GOVERNMENT COLLAGE OF NURSING,

ALAPPUZHA

SEMINAR
ON

TELEMEDICINE AND
TELENURSING

Subject: COMMUNITY HEALTH NURSING

Submitted to Submitted by
Mrs. Ananya G R Mrs. Sandra U S.
Assistant professor 1st Year MSc. Nursing
GCNA GCNA

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INTRODUCTION
The term telemedicine derives from the Greek “tele” meaning “at a distance” and the present
word “medicine” which itself derives from the Latin ‘mederi’ means ‘healing’.

Telemedicine is rapidly developing application of clinical medicine where medical information

is transferred through the phone or the internet or sometimes other networks for the purpose of
consulting, and sometimes remote medical procedures or examinations.

DEFINITION

“The delivery of Health care services where distance is a critical factor, by all Healthcare
professionals using information and Communication Technology for the exchange of valid
information for diagnosis, treatment and prevention of disease and injuries, Research and
evaluation, and for continuing education of Health care providers, all in the interests of
advancing the health of individual and their community.”

(WHO)

TELE CONFERENCE

" A tele conference is a telephone or video meeting between participants in 2 or more locations.
teleconferences are similar to telephone calls, but they can expand discussion to
more than 2 people

HISTORY OF TELEMEDICINE

Care at distance (also called in absentia care), is an old practice which was often conducted via
post: there has a been a long and successful history of in absentia health care which - thanks to
modern communication technology has metamorphosed into what we know as modern
telemedicine.

In its early manifestations, African villagers used smoke signals to warn people to stay away
from the villages in case of serious disease.

In the early 1900s, people living in remote areas in Australia used two- way radios, powered
by a Dynamo driven by a set of bicycle pedals, to communicate with the royal flying Doctor
service of Australia. The idea of performing medical examinations and evaluations through the
communication network is not new. Shortly after the invention of the telephone, attempts were
made to transmit heart and lung sounds to a trained expert who could asses the state of the
organ. However, poor Transmission Systems made the attempts a failure.

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1906: ECG transmission Einthoven, the father of electrocardiography, first investigated on
ECG transmission over telephone lines in 1906. He wrote an article Le tele cardiograms at the
archives internationals physiologies 4: 132 ,1906.

1920s: Help for ships telemedicine dates back to the 1920s. During this time, radios were used
to link physicians standing watch at shore stations to assist ships at sea that had
medical emergencies.

1924: the first exposition of Telecare perhaps it was the cover showed below of "Radio news
"magazine from April 1924, the article even includes a spoof electronic circuit diagram which
combined all the gadget of the day in to this latest Marvel information and photo by courtesy
of Dennis J. Streveler Ph. D Healthcare IT consultant.

1955: Tele psychiatry the Nebraska psychiatric institute was one of the first facilities in the
country to have closed circuit television in 1955.In 1971 the Nebraska medical centre was
linked with the Omaha veteran’s administration hospital and VA facilities in two other towns.

1967: Massachusetts general hospital this situation was established in 1967 to provide
occupational health services to airport employees and to deliver emergency care and medical
attention to travellers.

1971: Japan: first time implemented in two areas: Nakatsu -mura and Komagata - chop,
Wakayama using telephone line for voice and fax transmission and CATV system for image
transmission

1997: In India, Telemedicine practice was initiated in Lucknow and Chennai at 1997.

In Kerala, the first unit of Telemedicine was established at medical collage Trivandrum in 2003.

The first Ayurvedic Telemedicine centre was established in India in the year 2007 by Prathap
Chauhan, a well - known Indian ayurvedic doctor.

1997: In India, Telemedicine practice was initiated in Lucknow and Chennai at 1997.

In Kerala, the first unit of Telemedicine was established at medical collage Trivandrum in 2003.

The first Ayurvedic Telemedicine centre was established in India in the year 2007 by Prathap
Chauhan, a well - known Indian ayurvedic doctor.

USES OF TELEMEDICINE

1. Tele conferencing reaches large or sparsely - populated area

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It offers opportunities for people in outlying region to participate. people either from home or
from a local tele conferencing centre. In Alaska, where winter weather and long distance
between municipalities service as road block to public meetings, the state legislature has
developed the legislative telecommunication network (LTN).

