Chapter 48. Patient Safety, Telenursing, and Telehealth 

Loretta Schlachta-Fairchild, Victoria Elfrink, Andrea Deickman 

Background 

Tele is a prefix meaning “at a distance,” and it is used in terms such as telescope, or 

telemetry. The prefix tele, when combined with the term scope, has the single clear following 

meaning: an instrument to view phenomena at a distance.1

 However, in health care, as in other 

arenas, the prefix tele often takes on several meanings. For example, the term telemetry is 

described as a process,2 data,3 and an electronic device4 related to the task of remote measuring 

and reporting of information of interest. There is inconsistent and emerging nomenclature related 

to tele in health care. 

The inconsistent use of language associated with the delivery and management of health care 

at a distance has made it even more difficult to distinguish the ontology of terms and describe 

their related safety and quality issues. Specifically, previous literature has used the terms 

telehealth, telemedicine, and telenursing somewhat interchangeably, and the few articles 

reporting safety concerns were difficult to cluster for further analysis. 

Telenursing is the use of “technology to deliver nursing care and conduct nursing practice”5 

(p.558). Although the use of technology changes the delivery medium of nursing care and may 

necessitate competencies related to its use to deliver nursing care, the nursing process and scope 

of practice does not differ with telenursing. Nurses engaged in telenursing practice continue to 

assess, plan, intervene, and evaluate the outcomes of nursing care, but they do so using 

technologies such as the Internet, computers, telephones, digital assessment tools, and 

telemonitoring equipment. Bearing in mind that health services now provided via 

teletechnologies have expanded, the term telehealth is used to capture the breadth of services. 

For the purposes of this review, the Health Resources and Services Administration defines 

telehealth as “the use of electronic information and telecommunications technologies to support 

long-distance clinical health care, patient and professional health-related education, public health 

and health administration.”6

 Telemedicine, the original term, is defined as the practice of health 

care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using 

interactive audio, visual, and data communications.7 The American Nurses Association has 

defined telenursing as a subset of telehealth in which the focus is on the specific profession’s 

practice (i.e., nursing).8

 

The delivery of telehealth care is not limited to physicians and nurses; it includes other health 

disciplines such as radiology, pharmacy, and psychology. These disciplines also deliver care 

using electronic information and telecommunications technologies and are accordingly called 

teleradiology, telepharmacy, telepsychology, and so forth. Although they are not the focus of this 

review, these disciplines are selectively included here for two reasons: (1) the safety issues 

associated with care delivered using electronic and telecommunications technologies are more 

similar than they are different among the various health disciplines, and (2) the dearth of research 

on safety and quality in the telenursing literature led the authors to include important research in 

other health disciplines. By including the research findings on safety and quality from varied 

health disciplines, the body of telenursing knowledge is expected to expand. 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Research Evidence

Although the summary for the AHRQ evidence report, Telemedicine for the Medicare 

Population,9

 specifically mentions safety related to telemedicine and how evidence could be 

presented and researched, it is ironic to note that in all the evidence tables of all the AHRQ 

reports there are no studies that mention safety or specifically research patient safety in 

telehealth. Indirect evidence such as monitoring, prevention of acute care events or 

complications, testing the technology for comparison with in-person care, and outcomes research 

all allude to safety but do not address it specifically. It is clear that there is a gap in the literature 

and research evidence for telehealth specifically related to safety. However, telenurses and other 

health care professionals are continually struggling to increase the safety of their patients, 

increase the quality of health care, and decrease adverse events, although the evidence of the 

impact of these concepts is not apparent in the research. 

The four themes that emerged upon review of the literature offer insight into the field of 

telehealth and the practice of telenursing. Although not noted or researched specifically, patient 

safety is an important part of the diagnosis, monitoring, outcomes, and technical tools used in 

telehealth practice. 

Diagnosis and Teleconsultation 

A great deal of research has been done on the use of telehealth for diagnosing disease. It has 

been shown that diagnosis of disease using telehealth is successful (Evidence Table 1). For 

example, Schwabb and colleagues10 found that the remote interpretation and diagnosis with 

electrocardiogram results was just as good as interpretation in person. Additionally, telehealth 

has successfully been used as a tool for diagnosing acute leukemia.11 

In addition to diagnosis, educational sessions for providers, as well as patient education and 

psychosocial counseling, have been researched. Telehealth has been shown to be a successful 

endeavor for education and counseling through two-way audio and video technology.12–14

Providers of care also have seen great benefits from consultations through telehealth equipment. 

Similar to education and counseling, two-way audio and video technology has been researched 

and shown to be beneficial for consults between providers.15 For instance, home health nurses 

may use telehealth equipment to consult with specialists, or physicians may consult with each 

other regarding a particular patient. 

Monitoring and Surveillance 

Compliance and adherence problems are among the many issues that are important to 

achieving patient safety. After a patient leaves a provider’s office or a hospital, the patient is 

responsible for his or her own health care at home. Patients often do not follow a treatment plan 

as directed by a physician or provider due to several factors, including: miscommunication or 

faulty understanding of the treatment plan, lack of access to facilities needed for the treatment 

plan, and a complex treatment regimen that the patient cannot comprehend without additional 

guidance.16 This can cause negative outcomes and creates safety issues for the patient. Therefore, 

inventive and efficient telehealth-based methods of caring for patients are increasingly being 

used to improve compliance or adherence to the prescribed regimen of care, as well as for 

symptom management. Telehealth is one strategy for monitoring and communicating with 

2 
Telenursing, Telehealth, and Safety

patients beyond the acute care setting. It has also had an impact upon health care utilization rates 

for acute care services (such as decreasing visits to the Emergency Department) in studies with 

limited sample sizes, although large randomized trials have not yet been reported (Evidence 

Table 2). 

Adding to the problem of adherence in patients is a lack of access to quality health care, 

specialists, or nurses. With the current trend in outpatient care management, monitoring, and 

surveillance of patients, additional nurses are needed for the increasing number of home care 

patients and the increasing acuity of illnesses in these patients.17 Further, patients who live in 

rural areas or in medically underserved areas may not be receiving the expert care that is 

needed.18, 19 Traveling far distances to a treatment facility, time lost from work for treatment, and 

other responsibilities also contribute to the compliance issue. 

To meet the patients’ needs, and with the additional burden on nursing because of the current 

nursing shortage, many home care agencies are looking for innovative ways to care for a large 

number of patients. Telehealth technology offers increased productivity for nurses by decreasing 

travel time to remote areas, thereby increasing the average daily census.20 Especially in rural 

areas, where driving time to patients’ homes can take up the majority of a nurse’s day, new timesaving and patient safety initiatives are imperative, leading to further adoption of telehealth in 

home care. Audio and video technology can facilitate remote home health monitoring between 

patients and caregivers.17, 20 Often, peripheral devices placed in patients’ homes—such as 

thermometers, sphygmomanometers, and stethoscopes—are connected to the telehealth 

equipment so telenurses can monitor clinical signs remotely. Nurses are able to spend more time 

on direct patient care rather than indirect care, resulting in better use of their time and education. 

Hence, telehealth and telenursing address barriers to quality health care that are created by 

geographic location and costs associated with lost time. 

