Telehealth – the use of communication technologies to provide healthcare services remotely – offers both patient convenience and a promising solution to the crisis of limited healthcare access in Health Professional Shortage Areas (HPSAs) across the United States. Its use is spreading widely and, at The Ohio State University College of Nursing, we teach telehealth techniques across our curriculum, both on campus and online.
The Ohio State University College of Nursing incorporates telehealth across nursing curricula with innovative techniques, tools, pedagogy and learning environments to prepare students for the healthcare of today and tomorrow.
Access to healthcare services is limited for 84 million people who live in the 7,176 Health Professional Shortage Areas (HPSAs) in the United States. Telehealth – the use of digital information and communication technologies to provide healthcare services remotely – offers a promising solution to address this crisis. While some institutions of higher education teach telehealth content, few are actively engaged in teaching their health sciences students through clinical opportunities, and fewer still are evaluating how students use telehealth to provide patient care. Meanwhile, Ohio State is preparing undergraduate, graduate and doctoral nursing students to deliver telehealth care using immersive, experiential learning strategies.
The use of telehealth in clinical nursing practice is spreading widely. For , merely familiarizing her online students with the concept of telehealth was not enough. “The biggest push for me was not about introducing students to the concept, but ‘How are we going to know our online nurse practitioner students are prepared for practice?’” That question brought its own challenges: creating online learning environments for simulating care by telehealth, reimagining methods and tools to measure and assess student learning and performance with telehealth, and partnering with a team of faculty, clinicians, and instructional designers to expand nursing student opportunities to learn telehealth across on-campus programs.
Innovative pedagogy meets technology
Teall and faculty at the College of Nursing created, and continue to create, new educational materials to address these needs. Perhaps the most innovative has been their work with “standardized patients” – actors hired to role-play as patients – to create videos and livecasts of patient case study situations. Using webconferencing, a standardized patient can appear onscreen in classrooms online or on campus, and can speak to each student individually or to groups of students. Standardized patients are trained to act like real patients, and may forget things, answer the wrong questions, or act surly when in pain, so that students get to experience what it’s like to triage difficult situations.
The faculty have also created “store and forward” recordings of standardized patients that can be used to simulate real patient phone calls, questions, and concerns. Cases include behavioral health issues and pediatric exams, in which the student might need to engage with a concerned standardized patient parent to obtain information. Case recordings and the standardized patient scenarios are re-useable assets that instructors share to include telehealth opportunities across specialties and programs.
Instructors new to telehealth benefit from a “telehealth toolkit” Teall and others devised. It includes checklists, timelines and practical information, such as how to use telehealth equipment. “We started writing out everything we do in a checklist format so that faculty can replicate telehealth simulations and exams easily,” Teall related. This collection of pedagogy, case studies, and tools continues to grow and could be exported to other institutions to increase telehealth education nationally.
Ohio State’s innovative online programs immerse students from across the country in learning telehealth technology. Online nursing graduate students attend lectures about telehealth technologies. They practice e-visit videoconferencing and simulate providing care using telehealth exam stations. Later, they are precepted in clinical experiences using telehealth. During the final two semesters of the program they complete objective, structured clinical exams on their use of telehealth technologies and their etiquette as telehealth providers.
Ohio State’s Lima campus telehealth clinic
Ohio State’s commitment to telehealth goes beyond teaching: they have their own telehealth clinic. In early 2018, the College of Nursing opened a (a rural extension campus in an HPSA) to provide care to their students, faculty and staff. The clinic is staffed by a nurse and linked via state-of-the-art telehealth equipment to (THW), a nurse practitioner-led, interprofessional clinic operated by the college that is designated as a Federally Qualified Health Center Look Alike. Using Bluetooth technology, a nurse practitioner at THW can assess the heart sounds of a patient being examined by a nurse from 100 miles away as clearly as if she were in the room. The nurse at the clinic acts as the nurse practitioner’s hands, performing the exam using Bluetooth-enabled devices such as an otoscope, blood pressure cuff and stethoscope. Meanwhile, both nurse and patient can see and talk to the nurse practitioner from the clinic, who appears on a two-way video conferencing screen. Interdisciplinary health sciences students are precepted as healthcare providers at the clinic.