2. Teleconferencing providing broader access to public meetings

Tele conferencing provides broader access to public meetings, as well as widening the reach of
public involvement. It gives additional opportunities for participates to relate to agency staff
and to each other while discussing issue and concern from physically separate locations it
enables people in many different locations. It enables people in many different locations to
receive information first hand and simultaneously.

3. A wider group of participants means a broader range of ideas and points of view:

Audio interaction makes dialogue more lively, personal, and interesting. Teleconferencing
provides an immediate response to concerns or issues. It enables people with disabilities,
parents with child care conflicts, the elderly, and other to participate without having to travel.

4. Teleconferencing save an agency time and travel costs.

Without leaving their home office, staff members can have effective meetings that reach several
people who might not otherwise be able to come together. Teleconferencing reduces the need
for holding several meetings in different Geographic areas, thereby increasing public
involvement costs, particularly staff time and travel. Teleconferencing often enables senior
officials to interact with local residents when such as opportunity would not exist otherwise,
due to distance and schedule concerns.

5. Tele conferencing is used for training.

It opens up training hours and availability of courses for people unable to take specialised
classes because of time constraints and travel costs.

6. Tele conferencing is used for networking among transportation professionals on public

involvement and other topics

North Carolina State University sponsored a national tele conference a technology for
transportation describing applications of three- and four-dimensional Computer Graphics
Technologies. They have been found helpful in facilitating public involvement environmental
analysis.

7. Tele conferencing is method is taking surveys

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Tele conferencing is method for taking survey of neighbourhood organisation. It helps
demonstrate the array of views within an organisation and helps local organization meet and
determine position prior to a demonstrate the organisation meet and determine positions prior
to a survey of their views.

8.Tele conferencing is used in both planning and project development

It is useful during visioning processes, workshops, public information meetings, and round
tables.

9.The use of telecommunication Technology to provide enhance, or expedite health care

services.

The use of telecommunications technology to provide enhance, or expedite health care services,
as by accessing off- site databases or transmitting diagnostic images for examination at another
site (" long distance medicine "). Using a video conferencing link to large medical centre in
order that rural health care facilities can perform diagnosis and treatment. A specialist can
monitor the patient remotely taking cues from the general practitioner or nurse who is actually
examining the patient. A patient's blood can be placed under a microscope in the remote facility
and transmitted for examination.

Urgent meetings

In case of urgency, important decisions can be taken speedily as meetings can also be held at a
short notice. The whole meeting can also be recorded and the 'minutes of meeting'. Can be
assembled after the meeting, indirectly saving a lot of time.

TECHNOLOGY AND EQUIPMENT FOR TELEMEDICINE

 Internationally, technology standards are laid down by Technology Development Board

under the international Telecommunication union (ITU)
 The basic telecommunication connectivity between the patient and the doctor may be a
wired one or a wireless one.

Telecommunication connectivity

 Wired: telephone line

: ISDN line

: internet
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 : cable connection

 Wireless: satellite connection

: wireless internet

SPECIALITIES

Telemedicine covers a growing number of medical specialities such as

 Cardiology
 Home care
 Radiology
 Emergency care
 Surgery
 Dermatology
 Psychiatry
 Oncology
 Pathology
 Ophthalmology
 Haematology
 ENT
 Nephrology
 Pre hospital care
 Nutrition
 Rural health care
 Tele pharmacy
 Tele neurology
 Chronic disease management -diabetic mellitus, hypertension
 Occupational health
 Sports medicine
 Tele ICU
 Public Health and Infectious Diseases

NECESSITIES OF TELEMEDICINE

* PIR (PERSONAL INFORMATION RECORD)

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* PHR (PERSONAL HEALTH RECORD)

* EMR (ELECTRONIC MEDICAL RECORD)

* DICOM (DIGITAL IMAGING AND COMMUNICATION IN MEDICINE)

* PACs (PICTURE ARCHIVAL AND COMMUNICATION SYSTEM)

* AES (ADVANCED ENCRYPTION STANDARD

TYPES OF TELEMEDICINE PROCESS

 Real time or synchronous

Real time medicine could be a simple as a telephone call or as complex as telemedical video
conference and tele robotic surgery. It requires the presence of both the parties at the same time
and a telecommunication link between them that allows a real- time interaction to take place.
Video conferencing equipment is one of the most common forms of technology used in
synchronous television.

