Despite Provider Barriers: Telemedicine is the Future

Telemedicine has emerged as a method to serve rural and frontier populations that otherwise would have limited access to health care. Driven in large part by demand for greater efficiency along with the need to increase access to health care for patients. Worldwide adoption of telemedicine has made an increasingly mainstream method for receiving care however, it is oftentimes a disruptive technology. Despite more mainstream use and positive benefits for patients, provider barriers along several dimensions remain such as policy, billing, licensing, and the myriad of interactions between patients and providers with the technology. This review identifies a number of these barriers for providers and recommends ways in which they might be overcome. Additionally, we evaluated the impacts these barriers have on providers in the state of Utah.

Running head: DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE Despite Provider Barriers: Telemedicine is the Future Beth A. Silvero Jennifer L. Strege Sabrina L. Harman Westminster College MSN 610-01 Masters Project 1 DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE ©COPYRIGHT By Beth A. Silvero Jennifer L. Strege Sabrina L. Harman 2018 All Rights Reserved Acknowledgment We would like to acknowledge Deanna Waldron for all of her expertise and sense of humor, the faculty and staff of Westminster College, Masters of Science in Nursing, Family Nurse Practitioner program, and all of our family members for their support and patience. 2 DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 3 Abstract Telemedicine has emerged as a method to serve rural and frontier populations that otherwise would have limited access to health care. Driven in large part by demand for greater efficiency along with the need to increase access to health care for patients. Worldwide adoption of telemedicine has made an increasingly mainstream method for receiving care; however, it is oftentimes a disruptive technology. Despite more mainstream use and positive benefits for patients, provider barriers along several dimensions remain such as policy, billing, licensing, and the myriad of interactions between patients and providers with the technology. This review identifies a number of these barriers for providers and recommends ways in which they might be overcome. Additionally, we evaluated the impacts these barriers have on providers in the state of Utah. Keywords Telemedicine, telehealth, barriers, protocols, burnout, education, liability, policy, technology DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 4 Table of Contents I. Introduction………….……………………..……………..…………………………………….5 II. Methods………………………………………………………………………………………..7 III. Discussion a. Access to Care in Rural America………...……………………..…………….…...….7 b. Reimbursement…..……………………………………………………………………9 c. Licensing/Credentialing………….………………………….…………………….....13 d. Lack of Standardized Training………………….……...…………………………....16 e. Protocols…….……………………………………………………………………….19 f. Liability….…………………………………………………………………………...20 g. Technology..…………….…………………………………………………………...22 IV. Conclusion………………………………………………………………………………...…24 V. Appendices a. Appendix A……………………………………………………………………………26 b. Appendix B……………………………………………………………………………27 VI. References…………………………………………………………………………………....28 DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 5 Introduction Telemedicine is the use of technology, specifically, telecommunications, to provide healthcare from one location to another (Lindstrom, 2018). It allows for the electronic transfer of images, medical data, and health information as well as communications between healthcare personnel at different locations. It is a rapidly progressing and expanding field that allows greater access to care for patients. It can provide a wide range of specialty care such as cardiology, dermatology, neurology, and Tele-ICU. It provides greater accessibility and convenience to people who have mobility issues, do not have access to a car or public transportation, or live in rural areas and cannot drive hours to get to and from medical appointments. Telemedicine is also increasingly substituting for face-to-face visits even in areas well served with providers. Analysts predict that 7 million patients will use telehealth services in 2018, an increase from 350,000 in 2013 (Gabriel, 2018). According to Sharma, Fleischut, & Barchi (2017), more than half of all hospitals in the U.S. are using some type of telemedicine, and the American Telemedicine Association (ATA) noted that there are now 200 active networks for telemedicine. For the purposes of this paper, telemedicine will be used interchangeably with telehealth. Telemedicine dates back to the early 1900s with 2-way radio communication. In 1967, one of the first telemedicine clinics was established at Massachusetts General Hospital (Lindstrom, 2018). Around the same time, The National Aeronautics and Space Administration (NASA) and the Department of Defense started funding research in and implementation of telemedicine (Lindstrom, 2018). NASA was able to use the technology that provided healthcare for astronauts in space and apply it to collaborating with Indian Health Services and provide healthcare to the rural Papago population, becoming one of the most successful implementations of telemedicine in its history (Borg, 2009). DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 6 Telemedicine has emerged as a method of delivering affordable, quality care to those who live in remote locations. Although Utah is identified as an urbanized state with 75% of the population living along the Wasatch Front and St. George, there is still a need for telehealth services for rural and frontier populations that are spread over 25 of the 29 counties in Utah (Utah Department of Health (UDOH), 2013). Approximately 10% (325,000 people) of Utah’s population resides in rural or frontier areas which are medically underserved, often lacking access to quality healthcare services and specialized medical care (Appendix A). However, despite many positive benefits for patients and its ability to increase access to care, many barriers exist for providers that limit the implementation of telemedicine (Desjardins, 2014; Lindstrom, 2018; Adler-Milstein, Kvedar, & Bates, 2014). A review of literature shows among these barriers are: lack of access in rural areas, reimbursement for services provided by insurance companies, licensure, liability, provider burnout, inconsistent protocols and lack of adherence, and education and training on the telecommunications systems, along with the disruption of the traditional patient/provider experience (Adler-Milstein et al, 2014; Rutledge, Haney, Bordelon, Renaud, & Fowler, 2014; Shanafelt et al., 2014; Bolin et al., 2015; Raths, 2015; Dorsey & Topol, 2016; Ainslie & Bragdon, 2018; Lindstrom, 2018). Put in the other order Telemedicine is at the forefront of an increasingly technology-based healthcare delivery system. In the broadest sense, telemedicine is the ability to share information between providers and patients regardless of location. As telemedicine technologies gain increasingly wider acceptance, this sharing of information will open endless possibilities for improving the quality of medical care (Mamlin & Tierney, 2016). However, it will simultaneously disrupt standard medical practice. Methods DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 7 The authors conducted a systematic literature review by extracting a data search that yielded 116 articles, editorials, interviews, and reports from the Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed (MEDLINE), and Cochrane research databases. We used 53 of the 116 search results for this paper. Appendix A depicts the concentration of people living in rural areas versus urban areas in the state of Utah and surrounding areas. Appendix B depicts current states with parity laws, those pending legislation, and those with no parity laws. Studies were included if they were relevant to our specific topics, included significant and recent statistics, or were outdated yet included pertinent data that was still applicable to the current state of telemedicine. Limitations to our methods are data being outdated, difficulty interpreting laws and regulations, locating specific information that was not readily available, and difficulty navigating government and company websites. Also, our literature review was conducted using the most recent research, but may not be inclusive of all current literature available on this topic. Discussion Access to Care in Rural America According to the 2010 US Census Bureau, 59 million people, approximately 17% of the US population, live in rural or remote communities that face significant barriers to accessing health care compared with those living in urban areas (Bolin et al., 2015). Research shows people who live in rural America tend to be older, have fewer financial resources, experience transportation difficulty, and travel long distances to receive healthcare due to shortages of providers along with limited access to specialty care; including but not limited to general surgery and obstetrics. The provider-to-patient ratio in rural areas is 39.8 providers per 100,000 people compared with 53.3 providers per 100,000 people in urban areas (Hing & Hsiao, 2017). While DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 8 this may seem like a small difference in provider-to-patient ratio, this has lasting effects on provider burnout rates and poorer outcomes for patients (Shanafelt et al., 2015; Lin, Jha, & Adler-Milstein, 2018). In the past century, as a result of widespread closures, many rural counties lost their hospitals (Bolin et al., 2015). In an attempt to stem these closures, federal legislation was passed in the 1980s to create special categories for critical access hospitals (CAHs) with special protections (Bolin et al., 2015). In spite of this, rural hospital closures are on the rise again due to more recent cutbacks in Medicare reimbursement reduced funding, and deadlines for instituting electronic medical records (Bolin et al., 2015). In Utah, for example, twelve counties are rural with a population density between 6.1 and 99.9 persons per square mile. Thirteen of Utah’s counties are frontier, with a population density under 6.1 persons per square mile. Much of Utah is sparsely populated with limited infrastructure including limited access to traditional hospitals (UDOH, 2013). Although rural Utah hospitals have not been affected by such closures, rural residents do face long travel times and financial hardships making travel difficult. Telehealth has opened access to specialty care not otherwise available in these areas. The National Rural Health Association concludes rural areas suffer from greater incidence of chronic diseases, increased shortages of primary and specialty health providers, higher numbers of Medicare and Medicaid recipients, more geographical barriers to health care, and greater incidence of chronic diseases (Henderson, Davis, Smith, & King, 2014). Providers serving patients in these areas are unable to meet the complex needs of patients without the ability to consult with specialty providers. Limited access to telehealth services reduces providers’ ability to manage patients with chronic diseases in rural communities. DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 9 Reimbursement Reimbursement for telehealth services is a complicated process which has emerged as a barrier for providers in utilizing this form of healthcare services. According to a survey conducted by the American Academy of Family Physicians, 53% of the 5,000 respondents reported reimbursement was the largest barrier to implementing and using telehealth services (Moore et al., 2016). Reimbursement for telehealth is determined by a multitude of factors that include the state the provider practices in, the insurance the patient has, the type of visit conducted (i.e. live video conference), and the geographical location of the patient (Moore et al., 2016). It is because of these factors that it makes it difficult to provide telehealth services even with known benefits to patients (Daniel & Sulmasy, 2015, Dorsey & Topol, 2016, Henderson, Davis, Smith, & King, 2014). Each state in the union as well as the District of Columbia (DC) has a variety of laws and policies that affect the implementation of telehealth services. Some of these laws clarify regulations for telehealth, while others, called parity laws, specifically require reimbursement for this type of visit. In other words, these parity laws can be written in a way that allows for coverage of telehealth services, but not necessarily the payment amount for the visit (National Consortium of Telehealth Resource Centers, 2018). Consumer demand and need drive policy. In Delaware for example, a group of patients and family members joined together to form the Delaware Telehealth Coalition in 2015 (Raths, 2015). This coalition was able to petition state legislature to pass a bill requiring commercial insurers to pay for telehealth visits in their state at the same rate as if the visit had taken place inperson (Raths, 2015). Currently 31 states and DC require private and commercial insurers to cover the cost of a telehealth visit at the same rate as if the visit had taken place in-person (The DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 10 Center for Connected Health