Telehealth, mHealth Make Nurses Pivotal Presence in Healthcare

Telehealth and mHealth technology have propelled the nurse from a note-taker and hand-holder to a controller and dispenser of information. And they’re using those skill to improve care management and coordination.

Healthcare providers are finding that mHealth and telehealth programs designed specifically with the nurse in mind are improving clinical and workflow outcomes much better than a “one-size-fits-all” solution.

Realizing that the nurse is often the first point of contact for the patient, they’re designing connected health programs and tools that accentuate the nurse’s skills and improve the care management process for patients. And in doing so, they’re also making things a whole lot better for the doctor.

“Patients have a different rapport with nurses than they do with doctors,” says family nurse practitioner Mariea Snell, Assistant Professor of Nursing at Maryville University and Vice President of the Missouri State Board of Nursing. “We’re there when they come in (to the hospital, clinic or doctor’s officer). We talk to them and we spend time with them.”

“That interaction with the patient is unique,” she adds.

To build on that relationship, digital health tools for nurses focus more on tasks that appeal to patient engagement. Mobile devices and telehealth platforms help them answer patient questions about health concerns and treatment, ease their hospital stay, communicate quickly with doctors and facilitate clinical procedures and tests.

Telehealth programs, meanwhile, focus on connecting the nurse to care management tools, giving them more responsibilities in patient care and saving the doctor’s time for when it’s needed most.

“You’re building a level of trust with the patient,” Snell says. “You’re there to tell them what’s going on and to make their treatment easier.

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There are roughly 3.25 million nurses in the US, the largest professional healthcare group. And because they’re integral to care coordination and management within the hospital, health system executives are tailoring their enterprise mobile communications platforms to the nurse workflow.

“They are mobile professionals who are constantly on the go, working in high-stress, data-intensive environments dominated by inefficient paper-based processes,” a 2016 Spyglass Consulting report on mHealth and nurses states. “They have a constant need for direct and immediate communications with colleagues and patients, as well as real-time access to relevant patient information at (the) point of care.”

But those nurses at the forefront of the healthcare communications landscape are seeing a number of challenges, Spyglass Consulting Founder and Managing Director Gregg Malkary points out. These include inefficient communications platforms dominated by overhead and handheld pagers, landlines and VoIP handsets, lack of integration with electronic medical records platforms, and a general feeling of being overwhelmed by all the devices, monitors and alarms in the healthcare setting, “which leaves them little time for direct patient care.”

When the Children’s Hospital of New Orleans launched a new communications platform in 2017, executives wanted a simple tool that would enable staff to quickly and easily contact who they wanted to contact.

They first looked to their nurses for guidance.

“Everyone kept telling us to make sure you really engage your nursing staff,” says Ben Whitworth, the hospital’s Assistant Vice President of Hospital Operations, who’d been working on the project for more than two years. “When you think of communications in a hospital, the first thing that comes to mind is that it has to be easy for nurses and fit into their workflow.”

The hospital decided to give nurses a device they could use on site and give doctors an app they could load onto their smartphone. But the nurses, Whitworth says, preferred a hands-free device that would allow them to make a call while they were performing other, patient-focused tasks. So the hospital opted for a wireless badge.

“In our case, it was important to us to separate communications from other functions, like data access,” Whitworth says. “For now, this is what we needed, and what our nurses needed.”

Candace Friestad, MSN, MBA, RN, Director of Clinical Informatics at Avera Health’s McKennan Hospital & University Health Center, remembers a time not too long ago when nurses at the Sioux Falls, S.D. health system walked around with a pager, a hospital-issued mobile phone, and their own phone — as they beat a familiar path between patients and the computers at the nurse’s station.

That setup puts a lot of strain not only on the belt but on the nurse’s workload. And it prompted executives at the sprawling Midwestern health system to take a closer look at how nurses — and everyone else in the hospital – use mobile health devices.

“Everybody had a different use case,” says Friestad. So the health system worked with Voalte and Connexall to create an mHealth platform that put one enterprise device in everyone’s hands.

Avera McKennan launched the new platform in 2014 for just the nurses, then gradually brought in other departments and users to create a system-wide communications platform. Along the way, Friestad says, some departments signaled their preference to use their own phones, while most nurses liked the idea of coming to work, using one device and then leaving that device behind at the end of the shift.

“It’s efficient, and it gives (nurses) exactly what they need,” she says.

Rhonda Collins, RN, Chief Nursing Officer for mobile communications vendor Vocera, says nurses often sit at the epicenter of information exchange within the hospital setting. They’re the ones helping patients with their care and passing information to and from doctors, so they need mHealth devices that focus on tasks and communication.

Collins says the nurse’s role in healthcare has changed — thanks to technology.

“It has certainly made the nurse the holder of information – like the mouse for a computer,” she says. “They now have more ability” to direct and control that data, getting it where it needs to go at a faster and more efficient speed.

Technology can also help nurses improve their interactions with patients. In Chicago, nurses are using iPads to bolster their bedside manner.

At University of Chicago Medicine, they’re complementing the rounding process with a standardized questionnaire asking patients about their time in the hospital. The mHealth tool allows hospital executives to quickly pinpoint good and bad processes — and it gives the nurses a chance to measure their ability to deliver value-based care.