 Store and forward Telemedicine or asynchronous:

It involves acquiring medical data (like medical history, images, etc.) and then transmitting this
data to doctor or medical specialist at a convenient time later for assessment offline. It does not
require the presence of both the parties at the same time. e.g.: tele pathology, tele radiology,
tele dermatology.

METHODS OF TRANSMISSION IN TELEMEDICINE

1. Store and forward

2. Remote monitoring

3. Interactive services

1. Store and forward

It is Acquiring medical data (like medical images, bio signals, etc.) and then transmitting
this data to a doctor for medical specialist at a convenient time for assessment offline. It is does
not require the presence of both the parties at the same time. Dermatology (tele dermatology),
radiology, and Pathology are common specialities that are conductive to asynchronous tele
medicine. A properly structured medical record preferably in electronic form should be
component of the transfer.
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2.Remote monitoring

It is also known as self-monitoring / testing, enables medical professionals to monitor a patient

remotely using various Technological devices. This method is primarily used for managing
Chronic diseases or specific conditions, such as heart diseases, diabetic mellitus, or Asthma.
These services can provide comfortable health outcomes to traditional -in person patient
encounters, supply greater satisfaction to patients, and maybe cost- effective.

3.Interactive tele medicine: provide

Real time interaction between patient and provider, to include phone conversation, online
communications and home visits. Many activities such as history review, physical examination,
psychiatric evaluations, and ophthalmology assessment can be conducted comparably to those
done in traditional face to face visit. In addition, " clinician -interactive" tele medicine services
may be less costly than in- person clinical visits. The first interactive telemedicine system,
operating over standard telephone lines, for remotely diagnosing and treating patients requiring
cardiac resuscitation (defibrillation)was developed and marketed by med hone corporation in
1989 under the leadership of its President and founder, S. Eric Wachtel A year later the company
introduced a mobile cellular version, the Phone.

APPLICATION OF TELEMEDICINE

1.TELE HEALTH CARE

It is use of information and communication Technology for prevention, promotion and to

provide healthcare facilities across a distance. It can be divided in the following activities.

. Teleconsultation

. Tele follow -up

2.TELE - EDUCATION

Tele communication should be understood as the development of the process of distance

education (regulated or unregulated), based on the use of information and tele communication
technologies, that make interactive, flexible and accessible learning possible for any potential
recipient.

3.DISASTER MANAGEMENT: Telemedicine can play an important role to provide health

care facilities to the victims of natural disasters such as earth quake, tsunami, tornado, etc, and
man- made disaster such as war, riots, etc. During disaster, most of the terrestrial
communication links either do not work properly or get damaged so a mobile and portable tele
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medicine system with satellite connectivity and customized telemedicine software is ideal for
disaster relief.

4. Telemedicine Technology can be applied to provide home health care for elderly or
underserved, with the chronic illness. It allows home health Care professionals to monitor
patients’ stations rather, than travelling to remote area chronically ill or recuperating patients
for routine check -ups. Remote patient monitoring is less expensive, more time savings, and
efficient methodology. Tele home care virtual visits might lead to improved home health care
quality at reduced costs, greater patient satisfaction with care, increased access to healthcare
providers and fewer patients heading transfer to higher, more costly levels of care. A computer
telephone integrated (CTI) system can monitor vital function of patients 24hours a day and give
immediate warnings.

Telemedicine in Pandemic

The covid-19 pandemic has promoted the use of telemedicine ,a tool that has transformed
the provision of medical services .Several mode of implementation are useful to overcome
difficulties for patient care during the pandemic .Its benefits are specific to different fields of
medical practice .Such benefits ,along with the guidance and reported experiences should invite
health system to work for an effective and comprehensive implementation of telemedicine in
various fields.

GOVERNMENT INITIATIVES

DIT

 Telemedicine module for tropical medicine in west Bengal -wedel (Kolkata) IIT,
Kharagpur and school of tropical medicine, Kolkata.
 Telemedicine and Telehealth education facilities in kerala-3 speciality hospitals with
 4 district /rural hospitals.
 oncome network - Kerala and Tamilnadan states.

