1. Telenursing
Presented by:
Joan Ribbons, RN

2. Telecommunications is a vital part of Telenursing.

3. Objectives: Describe Telenursing
Describe and evaluate the hardware and software utilized with telenursing
Describe and evaluate the information system used with telenursing
Assess the role and functions of the nurse informaticist when working with telenursing
Examine related legal/ethical issues
Discuss the Advantages/Disadvantages from nursing perspective

4. Telenursing
health services delivered by telecommunications-ready tools supervised or directed by a nurse
concerns itself with client outcomes: acute care, chronic care, disease management, and quality of life
Telenursing is not new. It is something the Healthcare field is expanding on as technology continues to grow.
Today, Telenursing means using telephone and computer technology in nursing to assist in managing patient care. It does this by transmitting voice, data and/or video to provide quality medical care to homebound persons so they may stay in their home.
Teletriage is Telenursing. This providies a convenient form of nursing advice to persons, wherever they are. It’s offered by Hospitals, Medical Groups, and Medical clinics, e.g., Penn State University at Advice Nurse at
Telenursing practice uses the nursing process to assess, diagnose, intervene and evaluate outcome, in context of experiences, judgement, and clinical decision making (Bartz, 2009).
Telehomecare,to observe,assress, and teach patients; Telemonitoring which includes, usiing electronic equipment to monitor patieint’s vital signs, cardiac moniotors and disease management from their homes.

5. Telenursing Hardware:
telephone, internet, server, electricity
provider station, video patient station,monitoring station
Telephones and computers are in most households and telenursing is an integral part of the healthcare team. (Home is defined as anywhere outside of the medical setting). A telephone and computer can easily be added to a patients home environment to transmit data and knowledge. With sicker patients returning to the comfort of their homes nurses must meet this challenge and patients are “visited” by nurses in their homes by phone and computer. This is called a virtual home health visit”.
Everyone who has access to a phone may now have access to computers to be used to deliver healthcare services by -- telecommunications-ready tools supervised or directed by a nurse (McGonigle, 2009)
Let me have a show of hands of who has a computer and internet at home. 50% of people use computers at home in the USA (Google, 2010)
-Important that the patient can perform what is expected; like plugging in equipment to the phone jack and pushing a send button to transfer data to the telenurse.
- The NX Server Software requires the following Hardware: American TeleCare Provider Station, server and Video Patient Station and/or Monitoring Station.
High-Definition Video Conferencing in Healthcare - This case study discusses how Montana is using Polycom Solutions to bridge the gap in healthcare delivery and communications that plagues the largely rural and sparsely populated State of Montana (Whitepaper,
With the constant pressure to increase the quality of patient care and the desire to provide new services, while at the same time controlling costs, healthcare providers are leveraging the power of video networks to link patients, specialists, and clinicians, thus extending the reach of healthcare. Learn more in this informative whitepaper.
Interface is what we use to engage the hardware to communicate with others using applications. In the patient’s home is a scale which the patient or family caregiver must be taught to connect to the computer, which then delivers data to the software, which communicates to the nurse. Others would be Blood pressure monitor, pulse oximeter, thermometer,glucometer, spirometer, digital camera, and PDA-based or telephonic self-reporting devices.

6. Hardware used in Telenursing:
equipment that captures objective vital sign data
VNA of the Inland Counties in Minnesota use American Telecare Incorporated products, made possible by a grant through the US Dept of Agriculture to manage Chronic Disease. Nurses call the patient by phone, check patient’s BP, heart, and lung sounds, Pulse Oximeter reading and virtually assess the patient (Wachter, 2002).This describes a home care visit: actually a “virtual” visit.
Important that the patient can perform what is expected; like plugging in equipment to the phone jack and pushing a send button to transfer data to the telenurse.
High-Definition Video Conferencing in Healthcare - This case study discusses how Montana is using Polycom Solutions to bridge the gap in healthcare delivery and communications that plagues the largely rural and sparsely populated State of Montana (Whitepaper,
With the constant pressure to increase the quality of patient care and the desire to provide new services, while at the same time controlling costs, healthcare providers are leveraging the power of video networks to link patients, specialists, and clinicians, thus extending the reach of healthcare. Learn more in this informative whitepaper.
Interface is what we use to engage the hardware to communicate with others using applications. In the patient’s home is a scale which the patient or family caregiver must be taught to connect to the computer, which then delivers data to the software, which communicates to the nurse. Others would be Blood pressure monitor, pulse oximeter, thermometer,glucometer, spirometer, digital camera, and PDA-based or telephonic self-reporting devices.

