E-health carry benefits, drawbacks for occ-health

Remote care key issues include privacy, accuracy

Electronic communications and media have vastly expanded the reach of health care, enabling nurses to screen sick or injured employees who are hundreds of miles away.

Cyber medicine or telehealth or e-health encompasses any health care practice that utilizes computers, telephonic communication, handheld data sources, the internet, and any other electronic tool or resource. It's tailor made, in many regards, for occupational health settings.

"It's a low-cost form of medical service in the occupational setting," says Randi Kopf, JD, MS, RN, a nurse and attorney who specializes in health care issues. "You don't need to have a nurse or doctor on staff if you have a cyber examination room."

A cyber examination room might be little more than a dedicated private space equipped with a telephone and a computer-mounted webcam, she says. A physician or nurse at the other end can talk with and see the employee, and depending on how elaborate the cyber exam room, obtain blood pressure, temperature, blood glucose levels, and other diagnostic data.

E-health got its start in the early 1990s during Operation Desert Storm, when military doctors needed to be able to evaluate and treat injured soldiers in the field. Doctors found they could use laptop computers linked via satellite to advise medics in the field when the doctors could not be there in person.

"It's just grown tremendously from there, to the point that we now have doctors doing robotic surgery on patients in other parts of the world via satellite," says Kopf.

Nursing, particularly home health nursing, quickly recognized the potential for electronic health care. Homebound frail or elderly patients are much better off, Kopf says, sending in glucometer readings from home via internet than making a trip to the doctor's office on a cold, snowy day.

"Also, in the employment setting, employees with medical conditions or injuries who have to be at home can be monitored easily through telemedicine home care," she adds.

It starts with good data

Not having a nurse doing the exam in person means the nurse and the employee are at the mercy of the reliability of electronically gathered and transmitted data. Also, the intangible information a nurse collects when actually seeing a patient in person is lost.

"How reliable is the data that's coming in from a remote source?" Kopf asks, bringing up a downside to e-health. "If you gather an x-ray or EKG from an employee at another site and they are e-mailed to you, if the technology is not sufficient in terms of the quality of viewing and total compatibility [of the system components], you can have errors, and there already have been errors reported in diagnoses made from misread X-rays [gathered electronically]."

The occupational health nurse who practices cyber nursing has to be on guard that the availability of technology does not lead him or her to inadvertently or intentionally practice outside the nurse's scope of practice, she adds.

"Just because there's a doctor on the screen who tells you that you can do these sutures, if that's not in your scope of practice, you'd better not do them," she says. "This tends to be more of a problem with nurse practitioners."

Bringing a layperson into the loop is another pitfall of practicing remotely, Kopf says, and one that should be avoided.

"If someone who is not a nurse is giving medication [at the behest of a clinician on the other end of the electronic connection] — well, practicing medicine without a license is a criminal offense in most states," she points out.

Pay attention to privacy issues, HIPAA

The influence of technology on health care can be clearly seen in the explosion of electronic medical records (EMRs). President Bush announced in his first term that making American health care virtually paperless within 10 years would be a priority for his administration's health information czar, and while the United States has a long way to go before health care records are truly paperless, the strides have been impressive.

"NASA has been working on artificial intelligence that can be applied to EMRs in development. When you start typing in symptoms or a diagnosis, up pops a suggested diagnosis, examinations, and a treatment plan based on the symptoms and the information that is already stored in the EMR," Kopf explains.

EMR software is constantly being developed, refined, and released, but availability as yet has not translated into easy affordability, Kopf points out.

"Software and startup can be very, very expensive, so not all sites are going to be appropriate for it. If your company has invested in an EMR system, and it works, there are a lot of snags that go into being virtual," she says. "Hospitals that say they are paperless really are not, because you need to have access to records in case of a power loss or a disaster."

An EMR can be as simple as a record of a person's name, complaint, and treatment, or as sophisticated as an integrated menu of history, workers compensation background, diagnostics, and lifestyle health factors.

Practicing e-health on the job is catching on, but as with any big change, the cost of setting up a virtual examination room has given some employers pause. But after the initial cost of equipment and software, Kopf says, the savings are apparent. The benefits are, for many, outweighed by the drawbacks, she says.