Ministry of health and family welfare

 Integrated Disease Surveillance Project (IDSP)

 National onco NET project
 Teleophthalmology project
 National Digital Medical Library consortium

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  National Rural Telemedicine Network (NRTN)
 Approved teleophthalmology project to provide eye care speciality services to the
patient of rural and remote areas of Punjab, UP. Bengal states of India

National Informatics Centre

National Informatic Centre, a premiere its organization of the government, has initiated the
telemedicine activities for the peripheral doctors of Orissa and North-east region of the country.

Ministry of External Affairs

 SAARC telemedicine network: The South Asian Association of Regional Cooperation

(SAARC). The preparatory work for pilot project connecting one or two hospitals in
each of the SAARC countries with 3-4 Super speciality Hospitals in India is going on
 Pan –Africa e- network project: The Ministry of External Affairs, Govt of India is
implementing Telecommunications Consultants India Ltd (TCIL), which has been
designated as implementing agency, to establish a VSAT based telemedicine and tee

Indian Space Research Organization (ISRO)

 Govt of India set – up Space Commission and Department of Space (DOS) in June
1972:
 Providing connectivity between remote/rural hospital and super speciality hospital for
 teleconsultation.
 Treatment and training
 Continuing medical education
 Mobile telemedicine units for rural and community health
 As a part of application of space technology for health care and education, under
GRAMSAT (rural satellite) program, ISRO has initiated a number of telemedicine pilot
projects. These projects consist of linking through Indian National Satellite (INSAT),
remote / rural areas like Jammu and Kashmir and Ladakh in North near Himalayas,
offshore Islands of Andaman and Lakshadweep, North eastern states, dist. hospitals
/health centres.
 C-DAC, Mohali
 Telemedicine Projects in C-DAC, Mohali. Telemedicine started in 1999 in C-DAC,
Mohali, under the aegis of Ministry of Information Technology, Government of India.

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TELEMEDICINE IN INDIA

 existing system Limited only to private hospital

 Apollo group a hospital
 RN Tagore cardiac Hospital, Kolkata (Asia Heart Foundation)
 (No Tele Medicine System for Public Health Care
 Corporate sectors offering telemedicine systems
 Apollo Group
 Online telemedicine system Ahmedabad.
 Wipro GE
 SIEMENS
 Mfine
 Lybrate
 Docs App
 National Digital Health Mission

TECHNOLOGY TRENDS IN TELEMEDICINE

 The concept of telemedicine was introduced more than 30 years ago through the use
of telephone, facsimile machine, and slow -scan images, however, the enabling
Technology has grown considerably in the past decade.
 Telemedicine enables a physician or specialist at a one site to deliver Health Care,
diagnosis patient, give Intra- operative assistance, provide therapy, or consult with
another physician or paramedical personal at a remote site.
 Telemedicine system consist of customized the medical software integrated with
computer hardware, along with medical Diagnostic instruments connected to the
commercial VSAT (very Small Aperture Terminal) at each location or fibre optics.
Although telemedicine could potentially effective All Medical specialities, the
greatest impact of telemedicine.
 The greatest impact of telemedicine may be in fulfilling its promise to improve the
quality, increase efficiency and expand the access of the healthcare delivery system
to the rural population developing countries.
 3rd Generation wireless cellular system will offer video telephony that facilitate the
transfer of real time images to help with Communications between a patient or care
giver and a health -Care professional. Interestingly, this technology offers exactly

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 the kind of cost-effective solutions for the specific needs arise in rural areas
situation.
 Being cost-effective, it opens an innovative way to connect rural areas to the cities
that already have connectivity to the internet or have resources available on LAN.
Thus, it enables to Bridge the digital divide and provides a channel for
communication to the rural mass.
 It also makes it possible to get the timely feedback of the health problems taking
place in remote areas. In situations of epidemic outbreak such timely information
can save a significant number of lives.
 As wireless technology became more ubiquitous and affordable, applications such
as video telephony over POTS will gradually migrate towards 3rd generation
wireless systems. these techniques promise to the greatly improve the cost and
convenience associated with long been outpatient monitoring, and could potentially
extend monitoring to the border healthy population for preventive diagnostic and
alerts.
 Virtual reality as most of us are aware of is the ultimate situation like entering the
rabbit hole in Alice in Wonderland application in virtual reality for medicine pertain
to the planning of surgeries and use of data fusion that is to fuse virtual patients to
real patients as navigation aid in surgery. While research into tele - surgery helps to
jump-start robotics in the operating room, distant operations have remined on
elusive application. However, it may eventually prove to be one of the most
significant uses of robotic surgery.

