1. Telemedicine In Today’s Healthcare Arena
Jason M. Kramer, RN PHRN

2. Objectives Define telemedicine Define the types of telemedicine
Describe current telemedicine practices
Define the hardware used in telemedicine
Define the software used in telemedicine
Evaluate the usability of software
The objectives for the power point presentation. Defining Telemedicine and Describing current Telemedicine Practices. Telemedicine is the use of current technology to transmit patient information to advanced providers in order to evaluate changes in patients status or evaluate medical hardware. This can be done by phone, computer or video conferencing.

3. Objectives Define Information Systems
Discuss Advantages of Telemedicine
Discuss Disadvantages of Telemedicine
Discuss Ethical and Legal Issues of Telemedicine
We will be defining what an information system is and how it works.
We will also be looking specifically at the Medtronic Information System.
We will look at the advantages and disadvantages of Telemedicine as well as the ethical and legal issues associated with it.

4. Objectives Discuss Informatics Competencies
Discuss Functions and Responsibilities of Informatics Nurses
Finally we are going to look at the competencies necessary for the informatics nurse as well as discussing the functions and responsibilities of the informatics nurse.

5. What is Telemedicine Telemedicine
To communicate with patients outside of the hospital/clinic.
For health care providers to communicate with health care providers.
To monitor patients while they are at home.
Bullet 1: We can monitor patients with AICD’s, automatic implantable cardioverter defibrillator, remotely with wireless devices connected to their phones. The device can interrogate the AICD and download the data via phone line directly to the physician’s office alerting of any lead or device malfunctions.
Bullet 2: In June 1998 while working at a South Pole research center, Dr. Jerri Nielsen found a lump in her breast. She then had to perform surgery on herself to extract a tissue sample. The sample was positive for breast cancer and she began to treat herself with supplies that were air-dropped to her. Teleconferencing played a large role in her survival. She conferenced with physicians via , and video conference. She was later rescued from the station in October. (Grady, 1999)
3. Machines that monitor vitals signs and even insulin pumps and meters can be downloaded by phone to a physician’s office. The offices can then be alerted to such things as hypertensive and hypotensive crises. Endocrinologists can make changes to pump settings for more optimal insulin administration.

6. Definition of Telemedicine
“The use of medical information exchanged from one site to another via electronic communication to improve patients’ health status.”
Define Telemedicine as stated. Telemedicine is our ability to monitor our patients’ while not requiring them to come into the hospital. Any form of electronic communication is considered telemedicine.
(American Telemedicine Association, n.d., Telemedicine Defined Section ¶ 1)

7. Types of Telemedicine Real Time – Synchronous
Store and Forward – Asynchronous
Bullet One – Synchronous or Real time telemedicine requires two parties to be online at the same time with a communication link. This way the parties can text, speak, or communicate in real time. (Kale, n.d., Telemedicine ¶3)
Bullet Two – Asynchronous or store and forward telemedicine happens when data is downloaded to a computer system for later evaluation by a health care professional. For this type of telemedicine the two parties do not need to be online at the same time. (Kale, n.d., Telemedicine ¶4)

8. Current Telemedicine Practices
Radiology – Accessing and Reading Films from a remote site.
Cardiology – Interrogation of Pacemakers and AICD’s in a patients home by telephone.
Uploading of vital signs from home to a remote monitoring center
Diabetes – Linking of Glucometers with Insulin Pumps and Physician offices.
EMS – Video conferencing with Physicians from the field.
Radiologists can view films anywhere computers are accessible to them. Health systems can have a centralized reading room for the entire system. This leads to quicker readings of films and quicker diagnosis. Also, fewer radiologists are needed and they can be more specialized.
Cardiology – AICD’s can be interrogated while patients are sleeping without them being aware of the device being checked. The information is the sent via telephone line to the cardiology office that the patient visits and any problems with the device can then be addressed when the staff comes in.
Blood pressure and pulse rate machines can now link with the physician’s offices from home to reduce the number of visits for the patient. Medications can then be adjusted as needed
Diabetes – Insulin pumps can communicate with their glucometers to assist in programming of insulin boluses. Insulin pumps can also communicate to a computer with a wireless link that allows the information from the pump to be downloaded and then sent to the physician’s office, resulting in more appropriate and more frequent changes in basal and bolus rates by the physicians. Most patients only see their endocrinologist every three to four months.
EMS – Trials with video conferencing with physician’s have been in progress to allow M.D.’s to view the patient while getting report from the Paramedics so the treatment can be tailored to that specific patient and more information can be obtained. This is proving especially important for Trauma and cardiac patients.