Clinical and Health Services Outcomes 

The majority of research completed on outcomes after implementing telehealth has been 

related to chronic conditions such as diabetes, congestive heart failure (CHF), and chronic 

obstructive pulmonary disease (COPD). Often, morbidity and mortality are measured outcomes 

for these patients, and telehealth use shows better outcomes in these areas (Evidence Table 3). 

More specifically, telehealth technology has been shown to be a successful method of 

telehealth intervention, inducing communication that has helped patients’ HbA1c levels to 

decrease, as well as offering assistance to traumatic brain injury patients in transitioning from the 

hospital to the community.16, 21

In addition to the more widely used telehealth technologies, there are a number of devices 

and applications with specific functionalities that are making a difference in patient health care 

and safety as related to health outcomes. Glucoboy and Digiscope are two examples of these new 

technologies. The former is a diabetic tool in a video game cartridge format. The cartridge is 

inserted into Nintendo’s Game Boy and has been shown to help children with the management of 

type 1 diabetes mellitus.22 The Digiscope is a telehealth technology that allows for screening of 

diabetic retinopathy in a primary care physician’s office rather than under the specialized care of 

an ophthalmologist.23 These telehealth technologies have been shown to be practical alternatives 

to traditional care. 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Technical Issues 

Telehealth technology differs in every situation and can range from telephone calls 

postoperatively to preventing diabetic complications in children by using a popular video game 

system, to live, interactive voice and video patient education, to downloadable data devices used 

by patients with data interpreted by telenurses. Studies report various technology approaches 

used by various types of providers in different settings with diverse disease entities (Evidence 

Table 4). 

For instance, telephone technology has traditionally been used as a telehealth mechanism. 

While using a technology that is already in place in many patients’ homes, this technology can 

be used to deliver important aspects of health care, including education,21 psychosocial therapy,16

and emotional support. 

One of the most common technology configurations for telehealth applications uses two-way 

audio and video, or teleconferencing equipment. This technology allows patients and caregivers 

to communicate effectively, while allowing caregivers the benefit of seeing the patient. Other 

technologies can be incorporated into the main audio and video equipment to transmit specific 

health care data such as blood pressure and heart rate. These technologies makes telenursing 

possible because data to support patient safety in home care can be retrieved from home 

telehealth devices if proper terminology and data standards are employed.24

One innovative technology that has recently begun to be studied would allow patients to be 

monitored remotely with even less of a time burden placed on the nurse and the patient. Infrared 

technology offers perhaps the most continuous method of telehealth monitoring equipment. 

Infrared scanners have been shown to be effective in reporting deviations from a daily routine.25

With this technology, the monitoring of elderly or dependent patients is done from a remote 

location; patients can be monitored at home, in a nursing home, or in the hospital. Safety of the 

patient can be assessed without the patient purposely getting in front of a camera or logging on to 

speak to a nurse.

Evidence-Based Practice Implications 

The research related to telehealth and telenursing practice has shown great benefits related to 

diagnosis and consultations, monitoring and surveillance of patients, clinical and health services 

outcomes, and technology advancement. Each of these areas have important patient safety 

concerns, and while not studied as a unique entity, patient safety themes have emerged 

throughout the literature. Telehealth is a unique field that uses innovative technologies to 

improve patient care and thereby improve safety. These technologies range from the telephone to 

ubiquitous computing and only promise more in the future. Special concerns related to patient 

safety emerge with each of these methods of health care delivery. 

Technologies have evolved to offer more and broader capability for telehealth/telenursing 

practice. With telehealth technologies, patient adherence to care increases, access to care is 

improved, providers can network with each other, and the safety of patients can be monitored 

more closely in homes and alternative living facilities. 

With telephone-based telehealth, there is relatively no cost to the patient and no technical 

setup required for a telehealth interaction. Most patients already have a phone in the home that 

can be used for sessions. However, telephone discussions are usually limited to education and 

counseling because there are no visual cues for the provider/telenurse. 

4 
Telenursing, Telehealth, and Safety

Two-way audio and video increases the functionality of telehealth by allowing the 

telenurse/health care provider to see the patient. In addition, peripheral monitoring devices can 

be used by the patient to transmit clinical information to the remote provider. More patient 

education is required initially for the use of the equipment with this type of technology, and the 

initial investment costs for the telehealth equipment can be large. Further, the patient must have 

Internet access or transmission lines to accommodate the video equipment. 

Products such as the Glucoboy are innovative technologies that have been researched and 

shown to be effective in helping diabetic children maintain a healthy lifestyle.22 The new product 

has taken a monotonous, sometimes painful task and made it into a game for children. However, 

the cost of this technology and who bears the cost remain to be seen. 

Finally, infrared technology and sensor technology promise to deliver remote monitoring 

capabilities into the hands of providers. This has implications for caregivers and even family 

members of a person who lives at a distance. Falls, injuries, or illness will be easy to detect using 

such a system, offering immediate care to patients. However, the continuous monitoring nature 

of these devices may prove to be an infringement of patients’ rights to privacy, and therefore an 

ethical issue for health care providers to consider. 

With telehealth, confidentiality also remains a concern and must always be considered. While 

technology is becoming more sophisticated, telehealth sessions remain as a confidential 

interaction between a provider and a patient. Enclosed rooms without traffic or others present are 

imperative to maintain privacy. Health care providers need to be conscious of who is in 

attendance for the session and respect privacy and confidentiality of the patient. Further, as the 

numbers of new and innovative technologies emerge, researchers and developers must remember 

the security of patient information, regardless of how it is transmitted. In the researched 

technologies, data are transmitted over secure lines. However, new wireless technologies, 

increased use of e-mail by providers, and the continual threat of computer viruses increase the 

need for security and confidentiality of patient data to remain in the forefront of telehealth. 

The different platforms for telehealth are diverse, yet all increase the ability of telenurses to 

communicate with and receive data about their patients. Regardless of the specific telehealth 

technology utilized, the reliability and validity of data transmission is essential to the safety of 

patients. Further, accepted and proven nursing practice must not be compromised. It is 

imperative for nurses to see the telehealth technology as a medium for care, and not a tool to 

replace high-quality nursing practice. Patient safety will be maintained with telenurses who are 

able to focus on patient care and not the technology itself. 

Research Implications 

The possibilities for telehealth technology abound, although pitfalls are also a potential. 

Telehealth has evolved throughout the years, from the first telephone interventions to the 

present-day use of sensors and remote monitoring devices. Much research has been completed on 

telehealth technology; however, it can be expanded upon exponentially—and should be 

expanded to include safety as a variable in all studies. 

New wireless technologies have introduced new options for telehealth, which include 

nanotechnology and artificial intelligence.26 Both of these offer great possibilities for diagnosis 

and treatment. However, researchers have only begun studying the potential of these 

technologies that offer promises for future health care. 

5 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

In the shorter term, increasingly sensitive and accurate peripheral devices are needed for 

clinical monitoring. While the technologies currently exist, many can be improved upon to 

ensure valid clinical results. Peripheral device use can also be expanded. Ubiquitous computing 

is an option that will allow for clinical monitoring at home or in the community without being 

intrusive to the patient.26 There is a greater chance of adherence in patients with this type of 

technology; however, research will need to be conducted to confirm the expectations. 

