The Telenursing Revolution


The Telenursing Revolution

Using technology to reach patients down the hall or around the globe

By Sue Montgomery, RN, BSN, CHPN
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Now that you’ve spent years honing your bedside manner, it’s time to work on a new relational skill: your webside manner. With the rapid growth of digital health technologies for both providers and patients, care beyond the brick-and-mortar hospital setting is exploding. Soon, you may not just be seeing patients down the hall, but also across the globe.

That’s especially true if you work in facilities like Los Angeles’ Good Samaritan Hospital, which recently received a grant from the U.S. Department of Agriculture Rural Development to provide telehealth services to half a dozen remote areas in the U.S. territory of Guam.

What Is Telehealth?

“Telehealth” is a broad term that encompasses the many ways that patient care can be provided remotely through the use of communication technologies. The term “telemedicine” is typically used to describe the involvement of physicians within this paradigm, but telehealth can also include a variety of healthcare disciplines and specialty areas such as telenursing, telemental health, teledermatology and even teleICU.

In California, the term telehealth now has a legal definition thanks to A.B. 415, the Telehealth Advancement Act of 2011. That law removed some older restrictions on telemedicine and opened the door to significant expansions of telehealth practice in our state.

The Perfect Storm

A number of factors are creating a “perfect storm” for the emergence of this valuable digital health modality, which some see as the key to the future of optimized healthcare. On one hand, we have aging populations, increased demand for services and a marked increase in the incidence of chronic diseases; on the other, high healthcare costs and a shortage of healthcare professionals.

In the U.S., the Affordable Care Act is also changing the nature of healthcare, shifting the reimbursement structure from the traditional fee-for-service model to a pay-for-performance framework. Readmission penalties have hospitals scrambling to find new ways to enhance post-discharge care and detect problems early, before a patient lands in the ER.

Into that mix we add the growth of the Internet; improved communication technologies; increased access to affordable, high-quality devices; and a growing recognition of the quality of care that telehealth can provide. Those factors are making telehealth an increasingly viable way to feed our healthcare hunger.

Breaking Through

Traditionally, there have been several major barriers to wider adoption of telehealth services, including reimbursement restrictions, state licensure requirements, and resistance from healthcare professionals. However, in the past year, a number of new initiatives around the country have achieved real progress.

In June 2014, the American Medical Association adopted a telemedicine policy acknowledging the role of telemedicine in improving access to quality care. Within a few months, the American Association of Family Practitioners, the Federation of State Medical Boards and even federal agencies like the FCC and FTC all adopted positions in support of telehealth use.

All of this has been great news to the American Telemedicine Association (ATA), which has been working quietly for years creating a foundation and framework to help move the industry forward. In fact, the ATA has already created 14 sets of telemedicine clinical guidelines with seven more in development. The ATA also has a large selection of research and case studies.

Critical Care by Remote?

As nurses, we have a leg up on the rest of the healthcare world: We’ve been providing telenursing services in various forms for decades. However, the advent of new technologies is creating seemingly endless possibilities, whether you’re directly providing care or assisting others with the process.

I spent the first 12 years of my career in critical care units, so when I first heard the term “teleICU,” I just shook my head in dismay. How could quality care for the sickest of the sick possibly be provided from a distance?

Today, the American Association of Critical Care Nurses recognizes teleICU nursing as a distinct specialty with guidelines for practice and even a certification exam for a new CCRN-E credential. A recent article in The American Nurse describes the work that’s being done in this specialty and the way skilled teleICU nurses provide another set of eyes and ears for their overworked colleagues on the front lines.

Theresa Davis, RN, Ph.D., NE-BC, clinical operations director of Inova Health System’s enVision eICU, describes teleICU practice like this:
◗  Each teleICU nurse typically works a 12-hour shift, during which he or she monitors three to four dozen patients.
◗  Nurses and teleICU physicians use sophisticated cameras and remote sensors to assess physical indicators, allowing clinicians to carry out virtual rounds and alert bedside staff as needed.
◗  TeleICU nurses use evidence-based practice principles to assess for complications such as sepsis or stress ulcers and apply early preventive measures.

