Here are two potential ethical issues that could arise with telehealth delivered nursing care: 1. Privacy and confidentiality. When providing care via telehealth technologies like video conferencing, there is a risk of private health information being inadvertently disclosed if the virtual session is not properly secured. Nurses must take steps to ensure telehealth encounters occur in a private setting where the patient cannot be overheard or the screen viewed by unauthorized individuals. Appropriate security measures and informed consent about potential privacy risks are important. 2. Informed consent. It can be more difficult to fully explain to patients the nature and limitations of telehealth care compared to traditional in-person visits. Patients may not understand the technologies being used or realize certain physical exams cannot

1. Chapter 8
Telehealth and Applications for Delivering Care at a Distance
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All
rights reserved.
Introduction
Telehealth: Use of electronic information and
telecommunications technologies to support long-distance
clinical healthcare, health-related education, public health, and
health administration
Telemedicine: Use of medical information exchanged from one
site to another via electronic communications for the purpose of
improving patient care, treatment, and services
Telenursing: Use of telehealth technology to deliver nursing
care and conduct nursing practice
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All
rights reserved.
2
Terms are often interchanged in discussion and in the literature,
along with ehealth, mhealth.
All healthcare providers can export their clinical expertise using
telehealth, not only physicians.
Although telehealth has been documented since 1897, it is still
perceived as new in many instances.
2

2. Introduction (Cont.)
Successful Telehealth Programs
Rochester General Health Telehealth Program (Rochester, New
York)
Seacoast Missions Telehealth Program
(Bar Harbor, Maine)
University of Miami, Miami Miller School of Medicine (Miami,
Florida)
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All
rights reserved.
3
Introduction (Cont.)
Telehealth Historic Milestones
1897: First report was documented.
1964: Modern telehealth programs began.
1960s: National Aeronautics and Space Administration (NASA)
led telehealth initiatives.
July 2003 to December 2007: Veteran’s Administration (VA)
conducted a home telecare program analysis.
2008: Whole System Demonstrator (WSD) Programme was
launched.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All
rights reserved.
4
Introduction (Cont.)
Leading Telehealth Organizations

3. American Nurses Association (ANA)
United States federal government agencies
American Telemedicine Association (ATA)
International Council of Nurses (ICN)
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All
rights reserved.
5
Telehealth Technologies
Telehealth technologies enable the exchange of all types of data
(e.g., voice, video, wound, pathologic or radiologic images,
device readings) between patients and providers or between
providers on behalf of patients.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All
rights reserved.
6
How Telehealth Changes Healthcare Delivery
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All
rights reserved.
7
Figure 8-1 from text
7
Telehealth Technologies (Cont.)
Synchronous: Real-time or live
Example: Videoconferencing; Internet chat

4. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All
rights reserved.
8
There are two overarching types of telehealth technologies:
synchronous (live/realtime) and asynchronous (store and
forward).
An example of synchronous is live, interactive
videoconferencing between patient and provider.
8
Personal Health Eco-System
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All
rights reserved.
9
Figure 8-2 from text.
9
Telehealth Technologies (Cont.)
Asynchronous: Store and forward
Example: E-mail teledermatology consultation
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All
rights reserved.
10
An example of asynchronous is sending an email package
comprised of patient history, pictures of rash, complaints,
pertinent related diagnoses to request a dermatology
consultation when the dermatologist is available to respond.