7. Telenursing Software goal customized
--The goal is to gain knowledge through data received from patients to make informed decisions to manage patient care in a timely and convenient manner. Computer software programs are designed to collect and interpret health data gathered remotely via a telehealth communications system (McGonigle, 2009). Telehealth software allows for trending, triage, communications protocols, access and sharing.
-Customizing allows the patient’s needs to drive the care.
System includes Operating system and the software necessary for the computer to function, and Application is the software that allows users to complete specific tasks, as word processors, spreadsheet and presentation software, database managers, and media players (McGonigle, 2009)

8. Software Example NX Server -NX Server Software Features:
Vital signs: Physiological measurements, such as blood pressure and pulse, blood glucose, weight, temperature and PT/INR readings are time and date stamped for future reference and can be graphed to view trending analysis.
Patient-specific thresholds: Set by the clinician, thresholds indicate significant vital sign fluctuations for each patient. FDA approved medical peripherals are used with the American TeleCare Video Patient Stations and Monitoring Stations. When recorded measurement readings exceed the pre-determined threshold, they are colorcoded to readily stand out from readings that are within clinician-set limits.
Questionnaires: The clinician can remotely download questionnaires directly to the Monitoring Station. The patient responds using the touch screen on the Monitoring Station. Responses to these questions supply providers with additional data to help them more effectively manage their patients.
Session management: Designed to manage patients using the Video Patient Stations or Monitoring Stations, telehealth sessions can include instructions for the patients to take certain measurements or to respond to specific questions associated with their condition.
High-resolution snapshots: The Video Patient Stations automatically time and date stamp high-resolution snapshots. Stored images can be easily viewed using the Provider Station or any internet-connected PC running Microsoft® Internet Explorer 6.0.
Clinician notes: Clinicians can make notations regarding their observations during video visit calls with patients. “Free text" areas are also available to add specific notes.
Physician's orders: The physician can record information regarding the patient's episode of care.
Medication schedules: Text space is provided for patient names, medications, routes of administration and dosages and other necessary information.
Diagnoses: Physician diagnoses may be entered and stored.
Video visit scheduler: Clinicians can schedule video visits with patients. The system includes an Operating system and the software necessary for the computer to function, and Application is the software that allows users to complete specific tasks, as word processors, spreadsheet and presentation software, database managers, and media Example of software: NX Server®, and TelecChart ® Software from American TeleCare. Minimum recommended requirements for the NX Server Software server platform are: CPU Pentium lll GHz with 1 GB RAM and Hard Disk >15 GB, RAID is recommended along with an American TeleCare Provider Station, server and Video Patient Station and/or Monitoring System.
(Polycom, 2010)

