The Future of TELEHEALTH is NOW!

Doctor with stethoscope Reaches out of computer screen.

The idea that a health care provider could diagnose and treat a patient via teleconferencing technology was a concept more at home in the Star Trek™ realm than what is now an increasingly commonplace event.

Patient consultations currently take place via video conference, e-health including patient portals, remote monitoring of vital signs, sleep studies at home and cardiac monitoring during the patients’ work day are common.  While there are many other applications,  (ATA, 2015) “all are considered part of telemedicine and telehealth”.

There are a great many questions regarding reimbursement, regulations, infrastructure and access as well as provider and patient adoption and whether these will fall into a viable alternative to face-to-face health care.  There are a great number of barriers that need to be overcome for telehealth to enjoy parity with inpatient visits.

With the shortage of health care providers, particularly in primary care, congressional and media attention over the past year has increased dramatically.  According to a Georgia Public Policy Foundation study, without telehealth, patient access might be delayed, denied or otherwise not available.  (Bachman 2015) reflects patient savings in time and money and reduction of stress from delayed or denied face-to-face medical care.

Patient and Doctor Consult via TabletThe Affordable Care Act has brought millions of people into the healthcare system, and currently 44 states have telehealth legislation pending.  Bills are being debated in committees for eventual introduction in Congress. There is also greater media attention highlighted on network TV and radio news shows to include blogs within the online community of health care providers and patients.

There are concerns regarding whether or not patients will readily accept telehealth alternatives, but these are essentially unfounded.  Most of the population has grown along with online technology, which includes user friendly programs that assist with reliable practice.

Elderly senior citizens may face some challenges using digital tools, a Pew Research Study (Smith, 2013) found that, “Six in ten seniors – 59%- report using the Internet.”  This percentage has been increasing by 6% over a similar point annually.  In fact, the rate of adoption of social media among those age 60 and over is the fastest growing segment of the marketplace.

Concerns about reliability of data to inform the provider is mitigated by ongoing advances in the industry making telehealth technology the cutting edge of innovation.   Higher video and image resolution, efficient use of bandwidth has made connectivity more reliable with electronic health record systems facilitating the increased data exchange (iHealthBeat, 2013).  Real time IT-enabled transfer of patient monitoring has evolved sufficiently to support telemedicine platforms. (Darves, 2014)

Scientific studies in the area of telemedicine and quality of care “indicate that the use of telemedicine for such applications as monitoring of chronic care patients or allowing specialists to provide care to patients over a large region have resulted in significantly improved care.  For most telemedicine applications, studies have shown that there is no difference in the ability of the provider to obtain clinical information, make an accurate diagnosis, and develop a treatment plan that produces the same desired clinical outcomes as compared to in-person care when used appropriately”.  (2013 American Telemedicine Report, Telemedicine’s Impact on Healthcare Cost and Quality)

Doctor Consults Specialist and Discuss Readiology Image via ComputerThe same report found that the vast majority of the peer-reviewed research studies about the cost effectiveness of telemedicine (based on large sample sizes and following sound scientific rigor) are relatively new but are consistently concluding that telemedicine saves the patients, providers and payers money when compared with more traditional approaches to providing care.  An August 2014 study by global professional services company Towers Watson estimated telemedicine could potentially deliver more than $6 billion a year in health care savings to U. S. companies (Towers Watson, 2014).

Reimbursement has been a thorny issue in telehealth.  There is a wide discrepancy between how to pay in comparison to traditional in-office visits.  (U.S. Department of Health and Human Services Health Information Technology, 2014).

Health care provider regulatory bodies are just getting started in the process of interstate practice, NCSBN’s Nurse Licensure Compact (LNC) has been ahead of the curve since implementation in 2000.  The NLC allows RNs and LPNs/LVNs to have multistate licenses with ability to practice in their home state and other NLC states.  Currently there are 24 states in the NLC.  BONs (Boards of Nursing) have been actively involved in revising the NLC to ensure it reflects best practices and provides public protection and continued high standards.  Several organizations are actively involved in compiling state by state telehealth nursing licensure requirements similar to what is available for physician requirements.