“What I love about this technology is that it provides a team of highly experienced healthcare professionals who’ve got the backs of their colleagues at the bedside,” says Connie Barden, RN, MSN, CCRN-E, CCNS, co-chair of the American Association of Critical-Care Nurses Tele-ICU Nursing Guidelines Task Force.         

“TeleICU nurses and intensivists are not running around from one patient to the next, but have the time to observe what’s going on with several patients from that 30,000-foot view,” Barden says.

TeleICU in California

With a wide expanse of rural areas, many of them medically underserved, California is a fertile field for teleICU development.

Back in 2010–11, the Network for Excellence in Health Innovation, in collaboration with the Center for Connected Health Policy, conducted an initiative called “Planning for Tele-ICUs in California.” The project identified various serious obstacles, including limited startup capital, system compatibility issues and regulatory obstacles. Some of the latter have since been removed by A.B. 415 and the initiative concluded that the other challenges will be overcome as the advantages of telehealth become clear.

TeleICU has actually been practiced in Northern California health systems for a number of years. An October 2014 article in California Healthline reported that Sacramento-based Sutter Health has been using teleICU services since 2004, supporting about 150,000 patients in 18 hospitals. Another Northern California health system, John Muir Health, launched a teleICU program in its two acute care hospitals in 2007.

Both health systems report that the adoption of telehealth programs has significantly reduced ICU mortality and the average length of ICU stays. John Muir Health says its overall ICU mortality rates fell 45 percent in only 18 months while Sutter reports that its sepsis mortality rate has fallen 32 percent in the last six years.

ICU nursing is only one of the nursing specialties that will increasingly be impacted by the tide of telehealth. Over the coming decade, I anticipate that a growing field of new nursing disciplines will be attaching “tele-“ to their offerings, reaching beyond the clinical setting to help the patients who need them most. 



California Telehealth Resources
•    California Telehealth Network (
•    California Telehealth Resource Center (
•    Southern California Telemedicine Learning Center (
•    Center for Connected Health Policy: The National Telehealth Policy Resource Center (
•    American Telemedicine Association (

California Telehealth Facts
•    Although it has since been superceded by the 2011 Telehealth Advancement Act, the Telemedicine Development Act of 1996 was one of the first and most comprehensive telemedicine laws in the country and has been used as a model for other states’ telemedicine laws.
•    California was among the first states to adopt telemedicine reimbursement policies in its Medicaid program, Medi-Cal.
•    The Telehealth Advancement Act of 2011 updated the legal definitions of telehealth, streamlined medical approval processes for telehealth-delivered services and broadened the types of allowable telehealth-delivered services.
•    In September 2014, Gov. Jerry Brown signed A.B. 809, a bill intended to make it easier for rural patients to utilize telehealth technology, and A.B. 1174, which expanded Medi-Cal coverage to include teledentistry services beginning Jan. 1, 2015. The latter bill makes California one of the first states to cover teledentistry.

Practice Guidelines Available from the American Telemedicine Association
•    Practice Guidelines for Live, On Demand Primary and Urgent Care
•    Clinical Guidelines for Telepathology
•    Guidelines for TeleICU Operations
•    Core Operational Guidelines for Telehealth Services Involving Provider-Patient Interactions
•    A Lexicon of Assessment and Outcome Measures for Telemental Health
•    Practice Guidelines for Video-Based Online Mental Health Services
•    Quick Guide to Store-Forward and Live-Interactive Teledermatology for Referring Providers
•    Expert Consensus Recommendations for Videoconferencing-Based Telepresenting
•    Telehealth Practice Recommendations for Diabetic Retinopathy
•    A Blueprint for Telerehabilitation Guidelines
•    Practice Guidelines for Videoconferencing-Based Telemental Health
•    Evidence-Based Practice for Telemental Health
•    Practice Guidelines for Teledermatology
•    Home Telehealth Clinical Guidelines   

Sue Montgomery is a healthcare writer and editor. She’s been a nurse for over 30 years, formerly in critical care and hospice, and writes about end-of-life care, digital health and the bioethics of both. She's the senior content editor for nuviun digital health.

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