Policy, 2017, American Telemedicine Association, 2018); Appendix B. Per Raths (2015), “state legislatures are recognizing that parity laws are the easiest policy issue to deal with.” There is a significant lack in continuity of reimbursement from state to state, essentially 50 states, with 50 different laws governing the reimbursement process (Brooks, Turvey, & Augusterfer, 2013; Adler-Milstei et al., 2014). States with policies requiring private payer reimbursement lead to greater adoption of telehealth services for that state (AdlerMilstein et al., 2014). Only 13 percent of Utah hospitals had implemented some sort of telehealth services as of 2012 (Adler-Milstein et al., 2014). The highest uptake in telehealth services was in Alaska, Arkansas, and South Dakota. The lowest uptake in telehealth services where in Utah and Rhode Island (Brooks et al., 2013; Adler-Milstein et al., 2014). The highest and lowest adapting states all have fairly small populations and also have large rural populations. States that have parity laws to mandate private party insurance to reimburse for telehealth have higher incidence of implementation of telehealth services as well. Currently in the state of Utah there are no parity laws requiring private insurance companies to pay for telehealth visits. Although Utah Medicaid and Public Employees Health Plans (PEHP) do currently pay for this service, there is no requirement for third party payment (Bacon, personal communication, September 30, 2018). The results of the previously mentioned study suggested that factors beyond the population of a state, such as state policies regarding reimbursement, affected the implementation of telehealth (AdlerMilstein et al., 2014). This lower uptake is seen here in Utah and will continue to hinder implementation of telehealth until laws are changed that require third party payers to reimburse this type of service, as well as payments being equal to an in-person visit. DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 11 Private or employee sponsored plans and Medicaid are not the only insurance policies that are barriers for providers in implementing telehealth services. Medicare currently provides healthcare coverage to 59.1 million people in the United States (Centers for Medicare and Medicaid Services (CMS, 2018; Gabriel, 2018). CMS guidelines are often looked at as the gold standard for reimbursement for almost all insurance payers in the United States (Mehrotra et al., 2017). In 2001 however, CMS took a strong stance on telehealth and implemented stringent rules regarding the reimbursement for telehealth visits (Mehrotra et al., 2017). The federal government projected that Medicare would pay out one hundred and fifty million dollars for claims in the first five years after it was implemented. To date, Medicare has yet to pay out more than thirty million dollars in an annual year over the last 17 years (Gabriel 2018; Mehrotra et al., 2017). However, because of this initial fear, strict rules were made regarding what would be reimbursed. The restrictions include that the patient must live in a federally qualified rural area, facility type must be appropriate for the provider and the patient (i.e., must be seen in a clinic or hospital in a qualified rural area), only certain qualifying providers can do this type of visit, it must be billed using a qualifying billing code, and the visit must be conducted only using realtime-audio platforms (National Consortium of Telehealth Resource Centers, 2018). The real-time audio feed requirement for Medicare reimbursement is a hindrance to using telehealth to its full potential. Store and forward care is a promising area telehealth can be utilized in (Raths, 2015; Gabriel, 2018). Store and forward technology is when information is collected and then sent to the provider for review. Telehealth, when coupled with web connected devices and platforms, also shows potential for improving patient medication adherence. Medication adherence is a worldwide public health problem for chronic disease management particularly among elderly patients, members of minority ethnic and racial groups, low-income DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 12 adults, and people burdened by long travel times to a health care provider’s office (Zanjal & Talmale, 2016). The National Institute of Health (NIH) performed a systematic review of 50 studies to evaluate the effectiveness of remote technologies for chronic disease management and concluded that remote professional supervision when combined with remote monitoring and alerts has significant positive effects on adherence and clinical outcomes (Hamine, GerthGuyette, Faulx, Green, & Ginsburg, 2015). However, store and forward visits do not meet the standards for CMS reimbursement and Medicare will not pay for the visit (Merchant, Ward, & Mueller, 2015; Gabriel 2018). Since CMS guidelines are viewed as the gold standard for payment, these complicated and strict policy guidelines have become a major barrier to providers being able to implement telehealth services for patients (Raths, 2015; Merchant et al., 2015). Reimbursement and rigid payment qualifications are named as main barriers to provider implementation (Moore et al., 2016) endorse the idea of Desjardins (2014) that “once there is adoption by CMS, then adoption will occur with other payers” as healthcare services reimbursement “start with CMS” (Kvedar, n.d., as cited in Desjardins, 2014, p. 1). It is costly and confusing for providers to navigate the reimbursement process for telehealth services. Telehealth is a feasible solution for healthcare shortages, as well as a promising solution for medication and chronic health management (Zanjal & Talmale, 2016). Patients living in rural areas can benefit greatly from telehealth services only when the reimbursement process becomes clearer and is paid for equally to an in-person visit. This begins with CMS guideline relaxation and states adopting parity laws. DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 13 Licensing/Credentialing Licensing has also emerged as a barrier for providers. Licensing is a difficult, tedious process in and of itself, and is further complicated when it comes to telehealth (Merchant et al., 2015). Large portions of the population who can benefit most from telehealth reside in rural areas that may cross state lines. For example, the Wasatch Front in Utah services the surrounding rural areas in the state, as well as parts of Nevada, Wyoming, Montana, and Idaho (Appendix A). Patients from these areas travel a great distance just to receive care they would otherwise not have access to in their areas. Telehealth is an excellent option for patients who have limited funds for travel, are homebound and/or disabled, or prefer to stay in the comfort of their community (Raths 2015; Daniel & Sulmasy 2015). For telehealth services to be rendered by a provider in Utah to a patient living in rural Wyoming, the provider would need to be licensed in both states, which is costly and time consuming (Brooks et al., 2013). This is further complicated by the fact that states have different healthcare laws, thus requiring providers to adhere to different state medical practice rules that are often in conflict with one another (Brooks et al., 2013). The Federal Government has left it up to individual states to control their own licensing. (Nation Consortium of Telehealth Resource Centers, 2018). Most states require providers to be licensed in the state in which the patient is residing (Brooks et al., 2013). This is an antiquated system. The Nurse Practitioner (NP) licensing laws that are pieced together further complicate this barrier for implementation of telehealth (Kopanos, 2014). It is more important now than ever before to standardize licensing for NPs and other providers alike. As society looks to technology for convenience and access of specialty care, there needs to be standardization of this process. DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 14 The Nursing License Compact has been put in place to allow nurses to work in multiple states with the same license as long as the other state is part of the agreement (Brooks et al., 2013). The Federation for State Medical Boards created their own version of a compact in an effort to help ease the process of applying for a license in a different state (Telehealth Resource Centers, 2018). To date, ten state boards offer special telehealth licenses to practice across state lines (LeRouge & Garfield, 2013). Mario Gutierrez (Raths, 2015), executive director of the Center for Connected Health policy, believes that these compacts are just a band-aid to the problem instead of a real solution. He supports the federal government creating a nationwide telehealth license for providers employed by federally funded programs, “[w]hy not have such a license when we have such a shortage of specialists and such a poor distribution of services?” (Gutierrez, n.d., as cited in Raths, 2015, p. 1). Joel White, the Health IT Now Coalition executive director, supports a nationwide license, arguing that every physician has to take a nationwide competency exam, but has to get licensed in each and every state because the state medical boards make more money by that process (Raths, 2015). In an effort to solve this issue, House Bill 6719 was introduced in 2012 (Brooks et al., 2013). The bill proposed a new federal license that would allow providers to only be licensed in their physical state and could care for eligible patients anywhere in the United States (Brooks et al., 2013; Mehrotra et al., 2017). The bill did not pass and there have been no new bills proposed as a solution to this antiquated licensing system (Brooks et al., 2013). In addition to the frustrations that come with licensing, provider credentialing is a similarly frustrating barrier for providers who wish to offer telehealth services. Provider credentialing is done under regulations that each organization sets for themselves (Merchant et al., 2015; Brooks et al., 2013) Thus, each provider who wants to DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 15 provide telehealth services to a hospital or clinic outside of their organization must be credentialed with this other organization. Here in Utah for example, an employee of Intermountain Healthcare (IHC) who wants to render services to a patient in the University of Utah Healthcare organization must do the credentialing process for both organizations. This is costly and time consuming for providers (Merchant et al., 2015). CMS guidelines were updated in 2011 in an attempt to loosen this constraint on rural, small facilities (Merchant et al., 2015) The guideline was updated to allow credentialing by proxy, this means that services can be rendered by a provider to a contracting facility without having to credential separately (National Consortium of Telehealth Resource Centers, 2018). However, there are rules that do affect this guideline. The originating facility can only contract with CAHs (Merchant et al., 2015). CAHs are required to do the credentialing of the provider they wish to contract with for specialty services (Brooks et al., 2013). While these services would most likely not be available in these areas without the credentialing by proxy guidelines, it is often too expensive for small privately-owned hospitals to afford (Merchant et al., 2015, Brooks et al., 2013). This defeats one of the most valuable offerings of telehealth, opening up access to specialty care of those in rural communities. Further, when providers wish to care for patients outside of their main organization, the bylaws are often different in other organizations (National Consortium of Telehealth Resource Centers, 2018). These limitations greatly restrict telehealth and its capacity. Brooks et al. (2013) discussed circumstances when telehealth services have been critical including post-natural disaster. During these catastrophic events there is a surge of mental health needs and injuries requiring specialty provider services (Brooks, 2013). The current laws surrounding credentialing in different organizations and multi-state licensing inhibit telehealth’s DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 16 true ability to provide care to those who need it most and those who would otherwise not receive care at all. Lack of Standardized Training As discussed previously, telemedicine is an effective method of providing specialized medical care to people who live in areas that lack access to these services. However, most educational programs lack training in telemedicine to prepare students for this important component and increasingly utilized modality of care (Ali, Carlton, & Ali, 2015). The lack of telehealth training in educational programs creates a significant obstacle to students gaining competency in this arena (Ainslie & Bragdon, 2018). Moore et al. (2016) reported that over 50% of family physicians have identified lack of training as one of several significant barriers to incorporating telehealth into their practices. Hawkins (2012) explained the importance of NPs learning telemedicine as a modality for patient care and calls on NP faculties to ensure competence in information technologies. Gray & Rutledge (2014) stress the importance of NPs, especially those practicing in rural areas, being competent in collaboration and communication skills that are necessary for telehealth utilization. Many rural providers