Telehealth is a concept waiting for all of the factors influencing its acceptance as part of the health care delivery system to align.

References

American Telemedicine Association.  “What is Telemedicine?”

American Telemedicine Association. (2013) “Telemedicine’s impact on healthcare cost and quality.”

Bachman, R.E. (2015).  Telehealth & Patient-Centered Care. Georgia Puclic Policy Foundaiton, Atlanta

Darves, B. (2014). “Technology advances boosting Telehealth, but changes to widespread use remain.”

iHealthBeat (2013). “Health care providers leveraging advances in Telehealth technology.”

Smith, A. (2013). “Older adults and technology use: Attitudes, impacts, and barriers to adoption.”

Towers Watson. (2-14). “Current Telemedicine Technology Could Mean Big Savings. [News Release]

U.S. Department of Health and Human Services Health Information Technology. “What are the reimbursement issues for telehealth?”

Arizona State Board of Nursing Regulatory Journal, (2015), In Focus, Spring.

National CPR and AED Awareness Week

The Beat Goes On!

In December of 2007, Congress declared the first week of June each year as National CPR/AED Awareness Week in an effort to increase the number of people certified in cardiopulmonary resuscitation (CPR) and trained to use an Automatic External Defibrillator (AED). In today’s advanced technological world, the American Heart Association (AHA) has determined that in order to increase the survival rates for victims of sudden cardiac arrest, we need to go back to the basics of  CPR. This is not limited to healthcare workers but includes lay people as well. According to the AHA there is a 95 percent mortality rate for over 300,000 Americans who are victims of sudden cardiac arrest each year. It is also estimated that on average it takes 8 to 10 minutes for 9-1-1 to reach a victim. Survival rates for individuals with ventricular fibrillation treated by AEDs have been reported between 0% and 31%. Comparatively, the survival rates for performing CPR alone are reported between 0% and 6%.  More lives could be saved if members of the general public have training in the use of AEDs and CPR. .

Why is this important?

The reason that this is so important is after four minutes without oxygen going to the brain it will begin to die. After eight minutes it becomes the point of no return, irreversible brain death begins to occur. So even if the heart is restarted, the damage after eight minutes can never come back. This is why we need people to do CPR. In cases where CPR is performed immediately, this risk is cut in half. Victims’ chances of survival decrease by 7 to 10 percent each minute that they go untreated after their heart stops, so bystanders’ knowledge of CPR is a matter of life or death.

Why did they change CPR?

New CPR Rules: Pump First, and Save the Breaths for Later If you have ever been trained in CPR, we were all trained  A-B-C,  for “airway, breathing, compressions”. But the American Heart Association (AHA) recommends a different approach. The new mnemonic is C-A-B; we’re now supposed to start chest compressions right after calling 911; adjust the airway and leave the rescue breaths for last. The AHA wants to encourage people to be willing to administer CPR; so making the mouth-to-mouth breathing a less prominent part may make the procedure more palatable.  In recent years, the results of study after study have supported the fact that the victims who receive compressions alone from bystanders survive as well as those who received traditional CPR.  The guidelines apply to adults, children, and infants but exclude newborns.

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  • Establish responsiveness, if victim is not responsive, roll the person onto their back. Check for a pulse for no more than 10 seconds.
  • Call 911 or ask someone else to do so.
  • Start chest compressions. Place the heel of your hand on the center of the victim’s chest. Put your other hand on top of the first with your fingers interlaced.
  • Press down so you compress the chest at least 2 inches in adults and children and 1.5 inches in infants. “One hundred times a minute or even a little faster is optimal,” Sayre says. (That’s about the same rhythm as the beat of the Bee Gee’s song “Stayin’ Alive.”) Allow for a complete recoil of the chest after each compression. Give at least 30 compressions before you proceed to rescue breathing.
  • If you’re been trained in CPR, you can now open the airway with a head tilt and chin lift.
  • Pinch closed the nose of the victim. Take a normal breath, cover the victim’s mouth with yours to create an airtight seal, and then give two, one-second breaths as you watch for the chest to rise.
  • Continue compressions and breaths – 30 compressions, two breaths – until help arrives.

