TELEHEALTH – exploring patient safety and risk management in New Zealand.

 

Currently the delivery of the New Zealand health service is being greatly challenged. Issues such as  increasing cases in chronic conditions to be managed, both a population and health professional workforce which is aging, a shrinking health dollar and a consumer who has increasing expectations of the health system are a few of the visible challenges being grappled with.  Increasingly telehealth is being seen as a partial answer to the ever increasing demand on the service. Telehealth is the use of technology by health professionals to deliver health information and care when parties are not in the same physical locality. New Zealand with its remote areas requiring many miles of travel to reach a destination is ideal for providing a service through telehealth. A stock take commissioned by the National Health IT board and conducted by the New Zealand Telehealth Forum in 2014  identified that the only DHBs offering telehealth as a recognized part of their service, were Whangarei, Christchurch and Bay of Plenty. However, a year later (2015)  an environmental scan of the rest of the  DHBs  show that this has quickly changed. Many more health professionals are now using telehealth to enhance the health services, being offered to patients. This paper will explore how patient safety and risk management within telehealth in New Zealand is being managed. It does not promise to provide all the answers. Its purpose is to encourage further discussions around patient safety and risk management when using telehealth. The following sections will be addressed: the role of regulatory and professional bodies, Ministry of Health’s plans and strategies, clinical processes including privacy and technology infrastructure and security.

 

Regulatory and Professional  Bodies

There are three main Acts within New Zealand which regulate the  practice of nursing and three Codes which articulate the Acts. Nurses working in  clinical practice must comply with these .

 

 Firstly nursing is regulated by the Health Practitioners Competence Assurance Act 2003 (HPCA Act). This Act was published to “protect the health and safety of the members of the public by providing for mechanisms to ensure that health practitioners are competent and fit to practice their professions” It regulates a number of different professions under one common regime. Each profession has its own specific regulatory body.

 

The role of Nursing Council,(NCNZ)  the regulatory body for registered nurses in New Zealand, is to protect the health and safety of the public by setting standards and ensuring that nurses are competent to practice. The Code of Conduct (2012) which is the first of the Codes mentioned above, is the documentation which articulates standards of behavior that nurses are expected to uphold in their professional practice and against which their practice will be measured. This Code also informs the public as to what can be expected from a Registered nurse.  Framed around four core values of respect, trust, partnership and integrity and eight primary principles, the Code is a practical document which clearly describes the conduct expected of nurses.  While telehealth is an altered delivery medium, it still requires the nurse to meet these standards. To keep patients and nurses safe while using technology, Nursing Council New Zealand state  ”All nurses involved in clinical practice, including that offered by  TeleHealth, must abide by the Code of Conduct”. This statement protects both the patient and the nurse as it clearly states that by using telehealth to provide a nursing service, the standards are no different to that of nursing face to face. The standard of care offered must be the same. “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 “(Schlachta-Fairchild,  Elfrink,& Deickman, 2008) The nurse involved in a telehealth consultation, must have the required level of knowledge and skills needed to provide appropriate and safe care and not work outside their scope of practice. “Health consumers need to be able to trust nurses to be safe and competent, not to harm them, and protect them from harm”. (Code of Conduct 2012 - Trust)

 

Nurse Executives is a professional body for nurse leaders within New Zealand. Their role is to lead quality professional practice innovations, influence workforce development for the future and enhance nursing contribution for effective health outcomes. This professional body has just published a position paper on outlining key considerations (for nurses) when using telehealth.  The content includes: therapeutic relationships, competencies and scope of practice, client safety in relation to telehealth and professional practice. They emphasize the importance of;

  • not compromising patient safety in the decision to use or continue using telehealth
  • being aware of the limits within which care can safely be provided using telehealth
  • responsibility for ensuring that the telehealth services provided are safe, culturally appropriate and meet legal, professional and ethical standards is held by the nurse,
  • when involved in telehealth,  nurses have an obligation to advocate for systems that promote the safe and ethical delivery of Telehealth services  and to act when client care is compromised. (Nurse Executives 2015)

 

The second  Act  regulating nursing is the Health and Disability Commissioners  Act (1994). This Act regulates the provision of health and disability services through the office of the Health and Disability commissioner by the use of the Code of Patients Rights.(1996) This is the second Code which articulates standards for nursing practice. While there are ten rights within this Code which have relevance to patients the following four rights have particular relevance.

 

Holly Hedley (2015) in her paper, “Telemedicine in NZ and across borders – the legal challenges,” identified the following rights which apply to health professionals using telehealth.

 

Right 4  - the right to services of appropriate standard. This right is guided by the guidelines and standards provided by the regulatory and professional bodies  outlined above. Nursing care provided by telehealth must be provided at the same standard as that for face to face. 

Right 4 (4) provided in a manner that minimizes potential harm to a consumer. Trust and confidence in both the service and the health professional can be destroyed if the equipment used is not effective, efficient and in good working order or the nurse using this to provide the service, is unskilled in using it. Nurses are therefore required to have the required level of knowledge about the technologies they are using. They must also have the appropriate level of skills and knowledge to engage in the consult or bring another informed colleague into the consultation.

Right 5 the right to effective communication. Ensuring that consultation allows effective communication between the patient and the nurse. Right 5(2) states that the provider must provide an environment that “enables both the patient and provider to communicate openly, honestly and effectively” This would be met by ensuring that the consultation is held where privacy can be guaranteed, the patient can hear and respond in an informed manner and  the equipment is not faulty.