9. Usability of NX Server
easy to use/user-friendly/user satisfaction
efficient with standardized electronic health records
Interactive visual technology is limited
more realistic data, reflective of usual circumstances at home.
cost
-A system is usable when it involves using familiar equipment and ease of learning and interacting with procedures (Clinical Trials,2009).“Usability and user-friendliness are key factors in hardware such as noise, aesthetic presence, and obtrusiveness, and software matters such as user interfaces and device support” (JAMIA, ) A usable system has provisions for team based and individual interactions (Staggers, 2003)
-Data and information is recorded on standardized health records which may be safely accessed by third parties.
-Any system utilized between patients and providers depend on both explicit and tacit knowledge (McGonigle,2009) to be employed in an effective collaborative relationship, which Telenursing is. This may explain why nurses often overrode the software using the questions to guide them in their care.(Nurs Health Sci.2007.) Workarounds, are created when active participants are trying to tailor systems to fit the way they think and work (Staggers,2003). Workarounds were created to fit nursing needs and work flow.Decision aid software programs in telenursing: not used as intended? Experiences of Swedish telenurses (Polycom 2010).
-Interactive visual technology is limited since without face to face encounters, assessment is more difficult. However, I found in my research that user satisfaction, participation, and health care quality are equally good to face to face interaction. I think this is because patients and their caregivers, are empowered and active in their disease management. Also, by analyzing data nurses can inerpret trends emerging and identify interventions as needed (McGonigle, 2009)
-Most studies were conducted for 1 year, therefore not able to evaluate long-term perceptions. I have a feeling, in the future, we will find good outcomes as NIS develop better programs as people become more dependent on this type of care.
-Tell-A-Nurse found the cost to cover nurse licences in several states range from $ to $1, annually. Some states also require fingerprinting. A national licensure system is needed since telenurse services (easily) cross state lines.