5. 10
Telehealth Technologies (Cont.)
Telecommunications:
Wired, such as plain old telephone service (POTS), direct
service line (DSL)
Wireless, such as cellular or sometimes seen as Code Divisions
Multiple Access (CDMA), broadband, satellite, Bluetooth,
infrared (IrDA), WiFi (otherwise known as the Institute of
Electrical and Electronics Engineer (IEEE) Standard 802.11),
mobile broadband wireless access
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All
rights reserved.
11
There are two types of telecommunications technologies for
telehealth: wired or wireless. Future trends are toward wireless.
11
Telehealth Clinical Practice Considerations
Telehealth clinical competencies: United States, Canadian, and
international competencies for telehealth are developed.
Confidentiality, privacy, and informed patients: Are the same as
in-person care; telehealth requires additional attention to
privacy if cameras cannot show who is in the room with the
patient.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All
rights reserved.
12
Clinical Competencies: American Nurses Association and 41

6. major health care provider organizations developed and
endorsed Core Principles for Telehealth delivery. Specific to
telenursing, the International Council of Nurses published
research-based/validated International Competencies for
Telenursing. In the US, the American Nurses Association
published Competencies for Telehealth Technologies in
Nursing. In Canada, the NIFTE Framework has interdisciplinary
telehealth policy, procedures, guidelines and/or standards.
Confidentiality, Privacy and Informed Patients: same as in-
person plus telehealth requires additional attention to privacy if
cameras cannot show who is in the room with the patient.
12
Telehealth Clinical Practice Considerations (Cont.)
Telehealth scope of clinical practice: Is the same as with in-
person care.
Clinical telehealth procedures: Need defined protocols for
telehealth care, with evaluation and quality measures for
iterative improvement.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All
rights reserved.
13
Telehealth Scope of Clinical Practice: same as with in-person
care.
Clinical Telehealth Procedures: need defined protocols for
telehealth care, with evaluation and quality measures for
iterative improvement.
13
Telehealth Operational Success Factors and Barriers
Training key to provider telehealth acceptance and use:
Telehealth technology training
Technology and computer literacy training

7. Workflow changes with telehealth; preparation of providers
Key success factors
Barriers to telehealth success
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All
rights reserved.
14
Technology trends have moved toward online courses or
certificate education programs for telehealth. Two types of
training are required for telehealth success: telehealth-specific
instruction using live scenarios if possible and technology
literacy training (if needed).
Clinical workflow is modified when implementing telehealth
technologies. Health care providers can adjust by mapping out
the new workflow and by continuing to use the same patient
exam rooms for the telehealth patient, using similar medical
devices for telehealth exams, learning how to use the
communication and telehealth technologies, and interacting with
the same physicians and specialists for telehealth consultations
as used for in-person referrals.
Key Success Factors: Designated and dedicated telehealth
project manager or coordinator; designated interdisciplinary
telehealth team; adequate facility network infrastructure to
support the telehealth system; Project Management to include
and allow time for professional telehealth education and
training.
Barriers to Success: Funding limited; lack of communication
between administrative management, interdisciplinary team and
participants; failure to identify remote clinical partners to refer
patients or provide telehealth services; poor telehealth
equipment selection or performance.
14
B.E.L.T Framework

8. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All
rights reserved.
15
Figure 8-3 from text.
15
Licensure and Regulatory
Issues in Telehealth
State licensure: Most hurdles are bureaucratic and political, not
clinical.
Mutual recognition licensure: Allows nurses to practice across
states.
Credentialing and privileging: Decisions are made by facility,
therefore are not conducive to telehealth.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All
rights reserved.
16
State lines and geographic boundaries are arbitrary in the realm
of telemedicine and telehealth, but licensure and state practice
rules still need to be enforced. One of the major barriers to the
widespread implementation of telehealth is the cost and
procedural complexity of attaining separate licenses in each
state.
Mutual recognition allows nurses to practice in 24 states if they
have an RN license in any one participating state. Goal is to
include all 50 states.
CMS modified existing credentialing rules in 2011, and allows
hospitals or Critical Access Hospitals (CAHs) to utilize
information from the distant-site hospital or other accredited
telemedicine entity when making credentialing or privileging
decisions for the distant-site physicians and practitioners.

