the patient purposely getting in front of a camera or logging on to speak to a nurse.

Evidence-Based Practice Implications

The research related to telehealth and telenursing practice has shown great benefits related to diagnosis and consultations, monitoring and surveillance of patients, clinical and health services outcomes, and technology advancement. Each of these areas have important patient safety concerns, and while not studied as a unique entity, patient safety themes have emerged throughout the literature. Telehealth is a unique field that uses innovative technologies to improve patient care and thereby improve safety. These technologies range from the telephone to ubiquitous computing and only promise more in the future. Special concerns related to patient safety emerge with each of these methods of health care delivery.

Technologies have evolved to offer more and broader capability for telehealth/telenursing practice. With telehealth technologies, patient adherence to care increases, access to care is improved, providers can network with each other, and the safety of patients can be monitored more closely in homes and alternative living facilities.

With telephone-based telehealth, there is relatively no cost to the patient and no technical setup required for a telehealth interaction. Most patients already have a phone in the home that can be used for sessions. However, telephone discussions are usually limited to education and counseling because there are no visual cues for the provider/telenurse.

Two-way audio and video increases the functionality of telehealth by allowing the telenurse/health care provider to see the patient. In addition, peripheral monitoring devices can be used by the patient to transmit clinical information to the remote provider. More patient education is required initially for the use of the equipment with this type of technology, and the initial investment costs for the telehealth equipment can be large. Further, the patient must have Internet access or transmission lines to accommodate the video equipment.

Products such as the Glucoboy are innovative technologies that have been researched and shown to be effective in helping diabetic children maintain a healthy lifestyle.²² The new product has taken a monotonous, sometimes painful task and made it into a game for children. However, the cost of this technology and who bears the cost remain to be seen.

Finally, infrared technology and sensor technology promise to deliver remote monitoring capabilities into the hands of providers. This has implications for caregivers and even family members of a person who lives at a distance. Falls, injuries, or illness will be easy to detect using such a system, offering immediate care to patients. However, the continuous monitoring nature of these devices may prove to be an infringement of patients’ rights to privacy, and therefore an ethical issue for health care providers to consider.

With telehealth, confidentiality also remains a concern and must always be considered. While technology is becoming more sophisticated, telehealth sessions remain as a confidential interaction between a provider and a patient. Enclosed rooms without traffic or others present are imperative to maintain privacy. Health care providers need to be conscious of who is in attendance for the session and respect privacy and confidentiality of the patient. Further, as the numbers of new and innovative technologies emerge, researchers and developers must remember the security of patient information, regardless of how it is transmitted. In the researched technologies, data are transmitted over secure lines. However, new wireless technologies, increased use of e-mail by providers, and the continual threat of computer viruses increase the need for security and confidentiality of patient data to remain in the forefront of telehealth.

The different platforms for telehealth are diverse, yet all increase the ability of telenurses to communicate with and receive data about their patients. Regardless of the specific telehealth technology utilized, the reliability and validity of data transmission is essential to the safety of patients. Further, accepted and proven nursing practice must not be compromised. It is imperative for nurses to see the telehealth technology as a medium for care, and not a tool to replace high-quality nursing practice. Patient safety will be maintained with telenurses who are able to focus on patient care and not the technology itself.

Research Implications

The possibilities for telehealth technology abound, although pitfalls are also a potential. Telehealth has evolved throughout the years, from the first telephone interventions to the present-day use of sensors and remote monitoring devices. Much research has been completed on telehealth technology; however, it can be expanded upon exponentially—and should be expanded to include safety as a variable in all studies.

New wireless technologies have introduced new options for telehealth, which include nanotechnology and artificial intelligence.²⁶ Both of these offer great possibilities for diagnosis and treatment. However, researchers have only begun studying the potential of these technologies that offer promises for future health care.

In the shorter term, increasingly sensitive and accurate peripheral devices are needed for clinical monitoring. While the technologies currently exist, many can be improved upon to ensure valid clinical results. Peripheral device use can also be expanded. Ubiquitous computing is an option that will allow for clinical monitoring at home or in the community without being intrusive to the patient.²⁶ There is a greater chance of adherence in patients with this type of technology; however, research will need to be conducted to confirm the expectations.

Telehealth technologies will continue to evolve, as technology has in other business sectors. Health care needs to commit to this progress in order to provide up-to-date technology and safe devices for patients. The majority of studies that were reviewed compared telehealth care vs. in-person care and involved patient monitoring. Overall there were some positive outcomes indicating the benefits of telehealth. However, patient safety issues were not the main focus of these studies. Only one article was found that directly focused on safety issues: That article provided important information on the safety of wireless technologies; however, it was not a research article. Further, in a recent conference funded by the Agency for Healthcare Research and Quality, telehealth nursing experts were brought together to create a national agenda for telenursing research.²⁷ Themes for future research included cost effectiveness, clearly identified populations, standard outcomes, and standard methodologies to support telenursing. Specific research agenda topics identified were chronic disease management, patient empowerment, and enhanced self-care. While patient safety is a faction of all of these topics, it was not included specifically as a research agenda topic for telenursing. Therefore, the review of the current literature as well as decisions for future research goals indicate a gap of information and future direction regarding patient safety issues related to the use of telehealth in clinical practice.

Conclusion

The scarcity of research evidence focused primarily on patient safety in telehealth may in part be due to a lack of understanding about the emerging safety issues associated with telehealth and telenursing. The safety issues identified for telehealth and telenursing extend beyond the limited view of the precision of the information.²⁸ Telehealth encompasses a wide range of applications, including teleconsultations, telediagnosis, telepharmacy, e-health via the Web, telephone triage/telephone advice, tele-emergency support, disease management, and telehomecare. The safety issues associated with telehealth are, in turn, more complex and include not only apprehension about malfunctioning equipment, but also concerns regarding potential adverse effects on patient management decisions through delayed or missing information, misunderstood advice, or inaccurate findings due to patient or caregiver error.²⁹ Further research is clearly needed in the arena of patient safety as it is directly related to telehealth practice.

Search Strategy

The majority of research studies to date have focused upon teleradiology, telepathology, telepsychiatry, and other medical uses of telemedicine technology for medical care and diagnosis. These studies were purposely not included in this review. The purpose of this literature review was to focus upon the safety issues associated with care delivered by and relating to telenursing. The search strategy and distillation process of the literature consisted of three primary activities: (1) identification of meaningful MeSH^® search terms and searching in PubMed^®, (2) an alternative process for locating articles, and (3) identification and validation of safety and quality related themes.

Identification and Validation of Safety/Quality Themes

One author conducted the search and located all of the articles included in this review. A total of 41 articles were found to have some relevance to telehealth and safety. After an initial appraisal of the articles, they were examined for semantic similarities and differences. Four themes emerged among the 41 articles: (1) diagnosis and teleconsultations, (2) monitoring and surveillance, (3) clinical and health services outcomes, and (4) technical/ethical issues. The articles were then distributed among the authors, and the themes were validated. Where appropriate, articles were redistributed from their initial category to a more appropriate category. The included safety and quality topics are described in Table 1, below.

Table 1

Safety and Quality Topics as Related to Telehealth

It became clear to the authors that issues such as measuring return on investment are often tied to clinical outcomes; thus these studies were included in the review. Additionally, articles that addressed disparities to access in health care and the potential benefits of telehealth are included, as these articles address the prevention of safety problems.

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