These guidelines apply to children and adults alike, since AHA officials did not want separate and potentially confusing advise for different groups of people. The change in CPR is part of a larger revision of its emergency heart care recommendations.

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AEDs are user-friendly devices that untrained bystanders can use to save the life of someone in cardiac arrest.

  • Before using an AED, check for puddles or water near the person who is unconscious. Move him or her to a dry area, and stay away from wetness when delivering shocks (water conducts electricity).
  • Turn on the AED’s power. The device will give you step-by-step instructions. You’ll hear voice prompts and see prompts on a screen.
  • Expose the person’s chest. If the person’s chest is wet, dry it. AEDs have sticky pads with sensors called electrodes.
    • Apply the pads to the person’s chest as pictured on the AED’s instructions.
    • Place one pad on the right center of the person’s chest above the nipple.
    • Place the other pad slightly below the other nipple and to the left of the ribcage.
  • Make sure the sticky pads have good connection with the skin. If the connection isn’t good, the machine may repeat the phrase “check electrodes.”
  • If the person has a lot of chest hair, you may have to trim it. (AEDs usually come with a kit that includes scissors and/or a razor.) If the person is wearing a medication patch that’s in the way, remove it and clean the medicine from the skin before applying the sticky pads.
  • Remove metal necklaces and underwire bras. The metal may conduct electricity and cause burns. You can cut the center of the bra and pull it away from the skin.
  • Check the person for implanted medical devices, such as a pacemaker or implantable cardioverter defibrillator. (The outline of these devices is visible under the skin on the chest or abdomen, and the person may be wearing a medical alert bracelet.) Also check for body piercings.
  • Move the defibrillator pads at least 1 inch away from implanted devices or piercings so the electric current can flow freely between the pads.
  • Check that the wires from the electrodes are connected to the AED. Make sure no one is touching the person, and then press the AED’s “analyze” button. Stay clear while the machine checks the person’s heart rhythm.
  • If a shock is needed, the AED will let you know when to deliver it. Stand clear of the person and make sure others are clear before you push the AED’s “shock” button.
  • Start or resume CPR until emergency medical help arrives or until the person begins to move. Stay with the person until medical help arrives, and report all of the information you know about what has happened.
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AED
AED Setup and Use

 

RESOURCES: American Heart Association. 2010 Guidelines for CPR and Emergency Cardiovascular Care, October 2010
http://www.cardiacscience.com/marking-national-cpr-and-aed-awareness-week/
http://www.heart.org/HEARTORG/CPRAndECC/WhatisCPR/What-is-CPR_UCM_001120_SubHomePage.jsp
http://www.heart.org/HEARTORG/CPRAndECC/WhatisCPR/CPRFactsandStats/CPR-Statistics_UCM_307542_Article.jsp
http://www.heart.org/idc/groups/heart-public/@wcm/@ecc/documents/downloadable/ucm_317350.pdf
http://mycprcoach.com/hands-only-cpr/ Weisfeldt ML, Sitlani CM, Ornato JP, Rea T, Aufderheide TP, Davis D, et al. Survival after application of automatic external defibrillators before arrival of the emergency medical system: evaluation in the resuscitation outcomes consortium population of 21 million. J Am Coll Cardiol. Apr 20 2010;55(16):1713-20.
Automatic External Defibrillation Author: Joseph J Bocka, MD; Chief Editor: David FM Brown, MD http://emedicine.medscape.com/article/780533-overview
AED use: National Institute of Health – AED proceedures
Graphic and CPR Data: American Heart Association CPR Awareness Page