9. Hardware in Telemedicine
Personal Computer
Communication Link
Digital or Video Camera
Printer/Scanner
Video Conferencing System
Personal Computer – The personal computer is used to send and receive data from one computer to another. The computer may be integrated into a total care system which is attached to a non-invasive blood pressure cuff, ECG monitor, glucometer, or other diagnostic device
Communication Link – Some form of communication link must be utilized for both real time and store and forward transmissions. Telephone communication, satellite relay, or web based communication are some of the communication links that might be utilized.
Digital or Video Camera – A digital or video camera may be used to obtain photos of accident scenes or patient complaints. Video cameras may also be used for real time communication so that a physician can evaluate a patient.
Printer/Scanner – Printers and scanners may be facilitated to print diagnostic images for easier viewing and storing. Printers may also be used to print graphical displays.
Video Conferencing System – Video conferencing systems allow provider’s the ability to speak with their patients’ or other health care professionals in real time. The photo on the slide shows a system that is currently being used by some airlines to conference crews with physicians on land so that patients can be treated more promptly.
(EDT, n.d.)

10. “Medtronic” Hardware Information
Personal Computer
Insulin Pump
Glucometer
Continuous Glucose Monitor
Personal Computer – A personal computer is required to run the software for the CareLink system to download information to the physician’s office and generate reports.
Insulin Pump – The insulin pump infuses insulin as programmed by the user and physician. The insulin pump also stores data relayed to it from the glucometer and calculates bolus rates as prescribed by the user and physician.
Glucometer – The glucometer is used to monitor finger stick blood sugars in the diabetic patient. The glucometer relays information to the insulin pump in order to calculate insulin bolus rates.
Continuous Glucose Monitor (CGM) – The CGM monitors the patient’s blood sugar and with the insulin pump helps to identify trends for optimization of insulin therapy.
“Medtronic” is a registered trademark of Medtronic Diabetes, Inc.
(Untitled Photograph, n.d.)

11. Telemedicine Software
CareLink Software
CapSure Software
AMD Software Solutions
CareLink software is employed by the Medtronic corporation for communication with various patient devices. CareLink connects with devices by wireless recognition to download data from AICD’s, Pacemakers, and Insulin Pumps. The data is then downloaded to the physician’s computer for evaluation. CareLink is a registered trademark of Medtronic Diabetes, INC. (CareLink Personal Therapy Management Software, n.d.)
CapSure software is a real-time image acquisition, collaboration and information management software. CapSure can be used for primary care, emergency medicine/trauma care, dermatology, ophthalmology, and wound care. (Medical Imaging Telemedicine Telehealth Store and Forward, n.d.)
AMD Software Solutions provides software that is both synchronous and asynchronous. tConsult is a store and forward software that combines patient records with diagnostic images and data and sound. The software also can be linked to diagnostic equipment. AMD’s AGNES software is a real time software that can gather and relay patient data to a health care provider. (Encounter Management Software Tools | AMD Global Telemedicine, n.d.)

12. “Medtronic” Software Information
“CareLink” software for Medtronic Insulin Pumps
Effects of Insulin
Charting
Patterns
CareLink software allows the user to understand the effects of their insulin bolus on their bodies. This is done through easy to read charting that can also be downloaded and shared with their healthcare provider. The healthcare provider can then make necessary changes to the patients pump settings such as the basal and bolus rates. (Carelink Personal Therapy, n.d., Carelink Personal Therapy Management System ¶ 2,3,4)
The CareLink software also allows the patient to monitor high and low blood sugar patterns without having to do continuous finger sticks. With this software the continuous glucose monitor (CGM) can alert the pump to low or high blood sugars that will then set an alarm off on the pump itself to alert the patient. (Carelink Personal Therapy, n.d., Carelink Personal Therapy Management System ¶ 5)
(Untitled Photo, n.d.)