"There is a big startup cost, but it saves money in the end because you don't need a transcriptionist, the storage of paper files and the cost of the files, and the staff involved in keeping a medical records system," she says.

Privacy is a big question mark when it comes to EMRs. Kopf says that while advocates say EMRs are more easily secured than paper records, others disagree.

In addition, many records still must be kept in paper form, because many government offices will only accept handwritten signatures on paper forms; for example, many workers compensation offices will not accept electronic forms, and courts usually require original medical records for use as evidence because they are time stamped with ink on paper.

Security is an issue, Kopf says, because while paper records can be shredded and burned, electronic records tend to stay forever, even when they appear to be deleted. There have been reported cases of health records turning up in computers sold to the public as excess inventory by government agencies or medical organizations.

"Then there is a very big issue when the employer, a nonmedical person, may desire access to employee medical records, which violates HIPAA [Health Insurance Portability and Accountability Act]," she points out. "Who are you working for? That's a big issue in occupational health nursing, and an ongoing problem – is your allegiance to your patient or your employer?"

Added to the question of access is the question of security from hackers. EMRs can be accessed without ever going near the occupational health offices.

The U.S. Department of Health and Human Services issued a final rule on information security under HIPAA in 2003. Among the requirements for organizations covered under HIPAA are that they:

  • Limit physical access to electronic information systems;
  • Establish protocols for how records should be accessed and modified;
  • Restrict access to workstations where EMRs may be accessed;
  • Monitor any removal or receipt of any hardware or software that contains EMR information;
  • Back up and store all EMR data for retrieval when necessary; and
  • Create policy and procedures for final disposition of EMR information and the hardware or storage media that holds it.

What records may be kept on an employee in his or her EMR can vary, so Kopf stresses that occupational health nurses should familiarize themselves with the laws in their states, and consult with an expert on electronic recordkeeping and HIPAA when setting up or changing an employee health record system.

Some states, for example, prohibit any record of HIV exposure or diagnosis from going into an employee's medical file. The information has to be kept separately, which raises the question of how and when the information can be extracted — not an uncommon dilemma, she points out, since HIV is a pervasive condition that can affect many aspects of an employee's health.

Mental health treatment, chemical dependency, and genetic disorders are all protected conditions that may require special handling of EMRs, as well.

Kopf says she has been unpleasantly surprised to hear that some nurses are told by their employers that they — and their employees' medical records — are not covered by HIPAA.

"I don't care what your company is producing, you're covered by HIPAA, and I strongly suggest to those people that they seek experienced counsel in setting up their health practice," she adds.

She also has been asked if practicing e-health is really nursing. "Yes, you're acting as a nurse; so there's full liability," she says. "The duty of care becomes more problematic because the patient is not in front of you, and sometimes you might not know who you're giving the advice to. Clearly, HIPAA privacy rules dictate the realm of practice. On the other hand, you have unlimited access to consultation information. That's the good part of e-health; you save money, save time, keep employees healthy and with fewer sick days. You only need one system for the whole company, no matter how many different sites there are."

Occupational health nurses who use electronic charting have to be on guard that they don't lose their critical thinking skills. Being forced by a strictly structured EMR to conform to the limited choices presented in the record can cause a nurse to neglect considering other choices or possibilities, Kopf warns.

E-health information and resources are popping up throughout the health care information system. Most professional codes and associations now have, or are developing, resources dealing with electronically enhanced health care.

"And at last count, 15 federal agencies are involved in regulating cyber medicine," Kopf says. She suggests nurses investigate their states' nurse practice acts, boards of nursing, multistate licensing compact, code of ethics, and the professional codes of any nursing societies to which they belong for guidance in practicing e-health.

[For more information, contact:

Randi Kopf, RN, MS, JD, attorney, Kopf HealthLaw, LLC, Rockville, MD. Phone: (301) 251-2788.

"Innovation, Demand, and Investment in Telehealth," U.S. Department of Commerce, Technology Administration, 2004. Available online at www.technology.gov/reports.htm.]