are practicing “outside the scope of their training and licensure” (Galli, Keith, McKenzie, Hall, & Henderson, 2008, p. 275), when they are providing emergency medical care in rural areas; being skilled in telehealth provides them with some of the resources and collaboration they are lacking due to their geographical location (Gali et al., 2008). The American Association of Colleges of Nursing’s (AACN) 2011 version of The Essentials of Master’s Education in Nursing, states that graduates of master’s-level nursing programs will have “competence to determine the appropriate use of technologies and integrate current and emerging technologies into one’s practice and the practice of others to enhance care DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 17 outcomes” (AACN, 2011, p. 18). They further state that it is necessary for these graduates to obtain training and proficiency in using new technologies to enable them to provide quality care. Nurses who complete this level of education are a crucial factor in solving the problem of increasing healthcare provider shortages (AACN, 2011). Nurses who acquire the competencies described in this publication are an asset and “have significant value for current and emerging roles in healthcare delivery and design through advanced nursing knowledge and higher-level leadership skills for improving health outcomes.” (AACN, 2011, p. 3). In 2011, the AACN supported a 2010 recommendation from the Institute of Medicine (IOM), that included utilizing informatics when describing which core competencies all healthcare professionals should demonstrate (AACN, 2011). This panel further elaborated by stating that “knowledge and skills in information and healthcare technology are critical to the delivery of quality patient care in a variety of settings” (AACN, 2011, p. 18). In addition, Erickson, Fauchald, & Ideker (2015) state that telehealth experience and familiarity help ready these graduates to work in rural areas, where there is the greatest need for healthcare providers. Familiarity with the technology increases the comfort level, which further increases the likelihood that the student will use the technology in their future practice (Erickson, Fauchald, & Ideker, 2015). Federal and state regulations of telehealth do not require any type of standardized training in order to implement this practice (Nelson, 2017). The ATA offers degree or certificatelevel accredited training, and telehealth.org offers their own training program, each for a fee (http://www.americantelemed.org/home, https://telehealth.org/credentialing/). According to Nelson (2017), telehealth training is usually only provided on the job, there is no standardized provider training nor are there standard professional competencies. Schlachta-Fairchild, Varghese, Deickman, & Castelli (2010) reinforce this in their study, which found that training DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 18 and competency in telehealth is obtained through organizational training, mentoring, selftraining, or vendor training. Telehealth training should continue to be advanced and refined, and also include training on screen presence and remote examination (Won, Clark, Greenwald, Carter, & Sharma, 2017). Ali, Carlton, & Ali (2015) found that fewer than one third of educational programs incorporated training on telehealth into their curriculum. As Gray and Rutledge (2014) explain in their article, NP students are exposed to new opportunities to learn proficiency in communication technologies when their programs incorporate telehealth learning. The rapid growth of telehealth necessitates integrating training into the curricula for educational programs of all healthcare providers to better prepare them to apply these skills into their professional practices. Not only will these skills assist providers in meeting the challenges of administering healthcare in rural areas but also allow them to provide different types of healthcare (emergency care, critical care) while in the rural setting (Gray & Rutledge, 2014). NPs and physician assistants (PAs) are being utilized to fill the gaps for provider shortages, most often in rural areas (Gray & Rutledge, 2014). Due to their remote locations, they do not have access to professional networking or support that keeps them apprised on the most current practices. Additionally, many of them do not have access to health care specialists, impairing them from providing referrals and consultations for their patients (Erwin, 1998, Gray & Rutledge, 2014). These barriers to providing basic care have caused reluctance among new and/or younger providers to work in such remote locations, resulting in an overwhelming burden on existing rural providers (Rutledge et al., 2014). Protocols Lack of protocols on how to conduct telehealth patient care is a common barrier noted in our literature review. While we know the positive outcomes telehealth gives to patients, without DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 19 proper protocols for such visits, the benefits can be lost. Using telemedicine in concert with remote monitoring to reduce hospital readmissions for patients experiencing congestive heart failure is one example of where benefits to patients are lost due to lack of protocols (CrundallGoode & Goode, 2014). Randomized trials comparing traditional care with telehealth in the U.K. for chronic heart failure patients show reduced mortality, reduced hospitalizations, and reduced length of stay when telehealth is holistically integrated with primary care (Crundall-Goode & Goode, 2014). The results of these trials indicate, however, that positive telehealth outcomes are dependent on the nursing delivery model, specifically the availability of specialist nurses able to perform first technical and then clinical triage driven by the protocols, (Crundall-Goode & Goode, 2014). While remote monitoring holds considerable promise, the studies also indicate the barriers and pitfalls associated with telehealth must be clearly understood by all care providers (Crundall-Goode & Goode, 2014). Otherwise, problems like inadequate alert management or poorly modeled telehealth roles result in no reduction of mortality, hospitalizations, or length of stay (Crundall-Goode & Goode, 2014). The use of telemedicine in the Intensive Care Units (ICU) through remote monitoring via smart alerts and remote critical expertise via patient room cameras is also enabling smaller hospitals in rural communities; with fewer resources to care for the sickest patients, patients they otherwise struggled to care for in the past. Tele-ICUs typically work through a centralized system that displays vitals such as blood pressure, oxygen levels, heart rate, etc., coupled with machine learning algorithms that post alerts when emergency conditions arise (Kalb, Raikhelkar, Meyer, Ntimba, Thuli … & Scurlock, 2014). Tele-ICU monitoring falls under three often times intertwined models: continuous monitoring without interruption, scheduled care where patients DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 20 receive consultations based on a set schedule, and reactive care where the patients receive virtual critical care expertise as needed (Kalb et al., 2014). As with telehealth for chronic heart failure patients, studies show mixed results for TeleICU depending on implementation and adherence to protocols (Kalb et al., 2014). For example, a meta-analysis of several studies on Tele-ICU directed ventilator rounds, indicate improved adherence to low tidal volume lung-protective ventilation strategies (Kalb et al., 2014). This resulted in reduced ventilator duration and significantly reduced mortality largely due to improved clinical practice from computer-assisted advising (Kalb et al., 2014). A key takeaway is that outcomes are not so much improved by the algorithms themselves but rather their ability to mimic the protocol adherence of a controlled environment with an experienced clinical staff (Kalb et al., 2014). Further, telemedicine when coupled with web connected devices and platforms, also shows potential for improving patient medication adherence, as previously mentioned (Zanjal & Talmale, 2016). Protocols for telehealth are in their infancy and are needed to drive the care that providers give to their patients (LeRouge & Garfield, 2013). Without such protocols in place, benefits to patient outcomes will suffer. Providers and healthcare organizations need consistent protocols and standards in order to develop the basic groundwork for their telemedicine service to provide uniform, quality care that ultimately benefits patient outcomes and reduces provider liability. (LeRouge & Garfield, 2013). Liability Many health care organizations are unprepared for the rapid expansion of telehealth (Nelson, 2017). A number of liability issues exist with the implementation of telehealth, aside from those previously mentioned with licensing and reimbursement. The other liability issues include compliance of the Health Insurance Portability and Accountability Act (HIPAA), DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 21 security and privacy, peer review, and provider liability. Organizations must establish policies that guide the use of telehealth to protect patient privacy (Biddle & Milstead, 2016). These policies need to protect patient privacy and confidentiality as patients and providers communicate using e-mail and internet forums (Demiris et al., 2004). Types of patient safety violations that can occur include breach of confidentiality of medical data and breach of patient privacy. Providers using telemedicine must not only adhere to HIPAA regulations, but must also be responsible for ensuring that their location and the distant site are both secure, as well as the transmission between the two (Rutledge et al., 2017). The provider examining the patient from a remote location and possibly having a nurse or technician at the patient’s location assist with the exam, may get results that are inadequate and unreliable (Alvandi, 2017). Additionally, the patients themselves may feel that they have not received a complete and sufficient exam and may question the accuracy of the provider’s diagnosis and/or treatment plan (Alvandi, 2017). There is a personal connection that is lost when the visit is conducted via phone or screen, and it is more difficult to defend accusations of negligence when the exam is performed remotely. These factors increase the chances of malpractice allegations (Paterick et al., 2018). Furthermore, liability insurance coverage for providers is a necessity, but a standard telehealth liability insurance does not yet exist (Balestra, 2017). Telehealth is excluded from numerous professional liability policies, requiring providers to pay for additional coverage to cover this service (Balestra, 2017). Telehealth liability insurance policies are individualized to each policyholder, and take into consideration the specialty of practice as well as the regularity with which providers use telehealth for patient care (Tuckson, Edmunds, & Hodgkins, 2017). DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 22 Additionally, if the provider is working in other states, they need to also pay for malpractice liability insurance in those states as well (Balestra, 2017). Many medical boards are pushing for new policies that will expedite technological developments (Raths, 2015). While developing these new policies, they are trying to ensure flexibility “because they know they cannot keep changing policy as fast as the technology and delivery changes” (Raths, 2015, p. 19). The slower pace of policy development is a frustrating barrier for many health care providers and administrators; the lack of knowledge on telehealth by legislators as well as the Congressional Budget Office not supporting Medicare covering telemedicine services contribute to the stagnation (Raths, 2015). Guidelines for monitoring telemedicine providers must also be developed and established, as well as sharing review information. In order to abide by federal law, adverse events resulting from a provider’s telemedicine practice must be part of the shared internal review information (Balestra, 2017). Providers using telemedicine need to not only protect patient safety, but they must also safeguard themselves from malpractice and license concerns (Balestra, 2017). Technology There are a number of technology barriers to more widespread adoption of telemedicine such as broadband internet access in remote areas, computer literacy, security, privacy, expense, and supervision (Al-Majeed, Al-Mejibli, & Karam 2015). Technologists working to overcome these issues are making improvements day-by-day, especially when viewed from the perspective of where we are today compared with the past few decades (Al-Majeed et al., 2015). What is equally challenging, however, is overcoming emotional internal resistance from providers to DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 23 making substantial changes in the face of disruptive technology associated with the computerization of medicine (Shanafelt et al., 2015). Patient’s electronic access to providers is increasing daily. In many ways, yesterday’s telemedicine ability to share information regardless of location has become integrated with the way medicine is now practiced (Arndt et al., 2017). Providers can remotely check patient vitals, order tests, check lab results, view scans, schedule procedures and consult