E – NURSING Nurses all around the world have risen to the challenge of new technology. Today, the nurses work in a variety of E-Health programs such as tele-triage. They access online libraries and databases of clinical practice guidelines from computers in their work places. Nurse in specialized areas of practice now interact with their peers in discussion groups over the internet. Nurses are also involved in standards development for the implementation of electronic health records and many nursing educational programs are now offered online.
GOAL OF E-NURSING To enhance nurses to benefit from all developments in information, communication and technology, to improve nursing and client outcomes.
TYPES OF E – NURSING Smarter Decision Making: ICT initiatives such as electronic health records, telehealth, databases, e-mail and internet resources enhance the decision-making process. They give nurses access to timely, evidence-based and expert information, enabling them to make swifter, better-informed judgments on behalf of their patients. The result is safer patient care and better health outcomes.
CONT…….. E – Nursing work outs: Nurses reap the full benefits of technology into their daily practice. Health care organizations are beginning to acknowledge the necessity of providing nurses with access to information, communication and technology that supports nursing care, yet the implementation of such tools needs to be accelerated.
PURPOSE OF E – NURSING To guide the development of ICT initiatives in nursing so that nursing practice and client outcomes are improved.
IMPORTANCE OF E – NURSING It has got the tremendous potential to improve the practice of nursing, if applied in appropriate and useful ways.
METHODS E-learning methods may include the following Computer-based training Web-based lectures and presentations Virtual classrooms in which learners are logged on to an online classroom environment at different times (asynchronous) or at the same time (synchronous) as the learning activities are happening.
E – NURSING STRATEGY FOR PROFESSION Nurses In Clinical Practice
Participate in ICT initiatives, identify needs and evaluate possible solutions.
Increase competence in use of ICT.
Access multiple source of information for evidence-based practice.
Employers and Administrators
Recognize ICT as a tool of professional nursing practice.
Support involvement of nurses in ICT initiatives.
Encourage adoption of ICT that supports nursing practice.
CONT…… Educators and Researchers
Incorporate ICT competencies into curriculum.
Develop research programs to optimize nurses’ use of ICT.
Provide leadership for nurses’ involvement in ICT.
Recognize ICT competencies as part of entry-level and continuing competence requirements.
BENEFICIARIES OF E – NURSING Individual nurses Their clients Employers Nursing professional Regulatory organization The profession as a whole both nationally and internationally.
ADVANTAGES OF E – NURSING Integration of information, communication and technology. Improved information and knowledge in the nursing practice. Human resource planning will be facilitated. New models of nursing practice and health services delivery will be supported. Nursing group will be well connected. Improves the quality of nursing work environments. Contribution to the global community of nursing.
DISADVANTAGES High expense Decreases manual contribution Increases dependence on ICT Misuse of the technology provided
DEFINITION According to World Health Organization, telemedicine is defined as, “The delivery of healthcare services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities”.
CONT……. Telemedicine is defined as any health care provided to patients via technology across a distance. (Remmes, Thomson and Williams; 1996).
TYPES OF TELEMEDICINE Telemedicine can be broken into three main categories Store- and- forward (asynchronous) Remote monitoring Interactive services (synchronous)
1. STORE- AND- FORWARD Involves acquiring medical data (medical images, biosignals) and then transmitting this data to the doctor or medical specialist at a convenient time for assessment offline. It does not require both the parties at the same time. Medical specialties like dermatology, pathology etc is conducive to this kind. Most beneficial for population living in isolated communities and remote regions.
2. REMOTE MONITORING Remote monitoring also known as self- monitoring/ testing. It enables medical professionals to monitor a patient remotely using various technological devices. It manages chronic diseases or specific conditions, such as heart disease, diabetes mellitus or asthma. It gives greater satisfaction to patients. It is cost-effective.
INTERACTIVE SERVICES Interactive telemedicine services provide real-time interactions between patient and provider. It includes phone conversations, online communication and home visits. Many activities such as history review, physical examination, psychiatric evaluations and ophthalmology assessments can be conducted comparably to those done in traditional face-to-face visits. In “clinician-interactive” telemedicine services may be less costly than in-person clinical visits.
USES OF TELEMEDICINE Telemedicine is most beneficial for populations living in isolated communities and remote regions and is currently being applied in virtually all medical domains. Specialties that use telemedicine often use a “tele” prefix; for example, telemedicine as applied by radiologists is called Teleradiology. Similarly telemedicine as applied by cardiologists is termed as telecardiology etc. Telemedicine is also useful as a communication tool between a general practitioner and a specialist available at a remote location.
CONT……. The first interactive telemedicine system, operating over standard telephone lines, for remotely diagnosing and treating patients requiring cardiac resuscitation (defibrillation) was developed and marketed by Med Phone Corporation in 1989 in the U.S served as receiving and treatment centers. Monitoring a patient at home using known devices like blood pressure monitors and transferring the information to a caregiver is a fast growing emerging service. These remote monitoring solutions have a focus on current high morbidity chronic diseases and are mainly deployed for the First World, Glucometer.