COMPREHENSIVE LIST OF TELEMEDICINE STAFF ROLE

 CILINICAL STAFF
 Physicians
 Nurse practitioners
 Physician Assistants
 Registered Nurses
 Licensed practical Nurses
 Certified Nurse midwives
 Speciality clinicians

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 TECHNICAL STAFF
 Telemedicine co-ordinators
 IT support specialists
 Network administration
 Software developers
 Help desk technicians
 Audio visual technicians
 ADMINISTRATIVE STAFF
 Telemedicine programme managers
 Scheduling co-ordinators
 Patient registration specialists
 Medical records clerks
 Billing and insurance specialists
 Customer service representatives
 SUPPORT STAFF
 Medical assistant
 Health unit co-ordinators
 patient advocates
 social workers
 pharmacists
 Dietitians
 CONSULTANT STAFF
 Telemedicine consultants
 Health care consultants
 IT consultants
 Legal consultants
 TRAINING AND EDUCATION STAFF
 Telemedicine educators
 Clinical educators
 Technical trainers
 Simulation training specialists
 QUALITY ASSURANCE STAFF
 Quality improvement specialist
 Risk management specialist
 patient safety officers
 Accreditation co-ordinators
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  RESEARCH AND DEVELOPMENT STAFF
 Research scientists
 clinical researchers
 Data Analyst
 Health informaticists

LAW FOR TELEMEDICINE PRACTICE

 A draft low was published by the government of India as telemedicine act 2003. Once,
it is passed by the Parliament. It notifies the formation of telemedicine authority for
telemedicine licensing and related matters there will.
 Duties and liabilities of persons involved in telemedicine are described in the draft bill
for Institution and practicing doctors.

DRAWBACKS IN TELEMEDICINE

Tele conferences are somewhat formal events that need prior planning for maximum usefulness.
Although they require pre planning and careful timing, tele conference are conducted
informally to encourage participation and the exchange of ideas.

 They require pre-planning and careful timing; teleconferences are conducted

informally to encourage participation and the exchange of ideas.
 A large number of people are difficult to manage in a single teleconference.
 Cost can be high
 Teleconferences take time to organize
 Staffing needs can be significant
 Technical and management difficulties such as poor coordination between speakers
or people being misunderstood or not heard, result in bad feelings.
 Teleconferencing reduces opportunities for face-to-face contact between
participants and proponents of plan or projects
 The occurrence of technical failure when Tring to stablish a conference or during a
conference.
 Difficult for complex interpersonal communication, such as
negotiation or bargaining.

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BARRIERS IN TELEMEDICINE

 Physician / patient acceptance

Physician patient and have unique technology resources available in improve the patient
physician relationship. It has been found that patient no difficulty in accepting telemedicine
programme.

 Availability of technology

The basic system needs hardware, software and telecommunication link and can be
recovered by nominal change to the patient and student in case of tele education would be
much less than the physician travelling. Areas to the nearest Health Centre may not
be early to poor.

 Accessibility

The accessibility of people living in remote and rural areas to the nearest health Centre may not
be early to poor infrastructure of road and transport.

 Reliability

Some Healthcare professionals have about the quality of images transmitted for tele
consultation tele diagnosis.

 Funding issue

The insurance companies have to decide whether the cost of tele health care should be
reimbursed or not.

 Lack of trained manpower

Lack of training facility regards to application

 Legal and ethical

In case of any cross to order tele consultation which country applied in case those of the country
in which the patient is living or those of the remote physician.