What’s it like to use the telehealth clinic? “The patients love it,” Teall said. And as the on-screen nurse practitioner, she has enjoyed using the state-of-the-art equipment. This video equipment has no lag time, echo or scratchy sound to distract the patient—“That would never work,” Teall asserted—“You (the patient) don’t want to share personal information with someone who sounds like the Wizard of Oz.” Instead, “I’ve had people who have said, ‘Oh my gosh, this really is like you are sitting right here.” And there are advantages, such as the Bluetooth otoscope which magnifies the image of the eardrum and shows it in high definition, “so that the patient and I can really see it,” Teall says. Nursing students learn the special techniques of using this equipment, both in the nurse and nurse practitioner roles. For instance, Teall says, it’s important for nurses to learn not to step between the stethoscope and the broadcasting equipment, or to look at the video screen when they should be looking in the patient’s ear. Equally important, nursing students learn new ways of using telecommunications to talk to their patients and put them at ease.
Students learn and practice telehealth techniques so that they will be knowledgeable and comfortable when the time comes, and so that they can help patients feel comfortable, too. For instance, Teall explained, “If you are sitting in front of a camera as the provider and the patient is on the other side of the screen, you have to remember that all they can see is your head. So, when you start charting or documenting their visit using your computer, it’s important to say, ‘I’m going to turn my head. I’m going to put this into the computer now.’ Otherwise, all the patient sees is their provider not looking at them anymore.” Explaining the moves you’re making with equipment off-camera helps build patient trust, as does explaining off-camera sounds. If someone enters the room, Teall advises students to introduce any new people who enter the room before they are in sight, and explain why they’re there.
Students practice presenting as an onscreen healthcare provider. “The telehealth exam station transmits high-def sound and picture,” Teall explained, and it takes a bit of getting used to. “You have to not wear jewelry,” because clinking sounds can amplify greatly, and “sometimes you think you’re looking at the person, but you might not be if you are not looking at the webcam. So, we have to teach students to look directly at the camera and not necessarily at the picture on the screen; otherwise the person thinks you’re always looking at their shirt.” During online exams, students are graded in part on their etiquette, which includes how they communicate with patients and the attending nurse at the clinic.
When learning to care for patients calling in from remote locations, students are taught to ask, “Are you in a secure place? Are you in a place where we can talk confidentially?” Even if the patient can’t talk out loud, a secure conversation may be possible via texting. Practicing scenarios like these can help future healthcare providers keep a level head when treating telehealth patients in emergency situations.
Ohio State’s innovative online pedagogy includes simulated patient exams using telehealth stations on campus that are like those used at the Lima telehealth clinic. “Patients” range from patient actors to real people with medical conditions who have volunteered to help educate student nurses. “Pregnancy is one of the cases that we do,” Teall related. “Every 15 to 20 minutes, one of our students calls in, and the student has to orchestrate a prenatal visit. That’s how we know they can do it.” The student might listen to the baby’s heartbeat remotely and ask the mother questions about her health. Care is taken to educate students on implicit bias and cultural sensitivity as well.
Telehealth in your pocket
Ohio State is preparing students to attend to patients at a distance using technologies available almost everywhere: internet and cellphones. “This is about how to increase access to care. People who have low access to care, whether the reasons are geographic or financial, usually have a smartphone. And when a parent can access a provider by calling on their phone, there’s research that says if they share a picture or video of their child, this gives them more confidence that the provider knows what’s going on and it gives the provider more confidence that they were able to assess their child better,” Teall said. Parents using smartphone apps may be less likely to unnecessarily take a child to the ER or repeat a hospital visit.
