The Value of Video: Nurses’ Perspectives on Televisits

Utilizing telehealth technology to connect nurses to patients at home (for both remote monitoring and direct care via televisits) is intended to supplement and complement skilled in-home care. Research shows that, as a home care intervention, telehealth can reduce emergency department utilization and prevent re-hospitalizations for patients with chronic conditions, such as congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD).

On February 4, we discussed research data supporting the above assertions (see "Securing the Benefits of Telehealth in Home Care"). This week, another side of the story: what clinicians have to say about the value of video for televisits.

Home care agencies planning their first telehealth programs must consider whether they should focus only on remote electronic monitoring or implement a video-based telehealth program. Those who have achieved progress with remote monitoring are often interested in the extra value they might derive by adding video capability and beginning to offer televisits. Home care administrators who do look into video are well-advised to take into account that many nurses remain skeptical about televisits.

"Nurses can be apprehensive about video visits replacing or de-valuing the care they provide to their patients during home visits," explained Jan Wuorenma, RN, BSN, MBA, Vice President for Partner Development, American TeleCare, Inc. (ATI) "Home care agencies can use televisits to increase the total number of patient encounters per episode while reducing per episode costs – all without adding to nurses’ workloads. That is why it is best to hear from those nursing professionals who have actual experience with video telehealth."

Taking Wuorenma's advice, we went to the source and asked experienced nurses about the value of adding video to existing home telehealth programs. As a group:

• Telehealth experienced nurses say they are empowered
• Telehealth experienced nurses say they provide more complete care
• Telehealth experienced nurses say they develop patient-centered connections

Empowering nurses
Nurses experienced in telehealth have found that televisits empower them with more information to guide patient care decisions and maintain continuity of care between visits. “Remote monitoring of patients at home is the foundation of our approach to telehealth, especially for our patients with chronic diseases," explained Mimi Allen, RN, BSN, Director of Telehealth, Centura Health at Home in Denver. "It is the basic way we watch over them and track changes in their conditions between visits."

Allen continued, “We see a value to having video as part of a telehealth system that monitors, transmits and stores vital signs. There is so much information in video visits – eye contact, a patient’s expression, skin tone, recognition of a grimace with movement. All these can be important signals that you would not observe without video capability in a telehealth system.” Part of Centura Health, Colorado's largest health care system, Centura Health at Home has deployed ATI's LifeView™ Telehealth System.

Nina M. Antoniotti, RN, MBA, Ph.D. agrees with Allen. “The ability to see and visually assess patients enables nurses to better apply their critical thinking and clinical decision-making skills,” she commented. Antoniotti is Director of Marshfield Clinic TeleHealth, a service of Marshfield Clinic, the largest private group medical practice in Wisconsin and one of the largest in the U.S.

Offering more complete care
The second point nurses experienced in telehealth make is that televisits enable them to provide more complete care to patients.

“Using remote monitoring alone, a nurse cannot check dressings, inspect wounds or determine whether a homebound patient is using medical equipment or devices safely and correctly,” said Marshfield’s Antoniotti. "When a nurse telephones a heart disease patient at home and asks, for example, if he has taken his Coumadin, he may say yes; he may say no. The nurse cannot be certain. In a televisit, a nurse can get a good sense of whether the patient has taken his medication by looking at his face. In addition, a nurse can look for signs of possible side effects, such as shortness of breath or dizziness."

“In a virtual visit a nurse can do almost everything as in a home visit except touch the patient,” said Renee Pekmezaris, Vice President, Research, Office of Community of Health, North Shore - Long Island Jewish (NSLIJ) Health System in Manhasset, New York. The NSLIJ Home Care Network’s nurse case managers each care for 25 to 30 patients with heart failure. They supplement home visits with remote monitoring plus one to three televisits per week. Pekmezaris believes this adds more patient care.

Maria Roemer, RN is a Telehealth Nurse with the Visiting Nurse Association (VNA) of Hudson Valley, Tarrytown, New York. She sees the value of video in providing more comprehensive care. “Being able to see the patient makes a huge difference in understanding what’s going on with them.

"With patients with respiratory conditions, I can see, for instance, how their skin tone looks or if their lips are blue. I can listen to their lung sounds with our digital stethoscope,” she explained. “For patients with diabetes who have problems managing their conditions, I might suspect that they are not getting the right dosage of insulin. I can have them show me. I can watch them fill the syringe and make sure it is the right amount.”

“It is not about replacing home visits and the care that nurses can only provide in patients’ homes. It is about doing more for the patient. It’s about being there for our patients on days when a nurse is not making a visit,” added Rae Szymanski, Executive Vice President and Chief Operating Officer, VNA of Hudson Valley. “Video telehealth enables us to do more for our patients and add more encounters without a adding a big increase in costs.”

Developing patient-centered care connections
Nurses have also found that the video element of telehealth helps them develop good relationships with patients. “Patients have choices. Patients and their families who have telehealth with video visits appreciate the technology and value the service,” said Antoniotti. “Telehealth with video visits builds relationships.”

As the burden and complexity of disease increase, so too does the value of video interaction between patients and nurses. “Keep in mind the post-hospitalization home care environment. Our patients are elderly. They are often alone, vulnerable and feeling overwhelmed by the responsibility for self care. They are often anxious and depressed,” commented Szymanski. “The video component establishes a connection that a phone call just can’t match. Video visits are a point of connection to the outside world for homebound, elderly patients. A televisit provides real interaction before the next time their nurse comes to their home.”

“Elderly patients often take many medications. It’s easy for them to get confused,” said Roemer. “When I’m talking to a patient about their medications, and they can’t remember the name of a medication, I can have them hold up the bottle to the camera. I know how to advise them because I see exactly what medication we’re talking about. This can be very important as I maintain contact with patients in coordination with our primary nurses.”

“There is a much more comfortable and warm feeling when the patient can see their nurse via the telehealth system camera,” said Paula Morgan, RN, a Telehealth Nurse with Centura Health at Home’s Colorado Springs office. “When you have established a rapport with your patient through video visits, it is almost as if you could reach out and touch them.”