BRIEF REPORT

Nurse Practitioners in Telehealth:Bridging the Gaps in Healthcare DeliveryKristi Henderson, DNP, FNP, Tearsanee Carlisle Davis, DNP, FNP,Mary Smith, DNP, FNP, and Melissa King, MSN, FNP

ABSTRACTThere is no denying that many changes must be made in the health care delivery system in order to meetthe needs of all people and improve the health of our nation. Because of advances in technology over thepast 2 decades, telehealth has greatly improved patient access to health care and equipped providers withinnovative tools to provide quality health care to a larger population. The health care climate demands aninnovative approach to health care delivery with an attention to scalable and sustainable models. Telehealth,and the use of nurse practitioners, will be an integral part of these new models.

Keywords: connected care, nurse practitioners, telehealth, telemedicine� 2014 Elsevier, Inc. All rights reserved.

here is no denying that many changes mustbe made in the health care delivery system in

Torder to meet the needs of all people and

improve the health of our nation. Because of ad-vances in technology over the past 2 decades, tele-health has greatly improved patient access to healthcare and has equipped providers with innovative toolsto provide quality health care to a larger population.1

No longer does geographic location limit the healthcare services one can access. The health care climatedemands an innovative approach to health caredelivery with an attention to scalable and sustainablemodels. Telehealth, and the use of nurse practitioners(NPs), will be an integral part of these new models,which provide a scalable approach to coordinated andcollaborative care. However, the widespread adoptionand integration of telehealth can be difficult.

Telehealth is a broad term that includes video-conferencing, exchange of medical information viaelectronic communications, remote patient moni-toring, population health management, and mobilehealth technologies.2 Our academic medical center(AMC) has answered the call to minimize healthcare disparities related to geographic barriers to gainaccess to health care by using technology to bringcollaboration among multiple disciplines in a virtualenvironment. Our AMC operates a system-widecenter for telehealth that began as a pilot projectnearly 11 years ago. The first program that launched

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in 2003 was the telemergency program. This pro-gram uses NPs as the distant site providers and allowsfor direct connection to board-certified emergencyphysicians at our level I trauma center for a higherlevel of care using telecommunication equipment.3

In some rural areas, the closest, fully staffed emergencyroom was 40 miles away, and some rural emergencyrooms were staffed with physicians or NPs with littleor no formal emergency medicine training. As a result,the AMC frequently received poorly managed criticalcare patients in transfer to their emergency department,and some patients did not make it that far.

The tele-emergency program trains NPs throughan intense didactic and clinical continuing educationprogram that is in addition to the education receivedas a part of the NP’s formal degree-granting educa-tion and certification required for practice. Thecontent is focused on the clinical knowledge anddiagnostic procedure skills necessary to work in anemergency department and incorporates appropriateuse of the telemedicine equipment, which allowsthem to collaborate with board-certified emergencymedicine physicians. This curriculum focuses ontopics such as the approach to the emergency patient,cardiac emergencies, psychiatric emergencies, toxi-cologic emergencies, obstetrical emergencies anddelivery, and pediatric and orthopedic emergencies.This content is taught through a combination of in-person classes, online modules, simulation laboratory

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sessions, and clinical rotations. Once the NP com-pletes this 3- to 6-month training, they may go onto staff rural emergency departments that are a partof the AMC’s telehealth network. This programprovides a sustainable model for the utilization ofNPs to positively impact rural communities throughtelemedicine.

In this program, the NP uses bidirectional audio-conferencing and videoconferencing for collaborationwith emergency medicine physicians at the academicmedical center (Figure 1). The rural hospital emergencydepartments are outfitted with telemedicine equipmentthat is either mounted in the emergency department’sexamination room or contained on a telemedicine cartthat allows for mobility between examination roomsin the emergency department and the inpatienthospital rooms. In either scenario, a video monitor,camera, and microphone allow for videoconferencingbetween 2 geographically distant sites. The NP caneasily consult with the AMC’s department of emergencymedicine’s physicians or a stroke neurologist with apush of a button. Any of the AMC’s resources andspecialties can be consulted as the emergency physiciandeems necessary. This virtual care team provides atreatment recommendation to the NP at the ruralhospital. Should the patient require a transfer to afacility offering expanded services, the care that wasdelivered through telemedicine results in an improvedtransition of care from the rural hospital to the academicmedical center. A study by Henderson et al4 comparedpatient outcomes of cardiac arrest patients in 8 ruralhospitals using the telemergency program to thatof our AMC. The survival of cardiopulmonaryarrest patients in rural emergency departments hashistorically been significantly lower than that in the

Figure 1. AMC telemedicine workstation.