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EVIDENCE BASED PRACTICE IN TELEMEDICINE

Telemedicine is defined by three characteristics:

1.Using information and communication technologies

2.covering a geographical distance

3.Involving professionals who deliver care directly to a patient or a group of patients. It is said
to improve chronic care management and self-management in patient with chronic diseases.
However, currently available guidelines for the care of patient with diabetes, hypertension,
dyslipidaemia do not include evidence-based guidance on which components of telemedicine
are most effective for which patient populations.

Objective:

The primary aim of this study was to identify, synthesize, and critically, appraise evidence on
the effectiveness of telemedicine solutions and their components on clinical outcomes in patient
with diabetes, hypertension, or dyslipidaemia.

Methods:

We conducted an umbrella review of high-level evidence including systematic reviews and

meta-analysis of randomized controlled trails. On the basis of predefined eligibility criteria,
extensive automated and manual searches of the data bases PubMed, EMBASE, and Cochrane
Library were conducted. Two authors independently screened the studies, extracted data, and
carried out the quality assessments. Extracted data were presented according to intervention
components and patient characteristics using defined thresholds of clinical relevance. Overall
certainty of outcomes was assessed using the Grading of Recommendations, Assessment,
Development, and Evaluation (GRADE) tool.

Results: Overall, 3564 references were identified, of which 46 records were included after
applying eligibility criteria. The majority of included studies were published after 2015.
Significant and clinically relevant reduction rates for glycated haemoglobin (HbA1c; ≤-0.5%)
were found in patients with diabetes. Higher reduction rates were found for recently diagnosed
patients and those with higher baseline HbA1c (>8%). Telemedicine was not found to have a
significant and clinically meaningful impact on blood pressure. Only reviews or meta- analyses
reporting lipid outcomes in patients with diabetes were found. GRADE assessment revealed
that the overall quality of the evidence was low to very low.

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TELENURSING

Telenursing refers to the use of information technology in the provision of nursing services
whenever physical distance exists between patient and nurse, or between any number of
nurses. As a field, it is part of telemedicine, and has many points of contacts with other
medical and non-medical applications, such as telediagnosis, teleconsultation, and
telemonitoring. The field, however, is still being developed as the information on telenursing
isn't comprehensive enough.

Telenursing is growing in many countries because of the preoccupation in driving down the
costs of health care, an increase in the number of aging and chronically ill population, and the
increase in coverage of health care to distant, rural, small or sparsely populated regions.
Among its many benefits, telenursing may help solve increasing shortages of nurses; to
reduce distances and save travel time, and to keep patients out of hospital. A greater degree
of job satisfaction has been registered among telenurses.

Telenursing and nursing informatics

Nursing informatics, a branch of health informatics, has been defined by Judith Rae Graves
and Sheila Corcoran as "a combination of computer science, information science, and nursing
science designed to assist in the management and processing of nursing data, information, and
knowledge to support the practice of nursing and the delivery of nursing care" Telenursing is
a potential application of nursing informatics and as such, nursing informatics has served as a
critical background concept its development.

Applications
Home care
One of the most distinctive telenursing applications is home care. For example, patients who
are immobilized, or live in remote or difficult to reach places, citizens who have chronic
ailments, such as chronic obstructive pulmonary disease, diabetes, congestive heart disease, or
debilitating diseases, such as neural degenerative diseases (Parkinson's disease, Alzheimer's
disease or ALS), may stay at home and be "visited" and assisted regularly by a nurse
via videoconferencing, internet or videophone. Other applications of home care are the care of
patients in immediate post-surgical situations, the care of
wounds, ostomies or disabled individuals. In normal home health care, one nurse is able to visit
up to 5-7 patients per day. Using telenursing, one nurse can “visit” 12-16 patients in the same
amount of time.

Case management
A common application of telenursing is also used by call centers operated by managed care
organizations, which are staffed by registered nurses who act as case managers or perform
patient triage, information and counseling as a means of regulating patient access and flow and
decrease the use of emergency rooms.