9. 16
Licensure and Regulatory Issues in Telehealth (Cont.)
Reimbursement: Varies by state and insurer; Medicare is slowly
participating.
Malpractice and liability: Concepts applied with telehealth are
the same as with in-person care.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All
rights reserved.
17
Reimbursement: Medicaid varies by state; private insurers
vary; Medicare telehealth services can only be furnished to an
eligible telehealth beneficiary from an eligible originating site.
In general, originating sites must be located in a rural Health
Professional Shortage Area (HPSA) or in a county outside of a
Metropolitan Statistical Area (MSA). The originating sites
authorized by CMS include hospitals, skilled nursing facilities,
the office of the physician or licensed health care practitioner,
rural health clinics, community mental health centers, CAHs,
CAH-based dialysis centers, and federally qualified health
centers.
Liability jurisdictional issues include the “place of treatment”
dilemma, lack of establishing a bona fide doctor-patient
relationship with cybermedicine (medical care via the Internet).
Overall the traditional concepts of negligence, duty of care, and
practicing within one’s scope of legal license still apply to
telehealth as they do in traditional face-to-face encounters.
17
Telehealth and Direct Services
to Patients
Majority of healthcare is self-care provided in the home or

10. community.
Applications:
Direct, online patient telemedicine care
Remote patient telehealth visits and biometric sensors
Consumers monitored and linked with online healthcare
information
eHealth literacy: The e-Health Initiative (eHI); reliability and
accuracy of web content
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All
rights reserved.
18
The vast majority of health care is actually consumer self-care
delivered in the home or local community. Technology focus
should be on this area instead of expanding acute care system
approach.
Applications meet a need for access to care where there often is
none.
Direct, online patient telemedicine care – Teladoc, Online Care
anywhere.
Remote patient telehealth visits – Dept of VA Coordinated
Care/Home Telehealth largest telehealth program in the US;
AFrame Digital Watch with sensor with intelligent learning
platform.
Monitor/link consumers with online health care information –
WebMD; EverydayHealth.com.
eHealth literacy: The e-Health Initiative (eHI) provides helpful
information to healthcare leaders in their pursuit of consumer -
based HIT adoption. Based on the following guiding principles:
1) Consumer engagement in care; 2) Consumer access and
control of personal health information; 3) Consumer access to
electronic health information tools and services; 4) Consumer
privacy; 5) Consumer trust, and 6) Consumer participation and
transparency. Consumers must learn how to evaluate web

11. healthcare info and have must also have competency in:
1)Visual literacy (ability to understand graphs, read a label or
other visual information), 2) Computer literacy (ability to
operate a computer), 3) Information literacy (ability to obtain
and apply relevant information) and 4) digital literacy.
18
Components of Telehealth
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All
rights reserved.
19
Figure 8-4 from text.
19
Conclusion and Future Directions
Telehealth growth: Global socioeconomic, market, and
demographic factors
Mobile phone use growth contributions to mhealth adoption
CuRE© Research and Development Framework: uhealth
perspective
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All
rights reserved.
20
Telehealth growth will continue due to rising health care costs,
increasing prevalence of chronic diseases, an aging population,
demands for improved access to health care, and global
shortages of healthcare professionals.
mHealth capabilities now provide a wide range of wireless
monitoring opportunities, the transmission of information for a

12. variety of health conditions, such as diabetes and cardiovascular
diseases, and has increased access to persons and communities
in rural and isolated regions.
CuRE© (Canada-India Centre of Excellence for u-Health
Research and Education) Framework figure depicts creation of
large telehealth ecosystems and healthcare models via an
interdisciplinary and inter-sectoral approach that spans the
domains of technology, education, and health management in an
iterative process of knowledge sharing across various levels of
to inform health care policy decisions stakeholders. uHealth
means ubiquitous healthcare using telehealth, mHealth, and
operationalizing the concept of international global ecosystems.
ubiquitous health (u-Health) technologies integrate core
components of computers, wireless networks, sensors, and other
modalities, such as m-Health devices, to create an environment
that can monitor, respond to, and assist in meeting healthcare
needs of individuals.
20
Chapter 8
Telehealth
and Applications for
Delivering Care at a Distance
Copyright
©
2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.
Community and Public Health Reducing Hospital Readmissions
Among High-Risk Patient Populations Paper
You will select a diagnosis among high-risk patient populations
that are commonly readmitted to the hospital. Prepare a paper
that examines the rationale for readmissions among this
population and provide evidence-based interventions for
reducing hospital readmissions in this population.