with distant colleagues on a diagnosis (Sadasivam et al., 2013; Naseriasl, Adham, & Janati, 2015; Zanjal & Tamale, 2016). Virtual care also allows patients to check their own test results, read providers notes, follow up on medications, and avoid the hassle of office or urgent care visits for nonemergency conditions (Al-Majeed et al., 2015). Telemedicine has integrated geographically dispersed medical centers, reduced wait times, reduced hospital fees, and improved overall patient satisfaction (Sadasivam et al., 2013; Naseriasl et al., 2015; Zanjal & Talmale, 2016). However, research shows that although computerization is improving care and reducing mortality rates, it has also significantly increased workloads for providers (Lin et al., 2018). Along with the patient upside of unprecedented access is the downside for providers given that work can require twice as much screen time as direct patient care for routine clinical work (Arndt et al., 2017). To keep up, clinicians are either increasing their work hours, including nights and weekends, or adopting part time patient schedules to compensate for the increased workload (Arndt et al., 2017). As a result, health care professionals are experiencing alarming rates of burnout due to exhaustion and the accompanying cynicism that comes from depersonalization of electronic patient care (Shanafelt et al., 2015). As technology improves, as access to broadband expands, as billing issues are resolved, as regulatory barriers fall away, DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 24 perhaps the greatest unintended barrier is electronic health care systems themselves because of the depersonalization and increased workload created for healthcare professionals. Conclusion As telemedicine technologies gain wider acceptance, the sharing of information will open endless possibilities for improving the quality, as well as reducing the cost of medical care. Hindering these improvements are many barriers that have slowed the expansion of telemedicine into mainstream health care, and made practicing telemedicine difficult for providers. The technology is developing more quickly than policy can keep up with, and health care providers need to ensure that they are protecting patients and themselves when policy fails to do so. State and/or federal policies that facilitate interstate practice and appropriate provider reimbursement, and also ease the process of licensure and credentialing must be achieved for telemedicine to become integrated into the current healthcare system. Health care providers will be better prepared to provide healthcare via telemedicine when educational institutions start implementing telehealth simulation courses into their curriculum. Preparing students for the future in telemedicine will greatly benefit underserved populations by allowing greater access to not only general health care, but also to specialty medical care. Providers are experiencing burn-out and feelings of isolation when they practice in remote areas without support from and collaboration with other professionals; telemedicine facilitates collaboration and helps prevent isolation. Ultimately it is not just the patient who is affected, but the provider as well. In order to surmount some of the other barriers obstructing the full utilization of telehealth, CMS must spearhead broader coverage of telehealth services, policies promoting private payer reimbursement need to be implemented on the state level. State licensure must be DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 25 changed to allow telehealth practice in all states under one national license. Additionally, telehealth must be integrated into the health care model instead of being treated as a separate entity. Although multiple barriers to implementing telehealth exist, they are rapidly being overcome as the process and policies develop. Strategic and deliberate planning, from incorporating telemedicine training into educational curriculums to nationwide licenses, must be implemented going forward to provide greater access and higher quality healthcare to all Americans whether they are located in suburban or rural areas. Telehealth is a rapidly evolving and utilized modality of providing healthcare, especially for patients located in rural areas. The trouble lies in that all of the barriers that impede provider implementation are working in tandem with one another. One barrier builds upon or further complicates another. The solution to these barriers is not transparent; it requires one to be resolved before another can be addressed. It is the authors’ belief that further research is warranted in the areas of preventing provider burnout from technology, evidence-based protocols for telemedicine and how to effectively implement standardized training in educational programs. It is not until these provider barriers are addressed that telemedicine can be used to its full potential. DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE Appendix A Utah Urban, Rural, and Frontier Counties Map 26 DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE Appendix B United States Map of Parity Laws 27 DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 28 References Adler-Milstein, J., Bates, D., & Kvedar, J. (2014). Telehealth among US hospitals: Several factors, including state reimbursement and licensure policies, influence adoption. 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American Association of Colleges of Nursing. Washington, D.C. American Telemedicine Association (2018). State policy resource center: States with parity laws for private insurance coverage of telemedicine. Retrieved October 28, 2018, from http://www.americantelemed.org/policy-page/state-policy-resource-center Arndt, B. G., Beasley, J. W., Watkinson, M. D., Temte, J. L., Tuan, W. J., Sinsky, C. A., & Gilchrist, V. J. (2017). Tethered to the EHR: primary care physician workload assessment DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 29 using EHR event log data and time-motion observations. The Annals of Family Medicine, 15(5), 419-426. Balestra, M. (2017). Telehealth and legal implications for nurse practitioners. The Journal for Nurse Practitioners, 14(1), 33–39. Retrieved from https://doiorg.ezproxy.westminstercollege.edu/10.1016/j.nurpra.2017.10.003. Biddle, S., & Milstead, J. (2016). The intersection of policy and informatics. 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(2014) US Department of Health and Human Services. State Variability in Supply of Office-based Primary Care Providers: United States 2012, 151 (5), 1-7. Kalb, T., Raikhelkar, J., Meyer, S., Ntimba, F., Thuli, J., Gorman, M. J., . . . Scurlock, C. (2014). A multicenter population-based effectiveness study of teleintensive care unit–directed ventilator rounds demonstrating improved adherence to a protective lung strategy, decreased ventilator duration, and decreased intensive care unit mortality. Journal of Critical Care, 29(4). doi:10.1016/j.jcrc.2014.02.017 Kopanos, T. (2014). The Policy Implications of Telehealth. Journal for Nurse Practitioners, 10(10), A25. Retrieved from http://search.ebscohost.com.ezproxy.westminstercollege.edu /login.aspx?direct =true&db=c8h&AN=107840253&site=ehost-live Lerouge, C., & Garfield, M. (2013). Crossing the Telemedicine Chasm: Have the U.S. Barriers to Widespread Adoption of Telemedicine Been Significantly Reduced? International DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 32 Journal of Environmental Research and Public Health, 10(12), 6472-6484. doi:10.3390/ijerph10126472 Lin, S. C., Jha, A. K., & Adler-Milstein, J. (2018). Electronic health records associated with lower hospital mortality after systems have time to mature. Health Affairs, 37(7), 11281135. Lindstrom, R. (2018). Despite barriers, telemedicine plays an important role. Ocular Surgery News, 36(5), 4-5. Mamlin, B. W., & Tierney, W. M. (2016). The Promise of Information and Communication Technology in Healthcare: Extracting Value From the Chaos. The American Journal of the Medical Sciences, 351(1), 59-68. doi:10.1016/j.amjms.2015.10.015 Mehrotra, A., Huskamp, H. A., Souza, J., Uscher-Pines, L., Rose, S., Landon, B. E., . . . Busch, A. B. (2017). Rapid Growth in Mental Health Telemedicine use Among Rural Medicare Beneficiaries, Wide Variation Across States. 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Telehealth Reimbursement. www.telehealthresourcecenter.org Nelson, R. (2017). Telemedicine and Telehealth: The Potential to Improve Rural Access to Care: Despite the promise of remote health care services, their operation faces hurdles. AJN American Journal of Nursing, 117(6), 17–18. Retrieved from http://ezproxy.westminstercollege.edu/login?url=http://search.ebscohost.com/login.aspx? direct=true&db=c8h&AN=123295314&site=ehost-live Paterick, Z. R., Ngo, E., Patel, N., Chandrasekaran, K., Tajik, J., & Paterick, T. E. (2018). Malpractice Considerations: New Concerns on the Horizon. Podiatry Management, 37(5), 55–62. Retrieved from http://search.ebscohost.com.ezproxy.westminstercollege.edu/login.aspx?direct=true&db= c8h&AN=131105494&site=ehost-live Raths, D. (2015). Telehealth policy picture improving -- but slowly. Healthcare Informatics, 32(5), 18–21. Retrieved from http://search.ebscohost.com.ezproxy.westminstercollege.edu/login.aspx?direct=true&db= c8h&AN=110267894&site=ehost-live Rutledge, C. M., Haney, T., Bordelon, M., Renaud, M., & Fowler, C. (2014). Telehealth: Preparing Advanced Practice Nurses to Address Healthcare Needs in Rural and Underserved Populations. International Journal of Nursing Education Scholarship, 11(1), 1–9. https://doi-org.ezproxy.westminstercollege.edu/10.1515/ijnes-2013-0061 DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 34 Rutledge, C., Kott, K., Schweickert, P., Poston, R., Fowler, C., & Haney, T. (2017). Telehealth and eHealth in nurse practitioner training: Current perspectives. Advances in Medical Education and Practice, Volume 8, 399-409. doi:10.2147/amep.s116071 Schlachta-Fairchild L, Varghese SB, Deickman A, & Castelli D. (2010). Telehealth and telenursing are live: APN policy and practice implications. Journal for Nurse Practitioners, 6(2), 98–106. Retrieved from https://doi-org.ezproxy.westminstercollege.edu/10.1016/j.nurpra.2009.12.019 Sadasivam, R. S., Hogan, T. P., Volkman, J. E., Smith, B. M., Coley, H. L., Williams, J. H., ... & Allison, J. J. (2013). Implementing point of care e-referrals in 137 clinics to increase access to a quit smoking internet system: the Quit-Primo and National Dental PBRN HIQUIT Studies. Translational behavioral medicine, 3(4), 370-378. Shanafelt, T. D., Hasan, O., Dyrbye, L. N., Sinsky, C., Satele, D., Sloan, J., & West, C. P. (2015, December). Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. In Mayo Clinic Proceedings (Vol. 90, No. 12, p. 1600-1613). Elsevier. Sharma, R., Fleischut, P., & Barchi, D. (2017). Telemedicine and its transformation of emergency care: A case study of one of the largest US integrated healthcare delivery systems. International Journal of Emergency Medicine, 10 (21). doi:10.1186/s12245017-0146-7. Telebehavioral Health Institute. [(accessed on 14 October 2018)]. Available online: https://telehealth.org/credentialing/. Tuckson, R., Edmunds, M., & Hodgkins, M. (2017). Telehealth. The New England Journal of Medicine, 377(16), 1585–1592. Retrieved from DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 35 https://doi-org.ezproxy.westminstercollege.edu/10.1056/NEJMsr1503323. Utah Department of Health (2013). Retrieved October 28, 2018, from https://www.ruralhealthinfo.org/assets/1215-5000/utah-rural-health-plan-2013.pdf Won, C. Y., Clark, S., Greenwald, P. W., Carter, W. A., & Sharma, R. (2017). The Next Frontier of Emergency Medicine Residency Training: Telemedicine. Annals of Emergency Medicine, 70, S58. https://doi.org/10.1016/j.annemergmed.2017.07.170 Zanjal, S. V., & Talmale, G. R. (2016). Medicine reminder and monitoring system for secure health using IOT. Procedia Computer Science, 78, 471-476 Running head: DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE Title of Article Cons 36 Keywords Pros Telemedicine and its tranformation of emergency care: a case study of one of the largest US integrated healthcare delivery systems telemedicine statistics on telehealth use, virtual ER visits for patients with minor complaints. Sharma, R., Fleischut, P., & Barchi, D. (2017). Telemedicine and its transformation of emergency care: A case study of one of the largest US integrated healthcare delivery systems. International Journal of Emergency Medicine, 10 (21). doi:10.1186/s12245017-0146-7. Telemedicine and its Role in Revolutionizing Healthcare Delivery telemedicine, healthcare listed different methods of telemedicine used. Alvandi, M. (2017). Telemedicine and its role in revolutionizing healthcare delivery. American Journal of Accountable Care 5 (1). Y Innovations in Telehealth telehealth explains telehealth, benefits of telehealth Simkins, J. (2017). INNOVATIONS IN TELEHEALTH. PT In Motion, 9(3), 30-35. N Telemedicine and Telehealth: The potential to improve rural access to care. telehealth, rural barriers to care: cost, infrastructure, broadband, cost of training people, lack of standardized training, benefits of telemedicine Nelson, R. (2017). Telemedicine and Telehealth: The Potential to Improve Rural Access to Care: Despite the promise of remote health care services, their operation faces hurdles. AJN American Journal of Nursing, 