The College of Nursing seeks to further its mission of transforming health and transforming lives by educating the nursing workforce of the future in telehealth so that they may provide care at a distance and address the health professional shortage crisis. Faculty continue to expand the library of telehealth exam simulation cases, and to reimagine telehealth pedagogy. Future goals include expanding, refining and publishing their telehealth toolkit of educational methods, clinical practice tools and techniques. The college’s approach to telehealth education is scalable, cost-effective and is producing great results and marketability for its graduates, who have practical experience in telehealth and are ready to work as providers of telehealth care to those in need.
Open house planned for April 2, 2018
Ohio State Lima students, employees and dependents will now have access to onsite healthcare in the Student Services Center on campus through the Ohio State Total Health and Wellness at Lima health center, utilizing telehealth equipment connected to the Columbus campus.
The media and interested community members are welcome to an open house to celebrate the grand opening from 11 a.m. to 12:15 p.m., Monday, April 2, 2018. A ribbon-cutting ceremony and short program will be held at 11 a.m. in the west end of the Student Services Center. Jessica Campbell, RN, will be onsite to answer questions, and the telehealth equipment will be available for demonstrations.
“Onsite healthcare adds another dimension of health and wellness to the Ohio State Lima campus,” said Interim Dean and Director Joseph Brandesky. “Our students and employees now come from more than half of the 88 counties in Ohio. Some of them drive long distances or those living near campus are a fair distance from their primary healthcare providers. The facility provides a means for them to address day-to-day health concerns.”
With Ohio State Total Health and Wellness at Lima, the Ohio State College of Nursing will offer a nurse-practitioner-led comprehensive primary-care practice as part of a pilot program that takes a telehealth approach to health and wellness.
“We are so excited to bring primary-care health services to Lima through our nurse practitioner-led facility,” said Ohio State College of Nursing Dean Bernadette Melnyk, PhD, RN, CPNP/PMHNP, FAANP, FNAP, FAAN, who also serves Ohio State as vice president for health promotion and chief wellness officer. “Our team approach to care benefits patients in many ways by focusing treatment on the whole person.”
Ohio State Total Health and Wellness at Lima offers an interprofessional team approach to integrated physical and mental healthcare for students, employees and their dependents. A registered nurse will be available on-site and a certified nurse practitioner will be accessible through a remote telecommunications system.
“Offering telehealth services gives us a wonderful opportunity to extend our primary care services and provide that team approach to healthcare,” said Candy Rinehart, DNP, FNP, ADM-BC, FAANP, executive director of Advanced Practice and Community Partnership, nurse practitioner and director of Ohio State Total Health and Wellness at Ohio State Hospitals East. “In addition to family nurse practitioners, we can access mental health nurse practitioners, pharmacists, dietitians, social workers and other providers to support total patient care. Exams and conversations will take place in real time, with our registered nurse serving as our hands in the clinic, and the nurse practitioner in Columbus providing direction for both the exam and treatment.”
The new facility will be located in the west end of the Student Services Center. Renovations to a conference room have resulted in space for an examining room, office and storage area. The state-of-the-art telehealth equipment will allow the nurse practitioner and the patient to interact much like they would in person. What the onsite registered nurse sees as she conducts an exam in Lima is instantly available to the nurse practitioner in Columbus.
Ohio State Total Health and Wellness at Lima will be open 15 hours a week. Services will include health and wellness screenings, education and vaccines, physical exams, evidence-based management of new health problems or complaints, contraception counseling and management, integration of mental health services to complement Ohio State Lima’s Counseling and Consultation Services and healthy lifestyle programs. Patients are seen by appointment only. Please call (567) 242-6546 to schedule a visit.
Ohio State Lima is the first regional campus to offer telehealth through the three-year pilot program funded and administered through the College of Nursing. Future plans call for Ohio State Total Health and Wellness facilities using telehealth technology at all of Ohio State’s regional campuses.