Telephone triage
Telephone triage refers to symptom or clinically based calls. Clinicians perform symptom
assessment by asking detailed questions about the patient's illness or injury. The clinician's task
is to estimate and/or rule out urgent symptoms. They may use pattern recognition and other
problem-solving process as well. Clinicians may utilize guidelines, in paper or electronic
format, to determine how urgent the symptoms are. Telephone triage requires clinicians to
evaluate symptoms and provide health advice which guides patients to the appropriate level of
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care, (emergent, urgent, or nonurgent) according to their condition and symptoms. Telephone
triage staff also provides advice for self‐care at home for nonurgent patients.[5] It may involve
educating and advising clients, and making safe, effective, and appropriate dispositions—all
by telephone. Telephone triage takes place in settings as diverse as emergency rooms,
ambulance services, large call centers, physician offices, clinics, student health centers and
hospices.

Telephone Triage Reducing Emergency Department Visits

Telephone triage services are beneficial in decreasing the amount of nonemergent patient visits
to emergency departments. Emergency departments typically experience high patient volumes,
many of which are nonemergent. Emergency department waiting areas may become
overcrowded with patients due to the high patient volumes, resulting in many patients leaving
without being seen. The telephone triage staff has access to the electronic health records
generated by a health system encounters. The ability to access patients’ health records helps
the triage staff evaluate the patient more efficient due to the provided information such as
allergies and comorbidities. Having access to patients’ health records provides demographic
information which allows the triage staff to send emergency services to the patient if necessary.
Telephone triage service can help to decrease lower-acuity patient visits to an emergency
department by properly evaluating patients symptoms and guiding them to the appropriate level
of care.

Countries using telephone triage

An international telenursing survey was completed in 2005, reporting that the 719 responding
full-time and part-time registered nurses and advanced practice nurses worked as a telenurse in
36 countries around the world. 68% were reported to be working in the United States, compared
to only 0.6% in Finland. Some of these 36 countries include Australia, Canada, Norway, United
Kingdom, New Zealand, Iran, Sweden, and the Netherlands.

In Australia
In Australia, telephone triages are conducted in all states of Australia, the largest services are
federal and state government funded, known as Nurse-On-Call in Victoria, Healthdirect in all
other states and territories except Queensland where the state government supports its own
separate service known as 13HEALTH. The first telenursing triage was conducted in Western
Australia in 1999, where Triage nurses would estimate patient complexity and refer them to
Fremantle Hospital. Due to the remoteness of the Australian landscape it is vital that residents
living in rural areas have access to clinical support and care. Telenursing allows nurses to
overcome the barriers of distance and gives them the opportunity assist those who are unable
to access health care clinics or services due to either the late hour or the distance.

Mental health
Telenursing has also been utilized in mental health applications. Telepsychiatry (also known as
telemental health) can be effective in improving symptoms and quality of life among people
with mental health disorders. It is especially useful in many environments with limited access
to care, including rural areas, emergency rooms, natural disasters and crisis zones, and
warfronts. This technology delivers mental health care in areas that would otherwise not have
any mental health care resources. Much of the time, this use involves live interfacing between
patient and care giver, whether in video conference or over text thread. In addition, use of
asynchronous telepsychiatry, in which a detailed interview with the patient is video taped and
reviewed by a provider afterwards, has also proven an effective use of telepsychiatry.
Telepsychiatry improves integrated and patient-centered care, allowing for the incorporation of
mental health resources into the overall treatment of the patient.

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In addition to direct patient care, telenursing and telepsychiatry, the use of technology in mental
health has made a significant impact on crisis intervention and suicide prevention.
Organizations such as Crisis Text Line have incorporated text chatting into crisis therapy, and
have opened up a new line of resources available to people in mental health crises. This is
especially significant for adolescent mental health, as many teens are more likely to utilize text
message for therapy than in-person or over the phone.

Coronavirus pandemic
On March 27, 2020, legislation was passed in the United States to assist in the growth of
Telehealth capabilities across the country. The CDC recommends that telehealth be used
whenever possible to stop the spread of Corona Virus. Although Telehealth is not a new
concept, the appearance of the Corona Virus and COVID-19 has quickly accelerated both its
necessity and popularity. With societal changes occurring all across the globe, it became
apparent that the medical field needed to devise a new way of delivering care in order to
promote social distancing, quarantining when required, and the preservation of limited hospital
resources. State-wide lockdowns were implemented to decrease the spread of the novel Corona
Virus and Telehealth was and continues to be a way to make healthcare more accessible to
people all around the country, especially in rural regions of America. Telehealth makes it
possible for high-risk patients to remain safely in their homes while still receiving routine care
from their providers. It allows Corona Virus positive providers with mild symptoms to be able
to continue to see patients from home while they convalesce. The benefits of Telehealth during
a pandemic appear to outweigh the risks: it will decrease overhead costs, is convenient,
promotes infection control, connects medical personal from different regions, and allows for
rapid triage. Risk factors include increasing health care disparity due to lack of internet or
devices, technical difficulties, and a lack of hands on care. However, research indicates that
telehealth will continue to play a vital role in diagnosis and treatment until proper effective
treatment and/or a vaccine is available to the public. Hospital systems must access their
readiness for telehealth and implement it in a timely fashion.