117(6), 17–18. Retrieved from http://ezproxy.westminstercollege.edu/login?url=http://search.ebs cohost.com/login.aspx?direct=true&db=c8h&AN=123295314&s ite=ehost-live Y more specific to PT Citation Arti cle Use d Y DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 37 Factors Influencing the Adoption of Telemedicine for Treatment of Military Veterans With Post-Traumatic Stress Disorder telemedicine identifies barriers and facilitators. increasing access of care to Veterans for PTSD, very specific population Kruse, C.S., Atkins, J.M., Baker, Gonzales, E.N., Paul, J.L, & Brooks, M. (2018).Factors influencing the adotpion of telemedicine for treatment of military veterans with posttraumatic stress disorder. Journal Of Rehabilitation Medicine (Stiftelsen Rehabiliteringsinformation), 50(5), 385-392. doi:10.2340/16501977-2302 N Rural Trauma Telemedicine Telemedicin e, rural good history/explanation of telemedicine more specific to trauma Wesson, J. B., & Kupperschmidt, B. (2013). Rural Trauma Telemedicine. Journal Of Trauma Nursing, 20(4), 199-202. doi:10.1097/JTN.0000000000000012 N Telemedicine has a long way to go in rural areas Telemedicin e in rural areas very brief article Telemedicine Has a Long Way to Go in Rural Areas. (2016). AARC Times, 40(8), 44. N Is telemedicine helping or hindering the delivery of stroke thrombolysis in rural areas? A qualitative analysis telemedicine stroke identifies lack of Medicare reimbursement as a major issue. discussed reason why telemedicine is not being used as much as it could be in rural areas. benefits of using telemedicine to deliver specialty care specific to using telemedicine for delivering stroke care Moloczij, N., Mosley, I., Moss, K. M., Bagot, K. L., Bladin, C. F., & Cadilhac, D. A. (2015). Is telemedicine helping or hindering the delivery of stroke thrombolysis in rural areas? A qualitative analysis. Internal Medicine Journal, 45(9), 957-964. doi:10.1111/imj.12793 N DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE Telemedicine program delivers healthcare services far and wide. telemedicine, health care discusses technology challenges TelEmergency: A Novel System for Delivering Emergency Care to Rural Hospitals Telemedicin e, rural U of Mississippi : training NP's to deliver trauma care in rural ED's Despite barriers, telemedicine plays an important role telemedicine, barriers history of telemedicine, barriers to implementing telemedicine Barriers to telemedicine implementation. Usually it's not technology issues that undermine a project--it's everything else telemedicine, barriers Telemedicine: Benefits to Advance Practice Nursing and the Communities They Serve telemedicine, barriers outdated 38 Batton, D., Patterson, M., Settimo, R., Batton, D., Patterson, M., & Settimo, R. (2006). Telemedicine program delivers healthcare services far and wide. Biomedical Instrumentation & Technology, 4018-21. N Galli, R., Keith, J., McKenzie, K., Hall, G., & Henderson, K. (2008). TelEmergency: A Novel System for Delivering Emergency Care to Rural Hospitals. Annals Of Emergency Medicine, 51(3), 275-284 Y good informaiton but very brief coverage of topics Lindstrom, R. (2018). Despite barriers, telemedicine plays an important role. Ocular Surgery News, 36(5), 4-5. Y discusses technology barriers vs. inadequate leadership, staff resistance, inadequate tech support, lack of physician buy-in outdated, and not enough info on the barriers that we are writing about Stumpf, S., Zalunardo, R., & Chen, R. (2002). Barriers to telemedicine implementation: usually it's not technology issues that undermine a project -- it's everything else. Healthcare Informatics, 19(4), 45-48. N How Telemedicine affects APRNs 2005 - outdated information Reed, K. 2005). Telemedicine: Benefits to advanced practice nursing and the communities they serve. Journal of the American Academy of Nurse Practitioners, 17(5). N DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE Telemedicine simulation in online family nurse practitioner education: Clinical competency and technology integration telemedicine APRN training in telemedicine for APRNs, discusses benefits of skill set for NP students who have used simulation modules, similar to telemedicine. Assessing advantages and barriers to telemedicine adoption in the practice setting: A MyCareTeam exemplarB telemedicine, barriers Medicare Expands Telehealth Benefits The Next Frontier of Emergency Medicine Residency Training: Telemedicine. mostly about online training and evaluation of student NP's 39 Ainslie, M., & Bragdon, C. (2018). Telemedicine simulation in online family nurse practitioner education: Clinical competency and technology integration. Journal of the American Association of Nurse Practitioners 30(8). Y competencies in telemedicine for APRNS L'Esperance, S. T., & Perry, D. J. (2016). Assessing advantages and barriers to telemedicine adoption in the practice setting: A MyCareTeamTM exemplar. Journal Of The American Association Of Nurse Practitioners, 28(6), 311-319. doi:10.1002/2327-6924.12280 N Medicare telemedicine from AARP website. Good statistics on usage of telehealth. Details limited coverage of telehealth for Medicare Gabriel, B. (2018). Medicare Expands Telehealth Benefits. Retrieved from: https://www.aarp.org/health/medicareinsurance/info-2018/medicare-telehealth-fd.html Y telemedicine training training for medical residents in telemedicine use Won, C. Y., Clark, S., Greenwald, P. W., Carter, W. A., & Sharma, R. (2017). 144 The Next Frontier of Emergency Medicine Residency Training: Telemedicine. Annals of Emergency Medicine, 70, S58. https://doi.org/10.1016/j.annemergmed.2017.07.170 Y recommended strategies to overcome telemedicine challenges DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE Preparing Student Nurses for the Future of Wound Management: Telemedicine in a Simulated Learning Environment telemedicine training Telehealth nurse practitioner student clinical experiences: An essential education component for today's health care setting. telehealth nurse practitioner Telemedicine: The cost-effectve future of healthcare telemedicine cost NP program that incorporates telemedicine training brief synopsis of cost, did not have any information that was differernt from other articles. Did not go into detail very specific to student nurses, and only in wound management. very broad overview 40 Christiansen, S., & Rethmeier, A. (2015). Preparing Student Nurses for the Future of Wound Management: Telemedicine in a Simulated Learning Environment. EWMA Journal, 15(2), 23–27. Retrieved from http://search.ebscohost.com.ezproxy.westminstercollege.edu/logi n.aspx?direct=true&db=c8h&AN=110787595&site=ehost-live N Hawkins, S. Y. (2012). Telehealth nurse practitioner student clinical experiences: An essential educational component for today’s health care setting. Nurse Education Today, 32(8), 842– 845. https://doiorg.ezproxy.westminstercollege.edu/10.1016/j.nedt.2012.03.008 Y Rehm, J. (2016). Telemedicine: The cost-effective future of healthcare. Retrieved from: https://www.ajmc.com/contributor/johnrehm/2016/12/telemedicine-the-cost-effective-future-ofhealthcare on 9/23/2018 N DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE To telemedically err is human telemedicine Critical care telemedicine: evolution and state of the art telemedicine Telehealth: Preparing Advanced Practice Nurses to Address Healthcare Needs in Rural and Underserved Populations. telehealth, nurse practitioner review of telemedicine's possible impact on patient safety, telemedicine could even introduce new types of errors APRN education program that incorporates telehealth training. 41 Demiris G, Patrick TB, Mitchell JA, & Waldren SE. (2004). To telemedically err is human. Joint Commission Journal on Quality & Safety, 30(9), 521–527. Retrieved from http://search.ebscohost.com.ezproxy.westminstercollege.edu/logi n.aspx?direct=true&db=c8h&AN=106515569&site=ehost-live Y Lilly, C. M., Zubrow, M. T., Kempner, K. M., Reynolds, H. N., Subramanian, S., Eriksson, E. A., … Groves, R. H., Jr. (2014). Critical care telemedicine: evolution and state of the art. Critical Care Medicine, 42(11), 2429–2436. https://doiorg.ezproxy.westminstercollege.edu/10.1097/CCM.00000000000 00539 N Rutledge, C. M., Haney, T., Bordelon, M., Renaud, M., & Fowler, C. (2014). Telehealth: Preparing Advanced Practice Nurses to Address Healthcare Needs in Rural and Underserved Populations. International Journal of Nursing Education Scholarship, 11(1), 1–9. https://doiorg.ezproxy.westminstercollege.edu/10.1515/ijnes-2013-0061 Y DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE The Opportunity Awaits to Lead Orthopaedic Telehealth Innovation: AOA Critical Issues. telehealth policy Telehealth reaches the tipping point telehealth policy Designing web-based telemedicine training for military health care providers. telehealth, training Discusses in-home monitoring, benefits to patients 42 regarding telehealth in orthopedics Wongworawat, M. D., Capistrant, G., & Stephenson, J. M. (2017). The Opportunity Awaits to Lead Orthopaedic Telehealth Innovation: AOA Critical Issues. Journal of Bone & Joint Surgery, American Volume, 99(17), 1–6. https://doiorg.ezproxy.westminstercollege.edu/10.2106/JBJS.16.01095 N discusses business strategies regarding telehealth, does not discuss our topics Landi, H. (2017). Telehealth reaches the tipping Point. Healthcare Informatics, 17–18. Retrieved from http://search.ebscohost.com.ezproxy.westminstercollege.edu/logi n.aspx?direct=true&db=c8h&AN=122316119&site=ehost-live N Bangert D, Doktor R, & Johnson E. (2001). Designing Webbased telemedicine training for military health care providers. Journal of Continuing Education in the Health Professions, 21(3), 162–169. Retrieved from http://search.ebscohost.com.ezproxy.westminstercollege.edu/logi n.aspx?direct=true&db=c8h&AN=106931358&site=ehost-live N DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE Long-term effects of specialized stroke care with telemedicine support in community hospitals on behalf of the Telemedical Project for Integrative Stroke Care. Rapid Growth In Mental Health Telemedicine Use Among Rural Medicare Beneficiaries, Wide Variation Across States telemedicine, barriers Excellent for Medicare explanation, offers solution to getting Medicare on board Only refers to mental health and Medicare patients 43 Audebert HJ, Schultes K, Tietz V, Heuschmann PU, Bogdahn U, Haberl RL, … Schenkel. (2009). Long-term effects of specialized stroke care with telemedicine support in community hospitals on behalf of the Telemedical Project for Integrative Stroke Care (TEMPiS). Stroke (00392499), 40(3), 902–908. https://doiorg.ezproxy.westminstercollege.edu/10.1161/STROKEAHA.108 .529255 N Mehrotra, A., Huskamp, H. A., Souza, J., Uscher-Pines, L., Rose, S., Landon, B. E., . . . Busch, A. B. (2017). Rapid Growth in Mental Health Telemedicine use Among Rural Medicare Beneficiaries, Wide Variation Across States. Health Affairs, 36(5), 909-917. doi:10.1377/hlthaff.2016.1461 Y DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE Barriers to Health Care in Rural Mozambique: A rapid ethnographic assessment of planned mobile health clinics for ART telemedicine, barriers Only 15% of FPs Report Using Telehealth; Training and Lack of Reimbursement are Top Barriers telemedicine, barriers, providers Good for percentages of FPs who report certain barriers, good idea on conclusion Hospital View of Factors Affecting Telemedicine Use Telemedicin e, barriers, providers Touches on reimbursement and multi-state licensing as largest barriers for implementation 44 Barriers for patients only that are in thrid world countries, transportation and poor health care facility conditions, these are not common themes in other articles we reviewed Schwitters, A., Lederer, P., Zilversmit, L., Samo-Gudo, P., Ramiro, I., Cumba, L., . . . Jobarteh, K. (2015). Barriers to Health Care in Rural Mozambique: A rapid ethnographic assessment of planned mobile health clinics for ART. Global Health: Science and Practice 3(1), 109-116. http://dx.doi.org/10.9745/GHSP-D14-00145. N Not a formal published study, 'one pager', no idea on how to make changes Moore, M.A., Coffman, M., Jetty, A., Petterson, S., Ramiro, & Bazemore, A.. (2016). Only 15% of FPs Report Using Telehealth; Training and Lack of Reimbursement are Top Barriers. American Family Physician 93(2), 101. https//www.aafp.org/afp/2016/0115/p101.html. Y Merchant, K. A., Ward, M. M., & Mueller, K. J., (2015). Hospital View of Factors Affecting Telemedicine Use. RUPRI Center for Rural Health Policy Analysis: Rural Policy Brief. 