Telehealth technologies will continue to evolve, as technology has in other business sectors. 

Health care needs to commit to this progress in order to provide up-to-date technology and safe 

devices for patients. The majority of studies that were reviewed compared telehealth care vs. inperson care and involved patient monitoring. Overall there were some positive outcomes 

indicating the benefits of telehealth. However, patient safety issues were not the main focus of 

these studies. Only one article was found that directly focused on safety issues: That article 

provided important information on the safety of wireless technologies; however, it was not a 

research article. Further, in a recent conference funded by the Agency for Healthcare Research 

and Quality, telehealth nursing experts were brought together to create a national agenda for 

telenursing research.27 Themes for future research included cost effectiveness, clearly identified 

populations, standard outcomes, and standard methodologies to support telenursing. Specific 

research agenda topics identified were chronic disease management, patient empowerment, and 

enhanced self-care. While patient safety is a faction of all of these topics, it was not included 

specifically as a research agenda topic for telenursing. Therefore, the review of the current 

literature as well as decisions for future research goals indicate a gap of information and future 

direction regarding patient safety issues related to the use of telehealth in clinical practice. 

Conclusion 

The scarcity of research evidence focused primarily on patient safety in telehealth may in 

part be due to a lack of understanding about the emerging safety issues associated with telehealth 

and telenursing. The safety issues identified for telehealth and telenursing extend beyond the 

limited view of the precision of the information.28 Telehealth encompasses a wide range of 

applications, including teleconsultations, telediagnosis, telepharmacy, e-health via the Web, 

telephone triage/telephone advice, tele-emergency support, disease management, and 

telehomecare. The safety issues associated with telehealth are, in turn, more complex and include 

not only apprehension about malfunctioning equipment, but also concerns regarding potential 

adverse effects on patient management decisions through delayed or missing information, 

misunderstood advice, or inaccurate findings due to patient or caregiver error.29 Further research 

is clearly needed in the arena of patient safety as it is directly related to telehealth practice. 

Search Strategy 

The majority of research studies to date have focused upon teleradiology, telepathology, 

telepsychiatry, and other medical uses of telemedicine technology for medical care and 

diagnosis. These studies were purposely not included in this review. The purpose of this 

literature review was to focus upon the safety issues associated with care delivered by and 

relating to telenursing. The search strategy and distillation process of the literature consisted of 

three primary activities: (1) identification of meaningful MeSH® search terms and searching in 

6 
Telenursing, Telehealth, and Safety

PubMed®, (2) an alternative process for locating articles, and (3) identification and validation of 

safety and quality related themes. 

Identification of Meaningful MeSH® Search Terms and Searching in 

PubMed®

The U.S. National Library of Medicine developed MeSH®, a controlled vocabulary for 

indexing articles, which is located in the MEDLINE®/PubMed® databases. It took several 

iterations of MeSH® terminology to produce references that reflect the scope of safety and 

quality issues inherent in telehealth. For example, a search using the MeSH® terms “safety” and 

“telehealth” produced 12 articles, only 5 of which dealt specifically with monitoring equipment 

safety issues related to telehealth. Furthermore, the details of the MeSH search indicated that it 

could not find the term “telehealth” or “telemedicine” and instead suggested terms like 

“equipment safety” and “health care technology.” A further search of the PubMed® database 

yielded zero results for “telehealth” and seven journal titles for the term “telemedicine.” 

Alternative Process for Locating Articles 

Two of the seven journals identified through PubMed were Journal of Telemedicine and 

Telecare and Telemedicine and e-Health. Volumes of these journals were hand culled to locate 

any articles related to telehealth and its related safety concerns. As these articles were located, 

the reference list of each was also reviewed and relevant articles flagged for further searching. 

Additionally, professional organization sites such as the American Telemedicine Association and 

the Telehealth Information Exchange were searched to locate references to telehealth and safety. 

Identification and Validation of Safety/Quality Themes 

One author conducted the search and located all of the articles included in this review. A 

total of 41 articles were found to have some relevance to telehealth and safety. After an initial 

appraisal of the articles, they were examined for semantic similarities and differences. Four 

themes emerged among the 41 articles: (1) diagnosis and teleconsultations, (2) monitoring and 

surveillance, (3) clinical and health services outcomes, and (4) technical/ethical issues. The 

articles were then distributed among the authors, and the themes were validated. Where 

appropriate, articles were redistributed from their initial category to a more appropriate category. 

The included safety and quality topics are described in Table 1, below. 

7 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Table 1. Safety and Quality Topics as Related to Telehealth 

Number of 

Articles 

Category Included Topics 

2 Diagnosis and 

teleconsultation 

The use of EKG leads in diagnosis and Web-based decision support in 

the care of leukemia patients. 

11 Monitoring and 

surveillance 

Adherence issues among patients using telehealth technologies to 

manage asthma, medication regimen, and CHF. 

19 Clinical and 

health services 

outcomes 

The use of telehealth applications and telenursing for managing CHF 

and diabetes at home. The use of telehealth technologies for consults 

such as dermatology, cardiology, intensive care, and emergency 

care/trauma. 

19 Technical and 

ethical issues 

Questions surrounding interoperability of equipment, algorithms for 

applying telehealth development, and issues in developing various 

technologies. 

It became clear to the authors that issues such as measuring return on investment are often 

tied to clinical outcomes; thus these studies were included in the review. Additionally, articles 

that addressed disparities to access in health care and the potential benefits of telehealth are 

included, as these articles address the prevention of safety problems. 

Author Affiliations 

Loretta Schlachta-Fairchild, R.N., Ph.D., F.A.C.H.E., president and CEO of iTelehealth Inc. 

E-mail: lschlachta@itelehealthinc.com. 

Victoria Elfrink, Ph.D., R.N.B.C., assistant professor of nursing at the College of Nursing of 

Ohio State University and qualitative researcher and director of consumer informatics for 

iTelehealth Inc. E-mail: elfrink.7@osu.edu. 

Andrea Deickman, M.S.N., R.N., associate and research analyst at iTelehealth Inc. E-mail: 

adeickman@itelehealthinc.com. 

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50. Joseph AM. Care coordination and telehealth 

technology in promoting self-management among 

chronically ill patients. Telemed J E Health

2006;12(2):156-9. 

51. LaFramboise LM, Todero CM, Zimmerman L, 

Comparison of health buddy with traditional 

approaches to heart failure management. Fam 

Community Health 2003;26(4):275-88. 

52. McCue MJ, Palsbo SE. Making the business case for 

telemedicine: an interactive spreadsheet. Telemed J E 

Health 2006;12:99-106. 

53. Reardon T. Research findings and strategies for 

assessing telemedicine costs. Telemed J E Health 

2005;11:349-69. 

54. Wu RC, Delgado D, Costigan J, et al. Pilot study of an 

Internet patient-physician communication tool for 

heart failure disease management. J Med Internet Res 

2005;7(1):e8. 

55. Boye J. Wireless technologies and patient safety in 

hospitals. Telemed J E Health 2006;9: 373-82. 

56. Dansky KH, Ajello J. Marketing telehealth to align 

with strategy. J Healthc Manage 2005;50(1):19-30. 