13. Usability of “Medtronic” Software
Insulin Pump Software
Computer Software - Carelink
Users need to be familiar first with their insulin pump software and how to program their insulin pump. They must also be able to connect their pump via wireless USB to their computer. This requires some knowledge of computers, and the internet. Software in the pump is fairly easy to use; however, the user needs to be able to navigate menus in the pump itself. It does appear that the user was thought of in the development of the insulin pump software due to the fact that the menus are easy to navigate, and there is a backlight for nighttime use. The tasks needed to perform specific jobs with the pump is limited through the menus allowing for easy control of the pumps various functions. For example, a patient needs only perform five tasks to give themselves an insulin bolus. It does appear that the pump software went through clinical trials to ensure that use of the pump is simple. Once a user gets to know the pump it is fairly easy to use.
The CareLink software requires users to be able to log on to applications. It also is a point and click application that generates reports and requires some level of computer understanding. The software also allows the user to link their information with their physicians. Many doctor’s offices are using the software in the office and only downloading the data at the patient’s visit. The software appears to have been developed more with the health care professional in mind and not the patient. The software is easy for the computer savvy to use being that it is a windows based operation. Careful thought must be used to run this software if you are not familiar with it. There are many screens and outputs available and it is not always easy to get the data output that you want.
One other problem with the software is the size of text used in the software itself. The text can be very hard to read at times due to the size and or the color. This may be problematic for some patients who have varying degrees of retinopathy.
Axiom 2
The processes that are used in the software for the carelink system simplify tasks by allowing for a reduced number of steps to complete a task. The software also allows for the information to be displayed in easy to read charts.
Axiom 3
I do not believe that this software meets the third axiom. The software can be difficult for someone with limited computer skills to use. The software is not transparent as the companies would like. The usability of this software appears to be more for someone with computer knowledge.

14. Information Systems
An information system is a collection of methods, practices, algorithms and methodologies that transforms data into information and knowledge desired by, and useful for, individual and group users in organizations and other entities.
An information system is a collection of methods, practices, algorithms and methodologies that transforms data into information and knowledge desired by, and useful for, individual and group users in organizations and other entities.  This system can involve a combination of work practices, information, people, and technologies organized to accomplish goals in an organization. (“Learn more about”, n.d.)
(“Learn more about”, n.d. What is an Information System ¶ 1)

15. Information Systems Information that is collected and stored
Lists of customers/patients
Vital Signs
Physician documentation
The entire electronic health record system
Information systems collect and store information so that it is accessible and useful at a later time, or by numerous people. The electronic health record is an example of an information system. The information system contains a list of all of the patients for a health system or hospital. It can record data such as vital signs, physician documentation, lab, and radiology results. The system can then be accessed by whoever may need to view the patient’s record. This may be anyone from a nurses aid to the manager of the unit. Departments that need to interact with the patient may also access the patient information.

16. Medtronic Information System
Type of System
Special Purpose/Clinical
Users
Patients
Physicians
Nurse Practitioners and Physician assistants
Use
Diagnose
Document
The Medtronic “carelink” system is a special purpose clinical application the utilizes data storage and download. The system allows users to download their pump data and send this information to their physician, nurse practitioner or physician assistant for diagnosis of possible pump problems or need to change insulin delivery rates. The system can document pump settings, delivery times and amounts, as well as patient blood sugars.

17. Medtronic Information System
Configuration
Local Area Network
Mainframe
Data Standards
Health Care Informatics Standards Planning Committee
The information system used to support the “carelink” system uses a Local Area Network, or LAN, to communicate with a mainframe for storage of downloaded information.
The Data Standards used for the Information system are the Health Care informatics Standards Planning Panel. The committee which was formally established in February It is a standing organization having planning and coordination responsibilities regarding both national and international health standard. (Health Data Standards: The Players, n.d.)
There are no disease and procedure classifications used as this system is a tool for hospitals and clinicians. The disease and procedure classification is left to the health system itself to code.
Being that this system is not a Nursing system there is no use of a nursing classification system.
This system is a very efficient system that allows access and usability by clinicians and hospitals with support and easy access to documentation. The system also allows the user to store the needed information on the Medtronic mainframe and not use valuable space on their own. Overall I would recommend the system for use by clinicians. I am not convinced however that the general public should try to interpret the data that is processed by this system. Using it strictly for downloading information to their practitioners is a more prudent use of the system.

18. Advantages of Telemedicine
Improved Access
Cost Effectiveness
Patient Demand
Improved Access
Telemedicine can bring healthcare services to patients in distant locations. Rural areas that either were not accessible to healthcare, or where patients are not able to access healthcare, are now accessible. This improved access allows physicians and healthcare facilities to expand.
Cost Effectiveness
Telemedicine reduces the cost of healthcare and increases efficiency through better management of chronic diseases. It can also reduce travel times, and may result in fewer or shorter hospital stays.
Patient Demand
Some patients prefer telemedicine because it reduces their travel time as well as related expenses and stressors. Patients now have access to providers that they could not reach before.
(“What is Telemedicine?”, n.d.)