2015-5, 1-4. http://www.public-health.uiowa.edu/rupri. Y DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 45 Management of Heart Failure with Outpatient Technology Telemedicin e, technology, Good for remote monitoring patient devices to reduce hospital readmisions Specific to HF Murphy, N., Shanks, M., & Alderman, P. (2018). Management of Heart Failure With Outpatient Technology. The Journal for Nurse Practitioners. doi:10.1016/j.nurpra.2018.07.004 N Older adults and technology: in telehealth, they may not be who you think they are Telemedicin e, technology, Good discussion older population willingness to adapt to technology Letter to editorlooking for original article Greenwald, P., Stern, M. E., Clark, S., & Sharma, R. (2018). Older adults and technology: In telehealth, they may not be who you think they are. International Journal of Emergency Medicine, 11(1). doi:10.1186/s12245-017-0162-7 N Integrating Telehealth Into the Graduate Nursing Curriculum Telemedicin e, technology, education Adding telemedicine in the APRN Curriculum Erickson, C. E., Fauchald, S., & Ideker, M. (2015). Integrating Telehealth Into the Graduate Nursing Curriculum. The Journal for Nurse Practitioners, 11(1). doi:10.1016/j.nurpra.2014.06.019 N Rural Healthy People 2020: New Decade, Same Challenges Telemedicin e, Rural Rural Access to Healthcare Bolin, J. N., Bellamy, G. R., Ferdinand, A. O., Vuong, A. M., Kash, B. A., Schulze, A., & Helduser, J. W. (2015). Rural Healthy People 2020: New Decade, Same Challenges. The Journal of Rural Health, 31(3), 326-333. doi:10.1111/jrh.12116 Y DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE Evaluating barriers to adopting telemedicine worldwide: a systemic review Barriers, implementati on, telemedicine, mHealth, technology Good discusses barriers with technology Policy Recommendations to Guide the Use of Telemedicine in Primary Care Settings: An American College of Physicians Position Paper Telemedicin e, benefits, health outcomes, challenges good for challenges: cost liscensing, state regulation Connected Health: A review of technologies and stratagies to improve patient care with telemedicine and telehealth Telemedicin e, technology, Good review strategies to improve patient outcomes with telehealth Telehealth: Seven stratigies to successfully implement disruptive technology and transform health care Telehealth, technology Good article barriers not specific to US 46 Kruse, C. S., Karem, P., Shifflett, K., Vegi, L., Ravi, K., & Brooks, M. (2016). Evaluating barriers to adopting telemedicine worldwide: A systematic review. Journal of Telemedicine and Telecare, 24(1), 4-12. doi:10.1177/1357633x16674087 N Daniel, H., & Sulmasy, L. S. (2015). Policy Recommendations to Guide the Use of Telemedicine in Primary Care Settings: An American College of Physicians Position Paper. Annals of Internal Medicine, 163(10), 787. doi:10.7326/m15-0498 Y Limited examples, not part of research discussion Kvedar, J., Coye, M. J., & Everett, W. (2014). Connected Health: A Review Of Technologies And Strategies To Improve Patient Care With Telemedicine And Telehealth. Health Affairs, 33(2), 194-199. doi:10.1377/hlthaff.2013.0992 N Content already outdated compared with other research articles Schwamm, L. H. (2014). Telehealth: Seven Strategies To Successfully Implement Disruptive Technology And Transform Health Care. Health Affairs, 33(2), 200-206. doi:10.1377/hlthaff.2013.1021 N DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE Mobile technology and the digitization of healthcare Telemedicin e, mHealth, technology Good article Telemedicine technology: a review of services, equipment, and other aspects Telemedicin e, technology Telehealth and eHealth in nurse practitioner training: current perspectives Discussion of Mhealth in Europe 47 Bhavnani, S. P., Narula, J., & Sengupta, P. P. (2016). Mobile technology and the digitization of healthcare. European Heart Journal, 37(18), 1428-1438. doi:10.1093/eurheartj/ehv770 N Good, reviews HIPAA, types of telemedicine visits, EMR Baker, J., & Stanley, A. (2018). Telemedicine Technology: A Review of Services, Equipment, and Other Aspects. Current Allergy and Asthma Reports, 18(11). doi:10.1007/s11882-0180814-6 N Telemedicin e, APRN, training Good discussion APRN training Rutledge, C., Kott, K., Schweickert, P., Poston, R., Fowler, C., & Haney, T. (2017). Telehealth and eHealth in nurse practitioner training: Current perspectives. Advances in Medical Education and Practice, Volume 8, 399-409. doi:10.2147/amep.s116071 Y Patient perceptions of telehealth primary care video visits Telemedicin e, patient perspective good study patient perceptions of video visits Powell, R. E., Henstenburg, J. M., Cooper, G., Hollander, J. E., & Rising, K. L. (2017). Patient Perceptions of Telehealth Primary Care Video Visits. The Annals of Family Medicine, 15(3), 225-229. doi:10.1370/afm.2095 N Tips for seeing patients via telemedicine Telemedicin e, ehealth good discussion telemedicine technology, stethescope, otoscope Shih, J., & Portnoy, J. (2018). Tips for Seeing Patients via Telemedicine. Current Allergy and Asthma Reports, 18(10). doi:10.1007/s11882-018-0807-5 N small sample for study DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE Telehealth Insulin Program: Managing Insulin in Primary Care insuline, nurse practitioner, primary care, telehealth, type 2 diabetes good discussion pt mgmt of chronic disease Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014 Burnout Great discussion increased screentime and provider burnout Teledermatology: From Historical perpective to emerging techniques of the modern era Telehealth, provider, barriers Barriers and challenges in adopting Saui telemedicine network: The perceptions of decision makers of healthcare facilities in Saudi Arabia Telemedicin e, provider, barriers Similar barriers exsist in other countries that exsist here in the USA type 2 diabetes specific 48 Iannitto, J. M., Dickman, K., Lakhani, R. H., & So, M. J. (2014). Telehealth Insulin Program: Managing Insulin in Primary Care. The Journal for Nurse Practitioners, 10(8), 567-574. doi:10.1016/j.nurpra.2014.07.027 N Shanafelt, T. D., Hasan, O., Dyrbye, L. N., Sinsky, C., Satele, D., Sloan, J., & West, C. P. (2015, December). Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. In Mayo Clinic Proceedings (Vol. 90, No. 12, pp. 1600-1613). Elsevier. Y dermatology specific Coates, S.J., Kvedar, BA., & Granstein, R.D., (2015). Teledermatology: From historical perspective to emerging techniques of the modern era. The American Academy of Dermatology, 577-586. doi:10.1016/j.jadd.2014.08.14 N Saudi Arabia specific, some of the same barriers, but many different ones based on their healthcare system which is significantly different than ours Abdulellah, A., Atkins, A., Sharp, B., Balkhair, A., & Sunbul, T., (2015). Teledermatology: From historical perspective to emerging techniques of the modern era. The American Academy of Dermatology, 577-586. doi:10.1016/j.jadd.2014.08.14 N DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE Telemedicince in the Context of Different Medical Specialities. The Polish Perspective Telehealth, barrier Increasing the Capacity of Primary Care Through Enabling Technology technology, primary care, mHealth, telehealth, sensors, patient portal Technology, community, bringing specialist to the community Electronic health records associated with lower hospital mortality after systems have time to mature Telemedicin e, EHR, Technology E-referral solutions: successful experiences, key features and challenges-a systematic review Telemedicin e, technology, 49 OUTDATED, FROM 2003 Rudowski, R., (2003). Telemedicine in the context of different medical specialities. The Polish prespective., The Medical University of Warszawa. 54(3), 219-221, ISSN 1233-9687. N Not helpful with research Young, H. M., & Nesbitt, T. S. (2017). Increasing the Capacity of Primary Care Through Enabling Technology. Journal of General Internal Medicine, 32(4), 398–403. http://doi.org/10.1007/s11606-016-3952-3 N Accessing multiple EHR Lin, S. C., Jha, A. K., & Adler-Milstein, J. (2018). Electronic health records associated with lower hospital mortality after systems have time to mature. Health Affairs, 37(7), 1128-1135. Y E-referral technology Naseriasl, M., Adham, D., & Janati, A. (2015). E-referral solutions: successful experiences, key features and challenges-a systematic review. Materia sociomedica, 27(3), 195. Y DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 50 A Multicenter Population-Based Effectiveness Study of TeleICUDirected Ventilator Rounds Demonstrating Improved Adherence to a Protective Lung Strategy, Decreased Ventilator Duration and Decreased ICU Mortality Telemedicin e, technology, models, Good study implementing TeleICU protocol patient care Kalb, T., Raikhelkar, J., Meyer, S., Ntimba, F., Thuli, J., Gorman, M. J., . . . Scurlock, C. (2014). A multicenter population-based effectiveness study of teleintensive care unit– directed ventilator rounds demonstrating improved adherence to a protective lung strategy, decreased ventilator duration, and decreased intensive care unit mortality. Journal of Critical Care, 29(4). doi:10.1016/j.jcrc.2014.02.017 Y History of Telemedicine: Evolution, Context, and Transformation Telmedicine history Great information on telemedicine history Borg, S. W. (2009). History of Telemedicine: Evolution, Context, and Transformation. Jama, 302(16), 1813. doi:10.1001/jama.2009.1564 Y Utah Department of Health Utah Rural Utah rural population, Utah Department of Health. (n.d.). Retrieved October 28, 2018, from https://www.ruralhealthinfo.org/assets/12155000/utah-rural-health-plan-2013.pdf Y Medicine reminder and monitoring system for secure health using IOT Models Models of patient managment Zanjal, S. V., & Talmale, G. R. (2016). Medicine reminder and monitoring system for secure health using IOT. Procedia Computer Science, 78, 471-476. Y DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 51 Using telehealth for heart failure: Barriers, pitfalls and nursing service models Telehealth, barriers, models Great information on models & protocols, barriers in telehealth Crundall-Goode, A., & Goode, K. M. (2014). Using telehealth for heart failure: Barriers, pitfalls and nursing service models. British Journal of Cardiac Nursing, 9(8), 396-406. Y Impact of mHealth chronic disease management on treatment adherence and patient outcomes: a systematic review Telehealth, models Good discussion Mhealth technology models Hamine, S., Gerth-Guyette, E., Faulx, D., Green, B. B., & Ginsburg, A. S. (2015). Impact of mHealth chronic disease management on treatment adherence and patient outcomes: a systematic review. Journal of medical Internet research, 17(2), e52. doi:10.2196/jmir.3951 Y US Department of Health and Human Services. State Variability in Supply of Office-based Primary Care Providers: United States 2012 telemedicin, rural telehealth, access to care Hing, E, Hsiao, C. (2014) US Department of Health and Human Services. State Variability in Supply of Office-based Primary Care Providers: United States 2012, 151 (5), 1-7. Y Using New Communication Technologies: An Educational Strategy Fostering Collaboration and Telehealth Skills in Nurse Practitioners telehealth, nurse practitioners Experiential learning activity that promorted DNP student competencies in using a variety of technologies Gray, D. C., & Rutledge, C. M. (2014). Using new communication technologies: An educational strategy fostering collaboration and telehealth skills in nurse practitioners. Journal for Nurse Practitioners, 10(10), 840–844. https://doiorg.ezproxy.westminstercollege.edu/10.1016/j.nurpra.2014.06.01 8 Y Specific to NPs DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 52 Telemedicine still facing barriers in many states. telemedicine, state barriers Desjardins, D. (2014). Telemedicine still facing barriers in many states. Medicine on the Net, 20(5), 1–3. Retrieved from http://search.ebscohost.com.ezproxy.westminstercollege.edu/logi n.aspx?direct=true&db=c8h&AN=103980701&site=ehost-live Y Telehealth and telenursing are live: APN policy and practice implications. telehealth, nursing Schlachta-Fairchild L, Varghese SB, Deickman A, & Castelli D. (2010). Telehealth and telenursing are live: APN policy and practice implications. Journal for Nurse Practitioners, 6(2), 98– 106. https://doiorg.ezproxy.westminstercollege.edu/10.1016/j.nurpra.2009.12.01 9 Y Achieving success connecting academic and practice clinicians through telemedicine. telemedicine, training González-Espada WJ, Hall-Barrow J, Hall RW, Burke BL, & Smith CE. (2009). Achieving success connecting academic and practicing clinicians through telemedicine. Pediatrics, 123(3), e476-83. https://doiorg.ezproxy.westminstercollege.edu/10.1542/peds.2008-2193 N DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE Implementation of a simulation-based telemedicine curriculum. telehealth training The virtual clinical practicum: An innovative telehealth model for clinical nursing education. telehealth, training Enhancing telehealth education in nursing: applying King's conceptual framework and theory of goal attainment. telehealth training based on resuscitation simulation. telehealth education in nursing focuses on King's Conceptual theory 53 Wang, J. J., Lavigueur, O., Sheridan, M., & Stern, E. (2017). Implementation of a simulation-based telemedicine curriculum. Medical Education, 51(11), 1178–1179. https://doiorg.ezproxy.westminstercollege.edu/10.1111/medu.13433 N Grady, J. L. (2011). The Virtual Clinical Practicum: An Innovative Telehealth Model for Clinical Nursing Education. Nursing Education Perspectives (National League for Nursing), 32(3), 189–194. https://doiorg.ezproxy.westminstercollege.edu/10.5480/1536-502632.3.189 N Fronczek, A. E., Rouhana, N. A., & Kitchin, J. M. (2017). Enhancing Telehealth Education in Nursing: Applying King’s Conceptual Framework and Theory of Goal Attainment. Nursing Science Quarterly, 30(3), 209–213. https://doiorg.ezproxy.westminstercollege.edu/10.1177/0894318417708418 N DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE Telehealth a complex issue being addressed by state and federal governments. telehealth, state barriers Telehealth police picture improving but slowly. telehealth policy The policy implications of telehealth telehealth policy Using telehealth