57. Ganguly P, Ray P, Parameswaran N. Semantic 

Interoperability in telemedicine through ontologydriven services. Telemed E Health 2005;11:405-12. 

58. Keeys CA, Dandurand K, Harris J, et. al. Providing 

nighttime pharmaceutical services through 

telepharmacy. Am J Health-Syst Pharm 2002;59:716-

21. 

10 
Telenursing, Telehealth, and Safety

11 

59. Masucci MM, Honko C, Santamore WP, et al. 

Cardiovascular disease prevention for underserved 

patients using the internet: bridging the digital divide. 

Telemed J E Health 2006;12(1):58-65. 

60. Miller TW, Elliott B, Long K. Telehealth home health 

applications for adults with developmental disabilities. 

Telemed J E Health 2006;12(2):137-45. 

61. Seren E. Web-based analysis of nasal sound spectra. 

Telemed J E Health 2005;11(5):578-82. 

62. Tang Z, Johnson TR, Tindall D, et al. Applying 

heuristic evaluation to improve the usability of a 

telemedicine system. Telemed J E Health 

2006;12(1):24-34. 

63. Whited JD, Datta SK, Aiello LM, et al. A modeled 

economic analysis of a digital teleophthalmology 

system as used by three Federal healthcare agencies 

for detecting proliferative diabetic retinopathy. 

Telemed J E Health 2005;11(6):641-51. 

64. Yoon G, Lee JY, Jeon KJ. Development of a compact 

home health monitor for telemedicine. Telemed J E 

Health 2005;11:660-7. 
Evidence Tables 

Evidence Table 1. Diagnosis and Consultations Using Telehealth Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key Finding(s) Belachel 200511 Web-based clinical decision support tool Changing practice projects/ research Observational study with controls (Level 3) Other measurable variables with an indirect or unestablished connection to the target safety outcome (Level 3) 191 Acute leukemia cases from the database of Cliniques Universitaires Saint- Luc Brussels, Belgium Web-based clinical decision support tool to virtually diagnose and support secure and timely electronic data exchange regarding acute leukemia. The percentage o

correct classificathis experimentatesting was conswith the proposeprototype. 96.4% acute leukemia cwere correctly classified, provinWeb integration ca promising tool fdissemination of computerized desupport system tThe system is roand capable of deployment for rephysicians. 

12
Source Safety Issue 

Related to Clinical Practice 

Design Type Study Design 

& Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

Schwaab 200510 The study compared the 

accuracy of a 12-lead electrocardiogram (ECG) recorded by patients and transmitted to a cardiology call center via telephone (teleECG) with standard 12-lead ECGs. 

Nonrandomized trials 

Nonrandomized control trials (Level 2) Surrogate outcomes (Level 2) 

158 post myocardial infarction cardiac patients living at home with the capacity to communicate the teleECG via telephone. 

Tele-ECGs were compared with standard ECGs by two cardiologists and one internist, independently and blindly. 

In 155 of 158 pat(98%), the quality tele-electrocardio(tele-ECG) was adequate for diagReliability coefficfor PQ, QRS, and intervals between and standard ECAdditionally, negwaves and ST sedetection was vegood. Residual smyocardial infarccould be detectetele-ECG, with vegood agreement anterior as well aposterior localizaThe tele-ECG technique seems promising approareducing pre- and hospital time delathe initiation of thrombolytic ther

13
Evidence Table 2. Monitoring and Surveillance Related to Telehealth and Telenursing Practice 

Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key Finding(s) Chan 200330 Test the use of an Internet- based store- and-forward video home telehealth system to manage asthma in children Prospective cohort study Observational studies with controls (Level 3) Surrogate outcomes (Level 2) Pediatric patients ages 6–17 years with persistent asthma were recruited from among the population of patients with asthma in pediatric clinic at Tripler Army Base, Honolulu. The use of an Internet-based store-and-forward video monitoring system for patients with asthma, and followup with virtual visits via the Internet in comparison to in- person office visits. No overall change 

quality of life reporpatients. However, caregivers in the vifollowup group repan increase in the patients’ quality-of-survey scores. Emergency departvisits and hospital admissions for asthwere avoided. Restherapy was infreqhigh rate of satisfawith home telemonwas reported. Interbased, store-and-fovideo assessment children’s use of asmedications and monitoring tools in homes appeared effective and well accepted. 

14
Source Safety Issue 

Related to Clinical Practice 

Design Type Study Design & 

Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

Fragou 200531

Adherence to medication regimen 

Randomized controlled trial 

Randomized controlled trial (Level 1) Clinical outcomes (Level 3) 

108 diagnosed schizophrenic outpatients, part of the South London and Maudsley NHS. 

Telementoring using a new platform called @HOME, which offered clinicians early warnings about impending nonadherence as well as information about the pattern of medication taking. 

In comparison to thother two groups, patients using @Hshowed improvemethe Global Clinical Impression Scale asignificant reductioemergency visits amedical appointme

Gilbert and Sutton 200632

N/A Randomized 

controlled trial (Level 1) 

No outcome relevant to decreasing medical errors/ adverse events. 

1,457 callers to Quitline (smoking cessation program) were randomly allocated to a control group to receive usual care or to a repeated contact group to be offered abstinence 6 & 12 months after recruitment, quit attempts and 24 hours of periods of abstinence in nonquitters. 

Proactive telephon

counseling did not significantly decreaabstinence from smrate. 

15
16

Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key Finding(s) Lamothe 200617 Increased need for home care services Non- comparative studies Observational studies without controls (Level 4) No outcomes relevant to decreasing medical errors and/or adverse events (Level 4) Patient homes in Quebec and Manitoba, Canada; patients with chronic illness. Telehomecare monitoring, including disease measurements. Positive impacts on patients and health 

prevention. 

Manfredi 200533 N/A Observations No outcome relevant to decreasing medical errors/ adverse events 15 inmates were assess & treated in 37 consultations. Subjects were young white males. Interactive two- way audio-video communication between the psychiatrists & inmates. Services were read

accepted by inmatestaff. Telepsychiatrexaminations & treappear to be a feasmethod to increase access to mental hcare in rural jails. 

Marinella 200634 Use of telemedicine to monitor patients and 

deliver care. 

Observation, convenience sample 

No outcome relevant to decreasing medical errors/ adverse events. 

14 Spinal cord injury (SCI)patients at home after discharge from James Peteres VA Medical Center. 

Monitoring patients for safety, home accessibility, exercise by messaging device or videophone on weekly basis. 

Office visits increashospitalization and of stay decreased. reliability of monitodevice was identifiean obstacle. 
Source Safety Issue 

Related to Clinical Practice 

Design Type Study Design & 

Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

Prince 200535 Seniors will 

be able to safely age in place with use of telehealth 

Literature reviews/ narrative 

Design (Level 4) Outcomes: telehealth technology and services (Level 4) 

Review of previous research and reports of safer and longer aging in place for seniors when using telehealth technology and services. 

Telehealth can delay nursing home care, support aging in place at home, and provide inhome monitoring and health care services. 