19. Disadvantages of Telemedicine
Legal Issues
Liability
Reimbursement
Physicians/Patients
Some of the disadvantages of Telemedicine include, but are not limited to:
Legal Issues
Although we will explore these legal issues further in the upcoming slides, they include
Physician Licensure by State
Interstate Provision of Services
Dual or Multiple State Licensure
Reciprocity
Liability
In the event of an adverse patient outcome, who will be held liable? Should the referring practitioner in the state of the patients residence be held liable, or should the consulting practitioner be held liable? Another issue of liability is where should a suit be filed if need be. Should the suit be filed in the state of residence of the patient or in the practitioner’s state of licensure? (What is Telemedicine, n.d.)
Reimbursement
Currently, there are only 10 states in which Medicare will reimburse for telemedicine. In order to be reimbursed, the county must be designated as a health professional shortage area. Not only does Medicare restrict reimbursements, but most commercial insurances do not cover routine telemedicine. (What is Telemedicine, n.d.)
Physicians and Patients
Physicians are not embracing telemedicine readily due to the fact that they fear the loss of patients. Similarly, some patients are not using telemedicine due to the impersonality of the system. Many patients still prefer to have see a physician in person. (What is Telemedicine, n.d.)

20. Legal/Ethical Issues of Telemedicine
Interstate vs. Intrastate
Licensure
Accreditation
Interstate vs. Intrastate and Licensure
Currently, the licensing of a medical practitioner is handled by the individual states where the practitioner will be practicing. As far as intrastate communication there is little concern as the practitioner is in his or her state. However, when we deal with patients in other states we need to look at reciprocity of services and reimbursement. The licensure of the practitioner will also play a role in the liability of a practitioner in a law suit. Where does the patient or their family have to file suit against the practitioner? Should the suit be filed in the patient’s state or in the practitioner’s state?
Accreditation
Accreditation of practitioners and facilities is currently reviewed by and authorized by the state departments of public health, Centers for Medicare and Medicaid Services, the Joint Commission, and the Health Facilities Accreditation Program (HFAP). These governing bodies have set standards of accreditation for hospitals and practitioners alike for the use of telemedicine. Currently the departments of public health, Centers for Medicare and Medicaid, and the Joint Commission require that the practitioner be licensed in the state of the facility in which he or she practices. HFAP requires that the practitioner be licensed in the state of their home facility as well as the state of the patient in which they are providing services. (Busey & Michael 2008)

21. Legal/Ethical Issues of Telemedicine (cont.)
Reimbursement
Professional Liability Insurance
Privacy Issues
Reimbursement
The government allows the use of a telecommunications system as a substitute for face-to-face, “hands on” encounters for certain Medicare Part B consultations or office visit services. (Busey & Michael 2008) Currently, as stated earlier, there are only 10 states that Medicare reimburses for telemedicine. The counties must also be declared a health professional shortage area.
Professional Liability Insurance
At this point it is unsure if telemedicine services will be covered by the health care provider’s professional liability policy. Therefore, it is up to each provider to check with his or her insurance provider to determine what if anything would be covered.
Privacy Issues
Privacy of health information needs to be maintained at all times, therefore the proper actions need to be taken by providers to ensure that transmitted data is safe. Providers must provide encryption services or other security measures to guarantee the safety of the information. Providers need to establish a process for maintaining confidentiality of protected health information as stated by the Health Insurance Portability and Accountability Act (HIPAA).

22. Informatics Competencies
Beginning Nurse
To Communicate with other systems
Access Data
Upload and Download
Use Computerized Monitoring System
A beginning nurse is expected to use computers to communicate with other systems, access data, and upload and download data. The beginning nurse must also be able to use computerized monitoring systems to monitor patients. (Starren, Tsai, Bakken, Aidala & Morin, 2005)

23. Informatics Competencies
Experienced Nurse
Apply Monitoring System Appropriately
Perform Basic Trouble Shooting
Experienced nurses need to be competent in applying monitoring systems appropriately according to the data needed. Experienced nurses must also be able to perform basic troubleshooting in applications. (Starren, Tsai, Bakken, Aidala & Morin, 2005)