for heart failure: Barriers, pitfalls and nursing service models Telehealth, provider, barriers from 1997, however still has some relevant information statement from AANP Cardiac specific, not relatable to the subject as a whole 54 Walker JF. (1997). Health policy issues. Telehealth a complex issue being addressed by state and federal governments. AORN Journal, 66(4), 709–712. https://doiorg.ezproxy.westminstercollege.edu/10.1016/S00012092(06)62928-1 N Raths, D. (2015). Telehealth policy picture improving -- but slowly. Healthcare Informatics, 32(5), 18–21. Retrieved from http://search.ebscohost.com.ezproxy.westminstercollege.edu/logi n.aspx?direct=true&db=c8h&AN=110267894&site=ehost-live Y Kopanos, T. (2014). The Policy Implications of Telehealth. Journal for Nurse Practitioners, 10(10), A25. Retrieved from http://search.ebscohost.com.ezproxy.westminstercollege.edu/logi n.aspx?direct=true&db=c8h&AN=107840253&site=ehost-live Y Crundall-Goode, A., & Goode, K.M., (2014). Using telehealth for heart failure: Barriers, pitfalls, and nursing service models. British Journal of Cardiac Nursing, 9(8), 396-406. Retrieved from https://www.magonlinelibrary.com/doi/10.12968/bjca.2014.9.8.3 96. N DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 55 American Association of Colleges of Nursing, 2011. Essentials of Master's Education in Nursing. American Association of Colleges of Nursing. Washington, D.C. Researched this website for criteria for Master's Education in Nursing discusses preparing master's graduates American Association of Colleges of Nursing, 2011. Essentials of Master's Education in Nursing. American Association of Colleges of Nursing. Washington, D.C. Y Telehealth among US hospitals: Several factors, including state reimbursement and licensrue policies, influence adoption telehealth policies Adler-Milstein, J., Bates, D., & Kvedar, J. (2014). Telehealth among US hospitals: Several factors, including state reimbursement and licensure policies, influence adoption.Health Affairs, 33(2), 207–215. https://doiorg.ezproxy.westminstercollege.edu/10.1377/hlthaff.2013.1054 Y Telehealth and interprofessional education telehealth training Talk about reimbursement, importance of policy to drive telehealth. Importance of state policy for reimbursement. Talks about stats that are strong evidence of the importance of this kind of care for patients in ICU and chronic ilness OT, PT, and NP students at one school collaborate on pt care using telehealth over a few semesters as part of their graduate training.. Ciro, C., Randall, K., Robinson, C., Loving, G., & Shortridge, A. (2015). Telehealth and interprofessional education. OT Practice, 20(7), 7–10. Retrieved from http://search.ebscohost.com.ezproxy.westminstercollege.edu/logi n.aspx?direct=true&db=c8h&AN=109794528&site=ehost-live N https://www.healthypeople.gov/2020/ab out/foundation-healthmeasures/Disparities disparities https://www.healthypeople.gov/2020/about/foundation-healthmeasures/Disparities N discusses use of telehealth to overcome the barrier of geographical location Very specific to one program, did not eplain more about telehealth training in general DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE The intersection of policy and informatic telehealth policy Acceptability and cost-effectiveness of military telehealth mental health screening telehealth, barriers Telehealth Policy Issues Telehealth, reimburseme nt Telehealth Reimbursement Telehealth, reimburseme nt Show don't tell, telehealth benefits Telehealth, barriers Nurse management perspective on informatics in nursing practice 56 limited information on policy Biddle, S., & Milstead, J. (2016). The intersection of policy and informatics. Nursing Management, 47(2), 12–13. https://doi.org/10.1097/01.NUMA.0000479453.73651.89 Y Focus is on patient prespective of telehealth serviced, military and mental health focus. OUTDATED Jones, A.D., Etherage, J.R., Harmon, S. C., & Okiishi, J.C. (2012). Acceptability and cost-effectiveness of military telehealth mental health screening. Psychological Services, 9(2), 132-143. Doi: 10.1037/a0026709. N Quick and up-to-date review Very minimal, short one pager National Consortium of Telehealth Resource Centers (2018). Telehealth Policy Issues. www.telehealthresourcecenter.org Y Quick and up-to-date review Very minimal, short one pager National Consortium of Telehealth Resource Centers (2018). Telehealth Reimbursement. www.telehealthresourcecenter.org Y Short one pager, editoral, opinion piece, focus is only on marketing better, not barriers for providers Aiello, M. (2014). Show don't tell, tlehelath benefits. Healthcare Marketing Advisor. 3. N DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE Results from the World's largest telemedicine project- the whole system demonstrator Telemedicin e, barriers Telehealth delivers many benefits, but concerns linger Telehealth, provider, barriers Financial benefits of telehealth: Healthcare leaders are exploring pathways to payer reimbursement 57 Only focuses on patient barriers. Oganizational barriers, not provider specific Kidholm, K., Dinesen, B., Dyrving, A.K., Rasmussen, B.S. & Yderstraede, K.B. (2014). Results from the World's largent telemedicine project-the whole system demonstrator. EWMA Journal 14(1), 43-48. N Has good ideas on ways to make change, has some information regarding reimbursement OUTDATED (but still relivent), PT centered but could be applied to all providers Lawton, G. (2010). Telehealth delivers many benefits, but concerns linger. PT in Motion, 16-23. N Telehealth, provider, barriers Has limited discussion of reimbursement, good reasons for the 'why' and valid argumetns for the importance OUTDATED (but still relivent) Minich-Pourshdi, K., (2012). Financial benefits of telehealth: Healthcare leaders are exploring pathways to payer reimbursement. HealthLeaders, July 2012, 46-51. http://healthleadersmedia.com/finance/2012.july N Patient and provider perspectives on using telemedicine for chronic disease management amoung Native Hawaiian and Alaska Native people Telemedicin e, provider, barriers Technology discussed as primary barrier for providers specific to rural areas of Alaska and Hawaii (but relivent to the subject) Hiratsuka, V., Delafield, R., Starks, H., Ambrose, A.J., & Mau, M. M., (2013). Int J Circonpolar Helath, 72(1). http://dx.doi.org/10.3402/ijch.v72i0.201401 N Electronic communication improves access, but barriers to its widespread adoption remain Telehealth, provider, barriers Good discussion on ways providers can be reimburrsed for evisits. Reimbursement discussed is for phone calls patients make into the office, not for entire visit Bishop, T.F., Press, M.J., Mendelsohn, J.L., & Casalino, L.P., (2013). Health Affairs, 32(8) 1361-1367. Doi: 10.1377/hlthaff.2012.1151. N DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE Telemental Health: Proivder barriers to tlemental health, obstacles overcome, obstacles remaining Telehealth, provider, barriers Novel tlemedicine technologies in geriatric chronic non-cancer pain: Primary care providers perspectives Telemedicin e, barriers Healthcare provider's preceptions of barriers in implementing of home telecare in Taiwan: A qualitative study Telehealth, provider, barriers Good discussion on both reimbursement and licensing Interesting that the same problems we experience in the USA are the same experience as those in other countries 58 Brooks, E., Turvey, C., & Augusterfer, E.F. (2013) Telemental Health: Proivder barriers to tlemental health, obstacles overcome, obstacles remaining. Telemedicine and e-Health. 19(6) 433-437. Doi: 10.1089/tmj.2013.0068. Y Only discusses patient prespective and is limited to pain management only Mimi-Levine, A.B., Richardson, J.E., Granieri, E., & Reid, M.C. (2014). Novel tlemedicine technologies in geriatric chronic noncancer pain: Primary care providers perspectives. Pain Medicine 15(1) 206-213. http://academic.oup.com/painmedicine/articleabstract/15/2/206/1824135. N Exclusive to Taiwan Chiang, K.F., Wang, H.H., Chien, I.K., Liou, J.K., Hung, C.L., Huang, C.M., & Yang, F.Y., (2015), Healthcare provider's preceptions of barriers in implementing of home telecare in Taiwan: A qualitative study. International Journal of Medical Informatics, 84(2015), 277-287. http://dx.doi/org/10/1016/j.ijmedinf.2015.01.007. N DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE Barriers and benefits in telemedicine arising between a high-technology hospital service provider and remote public healthcare units: A qualitative study in Brazil Telehealth, provider, barriers Interesting that the same problems we experience in the USA are the same experience as those in other countries Rapid review of applications of e-health and remote monitoring for rural residents Telemedicin e, barriers Discusses training and education of providers as a barrier Barriers to the up-take of telemedicine in Australia- A view from providers Telehealth, provider, barriers Some of the same barriers from the USA, interesing that some problems are worldwide Differences in readiness between rural hospitals and primary care providers for telemedicine adoption and implementation: Findings from a statewide telemedicine survey Telemedicin e, barriers Exclusive to Brasil 59 Amaral de Souza, C.H., Morbeck, R.A., Hors, C.P., & Kozasa, E.H., (2016) Barriers and benefits in telemedicine arising between a high-technology hospital service provider and remote public healthcare units: A qualitative study in Brazil. Telemedicine and e-Health, 23(6), doi: 10.1089/tmj.2016.0158. N Banbury, A., Roots, A., and Nancarrow, S. (2014), The Australian Journal of Rural Health, 22(2014), 211-222. doi: 10/.1111/ajr.12127 N OUTDATED from 2011, only discusses infrstructure as a same theme we have discovered in the USA Moffatt, J.J. and Eley, D.S. (2011) Barriers to the up-take of telemedicine in Australia- A view from providers. Rural and Remote Health, 11(1581), 1-6. http://rrh.org.au N OUTDATED from 2011 Martin, A.B., Probst, J.C., Shah, K., Chen, Z., & Garr, D., (2011), Differences in readiness between rural hospitals and primary care providers for telemedicine adoption and implementation: Findings from a statewide telemedicine survey. The Journal of Rural Health, 3(36), https://doi.org/10.1111/j.1748-0361.2011.00369.x N DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE Interview with Expert in Utah Medicaid telehealth reimburseme nt telehealth, policy Parity laws specific to Utah discussed Nurse Pracitioners in Telehealth: Bridging the gaps in healthcare delivery telehealth, nurse practitioners discusses how telemedicine benefits patients and providers in rural emergency departments, and improves patient survival rates. Integrating Health Care Technology into patient care: Telemedicine telemedicine, healthcare Telehealth telehealth policy Are nurse practitioners ready for telehealth? point counterpoint article specific to NP's, does not discuss barriers, policies outdated information, not specific to our topics discusses reimbursement, licensing, liability, performance 60 Bacon, K. (2018). Personal communication. September 30, 2018. Y Rutledge, C. M., & Gray, D. C. (2015). POINT counterpoint...Are nurse practitioners ready for telehealth? Journal for Nurse Practitioners, 11(9), 860–861. https://doiorg.ezproxy.westminstercollege.edu/10.1016/j.nurpra.2015.07.00 6. N Henderson, K., Davis, T., Smith, M., & King, M. (2014). Nurse practitioners in telehealth: Bridging the gaps in healthcare delivery. The Journal for Nurse Practitioners, 10(10), 845–850. https://doiorg.ezproxy.westminstercollege.edu/10.1016/j.nurpra.2014.09.00 3. Y Lewarski J. (2007). Integrating health care technology into patient care: telemedicine. AARC Times, 31(7), 6–10. Retrieved from http://search.ebscohost.com.ezproxy.westminstercollege.edu/logi n.aspx?direct=true&db=c8h&AN=106170448&site=ehost-live. N Tuckson, R., Edmunds, M., & Hodgkins, M. (2017). Telehealth. The New England Journal of Medicine, 377(16), 1585–1592. https://doiorg.ezproxy.westminstercollege.edu/10.1056/NEJMsr1503323. Y DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE Telehealth and the law: The Challenge of reimbursement telehealth discusses Medicare reimbursement State of Telehealth telehealth good definition of telehealth Social, ethical, and legal barriers to Ehealth telehealth, barriers good information regarding barriers Telehealth and legal implications for nurse practitioners telehealth, policy addresses issues of licensing, reimbursement, fraud, privacy, peer review. Discussed ways for NPs to protect themselves. not any new or different informaiton 61 Fanburg, J., & Walzman, J. (2018). Telehealth and the law: The challenge of reimbursement. Contemporary OB/GYN, 63(10), 59–60. Retrieved from http://search.ebscohost.com.ezproxy.westminstercollege.edu/logi n.aspx?direct=true&db=c8h&AN=132575652&site=ehost-live. N Dorsey, E. & Topol, E. (2016). State of Telehealth. New England Journal of Medicine, 375(2), 154–161. https://doiorg.ezproxy.westminstercollege.edu/10.1056/NEJMra1601705. N outdated, information is not new compared to more recent articles Anderson, J. (2007). Social, ethical, and legal barriers to ehealth. International Journal of Medical Informatics, 76(5-6), 480-483. Retrieved from https://doi.org/10.1016/j.ijmedinf.2006.09.016. N none Balestra, M. (2017). Telehealth and legal implications for nurse practitioners. The Journal for Nurse Practitioners, 14(1), 33–39. https://doiorg.ezproxy.westminstercollege.edu/10.1016/j.nurpra.2017.10.00 3. Y DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 62 Telehealth Education in Nursing Curricula telehealth, education statistic on how many programs incorporate telehealth most of article was based on one study Ali, N., Carlton, K., & Ali, O. (2015).Telehealth education in nursing curricula. Nurse Educator, 40(5), 266–269. https://doiorg.ezproxy.westminstercollege.edu/10.1097/NNE.00000000000 00149). Y Legal Forum: Telemedicine and Competitive change in health care telemedicine, liability Interesting perspective on barriers to telemedicine in the late 1990's, still similar to today's barriers Outdated: 1997 LaMay, C. (1997). Legal Forum: Telemedicine and competitive change in health care.Spine, 22(1), 88–97. Retrieved from http://search.ebscohost.com.ezproxy.westminstercollege.edu/logi n.aspx?direct=true&db=c8h&AN=107329599&site=ehost-live N Malpractice Considerations: New concerns on the horizon telemedicine, liability section that specifically addresses liability issues with telemedicine. discusses concerns of malpractice in general, small section on telemedicine Paterick, Z. R., Ngo, E., Patel, N., Chandrasekaran, K., Tajik, J., & Paterick, T. E. (2018). Malpractice Considerations: New Concerns on the Horizon. Podiatry Management, 37(5), 55–62. Retrieved from http://search.ebscohost.com.ezproxy.westminstercollege.edu/logi n.aspx?direct=true&db=c8h&AN=131105494&site=ehost-live Y DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 63 Telemedicine - all the same challenges with a twist telemedicine, challenges brief article, addresses licensing, credentialing, peer review, medicare, medicaid. Did not cover anything new Batt, M., & Eades, C. (2016). Telemedicine- All the same challenges with a twist. H&HN: Hospitals & Health Networks, 90(5), 34. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=c8h&A N=115790453&site=ehost-live N Rural Health policy: Telehealth to bridget the rural-uban health care divide telehealth, policy interesting statistics on the use of telehealth in the country, discusses state policies Very brief synopsis on challenges, outdated Schmeida M. (2007). Rural health policy: telehealth to bridge the rural-urban health care divide. AAACN Viewpoint, 29(5), 18–8. Retrieved from http://ezproxy.westminstercollege.edu/login?url=http://search.ebs cohost.com/login.aspx?direct=true&db=c8h&AN=105920258&s ite=ehost-live&scope=site N written by an attorney who is a former RT, discusses licensure Specific to RT practice, but is relative to other health care professions. DeWitt, A. L. (2016). Telemedicine Presents Challenges. AARC Times, 40(2), 18–19. Retrieved from http://ezproxy.westminstercollege.edu/login?url=http://search.ebs cohost.com/login.aspx?direct=true&db=c8h&AN=112850220&s ite=ehost-live&scope=site N Telemedicine presents challenges DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 64 Issues in Telemedicine: Why is policy still light-years behind technology? telemedicine policy licensing, limited licensure module vs. national licensure module outdated, no new information than more recent articles. Simpson RL. (2002). Nursing informatics. Issues in telemedicine: why is policy still light-years behind technology? Nursing Administration Quarterly, 26(4), 81–84. Retrieved from http://ezproxy.westminstercollege.edu/login?url=http://search.ebs cohost.com/login.aspx?direct=true&db=c8h&AN=106956521&s ite=ehost-live N And the winner is....Telemedicine award winners bring specialized healthcare to rural areas. telemedicine discusses partnership between St. Mark's Hospital in SLC, UT, and Allen Memorial Hospital in Moab, UT. outdated (1998) Erwin A. (1998). And the winner is.....Telemedicine award winners bring specailized healthcare to rural areas. Healthcare Informatics, 15(9), 103–106. Retrieved from http://ezproxy.westminstercollege.edu/login?url=http://search.ebs cohost.com/login.aspx?direct=true&db=c8h&AN=107154748&s ite=ehost-live Y Implementing point of care e-referrals in 137 clinics to increase access to a quit smoking internet system: the QuitPrimo and National Dental PBRN HIQUIT Studies. telemedicine, technology technology providers and ereferrals and provider burn out Sadasivam, R. S., Hogan, T. P., Volkman, J. E., Smith, B. M., Coley, H. L., Williams, J. H., ... & Allison, J. J. (2013). Implementing point of care e-referrals in 137 clinics to increase access to a quit smoking internet system: the Quit-Primo and National Dental PBRN HI-QUIT Studies. Translational behavioral medicine, 3(4), 370-378. Y DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE 65 State Policy Resource Center: States with Parity Laws for Private Insurance Coverage of Telemedicine telemedicine, parity laws shows which states have parity laws and shows that Utah is not one of these states. American Telemedicine Association (2018). State policy resource center: States with parity laws for private insurance coverage of telemedicine. Retrieved October 28, 2018, from http://www.americantelemed.org/policy-page/state-policyresource-center Y State of Telehealth telehealth benefits and development of telehealth Dorsey, E. R., & Topol, E. J. (2016). State of Telehealth. New England Journal of Medicine, 375(14), 1399–1400. https://doi.org/10.1056/NEJMc1610233 Y Crossing the Telemedicine Chasm: Have the U.S. Barriers to Widespread Adoption of Telemedicine Been Significantly Reduced? Barriers, telemedicine US Barriers adoption telemedicine Lerouge, C., & Garfield, M. (2013). Crossing the Telemedicine Chasm: Have the U.S. Barriers to Widespread Adoption of Telemedicine Been Significantly Reduced? International Journal of Environmental Research and Public Health, 10(12), 64726484. doi:10.3390/ijerph10126472 Y Home telehealth by Internet of Things Technology, telehealth Good discussion virtual care visits from home Al-Majeed, S. S., Al-Mejibli, I. S., & Karam, J. (2015). Home telehealth by Internet of Things (IoT). 2015 IEEE 28th Canadian Conference on Electrical and Computer Engineering (CCECE). doi:10.1109/ccece.2015.7129344 Y DESPITE PROVIDER BARRIERS: TELEMEDICINE IS THE FUTURE Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations. Primary care, workload, burnout www.telehealth.org telehealth credentialing Telemedicin e, technology The Promise of Information and Communication Technology in Healthcare: Extracting Value From the Chaos Good discussion regarding increased provider workload due to EHR, patient increased access, less face to face patient care. Technology, promise, how to get there 66 Arndt, B. G., Beasley, J. W., Watkinson, M. D., Temte, J. L., Tuan, W. J., Sinsky, C. A., & Gilchrist, V. J. (2017). Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations. The Annals of Family Medicine, 15(5), 419-426. Y https://telehealth.org/credentialing/ Y Mamlin, B. W., & Tierney, W. M. (2016). The Promise of Information and Communication Technology in Healthcare: Extracting Value From the Chaos. The American Journal of the Medical Sciences, 351(1), 59-68. doi:10.1016/j.amjms.2015.10.015 Y Despite Provider Barriers: Telemedicine is the Future Beth A. Silvero, BSN, RN; Jennifer L. Strege, BSN, RN; Sabrina L. Harman, BSN, RN| Westminster College| Master of Science: Family Nurse Practitioner INTRODUCTION • Purpose: The purpose of this study was to identify barriers that inhibit the implementation of telemedicine for providers. Additionally, we looked at impacts these barriers have on providers in the state of Utah. • Methods: A comprehensive literature review was conducted using CINAHL, PubMed, and Cochrane databases, focusing on studies and articles relevant to the topic within the last 5 years, or outdated but pertinent to the study. Direct interviews with experts in the areas of telemedicine and Utah Medicaid were also conducted. • Keywords: Telemedicine, telehealth, barriers, protocols, burnout, education, liability, policy, technology BACKGROUND Telemedicine is the use of technology, specifically, telecommunications, to provide healthcare from one location to another. It allows for the electronic transfer of images, medical data, and health information as well as communications between healthcare personnel at different locations. It is a rapidly progressing and expanding field that allows greater access to care for patients, particularly those living in rural areas. Utah is identified as an urbanized state with 75% of the population living along the Wasatch Front and St. George, however, 25 of the 29 counties are considered rural or frontier areas. There is a need for medical services for those living in these areas and telemedicine has emerged as part of the solution. Despite known positive benefits and outcomes for patients who use telemedicine services, many barriers exist that inhibit the implementation of telemedicine services for providers. MAP OF RURAL UTAH SURROUNDING AREAS DISCUSSION Emergent themes: • Access to Care in Rural America: • Older population/high incidence of chronic disease in these areas • Higher volume of Medicaid/Medicare patients • Lower socioeconomic population • Need for providers to consult with specialty is unavailable with limited telemedicine access in rural areas • Reimbursement: • Strict CMS guidelines for payment of telemedicine visits • Live-video feed requirement for CMS • Parity laws differ amongst states • Licensing/Credentialing : • Multistate license is required to provide telehealth across state lines • Multi-organization credentialing is costly and time consuming • Standardized Training: • Training is not offered on how to conduct this type of visit in educational institutions • No regulations on standards for training requirements • Protocols : • No evidenced based protocols on how to conduct visits • Liability: • HIPPA violation concerns • Loss of personal connection with patient • No telemedicine liability insurance • Malpractice concerns • Technology: • Broadband internet connection • Resistance to change • Increased provider workload • Provider burnout from technology MAP OF PARITY LAW STATES CONCLUSION As telemedicine technologies gain wider acceptance, the sharing of information will open endless possibilities for improving the quality, as well as reducing the cost of medical care. Further, telemedicine is a rapidly evolving and utilized modality of providing healthcare, especially for patients located in rural areas. Hindering these improvements are many barriers that have slowed the expansion of telemedicine into mainstream healthcare and made practicing telemedicine difficult for providers. The trouble lies in all the barriers that prevent provider implementation working in tandem with one another. One barrier builds upon or further complicates another. The solution to these barriers is not transparent; it requires one to be resolved before another can be addressed. It is the authors opinion that further research is warranted in the areas of preventing provider burnout from technology, evidence-based protocols for telemedicine and how to effectively implement standardized training in educational programs. It is not until these provider barriers are addressed that telemedicine can be used to its full potential. IMPACT ON PROVIDERS IN UTAH REFERENCES • Limited face-to-face consultation with specialists • No parity laws resulting in lower uptake in Utah • Multi-state licensing is an issue as the Wasatch Front services the rural areas of surrounding states • No standardized training in most educational settings American Telemedicine Association (2018). State policy resource center: States with parity laws for private insurance coverage of telemedicine. Retrieved October 28, 2018, from http://www.americantelemed.org/policy-page/statepolicy-resource-center Utah Department of Health (2013). Retrieved October 28, 2018, from https://www.ruralhealthinfo.org/assets/1215-5000/utah-rural-health-plan2013.pdf APPROVAL of a thesis/project submitted by Author(s): Sabrina L. Harman Jennifer L. Strege Beth A. Silvero School Department: MSN Title of Thesis: Despite Provider Barriers: Telemedicine is the Future The above named master's thesis/project has been read by each member of the supervisory committee and has been found to be satisfactory regarding content, English usage, format, citations, bibliographic style, and consistency, and is ready to be deposited and displayed in the Westminster College—Institutional Repository. Chairperson, Supervisory Committee: Ronda Lucey Approved On 2/17/2023 1:30:03 PM Dean, School: Sheryl Steadman Ph.D Approved On 2/17/2023 1:40:30 PM STATEMENT OF PERMISSION TO DEPOSIT & DISPLAY THESIS IN THE INSTITUTIONAL REPOSITORY Name of Author(s): Sabrina L. Harman Jennifer L. Strege Beth A. Silvero School Department: MSN Title of Thesis: Despite Provider Barriers: Telemedicine is the Future With permission from the author(s), the staff of the Giovale Library of Westminster College has the right to deposit and display an electronic copy of the above named thesis in its Institutional Repository for educational purposes only. I hereby give my permission to the staff of the Giovale Library of Westminster College to deposit and display as described the above named thesis. I retain ownership rights to my work, including the right to use it in future works such as articles or a book. Submitted by the Author(s) on 12/18/2018 8:00:50 PM The above duplication and deposit rights may be terminated by the author(s) at any time by notifying the Director of the Giovale Library in writing that permission is withdrawn.