Telehealth has beesuccessfully used ihospital specialty ato provide health cservices. Research to benefit of seniorof telehealth in a systematic fashion acquire services aninformation so they age in place in thehomes safely and wgood quality of life. 

Rogers 200136

Randomized 

controlled trial (Level 1) 

121 adults with 

essential hypertension. 

A home service consisting of automatic transmission of blood pressure data over telephone lines, computerized conversion of the info into report forms, & weekly transmission of the report forms to physicians and patients. 

Telecommunication service was efficacreducing the mean arterial pressure of patients with estabessential hypertens

17
18

Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key Finding(s) Rotondi 200537 Descriptive study of provision of Web -based support services/ information to families of patients with traumatic brain injury (TBI) to improve their patient outcomes, to include safety Nonrandomized trial Observational study without controls (Level 4) Self-reports of satisfaction and Web utilization (Level 3) 17 female caregivers of patients with TBI were provided access to Web site for support/services from home. Study evaluated use of WeCare Web site for information, answers to questions, and support group with other caregivers for those with TBI. Caregivers used su

group as the most frequent function oWeb site. There is correlation betweecaregiver capability patient outcomes fpatients, to include outcomes of TBI pawho may have gait motion dysfunction result of their injury

Savard 200338 No outcome relevant to decreasing errors/ 

adverse events 

Case observations, two rehabilitation centers, convenience sample 

No outcome relevant to decreasing medical errors/ adverse events. 

117 teleconferences with 75 patients ages 9m–-86 yrs. (38 of the visit were with neurological diagnoses.) 

High-speed video conferencing with real-time audiovideo communication. 

Care of individuals neurological issues be supported. 

Smith 200614 Adherence 

with sleep apnea treatment—Continuous Positive Airway Pressure (CPAP)

Randomized controlled trial 

Randomized controlled trial (Level 1) Surrogate outcomes (Level 2) 

In-home patients with nonadherence to CPAP regimen. 

Telehealth educational sessions. 

Increased use of Cthe group with the telehealth educatiosessions regarding CPAP. 
Source Safety Issue 

Related to Clinical Practice 

Design Type Study Design & 

Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

Wang 200539 A feasibility 

study on an Internetbased compliance system to provide personalized care for patients suffering from chronic diseases. 

Changing practice project/research 

Observational studies with controls (Level 3) Other measurable variables with an indirect or unestablished connection to the target. 

The study monitored the chronic disease management of oral anticoagulation treatment in Spain, asthma care in the United Kingdom, and morbid obesity care in Greece in 25 patients residing at home with access to a personal computer and an Internet connection. 

The C-Monitor System consisting of an integrated service aimed at monitoring patients’ adherence to therapy at home via the Internet. 

Health care providecredited the C-Monhelping with the adherence in diseamanagement as determined by the system’s ability to cpersonalized theraschemes, provide aefficient communicchannel between providers and patieand offer satisfactomonitoring of patieadherence with treand their physical sThe performance osystem was assessall participants. Mothe patients and physicians agreed Monitor system proa more valuable sethan the traditional ambulatory system would like to use thMonitor service in tfuture for disease management. Suggestions for improvement of the system were offereboth types of partic

19
Evidence Table 3. Outcomes Related to Telehealth and Telenursing Practice 

Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key Finding(s) 

Adkins 200616 Type 1 diabetes adherence Pre- and post-test Observational studies without controls (Level 4) Surrogate outcomes (Level 2) In patients’ home: patients ages 7–18, elevated HbA1c levels and/ or DKA within the last year. Telephone therapist intervention. HbA1c levels decreas

patients when they received the telephonintervention. 

Bunn 200540 The effects of telephone consultation and triage on safety, service use, and patient satisfaction was examined. Systematic literature review Randomized controlled trials (Level 1A) Clinical outcomes: morbidity, mortality, adverse events (Level 1) The researchers reviewed randomized controlled trials, controlled studies, controlled before/after studies, and interrupted time series of telephone consultation or 

triage in a general health care setting; however, the majority of studies were in primary care. 

The researchers searched registers such as the National Research Register, Cochrane Central Register of Controlled Trials and searched databases like PubMed, EMBASE, CINAHL, SIGLE. A list of identified studies and review articles was produced and verified by two independent reviewers. 

The findings are mixeThere was inconclusivevidence about the frequency of return vigeneral practitioners (and in the reporting oaccident and emergendepartment (ED) visitAlthough telephone consultation appears have the potential to reduce unnecessary vto the GP or ED, quesremain about its effecservice use. Further rigorous evaluation is needed with emphasiservice use, safety, coand patient satisfactio

20
Source Safety Issue 

Related to Clinical Practice 

Design Type Study Design 

& Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

Dale 200441 The safety of 

nurses and paramedics offering telephone assessment, triage, and advice as an alternative to immediate ambulance dispatch for emergency ambulance service callers with “nonserious” problems was examined. 

Randomized controlled trial 

Randomized controlled trial (Level 1) Clinical outcomes (Level 1) 

635 patients treated by ambulance services in London and the West Midlands, UK, were the subjects. A multidisciplinary expert clinical panel reviewed data from various ambulance and ED records and call transcripts for patients triaged by nurses and paramedics. Calls were placed into categories that indicated if the dispatch of an ambulance was necessary or not. All cases for which one or more members of the panel rated that an emergency ambulance should have been dispatched were further re-reviewed for an assessment of the “life risk” that might have resulted. 

The intervention comprised nurse or paramedic telephone consultation using a computerized decision support system to assess, triage, and advise patients whose calls to the emergency ambulance service had been classified as “nonserious.” 

From the 239 usable cases, in 237 cases thmajority of the panel concurred with the nuor paramedics’ triage decision. Telephone amay be a safe method managing nonemerge(category C) calls. Fustudy is needed to exthe possibility of rare adverse events. 

21
22

Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key Finding(s) 

Dang 200642 Care coordination using telehealth reduces hospitalizations, thereby reducing exposure to medical errors Pre- and poststudy Design (Level 2) Outcomes (Level 3) 59 chronically ill VA patients. Outcomes were hospital admissions, bed days of care, number of emergency room visits, number of outpatient visits. Telecare management via an Internet-based home messaging device and whether it can impact health care utilization rates. Significant reduction i

hospital admission annumber of emergency room visits occurred ppost-6 months with ustelehealth care management. Significreductions in acute cautilization rates amonchronically ill patients a reduction in medicarates since exposure acute care is less. 
Source Safety Issue 

Related to Clinical Practice 

Design Type Study Design 

& Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

Finkelstein 200643 A study that examined 

patient outcomes and cost when home health care was delivered by telemedicine or by traditional means for patients receiving skilled nursing care at home. 

Randomized clinical trial 

Randomized controlled trial (Level 1) Clinical outcomes (Level 1) 

53 rural Minnesotans participated. Candidates for TeleHomeCare had to be (1) eligible to receive skilled home nursing care for either congestive heart failure (CHF), chronic obstructive pulmonary disorder (COPD), or chronic wound care; (2) able to use the equipment or have a supportive care partner who could do so; (3) live in a technically functional home environment. 

There were two separate interventions with two intervention groups. In group a, video intervention and traditional skilled nursing care at home was used, and the second group received traditional skilled nursing care at home, virtual visits using videoconferencing technology, and physiologic monitoring. 