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urban emergency department setting. In this study,rural emergency departments using resuscitationguided by telemedicine consultation with emergencyspecialists were found to have survival rates that werenot significantly different from those in our AMC.This finding suggests that telemedicine may improvethe quality of emergency care delivery in the ruralsetting.4 Although the impact on access to care andquality of care is critical, in order for a telehealthprogram to be adopted and integrated, there must bea solid business plan that shows a positive return oninvestment.

The economic evaluation of a telehealth programto determine the benefit-cost analysis should considerthe broad range of impact a program has on thehealth of individuals; the workforce and populations,and the impact on new jobs, economic development,and the cost of health care.5 The financial impact ofa telehealth program on a hospital or other clinicalentity can be assessed in a number of ways such as theability to retain patients admitted in the communityhospital (avoiding unnecessary transfers of patients), areduction in medical staffing costs (shared resources),an added medical service line, a decrease in the lengthof hospital admission, and/or the prevention of afinancial penalty from hospital readmissions. Theliterature is growing to show the positive financialimpact and the win-win scenario found in a tele-health program.5-10 In some cases, telemedicine hasprevented the unnecessary transfer of a patient to theAMC when the condition could have been managedat the local hospital with support via telemedicine.This results in benefits for both the patient and therural hospital. If the patient is stabilized and can stayat their local hospital, they are closer to home andfamily and are able to receive the care they needin a familiar environment. If the rural hospital is ableto keep the patient, it keeps the revenue in thecommunity and expands that hospital’s ability tosupport the community. In an analysis of the first8 tele-emergency hospitals, a comparison was donebetween the operational cost and the hospital censuspre- and postimplementation of the telemergencyprogram. The program analysis revealed a decrease inprovider staffing costs of 25% in the tele-emergencymodel and showed an increase in the distant hospitalpatient admissions of 20%.11 Although this report has

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Figure 2. Corporate Telehealth workstation.

been submitted for peer review and publication, thefindings have already led to telemedicine programexpansion and increased adoption. With avoidedtransfers, the AMC is then able to focus on the morecritically ill patients who need the level of care onlythey can provide. The success of this initial telehealthprogram and the increase of supporting literaturecreated the impetus for us to replicate this model inother specialties.

Over the past 10 years, the institution hasexpanded this initial program to a statewide tele-health network and achieved the designation as acenter for telehealth in July 2013. The center is ledby a chief telehealth and innovation officer who is adoctorally prepared nurse. The mission of the centerfor telehealth is to fill the gaps in health care andto improve the quality and accessibility of healthservices in order to decrease health disparities,manage chronic diseases, and improve the qualityof life. Our center for telehealth supports the in-stitution’s commitment to provide health care state-wide and matches the state’s need and demand fortelemedicine services. To date, over 30 differentspecialties are being offered via telemedicine to over100 unique nonaffiliated sites across our state, manyof which are manned by NPs. The center is nowreceiving requests nationally and internationally toextend these telehealth services outside the state.Currently, the AMC’s telehealth program does notextend outside of the state.

TELEHEALTH TODAYTelehealth is being delivered in a variety of inpatientand outpatient settings in our state, providing servicessuch as telestroke, teledermatology, telepediatrics,telepsychiatry, teleneonatology, and telecardiologycare to underserved areas. A primary focus of tel-ehealth programs is to fill the need for health careproviders, thereby improving access to care foranyone, regardless of their location. In October 2013,our AMC hired its first telehealth NP dedicated tothe delivery of health care through telehealth tech-nology for corporations and schools (Figure 2). Theprogram uses e-clinics to deliver care to studentsin their school clinics and to employees in theirworkplace. Because of this program, employees areable to seek care for minor illnesses without leaving

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work. Employers benefit from this service because itlimits the loss of productivity and reduces health carecosts. The program has seen great success in the pilotphase and has hired 2 additional NPs to meet thedemands of Mississippi corporations.

