Today I received my AARP Bulletin (yes, I am that old) and, to my delight, the first article tells of high-tech ways to stay healthy (Migala, 2015). AARP, with 37 million members, is the second largest member organization in the United States (T. Schreier, personal communication, April 6, 2015). Its members can be segmented into three life stages: 34 percent are baby boomers (ages 50-64), 33 percent are late boomers (ages 65-74), and 23 percent are of the silent/greatest generation (age 75 plus).
Migala (2015) quotes Thomas Hale, executive director for Mercy Virtual, who states: "New technologies allow more patients access to physicians and specialists, strengthen the doctor-patient relationship and allow you to obtain on-demand treatment." She then describes the benefits (with a few cautionary remarks) of nine tools that can help improve one's health: health apps, electronic medical portals, at-home disease monitoring, crowdsourcing (such as Crowdmed.com or Patientslikeme.com), telestroke, fitness devices, virtual doctors, virtual counseling, and videoconferencing. Mercy Virtual, by the way, provides telehealth services to help care providers in three areas: ConnectNow (Connecting), SafeWatch (monitoring), and CareEngage (managing) (http://mercytelehealth.com/services/).
Think about the 37 million AARP members reading about these advances in health care technologies. Now think about their children or caretakers, who will want to explore the options available for their aging parents or loved ones. I can imagine that some of these people will be asking their health care professionals which of these services, if any, are available for them now.
As the momentum builds, it will become imperative that we prepare our future nurse graduates to practice in the world of connected health. For me, it was validating to see this message being relayed to AARP members. After all, several of my previous columns focused on these high-tech tools. And, at the University of Colorado College of Nursing, we have started to include connected health learning opportunities in our curriculum.
WHAT WE ARE DOING
In 2012, the college of nursing received a HRSA advanced nursing education training grant focused on interprofessional education (IPE) and the use of technologies. To be eligible for this grant, applicants had to incorporate interprofessional (IP) competencies as part of the curriculum and explore the use of technologies to facilitate IPE. We partnered with the school of pharmacy and, on occasion, with the school of medicine.
The i-TEAM (Interprofessional Technology Enhanced Advanced Practice Model) project prepares advanced practice nurses (APNs) to function in an IP collaborative practice providing high quality health care in rural and medically underserved urban areas. The primary goal is to prepare a cadre of APNs with the requisite Interprofessional Education Collaborative competencies (Interprofessional Education Collaborative Expert Panel, 2011) to provide technology-enhanced collaborative care within the health care system. To do so, we offer learning opportunities through the master's core informatics course, advanced practice courses (team-based experiences with both standardized and virtual patients), and team-based clinical experiences employing digital health tools.
Graduates will demonstrate the four core IP competencies (values/ethics, roles and responsibilities, IP communication, and teams and teamwork) as defined by the Interprofessional Education Collaborative Expert Panel (2011) and the five Institute of Medicine (2003) health care professionals' core competencies: Informatics, Quality Improvement, Evidence-Based Practice, Patient-Centered Care, and Team-Based Care. Following are some grant-funded examples of our work with digital tools.
Foundations of Health Care Informatics
In this required core course for both master's and doctor of nursing practice students, one module is focused on the use of digital tools to encourage patient, family, caregiver, and consumer engagement in their health care. The digital tools covered are patient portals, secure messaging, personal health records, mobile apps, social media, and patient-generated health data tools. For their IPE experience, nursing and pharmacy students work collaboratively to address a patient request they receive through a patient portal.
The patient has requested some advice on the tools he should be using to manage his care. He specifically asks for recommendations for a good website, a mobile app to manage his care, and a social media platform to seek the support and advice of similar patients. Both the nursing and pharmacy students have access to the patient's electronic health record (EHR), which is contained in the Cerner Academic Education Solution EHR (Cerner EHR) that all students can access. (Visit http://www.cerner.com/solutions/education_and_training/academic_education_soluti/.)