There was no differenmortality between the groups. Morbidity, as evaluated by changes the knowledge, behavand status scales of tOmaha Assessment Tshowed no differencebetween groups exceincreased scores for activities of daily living study discharge amonintervention groups. Taverage visit costs we$48.27 for face-to-fachome visits, $22.11 foaverage virtual visits (group) and $32.06 an$38.62 for average monitoring group visitCHF and COPD subjerespectively. The findshowed that virtual visbetween a skilled homhealth care nurse and chronically ill patients home can improve paoutcome at lower costraditional skilled faceface home health care visits. 

23
24

Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key Finding(s) 

Grady and Melcer 200544 N/A Retrospective record review. Non- randomized trials No outcome relevant to decreasing medical errors/ adverse events Service members & their adult family members of National Naval Medical Center. Telemental health care via video- conferencing vs. care provided in person. Telemental health car

improved adherence, shorter times to next followup appointment

Grigsby 200545 A meta-analysis of the home telehealth literature using a systematic application of a health services research (HSR) method for assessing the impact of telemedicine on access, quality, and cost of 

care. 

Meta-analysis Randomized 

controlled trial (Level 1A) 

The criteria for inclusion included the use of telemedicine as a substitute for home visits by nurses and the use of information technology in the management of chronic conditions in the home environment. 

A comprehensive model for the evaluation of telemedicine based on an applied research matrix consisting of: cost of care, quality of care, and access to care as used in HSR. 

Despite its limited use telemedicine, the scoHSR is broader than tclinical trials, with a foon the system of careacceptance by the usand outcomes, costs, access. The methods HSR provide a valuabanalytical framework fassessment of telemedicine and to dthe real merit of telemedicine. 
Source Safety Issue 

Related to Clinical Practice 

Design Type Study Design 

& Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

Heizelman 200546 Comprehensive review and 

synthesis of the literature concerning clinical outcomes associated with various telemedicine applications. 

Systematic literature review 

Randomized controlled trials (Level 1A) 

Inclusion criteria were based on Donabedian’s Medical Care process as defined by clinical care processes (diagnosis, clinical management, and clinical outcomes) and user satisfaction. 

Key terms were used in searching the PubMed Web site to identify published studies in peer-reviewed journals that focused on the care process and outcome in telemedicine. Inclusion criteria included (1) published between 1996 and February 2004, (2) contained an abstract, (3) had a control group, and (4) not limited to voice communication only. 

There were 356 articles analyzed. 160 studies reto diagnosis, 61 studies related to clinical managand clinical outcomes, astudies dealt with user sfaction. Most clinical outstudies to date have focon diagnosis and patient satisfaction. A few studieinvestigated telemedicineffects on clinical managor patient-oriented clinicoutcomes. Diagnostic accuracy seems to be wdocumented in radiologydermatology, pathology, ECG interpretation. Psycdiagnosis is promising, bstudy sizes have been sand ophthalmology diagrequire further study. Thevidence for outcome anmanagement appears to with home/institution-basapplications for CHF, diaand blood pressure monitoring. Among clinichospital-based applicatiothe fields of dermatologycardiology (i.e., echocargraphy), and intensive cand emergency care/trahave stronger evidence their benefit. Overall usesatisfaction is well demostrated, especially in the of psychiatry, dermatoloand other multispecialty applications.

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26

Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key Finding(s) 

Henault 200247 Communication between care- givers for long- term diabetes management Case control studies Nonrandomize d controlled trial (Level 2) Surrogate outcomes (Level 2) VA Boston Healthcare System, male diabetic patients with elevated HbA1c levels. Using e-mail for communication of recommendations from pharmacist to primary care provider. Intervention and contr

groups both had a decrease in HbA1c le

Hilty 200448 Telepsychiatry clinical and educational videoconferenci ng applications are equal to or better than in- person and also reduce health care utilization Meta-analysis Design (Levels 1 thru 4) Outcomes (Level 3) Review of telepsychiatry studies from January 1, 1965, to July 31, 2003, containing the terms videoconferencing, telepsychiatry, telemedicine, effectiveness, efficacy, access, outcomes, satisfaction, quality of care, education, 

empowerment, costs. 

All 110 telepsychiatry studies that mentioned videoconferencing were reviewed. 

Telepsychiatry is effeand has been succesused to increase accecare, provide patient aprovider satisfaction igeneral, improve outcof care, and empower those using it. Further research on impact on patient outcomes is needed. Reduced hospitalizations and decreased use of acuservices are two key findings that point to ion hospital-based meerrors. 

Hopp 200649 Clinical 

outcomes with telehealth use; research for evidence-based practice 

Randomized controlled trial 

Randomized controlled trials (Level 1) No outcomes relevant to decreasing medical errors and/or adverse events (Level 4) 

Veterans Affairs Center home care patients. 

Interactive telehealth with voice and video and some peripheral attachments for home care patients. 

High level of patient satisfaction and healtrelated quality of life (HRQOL) scores; trentoward decreased outpatient health visitthe intervention group
Source Safety Issue 

Related to Clinical Practice 

Design Type Study Design 

& Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

James 200112 Obesity in the military, 

difficulty in longterm program sustainability 

Nonrandomized trials 

Nonrandomized controlled trial (Level 2) Clinical outcomes (Level 1) 

48 U.S. Navy and Army personnel in Hawaii, with a body mass index of at least 27. 

Obesity treatment program through telehealth. 

Successful weight management with the of telehealth. 

27
28

Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key Finding(s) 

Joseph 200650 The Veterans Health Administration (VHA) evaluated a care coordination program for diabetic, CHF, COPD, and mental health chronically ill patients using technology to promote self- management. Changing practice projects/ research Observational studies with controls (Level 3) Surrogate outcomes (Level 2) Enrollment in the program began by identifying patients with frequent ED visits or frequent admissions. Additionally, patients with hemoglobin A1c greater than 10 were identified. Following identification, collaboration from the primary care provider was obtained and the patient contacted to request their involvement in the program. Patient 

had to have a standard plain old telephone system (POTS), electrical service to the house, and be agreeable to monitor and transmit data daily. 

Patients were asked to answer a series of questions about their health status and habits using a digital messaging unit placed on their phone line. In some instances ancillary monitoring devices (i.e., glucometers) were directly connected to the messaging device or the patient entered the results information. This information was transmitted to the care coordinator, who would note abnormalities and contact the physician and monitor the patient closely for followup care. 

Defined clinical and utilization outcomes wdefined and comparethe findings for ED visand bed days (utilizatand hemoglobin A1c measurement for all diabetic patients, low density lipoproteins (Llevels on patients follofor hypertension, diaband CHF (clinical). Thwere no statistically significant findings; however, care coordinefforts have demonstrimproved glycemic cofor diabetic patients, improved lipid management, and decreased use of cosresources, such as Evisits and hospitalizatThe authors concludesubstantial gains in boclinical and resource outcomes have been shown. 
Source Safety Issue 

Related to Clinical Practice 

Design Type Study Design 

& Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

LaFraboise 200351 A pilot study to determine the 

feasibility of providing a heart failure disease management program through an inhome communication device, Health Buddy. 