10. Usability of Software user interface design customer support
software updates
- Cognitive modeling of users when designing Telenursing systems affect how individuals use the system (Staggers, 2003).
- A system is usable when it involves using familiar equipment and ease of learning and interacting with procedures (Clinical Trials,2009).“
Usability and user-friendliness are key factors in hardware such as noise, aesthetic presence, and obtrusiveness, and software matters such as user interfaces and device support” (JAMIA, ) A usable system has provisions for team based and individual interactions.
-Customer support and software updates are important to allow for customizing a system or program for patients and for nurses to provide quality care effectivelly. e.g.,Go to for Customer support for NX Server updates(Pinzari, 2003).
- Software updates:
ROME, Italy, December 21th, NX Server introduces major features and bug-fixes in respect to version 1.2.2, among them general usability enhancements and widened cross-platform support.
The release of NX Server product family contains updates to the following components:
1. nxnode
2. nxclient
3. nx-X
4. nxcomp
5. nxcompext
6. nxproxy
7. nxagent
8. nxdesktop
9. nxdarwin
10. nxviewer
11. nxwin
12. nxauth
13. nxssh
14. nxesd
15. nxkbd
16. nxkdrive
17. nxcompsh
18. nxrun
19. nxscripts
Additional information and a detailed list of errata can also be found in the release notices of the enclosed OSS components.
Supported Platforms
The release of NX Server includes support for the following platforms:
- Linux i386
- Solaris SPARC
New features and enhancements
1. Improved support for the RENDER extension
Now sessions running inside NX virtual desktops can fully leverage the eye-candy of font antialiasing and alpha-blending. This improvement doesn't only benefit the visual appearence, but also simplifies system administration by letting clients use server-side fonts, thanks to the fully supported XFT and fontconfig2 standards.
2. Use of the MIT-SHM extension
NX is now able to automatically detect and use the MIT-SHM shared memory extension to communicate with the X server. This offers a significant performance boost on Linux and Windows when using X desktops environments making heavy use of pixmaps or when running RDP or VNC sessions.
3. Sun SPARC Solaris 9 availability
NX Server has been made available on Solaris 9 for SPARC. This allows users to extend the NX Server scalability beyond the current limits of the Linux kernel to the 64 and more processors supported by the Sun SPARC architecture.
4. SSHD/PAM based authentication
NX Server administrators are given the option to achieve seamless integration of NX into the existing network infrastructure by letting users authenticate using any method supported by the underlying SSHD/PAM configuration.
5. Many internal improvements
NX Server now achieves a cleaner separation between the internal components through a redesigned interface. Communication between nxserver and nxnode has been redesigned to support multiple authentication schemes.
6. Better error tracking and reporting facilities
The new backlog of sessions and the reworked error reporting functionality should make it simpler for system administrators to identify the most common causes of problems and implement the needed workarounds.
7. New configuration file
The NX Server configuration file has been rewritten to provide more options and increased readability.
Bug Fixes
This is the list of highest severity TRs that have been resolved in this release:
1. --TRSL "NX authentication extensions"
It is now possible to add users to the NX system even if they are not listed in /etc/passwd file, for example SMB users who are authenticated by a Windows NT domain.
2. --TRSL "Adding a hard shutdown"
The new version of NX Server tries hard to kill the processes of the underlying layers that are found in inconsistent state.
3. --TRSL "RDP and VNC sessions fail unexpectedly"
nxdesktop and nxviewer have been improved to report the reason of the connection failure in all cases not covered by the previous versions.
4. --TRSL "Hung agent takes 100% of CPU utilization"
The session shutdown procedure has been fixed to kill a hung agent if it is not responding to NX Server notifications.
Known Problems and Limitations
1. It is not possible to run single applications in remote RDP desktops. When trying to launch a RDP session in single application mode a full desktop session will be executed.
2. Mouse buttons lose ability to set focus under particular conditions. This bug can occur when, inside a session, two windows are scrolled alternatively. After a number of iterations, clicking on a windows does not set the focus anymore.
3. There could be problems displaying some alpha blended images when enabling the RENDER extension. The same problems may affect the rendering of some web pages in Konqueror and Mozilla. NX system administrators can add the option
AGENT_EXTRA_OPTIONS_X = "-norender"
to the 'node.conf' configuration file to disable RENDER extension.
4. Desktop sessions on 8bpp X servers are not dealing with the installed colormaps correctly. X sessions running in single application mode don't seem to be affected by this misbehaviour.
5. When running sessions in single application mode it can happen that the proxy connection is not shut down at the time the last visible window is closed. In these cases users can terminate the session by using the NX Client Session Administrator. This behaviour can occur if a child process of the original application remains connected to the proxy server even after the parent process has exited.
6. There could be problems with keystrokes being incorrectly repeated. This problem seems to be related to timestamps being incorrectly rewritten by nxagent. A solution is being investigated.
7. On Mandrake 9.1 and Solaris, installations characters could be incorrectly displayed when using the RENDER extension. The problem is related to incompatibilities between the XFT and RENDER libraries shipped with the original OS and the libraries used by NX. The problem can be solved by upgrading the system libraries to the latest versions made available by the XFree86 project. Some users reported that the problem disappears when selecting a different system font.
Specific Solaris issues
1. There could be problems running X clients whose executable is not in the system path.
2. It is not possible to mount remote shares exported by clients. A solution to provide SMBFS funtionalities on Solaris is under evaluation.
3. When X sessions running on Solaris NX Servers are displayed on i386 clients, some mouse cursors can appear to be incorrectly shaped (Pinzari, 2003)
by: Gian Filippo Pinzari