Trends in Nursing Home Litigation

Nursing home lawsuits have become one of the fastest growing segments of health care litigation. There are nearly 17,000 nursing homes in the United States that currently care for 1.7 million residents, a figure that is expected to quadruple to 6.6 million residents by 2050.(1)  Over 90% of the nursing home residents are over the age of 65, and almost half are over the age of 85; the average age is more than 80.(2)   Issues of concern in care may include: adverse drug events, falls with injury, pressure ulcers, faulty medical equipment, problems with tube feeding, restraint usage, malnutrition, dehydration, residents rights violations, elopement, and abuse and neglect.

Federal definitions of elder abuse, neglect and exploitation appeared for the first time in the 1987 Amendments to the Older Americans Act. These definitions were provided in the law only as guidelines for identifying the problems and not for enforcement purposes. Currently, elder abuse is defined by state laws, and state definitions vary considerably from one jurisdiction to another in terms of what constitutes the abuse, neglect, or exploitation of the elderly. Broadly defined, elder abuse definitions may be categorized as follows: Physical abuse is defined as the use of physical force that may result in bodily injury, physical pain, or impairment. It may include, but is not limited to, such acts of violence as striking, hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, and burning. In addition, it may also include the inappropriate use of drugs and physical restraints, force-feeding, and physical punishment.

  • Sexual abuse is defined as non-consensual sexual contact of any kind with an elderly or disabled person or with any person incapable of giving consent. It includes, but is not limited to, unwanted touching and all types of sexual assault or battery such as rape, sodomy, coerced nudity, and sexually explicit photography.
  • Emotional or psychological abuse is defined as the infliction of anguish, pain or distress through verbal or nonverbal acts. Emotional/ psychological abuse includes, but is not limited to, verbal assaults, insults, threats, intimidation, humiliation, and harassment. In addition, treating an older person as an infant, isolating an elderly person from his family, friends or regular activities, giving an older person the “silent treatment”, and enforced social isolation are examples of emotional/ psychological abuse.
  • Neglect is defined as the refusal or failure to fulfill any part of person’s obligations or duties to an elder. Neglect may also include failure of a person who has fiduciary responsibilities to provide care for an elder (e.g., pay for necessary home care services) or the failure on the part of an in-home service provider to provide necessary care. Neglect typically means the refusal or failure to provide an elderly person with such life necessities as food, water, clothing, shelter, personal hygiene, medicine, comfort, personal safety, and other essentials included in an implied or agreed-upon responsibility to an elder.
  • Exploitation is defined as misusing the resources of an elderly or disabled person for personal or monetary benefit. This includes taking Social Security or SSI (Supplemental Security Income) checks, abusing a joint checking account, and taking property and other resources.(3)

Estimates of the frequency of elder abuse range from 2% to 10% based on various sampling, survey methods and case definitions.(4) In 2013, state long term care Ombudsman programs nationally investigated 135,620 overall complaints of abuse, gross neglect, and exploitation on behalf of nursing home and board and care residents. Among seven types of abuse categories, physical abuse was the most common type reported.(5)

As the incidence of elder abuse rises, more programs and techniques are being developed by facilities and federal and state organizations to protect our aging population. “Grammy Cams” are being utilized in some states (currently 7 states). This allows families or residents to install surveillance cameras in their room in the nursing care facility. Several states (e.g. California and Maine) are now utilizing Elder Death Review Teams (EDRT) to evaluate nursing home deaths that may be linked to abuse and neglect. Most states now require background checks for all paid caregivers and those with criminal backgrounds are prohibited from caring for elders in nursing homes. Nursing homes and assisted living facilities are providing more orientation and education to their staff on recognizing and reporting signs and symptoms of abuse.