“Rounds really help us [develop] the relations ship with the patient and their family,” says Sue Murphy, RN, BSN, MS, UC Medicine’s chief experience and innovation officer. “We put value to how we are delivering care.”

“We train and develop people how to round,” she says, describing a process that’s similar to health systems and telehealth providers training doctors on how to conduct a virtual visit. In fact, those nurse leaders charged with making rounds “see it as a sacred time” during which they’re engaging with patients and getting vital information.

“It’s not as much about the technology as it is about patient feedback and interactions,” she says.

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Nurses also have a significant investment in telehealth.

In 2016, a nationwide survey of some 1,200 nurses gave high marks to telemedicine in the ICU – an environment where nurses often need immediate access to doctors.

The study, conducted by Chicago-based Rush University Medical Center, found that telemedicine technology within the ICU gives nurses more confidence, knowing they have an instant resource from which to seek help. It also gives health systems more leeway in designing telemedicine programs for nurses.

“Tele-ICUs improve patient care by providing an enhanced monitoring capability to detect potential patient compromise earlier,” Ruth Kleinpell, RN, PhD, APRN-BC, CCRN, director of RUMC’s Center for Clinical Research and the study’s lead author, said.  They also “help promote collaborative care by using telehealth nursing and physician staff and on-site clinical staff to collectively manage patient care issues, as well as to enhance communications with patients and family members.”

In several cases, hospitals and health systems have set up telemedicine platforms to enable instant access to doctors and specialists, giving them more leeway to staff departments with nurses and giving those nurses the comfort of knowing they’re being supported.

“All they have to do is push that button and someone is there almost instantly,” says Ken Mattison, CEO of Florida Hospital New Smyrna, whose 12-bed ICU is now connected to a telemedicine platform run by Advanced ICU Care. And it’s much easier and less stressful for on-site nurses, he adds, who may have a simple question that might not rise to the level of a phone call at an odd hour to one of the hospital’s three intensivists.

“They feel less guilty pushing a button,” he says.

In another example, nurses in rural health systems throughout Pennsylvania are using telehealth to train as Sexual Assault Nurse Examiners (SANEs) through the Penn State College of Nursing, enabling them to treat and collect evidence from suspected sexual assault victims. They can also use the telehealth platform to connect with trained specialists while treating the patient.

As telehealth looks to define the benefits for nurses and doctors, at least one telehealth vendor sees value in creating a direct-to-consumer model that emphasizes the nurse

TriageLogic, based in Jacksonville, Fla., bills its offering as a “nurse triage” service, enabling health systems to create a tiered platform that funnels workflow to more appropriate care providers and reduces back-end costs.

“Nurses, before the doctor, are the common practice,” says Ravi K. Raheja, MD, the company’s COO and Medical Director. “They’ve always been the first point of contact with the patient. They can handle most of the calls, leaving the doctor to handle what he or she was trained to handle.”

“Over 80 percent of patients who call in to their physician’s office may not need urgent care, but they all urgently need empathy, someone to listen, and someone to care,” Marci Lawing, RN, BSN, TriageLogic’s clinical nurse manager, points out in a January 2017 blog. “That’s the role of the triage nurse. In addition to being a good clinician, a critical thinker, and making sure everyone stays safe, you are also there to provide empathy and care advice to help patients.”

Raheja says hospitals are starting to recognize a telehealth business model that puts nurses at the first point of contact and saves doctors for when they’re most needed. The platform costs less, improves patient engagement and creates minimal impact on a doctor’s workload.

A telehealth platform based on an interaction with a doctor, he says, “is far more expensive and complicated and would end up being underused.”

“Doctors don’t like it,” he adds.

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With the concept that the nurse is often the first point of contact for a telehealth program, it’s perhaps no surprise that cross-state licensing compacts were first discussed for nurses.

The Nurse Licensure Compact (NLC), developed by the National Council of State Boards of Nursing, was launched in 1997 with the goal of giving nurses practicing privileges in member states. In 2015, the Enhanced Nurse Licensure Compact (eNLC) was introduced to meet “the growing need for nurse mobility and clarification of the authority to practice for many nurses currently engaged in telenursing or interstate practice.”

The eNLC went live on Jan. 19, 2018 in some 29 states, enabling registered nurses (RNs) and licensed practical/vocational nurses (LPN/VNs) in member states to provide care to patients in other states without having to obtain additional licenses. The compact creates an expedited licensing process that gives nurses these privileges as long as they meet 11 uniform licensing requirements.

“Boards of nursing were the first health care profession regulatory bodies to develop a model for interstate licensure, and we are looking forward to the implementation of this new phase of nursing regulation,” NCSBN CEO David Benton, RGN, PhD, FFNF, FRCN, FAAN, said in a 2017 press release when the eNLC reached its target number of member states. “Patient safety was of paramount importance in the development of eNLC leading to the addition of new features found in the provisions of the model legislation.”

Armed with that extra mobility, expect nurses to garner more of a role in mHealth and telehealth in the future. Health systems will continue to expand their reach through telemedicine, creating networks that highlight care teams and care management – putting the highly paid, specialized doctor in one location and extending his or her knowledge out to nurses wherever they’re needed, be it the small hospital, clinic, community center or school.

“Nurses have always known how triage,” says Snell. “It’s something they’ve always been comfortable doing. Now we’re giving them the tools to do that better.

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