Randomized clinical trial 

Randomized controlled trials (Level 1) Clinical outcomes (Level 1) 

90 home care patients capable of living independently who had been discharged from the hospital within 6 months with a primary diagnosis of heart failure. 

The intervention, a telecommunication device named Health Buddy, was compared with traditional methods for home management of heart failure, including in-person visits and telephonic case management. 

Confidence in managdisease, quality of life index, functional statuand depression were measured in each of tclinical trial groups. Patients who received telephonic case management experiedecreased confidence managing their diseasother groups experienincreased confidenceFunctional status, depression, and qualilife did not differ amongroups. The findings suggest that using telehealth to manage care for heart failure ifeasible; however, furstudy is needed to determine differences might exist between various treatment met

29
30

Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key Finding(s) 

McCue and Palsbo 200652 A demonstration of the business case for telemedicine in nonrural areas was shown. The study differed from earlier investigations in that return on investment did not include the variables of provider or patient travel time. Changing practice project/ research Observational studies with controls (Level 3) Other measurable variables with an indirect or unestablished connection to the target safety outcome (Level 3) The case study of poststroke rehabilitation in urban settings in Oklahoma. Interactive spreadsheet was used to conduct multiple financial analyses under different capital investment, revenue, and expenses for poststroke rehabilitation services to urban patients, including five speech- language pathology (SLP) provided to poststroke patients over videophones or videoconferencing 

equipment and two physical therapy (PT) codes (individual activities and physical therapy evaluation). 

The outcome measurwere financial breakepoints and internal ratreturn. It was found thTotal of 340 telemedicvisits has the potentiagenerate a positive necash flow each year. By the fourth year, thiof service can producpositive present value return of more than $2and earn rate of retur20%, which exceeds thospital’s cost of capiThus business case wdemonstrated. Urban telemedicine programbe financially selfsustaining without accounting for reductitravel time by providepatients. 
Source Safety Issue 

Related to Clinical Practice 

Design Type Study Design 

& Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

31

Reardon 200553

A comprehensive review of telemedicine cost research and major issues affecting the yield from this research. 

Systematic literature review 

Randomized controlled trials (Level 1A) 

The criteria for inclusion included studies with major analytic components of health care services cost evaluations, cost analysis decision framework, and methods of inference that affect the quality and productivity of telemedicine cost research. 

Keywords evolved from first considering previous studies and then using keyword and database selection strategies to augment the literature. This approach is referred to as iterative triangulation. These terms were used to create a database of keywords, which resulted in overlapping sets of literature. The database of resulting articles consisted of 1,430 telemedicine articles. Sources for the studies were varied and included the NLM Database, CINAHL, Journal of Economic Literature, and AHRQ. 

This review supports previous conclusions the potential net savinsociety through specifuses of telemedicine. specifically populationremote areas, in prisoon ships may have retotal cost of care by accessing it through telemedicine. However, these specireported gains in the effectiveness of telemedicine depend the reduced cost of acto care. Specifically, the greatpotential for cost savifrom telemedicine seebe the production of hor wellness. When stuoutcomes are measurhealth maintenance owellness, as is usually done in home care, potential savings, especially for high-rischronically ill patientsseemingly greater. The review also concthat the productivity otelemedicine cost studsuffers from an underutilization of appropriate program evaluation and economethods. Better consguidelines and best practices on costs can provide common beneto cost research and aneeded to accurately
32

Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key Finding(s) 

Slater 200522 Type 1 diabetes noncompliance Pre- and post-test Observational studies without controls (Level 4) Surrogate outcomes (Level 2) In the community, children with type 1 diabetes and their parents. Use of Glucoboy device for monitoring blood sugar levels. Testing adherence increased by 200%; H

levels were lowered. 

Wu 200554 This pilot study evaluated the feasibility and patients’ acceptability of using the Internet to communicate with patients with symptomatic heart failure. Changing practice projects/ research Observational study with controls (Level 3) Surrogate outcomes: observed error, intermediate outcomes (e.g., laboratory results) (Level 

2) 

62 home care patients with symptomatic heart failure were enrolled into the program and instructed how to use the Internet communication tool. 

The study measured the proportion of patients who used the system regularly for at least 3 months and the safety and maintainability of the tool. Additionally, researchers conducted a content analysis of patient and clinician messages. 

The majority of the paquit using the systemhowever, 45% of the patients used the systand continued to use average for 1.5 years3-month time period twere over 5,000 entrimade by patients. The content analysis of a subset of the patient comments revealed thfollowing major categof communication: painformation, patient symptoms, patient questions regarding thcondition, patient coordinating own caresocial responses. The study concluded that Internet tool is a feasiand safe method of communication in a substantial proportion patients with heart fai
Evidence Table 4. Technical and Ethical Issues Related to Telehealth/Telenursing 

Source 

Safety Issue Related to Clinical Practice 

Design Type 

Study Design & Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

Bell 200421 Traumatic brain 

injury (TBI) patients and their transition to the community 

Changing practice projects/ research 

Observational studies without controls (Level 4) No outcomes relevant to decreasing medical errors and/or adverse events (Level 4) 

Patients’ homes, TBI patients discharged from University of Washington Medicine. 

Telephone followup program. 

Telephone supporfeasible means for followup of TBI patin the community. 

Boye 200655 Risk to patients 

from use of wireless devices. 

Literature review 

Possible outcome relevant to adverse events (Level 5) 

Review of sources of electromagnetic interferences in hospitals. 

A description of wireless communication devices used in the hospitals and the industry standards. 

Wireless technologare deemed suitabuse throughout hoareas, including ICORs, given that recommended separation distancfrom medical devicare observed. 

Britt 200615 Access to 

specialist care for high-risk pregnancies 

Pretest and post-test 

Observational studies without controls (Level 4) Other measurable variables with an indirect or unestablished connection to the target safety outcome 

Across the State of Arkansas, high-risk pregnancy patients. 

Using the ANGELS telehealth program to facilitate care and provider consultations. 

An increase in telemedical and telephone consultations. A sldecrease in transpto the high-risk clinwith a decrease in length of stay for patients. 

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34

Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key Finding(s) Dansky and Ajello 200556 The strategic objectives and marketing strategies for telehealth Non- comparative studies Observational studies without controls (Level 4) No outcomes relevant to decreasing medical errors and/or adverse events 29 home health agencies of a Midatlantic State, person at the organization responsible for implementing telehealth. Qualitative interviews were conducted to discover the reasons for telehealth adoption and the marketing strategies. Clinical excellence 

cost containment wthe main reasons fadopting telehealthMarketing strategiewere broad, but included brochuresarticles, Web site content, and fact sheets. 

Ferrante 200526 Wireless capabilities available to telemedicine for patient care Literature reviews, non- systematic/ narrative Observational studies without controls (Level 4) No outcomes relevant to decreasing medical errors and/or adverse events (Level 4) Literature review of current and future technology applications for medicine. Many applications 

new technologies for telemedicine. 

Frey 200520 Nursing shortage 

having an effect on home health agencies and their patients 

Changing practice projects/ research 

Observational studies with controls (Level 3) No outcomes relevant to decreasing medical errors and/or adverse events (Level 4) 

Home health agencies of a Midatlantic State. 