To accomplish this patient request, the team follows a series of steps. First, they access and familiarize themselves with the patient's health record. Second, they meet to determine how they should proceed to find and validate resources. To conduct a virtual meeting, the students choose from a variety of platforms, for example, Skype, Zoom, Canvas Learning Management System, Google Hangouts, or Firefox Hello. They then identify four to five criteria to select and assess three digital tools.
The students find the tools, evaluate them, and write a response to the patient that includes the following: an introduction of the team to the patient, the three digital tools, how they were evaluated, and how they can be used and accessed by the patient, taking into account the patient's knowledge and health literacy. In a closing statement, they offer further help. The patient's response is entered into the Cerner EHR as a clinical note for grading by the instructor.
Health Assessment and Advanced Pharmacology
In these courses, nursing students have a variety of IPE experiences with second- or third-year PharmD students. Some IPE experiences require consults for patient care through the Cerner EHR. Other learning opportunities include an IPE exercise using standardized patients. With our psychiatric/mental health students, we have experimented with virtual patient visits in Second Life for patients seeking a pharmacy consult.
These various IPE experiences allow students to understand how EHRs can be used as a communication mechanism to provide collaborative care when all disciplines are not on site. They are also used to keep teams informed of the patient's health progress and to ensure that teams work together to provide optimal care.
Digital Tools for Virtual Visits
Given that Colorado is a large state with 17 urban counties, 24 rural counties, and 23 frontier counties, we want our APN students to have experience with the digital tools that will eventually be a part of their tool kit for practice. To expose APN students to the health apps available for virtual patient visits, we purchased iPads for use in class and items that can be used with an iPad or iPhone as follows.
* ThinkLabs Digital Stethoscope (http://thinklabs1.com/) (Figure 1)
* Masimo iSpO2 Pulse Oximeter (http://masimopersonalhealth.com/) (Figure 2)
* Withings Wireless Blood Pressure Monitor (http://www.withings.com/us/blood-pressure-monitor.html) (Figure 3)
* Withings Smart Body Analyzer (http://www.withings.com/us/smart-body-analyzer.html) (Figure 4)
To the surprise of most students, these items can be easily purchased by patients and their families, for example, from Amazon.com. To illustrate their value for connected health and virtual visits, we conducted three pilots with these digital tools.
PILOT 1
Community health baccalaureate students took the tools to do a patient visit. The students were able to use the tools successfully to take vital signs and explain the various readings to patients. The students found that patients were receptive to using these tools. In some instances, they could not share data immediately with faculty because of the lack of Internet connectivity.
PILOT 2
We asked for volunteers from the nursing and pharmacy classes to participate in a virtual follow-up visit with a patient, portrayed by a faculty member. The nursing and pharmacy faculty who supervised the visit devised the scenario.
The patient in the scenario had recently been diagnosed with pulmonary hypertension after the completion of both radiation and chemotherapy treatments for cancer. She had been placed on two new drugs and sent home with a blood pressure monitor and a pulse oximeter, but failed to schedule a follow-up visit. Prior to the visit, the nursing and pharmacy students checked her records and found readings from the monitoring devices that needed investigation. They were also concerned about the patient's previous adherence with medications. The goal of the visit was to check on her understanding of her drug therapies and how she was using the tools.
Together in a room with the faculty member, the students conducted the video visit using the GoToMeeting platform. They asked the patient to demonstrate how she used the devices, and this became a teachable moment. The patient demonstrated how she took her blood pressure, placing the cuff on her wrist and the pulse oximeter on her finger. The patient also was confused about the purpose of the various drugs she took; when her prescription for one drug ran out, she said, she just took two Lasix drugs, thinking both were "water pills." The team also worked with the patient to help her establish goals for the next visit.