ADVANTAGES OF TELEMEDICINE For the patients
People at remote areas get top class medical facility from reputed hospitals.
Reduces travel cost and save time for the rural patients.
Reduces lot of inconvenience for the rural patients.
CONT…… For the hospitals
Hospitals can spread their reach in remote villages and serve people without much investment on the infrastructure.
The hospitals get revenue from the reference made from the remote locations.
After care or post operated care patients need not come to the main hospital for minor consultation.
Primary diagnosis can be done with the use of telemedicine and patient can come to the main hospital for major surgery.
Hospitals can have CME programmes with other hospitals and medical colleges.
Hospital can run training programme from their hospitals to doctors of other hospitals.
A rare operation or a diagnosis can be broadcast to other hospitals.
Doctors can learn new techniques by connecting to foreign hospitals. Overseas consultation and second opinion can be got.
Job interviews can be conducted.
Live images like ECG, USG, CT scan, Echo, X-rays and any video output from medical instruments can be transmitted.
Screen captures software- use of graphic image.
Clip art – commonly used in library as graphical image such as computer, flowers, building, a nurse etc.
Multimedia application- conferencing, video games.
Practicum – invitation preparation, collect data and display in graphic form.
APPLICATION Tele-health care: It is the use of information and communication technology for prevention, promotion and to provide health care facilities across distance. It can be divided in the following activities Teleconsultation Telefollow-up Tele-education: Tele-education should be understood as the development of the process of distance education (regulated or unregulated), based on the use of information and telecommunication technologies, that make interactive, flexible and accessible learning possible for any potential recipient.
CONT…… Disaster Management: Telemedicine can play an important role to provide health care facilities to the victims of natural disasters such as earthquake, tsunami, tornado, etc and man-made disaster such as war, riots etc. During disaster, most of the terrestrial communication links either do not work properly or get damaged so a mobile and portable telemedicine system with satellite connectivity and customized telemedicine software is ideal for disaster relief.
CONT…… Tele-home health care: Telemedicine technology can be applied to provide home health care to elderly or underserved, homebound patients with chronic illness. It allows home health care professionals to monitor patients from a central station rather than travelling to remote areas chronically ill or recuperating patients for routine check-ups. Remote patient monitoring is less expensive, more time savings, and efficient methodology. Tele-home care virtual visits might lead to improved home health care quality at reduced costs, greater patient satisfaction with care, increased access to health care providers and fewer patients needing transfer to higher, more costly levels of care. A Computer Telephone Integrated (CTI) system can monitor vital functions of patients twenty four hours a day and give immediate warnings.
BARRIERS Physician/ Patient Acceptance Physicians and patients have unique technological resources available to improve the patient-physician relationship. It has been found that patients have no difficulty in accepting telemedicine program. The survey conducted by SGPGIMStele-follow up program for the patients of Orissa state revealed that 99% patients were satisfied as they don’t have to travel 1500km to show their diagnostic reports to their doctors. In tele- consultation they were also happy that they get the specialist consultation and their cases have been seen by some expert doctors. Doctors in government sector tend to look upon telemedicine as an additional duty or workload. Therefore, there is need to weave telemedicine into the routine duties of the doctors. The private doctors sometime fear that telemedicine is likely to increase their practice further.
CONT……. Availability of Technology at a Reasonable Cost It is myth that to establish a telemedicine platform is an expensive. The basic system needs hardware, software and telecommunication link. In all areas there is a significant reduction in the prices. Most of these costs are well within the reach of most of the hospitals, and can be removed by nominal charge to the patients and students in case of tele-education which would be much less than the physically travelling.
CONT……. Accessibility Although information technology has reached in all corner of the country but the accessibility of people living in remote and rural area to the nearest health center (PHCs, CHC or district hospital) may not be easy due to poor infrastructure of road and transport. It may be possible that the available telemedicine system in the health centers may not function because of the interruption in power supply
CONT……. Reliability Some health care professionals has doubt about the quality of images transmitted for consultation and tele-diagnosis. In tele-radiology, telepathology, tele-dermatology the quality of image (colour, resolution, field of view etc) should be international standards to avoid any wrong interpretation and mis-diagniosis. The delay in transmission of data may be of critical importance in tele- mentoring and robotic surgery and have to be reduced to the minimum. Funding/Reimbursement Issues There should be a format to calculate the investment and recurring cost of the telemedicine system. The insurance companies have to decide whether the cost of tele-health care should be reimburse or not.