13. Submission Instructions:
· Your paper should be no more than 3 pages long.
· Your paper should be formatted per APA and references
should be current (published within last five years) scholarly
journal articles or primary legal sources (statutes, court
opinions)
Read
· Mauer, F.A. & Smith, C. M. (2013).
· Chapters 7-9 & 30Watch
· The Healthcare System of the United States (7:35)
Healthcare Triage. (2014, February 17). The healthcare system
of the United States [Video]. https://youtu.be/yN-MkRcOJjY
· The Healthcare System of the United States
· (Links to an external site.)
·
Online Materials & Resources
· Explore your state’s Department of Community Health
website.
· Explore your community’s Health Department website.
Individual Rights & Vaccination Policy
School board trustees are requesting public comment before
they vote on a vaccination policy for all children in a local
school district. Should individual rights (e.g., parents’ rights to
decide whether to vaccinate their children) be compromised to
control the spread of communicable diseases for the good of
society?
Submission Instructions:
· Your initial post should be at least 500 words, formatted and
cited in current APA style with support from at least 2 academic

14. sources. Your initial post is worth 8 points.
Read
· Mauer, F.A. & Smith, C. M. (2013).
· Chapters 7-9 & 30Watch
· The Healthcare System of the United States (7:35)
Healthcare Triage. (2014, February 17). The healthcare system
of the United States [Video]. https://youtu.be/yN-MkRcOJjY
· The Healthcare System of the United States
· (Links to an external site.)
·
Online Materials & Resources
· Explore your state’s Department of Community Health
website.
· Explore your community’s Health Department website.
Ethical Issues
Identify and discuss at least two potential ethical issues that
could be of concern for nurses with telehealth delivered care.
Submission Instructions:
· Your initial post should be at least 500 words, formatted and
cited in current APA style with support from at least 2 academic
sources. Your initial post is worth 8 points.
Nelson, R., & Staggers, N. (2014).
· Chapter 8
Online Materials & Resources

15. · Visit the CINAHL Complete under the A-to-Z Databases on
the University Library's website and locate the articles below:
· Hutcherson, Carolyn M. (September 30, 2001). "Legal
Considerations for Nurses Practicing in a Telehealth Setting".
Online Journal of Issues in Nursing. Vol. 6 No. 3, Manuscript
· Doran, D., Haynes, B. R., Estabrooks, C., Kushniruk, A.,
Dubrowski, A., Bajnok, I., et al. (2012). The role of
organizational context and individual nurse characteristics in
explaining variation in use of information technologies in
evidence-based practice. Implementation Science, 7, 122. DOI:
10.1186/1748-5908-7-122
· Nagel, D. A., Pomerleau, S. G., & Penner, J. L., (2013).
Knowing, caring, and Telehealth technology: “Going the
Distance” in nursing practice. Journal of Holistic Nursing,
31(2), 104-112.
· Kluge, E. H. (2011). Ethical and legal challenges for health
telematics in a global world: Telehealth and the technological
imperative. International Journal of Medical Informatics, 80(2),
e1 - e5
· Explore/View the website(s) below:
· Healthit.gov. (2019). Telemedicine and Telehealth |
HealthIT.gov. Retrieved from
https://www.healthit.gov/topic/health-it-
initiatives/telemedicine-and-telehealth
· (Links to an external site.)
·
· Dunn/BCMJ, G. W. (2004, August). Legal issues confronting
21st-century telehealth | British Columbia Medical Journal.
Retrieved from https://www.bcmj.org/articles/legal-issues-
confronting-21st-century-telehealth