The school telehealth program is similar in thatstudents are allowed to receive episodic care forminor illnesses via telehealth, which allows parentsto stay at work when they choose to do so. In thisprogram, the school nurse serves as the facilitator whoconnects to the telehealth system for an NP tele-consult at which time the patient is assessed, diag-nosed, and treated. If there are needs that requirein-person examination or follow-up, the NP co-ordinates these appointments with a local provider inthe patient’s community. The benefit is that studentswho may not have a primary care provider haveaccess to care when they need it and receive assistancein securing a medical home for ongoing needs. NPsworking in these 2 programs have a family medicineand/or urgent care background and are knowledge-able about resources in the community.

COORDINATION OF CARE IN THE COMMUNITYHealth care reform is placing a strong focus onthe coordination and continuity of care among allpopulations but specifically for those populationswith multiple chronic illnesses and risk factors,which leave them the most vulnerable.12 Riskfactors such as polypharmacy, poor health literacy,and lack of supportive resources place a greater needfor interprofessional collaboration and can all be

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positively affected with the appropriate use oftelehealth. Telehealth will play an instrumental rolein the utilization of a collaborative approach thatdelivers quality care, enhances patient safety, andgenerates cost savings.13 Telemedicine is instrumentalin preventing excessive health care costs throughremote patient monitoring. Research studies arebeginning to reveal the impact of remote patientmonitoring on hospital readmissions, diseasemanagement, avoidance of emergency room visits,and patient satisfaction.10,14,15

A study by Pekmezaris et al10 studied the impactof remote patient monitoring on heart failure patients.The study indicates that remote patient monitoring hasthe potential to provide a cost-effective and conve-nient method to manage heart failure.10 Remotepatient monitoring aids in containing healthcare costsby enabling nurses and other health care providersto intervene when there is a change in health statusand eliminates the need for costly home care visitsfor monitoring only.16 Cost savings are seen withan efficient and coordinated delivery system thatminimizes exacerbations of chronic illnesses, curtailsadverse events, reduces hospitalizations, and reservesthe use of emergency rooms for truly emergencycare.

The National Rural Health Association reportsthat rural areas have greater shortages of primary andspecialty health care providers, a larger populationof individuals who rely on Medicare and Medicaid,an increased prevalence of chronic disease, andgeographic barriers that force travel over long dis-tances in order to gain access to specialty health careservices.17 Telehealth technology will allow forvulnerable populations in underserved areas toovercome some of these challenges by reducinggeographic disparities and health care workforceshortages and increasing access to preventive services.An example of how telemedicine is bringing neededservices to the rural community is telepsychiatry.There is a vast shortage of mental health providers inrural communities. Often, primary care providers areforced to treat patients suffering from mental illnesswithout the expertise of mental health professionals.Telepsychiatry allows patients in rural communitiesto have access to the same level of care as those in

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larger cities by using videoconferencing to conductmental health evaluations and regular follow-up.18

The provision of subspecialty care to children withspecial health care needs who live in rural communitiesis also a benefit of using telehealth. Traditionally,parents would be taxed with the burden of travelingfar distances to receive the care that their childrenneeded. Marcin et al19 reported that pediatricsubspecialty consultations can be provided to thesechildren with high satisfaction for families and ruralproviders. The utilization of telehealth has thepotential to meet the Institute for HealthcareImprovements’ triple aim for better health, betterhealth care, and lower costs.5-10,13,15