CONT…….. Lack of Trained Manpower Telemedicine is a new emerging field, there is lack of training facilities with regards to application of IT in the field of medicine. Most of the health care and IT professionals are net familiar with the terms commonly used in telemedicine such as HIS, EMR, PACS, etc. telemedicine is also not the part of course curriculum of medical schools. Legal & Ethical Telemedicine technology has been proved and established and its advantages and benefits are well known but still many health care professionals are reluctant to engage in such practices due to unresolved legal and ethical concerns. In case of a cross-border tele-consultation which country’s litigation laws will be applied in case those of the country in which the patient is living or those of the remote physician.
CONT……. Privacy and security concerns There are many issues that should be considered regarding the security, privacy and confidentiality of patient data, in telemedicine consultations. How are patient’s rights of confidentiality of their personal data ensured and protected? How to ensure security of the data and restrict its availability to only those for whom it is intended and who are authorized and entitled to view it? How to prevent misuse and even abuse of electronic records in the form of unauthorized interception and /or disclosure?
DEFINITION Tele nursing refers to the use of telecommunications and information technology for providing nursing services in health care whenever a large physical distance exists between patient and nurse, or between any numbers of nurses.
APPLICATIONS Tele nursing applications is home care. For example, patients who are immobilized, or live in remote or difficult to reach places, citizens who have chronic ailments, such as chronic obstructive pulmonary disease, diabetes, congestive heart disease, or disabilitating diseases , such as neural degenerative diseases (Parkinson’s disease, Alzheimer’s disease, ALS) etc, may stay at home and be “visited” and assisted regularly by a nurse via videoconferencing, internet, videophone etc. Still other applications of home care of patients in immediate post-surgical situations, the care of wounds, ostomies, handicapped individuals etc. In normal home health care, one nurse is able to visit up to 5-7 patients per day. Using tele nursing, one nurse can visit 12-16 patients in the same amount of time.
CONT…… A common application of tele nursing is also used by call centers operated by managed care organizations, which are staffed by registered nurses who act as case managers or perform patient triage, information and counseling as a means of regulating patient access and flow and decrease the use of emergency rooms. Tele nursing can also involve other activities such as patient education, nursing tele consultations, examination of results of medical tests and exams, and assistance to physicians in the implementation of medical treatment protocols.
LEGAL, ETHICAL AND REGULATORY ISSUES Tele nursing is fraught with legal, ethical and regulatory issues, as it happens with tele health as a whole. In many countries, interstate and intercountry practice of tele nursing is forbidden (the attending nurse must have a license both in her state/ country of residence and in the state/ country where the patient receiving telecare is located). Legal issues such as accountability and malpractice etc. are also still largely unsolved and difficult to address. In addition, there are many considerations related to patient confidentiality and safety of clinical data.
GUIDELINES FOR TELE-NURSING (GIVEN BY AUSTRALIAN NURSING AND MIDWIFERY COUNCIL) Nurses and midwives practicing in tele nursing shall be registered nurses or midwives. Enrolled nurses involved in tele nursing need to be under the supervision of a registered nurse or midwife. Nurses and midwives practicing tele nursing are personally responsible for ensuring that their nursing and/or midwifery skills and expertise remain current for their practice. Nurses and midwives who are practicing tele nursing in Australia are expected to practice within the framework of the ANMC National Competency Standards for Registered Nurses, National Competency Standards for the Midwife, the ANMC Code of Professional Conduct for Nurses in Australia and other relevant professional standards.
CONT……. The legal issues involved in tele nursing across jurisdictions are still untested and therefore unsettled. In the absence of a settled position, it is the ANMC’s view that nurses and midwives are required to be registered in the jurisdiction where they are located when providing the tele nursing advice, and also in each jurisdiction where their tele nursing advice may be received and acted upon. Nurses and midwives should discuss the need for multiple registration status with their employer and the relevant NMRA, and the need for professional indemnity in all jurisdictions with their employer. Nurses and midwives have a duty to inform consumers of their name, qualification and registration status. Consumers may wish to confirm registration status with the relevant nursing and midwifery regulatory authority.
CONT……. Nurses and midwives should inform consumers of tele health process including other person/professionals who may be participating or present in the tele health consultation and obtain consent before proceeding. Nurses and midwives in tele nursing have a duty to provide privacy and confidentiality in all interactions. Nurses and midwives must comply with government and institutional policies relating to privacy, confidentiality, informed consent, information security and documentation during the provision of tele nursing care. Nurses and midwives are required to documentation during the provision of tele nursing care. Nurses and midwives are required to document all interactions during the tele nursing consultation.
CONT…….. Nurses and midwives practicing in tele nursing should be aware of both the evidence base for the practice and the areas of practice in need of research. Nurses and midwives practicing tele nursing should engage in evaluation of their practice in relation issues of quality, safety and patient outcomes. Enquiries regarding a nurse or midwife’s registration status or complaints about practice can be made to the relevant nursing and midwifery regulatory authority with which the nurse or midwife registered to practice.