24. Functions/Responsibilities of Informatics Nurse Specialist (INS)
Informatics Nurse Specialists
Devising strategies for installing applications/systems
Applying installation tools during implementation
Managing the installation process
Developing testing, implementation, conversion, and backup plans
Assisting in the resolution of basic software problems
Informatics Nurse Specialists (INS) must be able to devise strategies for installing applications and systems in the patient’s home. They must be able to apply installation tools during the implementation of the system. They must be able to manage the installation process. The INS must be able to develop testing, implementation, conversion, and backup plans in case of system failures. The INS must also assist in the resolution of basic software problems.
(Starren, Tsai, Bakken, Aidala & Morin, 2005)

25. Functions/Responsibilities of Informatics Nurse Specialist (INS)
Performing complex troubleshooting in applications
Producing short- and long-term training plans
Producing training manuals and operating manuals
Delivering user training programs
Evaluating user training programs
The INS must be able to perform complex troubleshooting in applications. They need to be able to produce short- and long-term training plans for patients as well as other practitioners. The INS needs to produce training manual and operating manuals tailored to the organization. Finally the INS needs to deliver and evaluate user training programs.
(Starren, Tsai, Bakken, Aidala & Morin, 2005)

26. Summary What is Telemedicine Real time –Synchronous
Store and Forward – Asynchronous
Usage
Components
Informatics Systems
Telemedicine is used to communicate with patients and providers outside of the hospital. Real-time, or synchronous, is the live consultation of provider and patient. Store and Forward, or asynchronous, is the use of or discussion boards for communication. The usage of telemedicine is growing to various aspects of the medical field. Components of telemedicine include the hardware and the proper software. The information system is a collection of data and methods to store that data so that it can be used later.

27. Summary (Cont.) Advantages Disadvantages Informatics Competencies
Functions and Responsibilities of the Informatics Nurse Specialist
Advantages of telemedicine include improved access to providers, cost effectiveness, and patient demand. Disadvantages include Legal issues, liability, reimbursement, and physicians and patients. Informatics competencies are required for the beginning nurse as well as the experienced nurse. Finally, we looked at the functions and responsibilities of the informatics nurse specialist.

28. Bibliography
American Telemedicine Association. (2010).  Telemedicine Defined. Retrieved September 11, 2010, from
Busey, J.C., & Michael, P. (2008, August). Telehealth—opportunities and pitfalls . Journal of the American Dietetic Association, 108(8), Retrieved from

29. Bibliography (Cont.)
CareLink Personal Therapy Management Software. (n.d.). Insulin Pumps, CGM (Continuous Glucose Monitoring), Minilink Transmitter, Paradigm Revel, Diabetes Glucose sensors and meters | Medtronic Diabetes | Formerly Minimed. Retrieved October 5, 2010, from
Encounter Management Software Tools | AMD Global Telemedicine. (n.d.). Telemedicine Equipment & Telehealth Technology - AMD Global Telemedicine. Retrieved October 5, 2010, from

30. Bibliography (Cont.)
Grady, D. (1999, October 22). Doctor at south pole received medical help via video. The New York Times, Retrieved from
HEALTH DATA STANDARDS: THE PLAYERS. (n.d.). UW Faculty Web Server. Retrieved October 28, 2010, from

31. Bibliography (Cont.)
Learn More About Information Systems (IS). (n.d.). UMBC An Honors University in Maryland. What is an Information System. Retrieved November 11, 2010, from
Medical Imaging Telemedicine Telehealth Store and Forward. (n.d.). Global Telemedicine Telehealth Medical Imaging Technology . Retrieved October 5, 2010, from

32. Bibliography (Cont.)
Starren, J., Tsai, C., Bakken, S., Aidala, A., & Morin, P. (2005, August 5). The role of nurses in installing telehealth technology in the home. Retrieved from
Telemedicine. (n.d.). Dr. Sachin Kale, MD. (Pathology), Aurangabad, Maharashtra, India.. Retrieved October 5, 2010, from

33. Bibliography (Cont.)
What is Telemedicine. (n.d.). Center for Rural Health, University of North Dakota School of Medicine and Health Sciences. Retrieved November 16, 2010, from ruralhealth.und.edu/pdf/whatistele.pdf
What is Telemedicine and Telehealth?. (n.d.). American Telemedicine Association. Retrieved November 16, 2010, from

34. Photographic Bibliography
EDT (Credit given), Tempus IC System [Photograph] retrieved October 5, 2010 from
Untitled Photograph of Medtronic Insulin Pump and Hardware. Retrieved October 5, 2010 from
Untitled Photograph of Medtronic CareLink USB wireless upload device. Retrieved October 5, 2010 from