We are living in a virtual world. Merriam Webster defines virtual as "being on or simulated on a computer or computer network."1 This includes activities that occur primarily online. We connect, communicate, play games, shop, and work online. And now more than ever, we also obtain healthcare online.

The US Department of Health and Human Services defines telehealth "as the use of electronic information and telecommunications technologies to support and promote long-distance clinical healthcare, patient and professional health-related education, and public health and health administration."2 Telehealth care, also called virtual healthcare, is provided synchronously or asynchronously via audio, text, or video communication. Data are transmitted via transmission lines or satellite connections. Its hallmark is that providers care for patients who are located anywhere in the world-assuming a network connection can be established.

The COVID-19 pandemic forced the healthcare delivery system to adjust their care delivery amidst stay-at-home and social distancing decrees3 from in-person care to virtual care. But how did we get here? Based on the aforementioned definitions, virtual healthcare requires the use of computers or computer networks. However, personal use computers only entered the mainstream about 40 years ago.4,5

Early versions of telehealth care were established as early as the 1970s.6 However, establishing large-scale telehealth systems remained cost-prohibitive. By the 1990s, state and federal governments started to invest into establishing the necessary infrastructure, as well as telehealth networks with the goal of making healthcare not only more accessible but also cheaper. The videos, sounds, and images needed to successfully connect patients and providers were transmitted using telephone lines and satellites7 at transmission speeds around 24 kilobits per second.8 Considering that today's recommended minimum transmission speeds are about 80 times faster,9 this clearly affected quality and speed of the transmitted data.

Nevertheless, virtual and telehealth visits started to take hold. Ideas on how far technology could push medicine included patient interacting with an adaptive computer system to upload blood pressure readings or blood glucose measurements using the patient's telephone keypad.10 Another report discussed ideas on implementing teleconsultation, personnel status monitors (aka a device that provides location services and vital sign monitoring), trauma pods for casualty evacuation and to perform remote surgery if needed, and training using virtual 3-dimensional (3D) reality.11 Fast forward 25 years and patients now wear medical devices that upload glucose readings or blood pressure measurements to the cloud. The consumer market for health-related monitoring devices is on the rise. For example, the smart watch market is expected to be valued at more than $23 billion by the end of the year.12 Robotic surgery is performed daily. And virtual reality has become a reality within many private households, as well as healthcare education and simulation settings.

What does this mean for patients? There are clear benefits to telehealth care, especially for patients who live in rural areas or needing specialty care, that is not provided in their local area. I am thinking of a friend whose child has a rare disorder. She will travel cross-country at least twice per year to ensure that her child gets the care they deserve. I am sure that she would appreciate the cost and time savings of not having to travel to fulfill her child's basic needs.

However, Hawkins13 warned in 1998 that it is important to not lose the person in the technology. Using telehealth may lead to missing nonverbal communications cues, which can be a disadvantage, especially for those patients who have difficulty with verbal communications, to include people not fluent in the local language, people who are deaf or hard of hearing, or patients who have mental disabilities.14 We also need to consider that not everybody has the means or the ability to access telehealth capable devices or the Internet.

There are appointments that are well suited for telehealth encounters such as counseling appointments or follow-ups on diagnostic testing.15,16 But others require touch. Unless patients can actively participate in their appointment and have access to medical equipment capable of connecting test devices to their computer, tablet, or phone, it is impossible to auscultate heart, breath, or bowel sounds. It is impossible to palpate the abdomen or a breast lump without being in the same room with a patient. Telesurgery may have patient and surgeon in different locations, but surgery cannot be completed unless a nurse is in the room with the patient to provide essential perioperative care. This does not mean that this cannot change.

Since its inception some 50 years ago, virtual healthcare has come far. Technological inventions have led to smaller, more portable technologies and improved diagnostic techniques.17 Healthcare 4.0 builds on advances in cyber-physical systems and cloud computing. Mini-laboratories requiring minimal amounts of blood or other specimens, wearable devices, 3D printing, and customized materials will be as much in our future as big data, artificial intelligence, and precision medicine.17 Future trends and innovations in healthcare will enhance communication between patients and providers, improve clinical outcomes, enhance the consumer experience, improve efficiency, and expand consumer and clinician access.18

So where do nurses fit into virtual healthcare? Everywhere, because even virtual healthcare needs clinicians. Nurses will be there with the patient at the bedside, providing care. Nurses will evolve and adjust to using new technologies like they have so many times before. They will contribute to improved patient outcomes, providing state-of-the-art, efficient care. But more so, nurses will do the one thing a machine cannot: they will provide the human touch.

-Alexandra Michel, PhD, CNM, FACNM

Nancy Atmospera-Walch School of Nursing

University of Hawaii

Honolulu

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