Telehealth
Note: This information was collected in response to a draft
of the National Initiative for Telehealth Guidelines and adapted
here as a resource to explain RNAO’s belief’s surrounding
the system and the role of the RN in it.
Telehealth can increase access to care, particularly for those
in remote areas or who would have difficulty accessing the health-care
system. It can act as a bridge between sectors and link parts of
the health-care system to increase seamlessness in the delivery
of care. One of the strengths of telehealth is its ability to be
a natural extension of primary health care by increasing accessibility
and linking patients with their own providers.
Telehealth is not without challenges, however, and these must be
addressed early on to avoid fragmentation and compromising quality
of care.
Telehealth is a relatively new area of practice. RNAO supports
the development of a comprehensive policy for telehealth in Canada,
with consistent guidelines and standards within jurisdictions. It
is important to ensure we are not creating a new silo and that every
effort is made to integrate telehealth into the existing structure
of our health-care system, linking the organizations and providers
that are in place. The values, principles, and standards of care
should be consistent with our health-care system. This means that
this type of care must be publicly funded and thus universally accessible
for whom this mode of care makes sense.
Although telehealth provides unique challenges, telehealth should
complement care that already exists and address a gap in service
delivery that cannot be met in any other way. RNAO has long maintained
that telehealth practice must never be used as a substitute for
face-to-face care. In fact, the Standards of Practice by the College
of Nurses of Ontario, the regulatory body for nurses in this province,
maintains that telenursing practice should never be a replacement
for current health care services.
It is also our opinion that the registered nurse is the most appropriate
provider to be in first contact with members of the public accessing
telehealth services. The registered nurse has the knowledge, skill
and expertise to provide necessary safe and effective care to the
clinical encounter. That level of expertise and knowledge cannot
be replaced by “training” a less qualified individual
to answer calls. It is precisely because the potential risk is higher
when there is no opportunity for direct contact with the patient
that a skilled clinician is essential. An added complication of
this type of care is that the context of the individual requiring
care is not as evident (e.g. social, economic, environmental, cultural
context) as during face-to-face encounters.
Organizational Leadership
Central to the success of telehealth initiatives within organizations
is the integration of telehealth policies into existing organizational
policies. The importance of workplace readiness for telehealth cannot
be overstated because all aspects of the work environment will be
affected.
It is important to acknowledge that the appropriate skill, experience
and educational preparation are critical in telehealth, particularly
for those providing clinical care.
Two key principles are the need for accountability. For example,
all individuals receiving telehealth services need to be clear as
to who is providing service and where they are located, their credentials,
who is participating in the encounter, how the care will be documented,
and what recourse is available if an individual is dissatisfied
with the care provided. Organizations and health-care providers
must be vigilant about ensuring informed consent.
In terms of health-system readiness, it should be noted that telehealth
policies and procedures must be consistent with the values and standards
of the health-care system and contribute to the sustainability of
health-care services. Services must also be accessible to all residents.
The issues of privacy, confidentiality, security, ethics and informed
consent cannot be overstated since telehealth presents challenges
not seen in face-to-face contacts.
Human Resources
This is a significant issue given the involvement of nursing in
telehealth and the shortage of registered nurses. Because of the
level of skill required in telehealth, it is critical that registered
nurses not be replaced with less qualified providers.
Accountability issues must be addressed in telehealth because of
the level of risk involved. As a principle, to address patient safety,
accountability and problems of liability, it is critical that registered
nurses are regulated health professionals and have the necessary
competencies to provide telehealth care and to effectively refer
to other providers when needed. As a minimum, all jurisdictions
should ensure there are standards of practice for health-care providers
involved in telehealth.
The issue of health human resources in nursing is paramount. The
guidelines and principles suggest that staff need the necessary
competencies and qualifications. In our view, they also should be
experienced because of the autonomous nature of the practice and
the level of skill and judgment required. The College of Nurses
of Ontario, for example, specifies in their Telephone Nursing Practice
Standards that this practice must be carried out by a registered
nurse because it is beyond the scope of the registered practical
nurse.
In an environment in which there are shortages of registered nurses,
agencies and organizations may resort to less qualified staff, an
approach that will compromise safe effective care.
Clinical Standards and Outcomes
Clinical care is central to telehealth. The duty of care in telehealth
is the same as the duty of care in a face-to-face encounter. Patients
also need to know what recourse they can take if problems arise
as a result of the advice or care they have been given. We cannot
emphasize enough that while consent for teletriage is implicit,
it must be informed.
Informed consent means that the patient is fully aware to whom
they are speaking and their credentials, who else is party to the
interaction, and where the care provider is located.
While we believe that registered nurses are uniquely qualified
to carry out teletriage and provide telehealth services, it is essential
that other clinical support also be available. Nurses in telehealth
require access to clinical support and continuing education, especially
in view of the special challenges posed by telehealth practice.
Nurses also need appropriate liability, a responsibility of both
the organization and the registered nurse.
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Page content adapted from the Submission
to National Initiative for Telehealth Guidelines. NIFTE Framework
of Guidelines. Referencing
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