Since the rise of the coronavirus pandemic in the United States, telemedicine has risen
exponentially, with estimates that telemedicine market size will be around $175 billion up from
$45 billion in 2019. Reasons for the increase in telemedicine are numerous, however, reasons
include reducing the exposure of staff to ill individuals and reducing overcrowding the
healthcare facilities. Thus, telehealth has significantly grown during the pandemic as it
increases social distancing by reducing the need for patient travel and going to crowded places.
Another benefit of telehealth is it reduces the amount of PPE that is needed for healthcare
professionals that are already in limited supply. Ultimately, telehealth has many benefits
beyond the pandemic, such as increasing the number of people who seek preventative care
since they can do so from home.

Legal, ethical and regulatory issues

Telenursing is fraught with legal, ethical and regulatory issues, as it happens with telehealth as
a whole. In many countries, interstate and intercountry practice of telenursing is forbidden (the
attending nurse must have a license both in their state/country of residence and in the
state/country where the patient receiving telecare is located). The Nurse Licensure
Compact helps resolve some of these jurisdiction issues. Legal issues such
as accountability and malpractice, etc. are also still largely unsolved and difficult to address.
Ethical issues include maintaining autonomy, maintaining a patient's integrity as well as
preventing harm to a patient.

Telenursing professionals use an electronic medical record (EMR) when storing and charting
patient data. Digital clinical data transmission increases the risk that outside sources may

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intercept and exploit sensitive patient information. As a result, telehealth nurses should audit
their current security measures and assess how their patient privacy and protection policies
protect their patients. Most telehealth nurses work for a hospital or organization that provides
them with a laptop and a very high level of security and encryption so that hackers and outside
sources may not intercept patients' sensitive and personal information. Telehealth nursing aims
to improve access to care, but practitioners and patients alike have concerns about security
breaches, according to a report published by the National Center for Biotechnology (NCBI)
stating that security is critical for long-term telemedicine success.

Currently, the Health Insurance Portability and Accounting Act (HIPAA) outlines rule sand
regulations on how healthcare providers store and share patients' personal data. HIPAA requires
that patients identifiable information be encrypted so that only the healthcare professionals
involved in their care can access it. However, HIPAA only applies to certain "entities" that
included healthcare providers and insurers but not the patients.

In addition, there are many considerations related to the patient confidentiality and the safety
of clinical data.

SUMMARY
Telemedicine has a variety of applications in patient care, education, research, Administration
and public health. Clinician health service researchers and other have been investigating the
use of advanced telecommunication and information technologies to improve healthcare.
Advances in telecommunication and technologies are revolutionizing education and health
services globally, including the provision of nursing services. Decreasing time and distance,
these advances increase access to health and health care, especially to underserved populations
and those living in rural and remote areas.

REFERENCES

 Kour Brar Navdeep; Text book of Advanced nursing practice ;3rd edition; Jaypee
publications; page no:190-200.
 Erb and Kozier; Text book of foundation of nursing concept, process and practice ;8th
edition; publication person; page no:151-152.
 *P. Basheer, Shabeer; Text book of Advanced Nursing Practice ;2nd edition; enmesh
publication; page no:116-122.
 *Perry potter; Text book of foundation of nursing ;6th edition; Publication Mosby; page
no 151-152.
 *Helen harks reader many Ann Hogen; text book of fundamental of nursing caring and
clinical judgement ;2nd edition; Saunders publication, page no 1126
 *Lippincott; text book of Basic nursing;9th edition; Wolters Kluwer publication; page
no 22,403,1553,1597.

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