11. American TeleCare’s ® NX Server System
Web-based, using:
- Video station
- Monitoring station
American TeleCare's® NX Server Software is webbased and designed to securely store and display patient information using a SQL type database platform. The software is designed to manage data collected using American TeleCare® Video Patient Stations and American TeleCare Monitoring Stations.
The web server communication interface limits communications with the NX Server to encrypted sessions using Secure Socket Layer (SSL) technology. This provides privacy for data uploads from the Monitoring Stations and the Video Patient Stations. Only licensed authorized users (requiring a valid user name and password) may access patient data at an authorized workstation on the network.
TeleChart,® tailored specifically for home telehealth, is an electronic medical record (EMR) system incorporating a relational database component of the NX Server Software.
Patient data may also be forwarded to a third-party EMR using an industry standard Health Level Seven® (HL7) protocol, via optional interface software developed by American TeleCare. Patient data forwarded to a third-party EMR is subject to the functionality included in the third-party EMR software.
The TeleChart EMR catalogs the patient's record and retains readings obtained during home video visit encounters and/or monitoring data uploads.
NX Server Software Features:
Vital signs: Physiological measurements, such as blood pressure and pulse, blood glucose, weight, temperature and PT/INR readings are time and date stamped for future reference and can be graphed to view trending analysis.
Patient-specific thresholds: Set by the clinician, thresholds indicate significant vital sign fluctuations for each patient. FDA approved medical peripherals are used with the American TeleCare Video Patient Stations and Monitoring Stations. When recorded measurement readings exceed the pre-determined threshold, they are colorcoded to readily stand out from readings that are within clinician-set limits.
Questionnaires: The clinician can remotely download questionnaires directly to the Monitoring Station. The patient responds using the touch screen on the Monitoring Station. Responses to these questions supply providers with additional data to help them more effectively manage their patients.
Session management: Designed to manage patients using the Video Patient Stations or Monitoring Stations, telehealth sessions can include instructions for the patients to take certain measurements or to respond to specific questions associated with their condition.
High-resolution snapshots: The Video Patient Stations automatically time and date stamp high-resolution snapshots. Stored images can be easily viewed using the Provider Station or any internet-connected PC running Microsoft® Internet Explorer 6.0.
Clinician notes: Clinicians can make notations regarding their observations during video visit calls with patients. “Free text" areas are also available to add specific notes.
Physician's orders: The physician can record information regarding the patient's episode of care.
Medication schedules: Text space is provided for patient names, medications, routes of administration and dosages and other necessary information.
Diagnoses: Physician diagnoses may be entered and stored.
Video visit scheduler: Clinicians can schedule video visits with patients.
The NX Server Software operates on a Windows® 2000 server platform. Minimum recommended requirements for the server platform are:
* CPU: Pentium III 1 GHz
* Memory: 1 GB RAM
* Hard Disk: >15 GB, RAID recommended
The NX Server Software requires the use of an American TeleCare Provider Station, server and Video Patient Station and/or Monitoring Station.

12. Review of American TeleCare’s ® NX Server System
To gather and manage data by Nurses
for Patient-specific thresholds.
This system is used by nurses and doctor’s and third parties (and Health Level Seven® (HL7) protocol, via optional interface software developed by American TeleCare) protocols in home settings.
NX Server Software Features:
Vital signs: Physiological measurements, such as blood pressure and pulse, blood glucose, weight, temperature and PT/INR readings are time and date stamped for future reference and can be graphed to view trending analysis.
Patient-specific thresholds: Set by the clinician, thresholds indicate significant vital sign fluctuations for each patient. FDA approved medical peripherals are used with the American TeleCare Video Patient Stations and Monitoring Stations. When recorded measurement readings exceed the pre-determined threshold, they are colorcoded to readily stand out from readings that are within clinician-set limits.
Questionnaires: The clinician can remotely download questionnaires directly to the Monitoring Station. The patient responds using the touch screen on the Monitoring Station. Responses to these questions supply providers with additional data to help them more effectively manage their patients.
Session management: Designed to manage patients using the Video Patient Stations or Monitoring Stations, telehealth sessions can include instructions for the patients to take certain measurements or to respond to specific questions associated with their condition.
High-resolution snapshots: The Video Patient Stations automatically time and date stamp high-resolution snapshots. Stored images can be easily viewed using the Provider Station or any internet-connected PC running Microsoft® Internet Explorer 6.0.
Clinician notes: Clinicians can make notations regarding their observations during video visit calls with patients. “Free text" areas are also available to add specific notes.
Physician's orders: The physician can record information regarding the patient's episode of care.
Medication schedules: Text space is provided for patient names, medications, routes of administration and dosages and other necessary information.
Diagnoses: Physician diagnoses may be entered and stored.
Video visit scheduler: Clinicians can schedule video visits with patients.
It is webbased and uses a local area network.
I would like to recommend this system because FDA medical peripherals are used, and it appears to do it all, with customer service. American TeleCare, Inc., is the leader in this emerging modality of healthcare delivery, having installed more than 95 percent of all video-based home telehealth programs nationwide.It is designed with the patient in mind: with a high contrast color screen, large font,and icons, easy operating instructions, on screen volume and navigation control, and it’s compact and durable for home life.
I seems to be ready for Electronic Medical Records, but I could not find what standards are used in this system. It did mention that it could utilize HL7 standards. It did not mention a Disease and Procedure Classification System but eluded to third parties being able to access this system with proper authorization. Therefore, with my knowledge as of now, I would suggest contacting the company to get answers to these questions. If they met these criteria, I would also ask the price of such a system and training costs and if they rent the system. I n my research I found that Systems may be rented to be cost effective.