The student teams approached the scenario in different ways. Some were collaborative and engaged the patient as a member of the team. In some instances, one discipline dominated the encounter. For example, the nursing student in one team was so domineering that the patient commented she was "coming through the computer screen." Faculty observed how the patient moved further and further away from the screen as the nurse continued her directives.
The debriefings provided a lot of insight. Students were able to observe how it was possible to conduct the visit and many were pleased with the interactions. Faculty could observe the students and see their interactions with each other as well as with the patient.
PILOT 3
This pilot involved both a pharmacy and nursing student during a follow-up visit with a standardized patient (SP). The school of medicine manages a cadre of SPs who serve in various simulations across the disciplines. We were fortunate to work with a 73-year-old SP, whom we trained with a new scenario created by Drs. Krista Estes and Eric Gilliam, from the college of nursing and school of pharmacy, respectively. Sarah Knapfel, project coordinator for the iTEAM project, developed the training materials, worked with the SP, and created the patient record on the Cerner EHR.
Once again, students were asked to review the patient's health record and plan the virtual visit. Everyone was to sign on to the virtual conferencing system at a specified time. The virtual platform, Zoom (https://www.zoom.us/), is available to all faculty and students at the University of Colorado Denver and Anschutz Medical Center campuses. It is a cloud-based video conferencing service that is not HIPAA compliant, and it would not be used for a visit with a real patient. However, it is easy to use and has a record function, which allows faculty to record and analyze each virtual visit and provide debriefing with the team. Participants use their speakers/microphones and video camera on their computers or tablets for an interactive virtual meeting. All participants are shown on the screen with the person who is talking highlighted in yellow. (Figure 5 shows the SP and the pharmacy and nursing students.)
Five teams participated in the pilot and all were able to connect with the SP. It was interesting to note how each group differed slightly in how they approached the visit. Some demonstrated a collaborative model of care that involved the patient as a partner in the virtual visit. Other teams stumbled over one another in talking to the patient. It was clear to the students during the debriefing that they needed to be better prepared for the visit. In general, students thought the experience was positive and offered helpful suggestions, and the SP enjoyed the experience. The evaluation results of these experiences are being analyzed for a future publication.
SOME TAKEAWAYS
Here are some takeaways that will inform our next steps as we integrate and evaluate virtual visits, with real patients, within the curriculum.
1. Students need more preparation in conducting virtual visits. This means providing best practices in terms of interacting in a virtual environment, being comfortable with the technology, understanding time delays, and being aware of video netiquette. We are finding that some students lack computer and digital literacy skills, especially in terms of using videoconferencing technologies. And some students do not realize how they will appear on video. One student conducted his video visit outside with the result that students on campus appeared on screen. A nursing student used her laptop computer in her bedroom. We need to remind students how to look and act like professionals.
2. Student teams that met before the scheduled meeting with the patient did best at meeting their goals and acting like a team. They had discussed their roles and who would take responsibility to address the various patient issues. Those who did not meet beforehand tended to talk over each other, repeated questions, and missed some of the important issues that should be part of a follow-up visit. One lesson learned was that team members need to have a greater understanding of the roles and responsibilities of their discipline as well as improved communication.
3. In the new world of connected health, health care professionals need new skill sets to bring patients in as partners in their own health care. Although nurses are seen as patient advocates and are perhaps more patient-centric than other professionals, they must understand how to use digital tools to foster patient activation and engagement. Our curriculum needs to strengthen this component.
4. Students need more experiences not only using digital tools themselves, but to gain a greater understanding of how patients, families, and caregivers use these tools. As with anything new, patient interest can be measured along a continuum. Some refuse to use digital tools while others want to use the most innovative techniques to manage their health.
Thank you for allowing me this opportunity to share with you our experiences at the University of Colorado College of Nursing. I am hoping that some of you will contact me with your experiences so we can all learn from each other how to prepare our next generation of nurses to work in a connected health environment. As always, you can reach me at mailto:[email protected].
REFERENCES