Use of telehealth for home health agency visits vs. traditional visits. 

Average daily censpatients seen was increased. 
Source 

Safety Issue Related to Clinical Practice 

Design Type 

Study Design & Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

Ganguly 200557

The development methodology for interoperable telemedicine systems 

Changing practice projects/ research 

Observational studies without controls (Level 4) No outcomes relevant to decreasing medical errors and/or adverse events (Level 4) 

School of Computer Science and Engineering, The University of New South Wales, Kensington, NSW 2052, Australia. 

Development of an ontologydriven, multiagent system for diabetic treatment using diabetes ontology and agent system called Foundations of Intelligent Physical Agents (FIPA) standardbased ontology development. 

Yet untested desigthat focuses on a Fcompliant model fointeroperable telehtechnologies. 

Keeys 200258 Overnight 

pharmacist access in an acute care facility 

Quality improvement projects/ research 

Observational studies without controls (Level 4) Other measurable variables with an indirect or nonestablished connection to the target safety outcome (Level 3) 

A 340-bed acute care community hospital, hospital staff. 

Enhancing current afterhours pharmacy on-call coverage with a telepharmacy group. 

Successful quality improvement. 

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Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key Finding(s) Masucci 200659 Descriptive study of patients without computer experience and whether they were able to safely and effectively use telemedicine technology Non- randomized trial Observational study (Level 4) Self-reports (Level 3) 44 subjects with little/no computer experience and with hypertension, diabetes, and other cardiovascular risk factors were provided telemedicine systems. Patients with no or limited computer experience were given a 2-hour class in use of the telemedicine technology system. Patients utilized th

system accurately safely using IDs anpasswords. Prior access to computeand prior computeexperience was nopredictor of use of telemedicine systeHaving access to telemedicine systemay reduce risk focardiovascular dis

McConnochie 200618 Social and economic burden of childhood illness/access to health care Randomized controlled trial Randomized controlled trials (Level 1) Surrogate outcomes (Level 2) University of Rochester Medical Center primary care practice or pediatric ED, pediatric patients. Three models of telemedicine: basic, simple, and extended. Approximately 85% 

visits offered succetelemedicine intervention. 
Source 

Safety Issue Related to Clinical Practice 

Design Type 

Study Design & Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

Miller 200660 The use of 

telehealth technology in home health care for adult persons with developmental disabilities was examined, and algorithm for delivering telehealth services to developmentally disabled persons developed. 

Changing practice projects/ research 

Observational study without controls (Level 4) No outcomes relevant to decreasing medical errors and/or adverse events (Level 4) 

The researchers examined the utilization of telehealth needed by multidisciplinary clinicians, including physicians, nurses, physical therapist, occupational therapist, and speech language pathologists, etc., to meet the health care needs of rural adults with developmental disabilities. 

Following an examination of the utilization of services, the authors developed an algorithm for telehomecare for adults with disabilities. 

A practice-based algorithm and modtelehealth care delto meet the needs rural adults with developmental disabilities was developed. The unconsideration regathe need to determthe risk-managemneeds for using telehealth technolowith this population also described. 

Seren 200561 Postoperative 

nasal airflow pattern detection for the prevention of hospital visits 

Case control studies 

Nonrandomized controlled trial (Level 2) Other measurable variables with an indirect or nonestablished connection to the target safety outcome (Level 3) 

In-home, 27 patients post septoplasty. 

Use of Web technology, Web Add, and Odiosoft-rhino programs to record and transmit sound from nasal passages. 

Significant differenthe sounds transmbetween the group nasal blockage anthose without nasablockage. 

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Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key Finding(s) Suzuki 200625 Daily health monitoring of elderly Non- comparative studies Observational studies without controls (Level 4) Other measurable variables with an indirect or unestablished connection to the target safety outcome (Level 3) Nursing home, three elderly patients. Use of infrared scanner sensor output in nursing home patients’ rooms, as compared with the reported activities of the patients. The sensors were 

to identify the repopatterns of activity

Tang 200662 Medical errors related to usability and interface design Quality improvement projects/ research Observational studies without controls (Level 4) Other measurable variables with an indirect or nonestablished connection to the target safety outcome Digital emergency medical system interface prototypes. Heuristic evaluation of interface usability. Heuristic evaluatio

serves as a useful technique in desiguser interfaces. 

Thomas 200413 Improved education for 

surgical patients 

Quality improvement projects/research 

Observational studies without controls (Level 4) No outcomes relevant to decreasing medical errors and/or adverse events (Level 4) 

University of Kentucky Chandler Medical Center/ Kentucky Telehealth Network locations Patients undergoing joint surgery 

Use of telehealth for preoperative education in addition to the conventional method of education. 

Patient satisfaction positive with the usthe telehealth mod
Source 

Safety Issue Related to Clinical Practice 

Design Type 

Study Design & Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

Wei 200619 Access to 

experienced ophthalmologists 

Changing practice projects/ research 

Observational studies without controls (Level 4) Other measurable variables with an indirect or unestablished connection to the target safety outcome (Level 3) 

Los Angeles County Department of Health Services, high-risk diabetic patients. 

Use of Webbased telemedicine system. 

Web-based architesuccessful in captuand transmitting images. 

Whited 200563

Access to routine eye examinations for diabetics 

Quality improvement projects/ research 

Observational studies with controls (Level 3) Other measurable variables with an indirect or unestablished connection to the target safety outcome (Level 3) 

Indian Health Service, Department of Veterans Affairs, and Department of Defense, diabetic patients. 

Monte Carlo simulation, modeling the use of the Joslin Vision Network telehealth model vs. conventional clinic-based ophthalmoscopy. 

The Joslin Vision Network is less coand more effective detecting diabetic retinopathy than conventional clinicbased methods. 

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Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key Finding(s) Yoon 200564 The accuracy of a single finger probe using photoplethysm- ography (PPG) was tested as a digital monitoring device for hematocrit, SPO2, respiration, pulse, and blood pressure Changing practice/ research Observational studies with controls (Level 3) No outcomes relevant to decreasing medical errors and/or adverse events (Level 4) Sample size varied for each type of measurement. Hematocrit testing was performed on 549 patients at Samsung Hospital, Seoul, South Korea. Five healthy adults were used to test the predictive power of the PPG waves for the other parameters. A palm-sized digital health monitor used a finger probe and a light emitting diode (LED) array. The light was measured to obtain PPG signals. Hematocrit, pulse, respiration rate, and saturated oxygen in arterial blood (SpO2) were measured and predictive algorithms developed to measure the clinical accuracy 

of the PPG diagnostics. 

The accuracies wewithin clinically acceptable errors. work showed that method and algoritfor multiple physiological signameasurement basa single LED sensvalid. 

ZimmerGaller and Zeimer 200623

Adherence in retinopathy screening and treatment 

Retrospective cohort study 

Observational studies without controls (Level 4) Other measureable variables with an indirect or unestablished connection to the target safety outcome (Level 3) 

Primary care practices throughout 7 States and the District of Columbia. Diabetic patients who are not receiving recommended eye examinations. 

Use of DigiScope imaging. 

DigiScope implementation is shown to be a pracalternative for patienot receiving routineye examinations