13. Advantages of Telenursing
increases patients’ ability to self-care, in a range of patients, and settings
nursing care at home
timesaving
cost efficient
-Patients who become more involved in their care via telenursing, are empowered and become more involved in their care. Surveys by American Association for Retired Persons show the 90% of seniors want to remain independent at home (McGonigle, 2009) and telenursing helps make this possibe.
-Patients do not need to spend time traveling to a clinic, etc. or make unnecessary trips.
-Money is saved in multiple areas e.g., patient travel expenses, medical office or emergency room visits
Positive findings: One nurse may televisit patients saving time in one day The use of Telenursing in the home was determined to achieve cost savings, improved access to home care support without any differences to clinical outcomes when compared to traditional nursing care (JAIMA,2008).
A recent clinical trial found a decrease in readmissions after using simple telephone questionnaires related to their health (JAIMA,2008).
With the constant pressure to increase the quality of patient care and the desire to provide new services, while at the same time controlling costs, healthcare providers are leveraging the power of video networks to link patients, specialists, and clinicians, thus extending the reach of healthcare. Learn more in this informative whitepaper (Polycom, 2008).

14. Disadvantages of Telenursing
In a medication administration example, patients made medication administration errors
Stress and potential for error
In this study of 25 patients and 18 comparison subjects, patients with schizophrenia demonstrated significantly more quantitative errors in dispensing medication and took medications late more often than comparison subjects(Academic Psychiatry, 2009).
A major problem for Telenurses is that they can’t see their patients face to face. They feel considerable responsibility and fear making wrong decisions(IHE-ONLINE,2008). This may add stress to their job, and may increase error. Since nurses cannot always see their patients they will have to rely on their other communication skills, such as hearing, listening, and asking questions that will elicit answers that provide useful information for the nurse to interpret and analyze to form decisions upon which she/he will base decisions.

15. Ethical Issues of Telenursing Central concept in nursing Communication skills Competing interests
-A major problem for Telenurses is that they can’t see their patients. They feel considerable responsibility and fear making wrong decisions(IHE-ONLINE,2008). This may add stress and a chance for error to their job, and is another area to be considered in Ethics. For example: During a phone visit a nurse will not see the patient. This is important when assessing a patient. One way to do this would be to ask patients specific questions about color. Another would be to ask the patients home companion questions to help with your assessment. This raises questions of Ethics and breeching confidentiality.
-Telenurses must have good communication skills to ensure the patient’s autonomy, integrity,priority setting, dignity, solidarity, and cost efficiency.
Documenting must be clear and objective.
When patients agree to telenursing, there is an education process during which patients become more involved in understanding and taking responsibility for their health.
-”Ethicists have dwelt on patients’ internally competing interests in knowledge of their own health (e.g., knowing one’s risk for breast cancer can lead to life-extending changes and/or can have a negative impact on quality of life) as well as externally competing interests between the patients and insurers and between patients and researchers (or public health officials).”Competing interests exist between patients and researchers; harvesting data for commercial use, and insurer’s and themselves e.g., know their diagnosis/may have a negative impact on their life (JMAIA, 2008).
- Discussions for Ethical competence building is needed in Telenursing (Wachter, 2002) Care Ethics - Is responsiveness to the needs of others that dictates providing care, preventing harm and maintaining relationships. Benjamin and Curtis base their framework on "care ethics" (McGonigle, 2009).