(6) Long term care organizations and associations are pairing with government agencies to promote public awareness of elder abuse and reporting mechanisms. State and federal survey agencies are focusing on abuse in nursing homes and have initiated procedures for timely investigation of complaints of abuse and neglect. Even one incident of abuse is unacceptable and we, as health care providers and litigators have an obligation to protect and defend our elders.

The National Center on Elder Abuse — www.elderabusecenter.org
State Long Term Care Ombudsman Programs — www.ltcombudsman.org
National Committee for the Prevention of Elder Abuse (NCPEA) — www.preventelderabuse.org
National Association of Adult Protective Services Administrators (NAAPSA) — www.naapsa.org
US Department of Justice, Office of Victims of Crime — www.ojp.usdoj.gov
US Administration on Aging — www.aoa.gov
American Society of Adult Abuse Professionals and Survivors — www.ASAAPS.org

References:
1 U. S. House of Representatives, Committee on Government Reform, Minority Office
2 Centers for Medicare and Medicaid Services, Department of Health and Human Services, Health Care Industry Market Update: Nursing Facilities. CMS, 2002:43.
3 National Association of Adult Protective Services Administrators; National Center on Elder Abuse; Elder Abuse Awareness Kit; April 2001, pg. 4.
4 Lachs, Mark S. and Karl Pillemar, Oct. 2004, “Elder Abuse,” The Lancet, Vol. 364: 1192-1263.
5 National Ombudsman Reporting System Data Tables, 2013 – 2014. Washington DC: US Administration on Aging.
6 Long-Term Care Services in the United States: 2013 Overview

Use of Technology Distinguishes R&G

Historical Perspective for a Successful Legal Nurse Consulting Firm

R&G Medical Consultants was founded in February of 1992 by Rosie Oldham, BS, RN, LNCC. Her background in Nursing Administration, Risk Management and Quality Improvement was extremely valuable in the startup of this legal nurse consulting firm.

R&G’s first cases were personal injury and in December of 1992, the firm began working on product liability cases (resulting in completion of over 750 cases). This led to staff expansion and the use of 32 nursing contractors. During this project R&G   implemented total quality management procedures. Peer review of work products led to a successful 100% deficiency free submission of claims. From 1994 to 1996, R&G processed over 450 toxic tort cases (water contamination) for the defendants. This successful project required our nurses to input medical information into a statistical data base for our clients. In 1997, R&G began focusing on complex Medical Malpractice and Personal Injury cases. Rosie Oldham,  CEO, also self-published the Medical Legal Internet Directory which contained over 3000 web sites for medical legal research. This directory was published in 2nd and 3rd (on CD) edition by Lawyers and Judges and contains over 5000 web sites. The MLID has been heralded as a great research tool for medical and legal case issues and is sold internationally.

In 1998, one of R&G’s goals was to solidify our position as “the technical leading” legal nurse consulting firm in the United States. At that time, our client base extended across 23 states and into Canada and Israel. The service areas of the firm were expanded to include graphics and illustrations  in our work products that were ultimately used as demonstrative evidence. Merit Screens were streamlined and are now offered for a flat fee. In addition, new software was added to our information systems to track cases, provide conflict checks and expert witness data management. In 1999, we to acquired equipment (laptops/projectors), software, and trained our “technical nurse consultants” adding a new service of technical trial support and settlement consulting services. Utilizing computerized demonstrative evidence, videos and synchronized depositions, we have successfully settled many cases in AZ, NM and NV. The integration of legal nurse consultants providing technical support culminated in our November, 2001, 18 million dollar verdict for a personal injury case in Nevada.

Since January, 2002, R&G began providing services on   large product liability mass tort and has over 140 RNs working on this defense pharmaceutical project. The successful thirteen year growth and expansion for R & G is a direct outcome of our team approach  in 43 states with great attorney clients. The caliber of our staff is educationally beyond the norm (MS, NP, PhD, JD, and MD’s) and directly contributes to our continuing success. Our clients love our “can do” attitude!