Right 6 the right to be fully informed. Nurses must ensure that their patients are provided with the information that “a reasonable consumer, in that consumer’s circumstances would expect to receive” With reference to a telehealth consultation, this could refer to limitations or risks of the telehealth service, and technology, information that they do not have to have a telehealth consultation if they would prefer face to face and if they choose not to, what are the alternative possibilities.

Right 7 The right to make an informed choice and give informed consent. This right may need to be met, by having the patient bring a family member or caregiver with them to explain the content of the consultation and what is being asked of them. (Hedley, 2015)

The third Act regulating nursing practice is the Privacy Act 1994. This Act controls how ”agencies” collect, use, disclose, store and give access to “personal information” (Almost any person or organization that holds personal information is an “agency”. ) The Health information Privacy Code 1994 is the Code that relates to the health sector. It has been developed to inform the patient what is happening to their health information and also ensure that health professionals will protect this information so it will remain private.   Nurses must ensure that the patient understands that all health disclosures within a consultation, will only be shared with those involved directly with the care of that patient.  They must also ensure privacy when collecting information and storing it.

 

Ministry of Health Plans and Strategies.

For a telehealth service to protect patient safety and manage risk, funding must be consistent to ensure the continuity of the service otherwise the service staggers and patients lose trust.   While it is not imperative to have support from top, if service delivery through telehealth is visibly mandated  in government documents, District Health Boards are more likely to raise it in their list of priorities and thus include it in their budgets.  

 

In New Zealand, the National Health IT Board, sets priorities for regional and national IT investments over a five year period. This applies to all those engaged in planning or delivering health care services.  The Board included the start up of telehealth within their National Health IT Plan 20013-2014, as an emerging priority, which means that if there is a surplus in the budget, DHBs can consider it. In 2015 this priority is to change to the level of important which is DHBs strongly responding to a need in their region.  The vision is to provide a better, faster, more convenient health service to the people of New Zealand.  They need to ensure DHBs are budgeting for this change so the service continues and remains safe and seamless  for patients.

 

 

Clinical processes, including privacy.

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 poor documentation, which includes delayed or missing information , misunderstood advice or inaccurate findings due to patient or caregiver error due to the patient not being appropriate for telehealth consult  or incomplete information due to lack of privacy during the consultation.  (Schlachta-Fairchild, Elfrink,& Deickman,2008 )

 

Documentation must be clear and full, including that the consultation was conducted by telehealth. This  ensures that the care provided at the next consultation is based on facts from the previous visit and advice and treatment given is able to be built on successfully, assisting in empowering the patient and encouraging a strong health partnership and participation in self managed care. 

 

In their paper,” Using telehealth for heart failure: Barriers, pitfalls and nursing service models”

 Crundall-Goode &  Goode, (2014) write” Telehealth should not be viewed as a panacea: there will be a group of patients where telehealth is not in their best interests.” Criteria for selecting patients for telehealth consults should therefore be identified as the service is in its implementation stage.  Patients who should be considered further before being offered  a telehealth consult are those who are cognitively impaired,(dementia)  those who have English as a second language, vision impaired , have mental health issues, those who may not be  technology  literate (i.e. they may not have the dexterity to use the technology or do not understand it, or are not health literate.) This may mean that when the consultation is being arranged either family, caregiver or the patient themselves are contacted to clarify whether the patient is able to participate safely in the consultation.

 

Managing privacy and confidentiality can be quite a concern when delivering a telehealth service . Sessions should be held in enclosed rooms with no people traffic to ensure they stay a confidential interaction between patient and nurse and patients are relaxed and comfortable providing their information.  The patient must be reassured that the consultation is not being recorded.

 

Technology Infrastructure and Security

Telehealth relies on transmitting data. “ This means secure networks and data transmission are critical to confidentiality and privacy” (Firas Sarhan, 2009) Poor transmission of data could also impact on the diagnosing and therefore treatment of a patient.  As the numbers of new and innovative technologies emerge, those working with this technology must remember that the security of patient information, regardless of how it is transmitted.  ” New wireless technologies, increase use of email by providers and the continual threat of computer virus increase the need for security and confidentially of patient data to remain in the fore front of telehealth. (Schlachta-Fairchild, Elfrink,& Deickman,  2008)

 

In conclusion, this paper has explored  patient safety and risk management issues for New Zealand registered nurses who are using telehealth to deliver care. It has explored the role of regulatory and professional bodies to ensure nurses provide a safe level of care to patients. It has highlighted the importance of support from top government levels to ensure continuous funding resulting in seamless care. It has identified specific criteria for choosing patients who are appropriate for telehealth consultations so they are able to participate effectively .Lastly the importance of secure and safe data transmission has been described.

 

I present this paper on Telehealth – exploring patient safety and risk management in New Zealand  to encourage a much wider  international conversation to take place.

 

 

 

 

References

Hedley, H.(2015) Telemedicine in NZ and across borders – the legal challenges. A summary paper presented at Confernz Medical Law Conference .July 2015.

Nursing Council New Zealand www.nursingcouncil.org.nz

Nurse Executives of New Zealand.  Position paper on Telehealth. March 2015

NZ Stocktake Summary report of DHBs telehealth activity. Dec 2014.

Crundall-Goode, A & Goode.KM. (2014) Using telehealth for heart failure: Barriers, pitfalls and nursing service models.  British Journal of cardiac nursing Vol 9 No 8 August 2014

Sarhan,F.(2009) Telemedicine in healthcare 2: the legal and ethical aspects of using new technology. Nursing Times.   43 c(105) 18-20

Schlachta-Fairchild, L., Elfrink,V.,& Deickman, A.(2008) Patient Safety, Telenursing and Telehealth. In Hughes.,R.G.(Ed) Patient safety and quality. An evidence based handbook for nurses. (p) Rockville