16. Legal Issues licensing scope of practice safety security and HIPAA
accountability
legal competencies
-Licensing is especially important when a clinic is close to state lines: Patients call from multiple states.
-Scope of practice is the same as in face to face model. Nurse’s documentation must be very accurate and complete. Patients must understand and sign consent forms/ releases to receive telehealth services. It is also very important for the Nurse Informaticist to upgrade information systems to ensure that a high level of data security is provided at all times. The timeliness of the information alone is of immense importance making earlier interventions possible. Interactive visual technology is limited because of costs and scheduling problems with it. But I see this as a challenge which will be met in the near future. (McGonigle, 2009).
-Safety: Nurses need to be sure patients understand their responsibility and that they can fulfill their roles to provide safe care. Nurses must remember “do no harm”. The Informaticist must upgrade information systems to ensure that a high level of data security is provided at all times.
-Security: Nurses and patients must follow protocol to protect the security of all information, remembering that all data collected will need to be secured for the life of the patient. HIPPA regulations must be ifollowed to assure privacy..
An added problem is that there are more people in the patients home that are involved in the patients care at times, and they too must understand and be educated in the importance of protecting patient’s privacy.
-Accountability for practice and potential for malpractice are largely unresolved. Nurses need to be vigilant in documentation which include conformed consents, clinical data, confidentiality, and safety (McGonigle,2009).
- Legal competence includes maintaining knowledge of and abiding by licensing laws and scope of practice.

17. Informatics Competencies
Computer skills
Informatics knowledge
Informatics skills
Communication skills
-Nursing informatics competencies are essential in Nursing as it becomes more technologically advanced. All nurses must be competent and confident in basic Informatics skills.e.g., using , Using Internet to locate and download information, using computerized patient monitoring systems, identifyiing basic components of a computer system, and recognizing limitations of a computer program due to its design and capacity of the computer. A complete list of NI competencies is available at (McGonigle, 2009).
Four levels of Practicing Nurses advance from: Beginning, experienced, Informatics nurse specialist, and Informatics innovator. Skills and knowledge develop from basic to having the ability to conducts research and generating informatics theory. -Communication skills are important since the Telenurse makes assessment based on verbal communication. Kinsella and Albright remind us that good communication skills are needed to “effectivly increase nurses’ knowledge of their patients’ status in a timely manner”(McGonigle, 2009). Following protocol and having the ability to listen and hear what the patient or the patient’s caregiver is saying is critical. Writing skills are important in documenting the interaction.
Example; Using Centramax software to handle Triage, Telenurses use this software program to guide them through questions to aid in determining a nursing diagnosis. The Telenurse then needs to determine what to recommend. Understanding the software being used is necessary in order to perform her job in a timely manner, providing quality care, as well as cost efficiency and time-savings, e.g., saving a trip to the emergency room or clinic. Telenurses must maintain computer competencies to be able to meet the continuing challenges of Telenursing in order to provide reliable medical advice in a responsible manner maintaining the patients’ dignity and integrity (Wachter, 2002)
-Nurses need to stay current with the software and hardware they will be using, as well as their patients will be using. They should hopefully also be involved with the process of user-centered-design and advocate for it.
-specific competencies for the telenurse would be he/she iis able to assess and address the patient’s needs, limitations, and expectations early.