Population health management and chronicdisease management programs are also capitalizingon the use of technology.14 A program recentlyimplemented by our AMC, the Mississippi DiabetesTelehealth Network, aims to bring a diabetes careteam to an existing rural health clinic that currentlydoes not offer any specialty care. Diabetics whosedisease is currently uncontrolled are eligible forthis program. Patients enrolled in the program areprovided with a computer tablet that allows for real-time health sessions and coaching as well as remotemonitoring of vital signs and glucose levels.20 Thecommunity physician or NP in the rural health clinicwill have access to endocrinologists, ophthalmologists,specialty NPs, nurses, diabetes educators, pharmacists,and nutritionists to bring a team approach to theirhealth care. Until now, this type of approach was onlyaccessible to those in urban areas. Because so muchof diabetes management is related to behavior and lifestyle changes, this program will also provide dailyhealth sessions delivered through a computer tabletto include symptom and compliance assessment,education, and remote monitoring of the patient’sglucose level and vital signs. NPs who staff the ruralhealth clinic will be able to refer patients to specialistslocated at the AMC for care that would otherwisenot be accessible. It is expected that patient complianceto treatment will improve because their primary careprovider, the NP, will be able to facilitate additionalservices via telemedicine. This is another example ofhow NPs are pivotal in the improving access to carein rural communities.

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CRITICAL CARE SERVICESThe use of technology can provide a cost-effectiveand efficient way to deliver health care, provide ed-ucation, and manage chronic disease. The health caresystem is demanding more with fewer resources.Workforce shortages, the geographically dispropor-tionate spread of health care providers, and the lackof access to care, whether caused by a lack of trans-portation or a lack of health care services in an area,create barriers that the current model of health carehave been unable to overcome. In the current teleeintensive care unit (ICU) program, critical care pa-tients are monitored remotely 24 hours a day byexperienced critical care nurses. This is in addition tothe bedside critical care nurse. The preliminary datafrom our model suggest it to have a positive impacton safety and quality and allows for earlier inter-vention for changes in patient status. Initially, therewas uncertainty as to whether it was cost-effectiveat our AMC, which resulted in the program being“turned off.” The result was an increase in safetyand quality concerns that led to reinvigoration ofthe program. The program remains active and isexpanding in our AMC. The literature reveals asimilar picture of inconsistent outcomes of an ICUtelemedicine program. The data are conflicting onthe cost-benefit analysis, but numerous studies sug-gest that when telehealth services are implementedwith well-defined patient inclusion criteria and pro-tocols that it can be cost-effective.21-24 This has beentrue for our AMC. Plans are currently being draftedthat will include adding acute care NPs to the ICUtelemedicine model currently used in the AMC. TheNP would be a part of the intensivist team and willensure continuity of care in this population. TheNP in the tele-ICU will be able to intervene muchsooner and place orders that will prevent a delay incare and improve patient outcomes. Future studiesare needed to determine the impact of the NP onthis model.

MOVING FORWARDRural and community hospitals have threatenedviability and survivability. The tele-ICU program andother telehealth services allow the smaller hospitalsto keep their own patients in their facility safely and

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prove to be a quality and financial benefit to thecommunity.15 Financial challenges have often beenthe reason that rural agencies have shied away fromnontraditional models of care delivery. The centerfor telehealth not only creates and implements theprograms, but doctorally prepared NPs work withcommunity agencies to identify needs and createprograms that produce a revenue stream that willensure sustainability. Each site has different resources,and with that in mind, no 2 programs are identical.Based on the needs of the agency and the resourcesavailable, the center for telehealth devises a realisticplan, and NPs are a key component to this transformedhealth care delivery model. Technology will continueto change the way nurses practice. The standard of carenow includes telehealth to improve access, quality, andpatient outcomes.

For more information, contact the center for tele-health at (601) 815-2020 or www.umc.edu/telehealthand follow us on Facebook and Twitter.

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All authors are affiliated with the University of MississippiMedical Center. Kristi Henderson, DNP, FNP, ACNP,FAEN, is chief telehealth and innovation officer and an RWJFexecutive nurse fellow and can be reached at khenderson@umc.edu. Tearsanee Carlisle Davis, DNP, FNP, and Mary Smith,DNP, FNP, are telehealth nurse practitioners and Melissa King,MSN, FNP, is the TelEmergency NP director. In compliancewith national ethical guidelines, the author reports no relationshipswith business or industry that would pose a conflict of interest.

1555-4155/14/$ see front matter

© 2014 Elsevier, Inc. All rights reserved.

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Volume 10, Issue 10, November/December 2014