18. Role of Professional Nurse Informaticist and Informaticist Nurse Specialist in Telenursing
System Specialist
System Manager
Patient Safety
Membership in Professional Organizations
-In Telenursing, the Nurse Informaticist and Information Nurse Specialist work as a liason between technology and safe healthcare as a system specialist.. He/she may work as a project manager, consultant, educator, researcher, product developer, decision support/outcomes manager, advocate/policy deviloper system specialist or entrepreneur (McGonigle, 2009)
The Nurse Informaticist may obtain an advanced degree or a post-master’s certificate through the American Nurses Credentialing Center or exam sponsored by HIMSS. The NI may continue education in college in a Graduate Degree Program(McGonigle, 2009).
The role of the nurse informaticist, Nursing Informatics Specialist (NIS), at Winthrop University Hospital (WUH), as described in the 2002 position description, is as system manager of the SMS or Envision hospital information system. The Nurse Informatics Specialist is responsible for the development, implementation and training within the Nursing Department. In collaboration with the Nursing Department, including the unit secretaries and the Medical Information System (MIS) staff, the Nurse Informatics Specialist is responsible for the clinical informational needs of the nursing department. The NIS conducts orientation programs for the nurses, ancillaries, and the physicians and serves as a resource person for all other departments regarding the SMS hospital information system. Application implementation, enhancements and conversions of the system are coordinated and directed by the NIS. Policies and procedures regarding the information system are written, implemented and maintained. The NIS is also responsible to update the staff on the design of the SMS system and the use of the order entry, results reporting and new program functions on the system. Additionally, the NIS is involved in CQI activities and serves on the CQI committee. From this I can summarize that the NI and INS in Telenursing do much the same.To put it in a nutshell, this position is more than a “Resource Person”. It is a position incorporating all of the above as well as developing new methods of organizing data to enhance research (Lucas, 2004).
The Nurse Informaticist focuses on how to improve patient care and safety as well as the workflow and processes, of nurses and other healthcare workers.
-The benefits of membership in a professional organization are educational and professional development, development of policies,and subscriptions to publications and journals. They also provide networking opportunities and a united voice of NI.
(McGonigle, 2009)

19. Summary: Telenursing Telenursing is virtual nursing safe
cost effective
HIPAA compliant
provides quality care
-Like real-time, face to face home health, telenursing is complex and knowledge intensive (IHE-ONLINE, 2008), where nurses work.
independently, make decisions about the patient’s need for further care, give advice on self-care or refer to appropriate service for help from a remote location((Wachter, 2002). In telenursing, sometimes nurses cannot see their patients(a disadvantage which can be overcome by the telenurse relying on communication skills and data collected (vital signs, weight,trends, verbal communication) and using their knowledge base to analyze the information gathered. Even when they may see their patients on video monitors, the nurse is able to assess the patient using wisdom and knowledge in a safe way following protocol of patient stardards, while being compliant. With a usable system as TeleCare’s ® NX Server Software System and Hardware (American TeleCare Provider Station, server and Video Patient Station and/or Monitoring Station), the telenurse is able to gather and interpret data, document interventions and manage patient care safely. With the Nurse Informaticist acting as a liason between the Telehealth nurse and the technology being used, patients receive timely care in the comfort and convenience of their homes, wherever they are. Doctors have electronic access to the electronic health records generated and are able to provide professional decisions based on the data and the documentation of the telenurse. Legal and ethical issues arise, particularly with caregivers and others in the patient environment. Not much research has been done in this area. Some efforts are being made to have nurses licenensed in a National registry. Clear and complete, objective documentation is important. Good communication and assessment skills are essential for the telenurse.
I think we may employ collaborative learning in our patient / provider relationship. Using this style of learning ensures usability of whatever trend we decide to use to meet our patient needs. With critical thinking, we are able to provide practice-based nursing with best practices for the patient. Nurses will be utilizing Telehealth more and more, especially with the shortage of Doctors in the United States, and the new National Helathcare plan being developed by the US government. Another source of the large amount of “baby-boomers” wanting homecare, which already is using Telenursing with the increasing number of people with chronic diseases, such as Diabetes. Since increasing the quality of life for our patients is our goal, Telenursing is definitely in the right place at the right time. It is convenient, empowering for the patient and family, timely, cost saving, and being implemented with best practice, and evidence-based standards. I recommend embracing the use of information technology in the most current, and safe way to provide patient-centered healthcare to as many people who need it: eventually that’s everyone.

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