HomeCurrent JournalTelehealth for Older Women: Practice Considerations for the WHNP

Telehealth for Older Women: Practice Considerations for the WHNP

By Kimberly L. Lynch, DNP, MBA, APRN-FPA, NP-C

Telehealth can be a beneficial and safe option to facilitate and provide remote access to healthcare for patients. As technology has advanced and patients and providers have become more proficient in using devices, telehealth as a platform has become an innovative option for delivering care, especially since the coronavirus public health crisis. Women’s health nurse practitioners may want to consider providing telehealth services for particular segments of their patient population and particular aspects of care based on demand and interest. Older women represent one patient population that may benefit from telehealth visits for preventive services and chronic health condition management. Implementing a telehealth platform has advantages and disadvantages from both provider and patient perspectives that should be considered.

In this digital age, technology has increased significantly in offering innovative ways to deliver healthcare. Telehealth involves utilizing technology in the delivery of healthcare, including patient monitoring, consultation, and education.1,2 With numerous platforms available, methods now include synchronous or live videoconferencing, store-and-forward, remote patient monitoring, and mhealth (Table).3–7 Telemedicine falls under the umbrella concept of telehealth using technology in providing healthcare.2,5

Table. Methods for telehealth delivery
Telehealth modality Description Practice considerations
Synchronous Two-way interaction using videoconferencing equipment, done live, in real-time, provider and patient can see and hear each other during visit. Synchronous modalities provide opportunities for a real-time face-to-face visit where the provider and patient can see and hear each other. The provider is able to visualize patient for partial video exam and can verbally address concerns, questions, and ensure clear communication.
Store-and-forward Asynchronous interaction, where data are viewable at a later time. Useful for monitoring and delivering feedback via email, cell phone, automated messaging systems, and other equipment where face-to-face contact is not warranted. Patient’s health data can be sent to a healthcare provider who in turn can access at a later date. For example, this can include patient’s data in regard to specialist consults, medical imaging, labs, etc.
Remote patient monitoring Involves collection of personal health and medical data from the patient in one location for review by a provider who is in a different location. Patient can use handheld and/or wearable medical devices, smartphone, and Bluetooth technology for tracking/monitoring outside clinical environment, collecting health data remotely and transmitting this electronically to other locations such as their provider’s office.
mhealth Self-managed care performed by the patient using mobile phones or other wireless technology, and does not necessarily involve monitoring by a provider. Patients may use their phone, mobile Apps to track health information. Helpful for reinforcing patient education and self-care management without direct provider monitoring. This can be useful for reinforcing preventive care, tracking and/or managing health conditions, fitness/exercise, weight/diet, vitals, glucose, even appointment reminders.

Telehealth was originally developed for the purpose of providing care for underserved and rural populations.1,2 Although not a new concept, specific criteria and regulations for use, combined with reimbursement concerns, have limited its implementation. The Covid-19 public health crisis has brought about new challenges of providing care and optimizing patient outcomes, thus pushing forward the need for more providers to offer remote access through various technologic platforms. The Coronavirus Aid, Relief, and Economic Security (CARES) Act provided a regulatory waiver and temporarily extended reimbursement to telemedicine.8,9 This facilitated adaptations on many levels, including a rapid change in the way services were rendered. Providers realized the benefits from their use and the necessity to include virtual access options. This also raised questions and concerns about patient use of technology, satisfaction, and provider confidence with the virtual platform compared to standard in-person visits.

According to data reviewed from the National Health Interview Survey, years 2011 to 2018, 1 in 4 adults reported using at least one form of digital technology to interact with a healthcare system.10 Use differed with demographics, being higher among those who are younger than age 65 years, female, non-Hispanic white, born in the US, college educated, and higher income.10

Results from a comprehensive literature review on studies that used patient satisfaction to measure the effectiveness of telemedicine found that preferred modality, ease of use, improved communication, reduced travel time, improved outcomes, and low cost accounted for 62% of patient satisfaction experiences.11,12 A prospective, bicentric study also supported positive patient response, with 83% of those surveyed expressing satisfaction with the telemedicine visit and 89.5% satisfied that their problem was addressed during the visit.13 Only 10% expressed increased stress with the telemedicine encounter.13 The study found no significant correlation among age, gender, and reason for the encounter. Those patients older than age 65 years had similar satisfaction to that noted for younger patients.13

As recent public health issues have facilitated a change and opportunity to implement telehealth platforms, women’s health nurse practitioners (WHNPs) may consider providing telehealth services for particular segments of their patient population and particular aspects of care based on demand and interest. For example, older women who have deferred routine preventive healthcare visits because of fears of Covid-19 may be receptive to telehealth visits. They are also more likely than younger patients to have chronic health conditions that need regular, ongoing monitoring some of which can be accomplished via telehealth. This population may benefit from an individualized telehealth approach for some aspects of their healthcare.14–16 Attention to barriers, facilitators, advantages, and disadvantages is needed when planning care through telehealth for older women. Only limited data are available on telehealth and health outcomes in this population.

Advantages and disadvantages to using telehealth in practice

The advantages of telehealth can be many from both provider and patient perspectives and can reduce barriers to healthcare. For the patient, the convenience of telehealth is well recognized. Benefits include reduced time and traveling because appointments can be done virtually.17,18 From the provider perspective, telehealth can be convenient with visits scheduled throughout the day or even after hours without increasing labor or overhead costs. Providers report that incorporating telehealth into a traditional healthcare practice is a valuable tool for improving patient care.19 Virtual access can reduce patient wait times, reduce unnecessary emergency room visits, and improve patient satisfaction, providing the opportunity to deliver efficient, cost-effective quality care.2

One frequently mentioned disadvantage of telehealth is the limitation in performing physical examinations.1,2 Although some components of the exam may be obtained visually and audibly in synchronous visits, there is still the inability of the provider to have a hands-on assessment.5 The telehealth platform may work better for low complexity presentations than acute and complicated cases.

Other disadvantages include the potential for feeling disconnected with lack of in-person engagement, limited or unavailable internet access in rural or remote areas, technical difficulties on the provider and patient user end, security risks for data breaches, and reimbursement and regulatory barriers.

Considerations specific to the older woman and use of telehealth

A 2017 study from Pew Research Center found that 67% of seniors use the internet, and the use of technology in the form of smartphones, tablets, and even use of social media increased among older adults between 2000 and 2016.5,20 With the social isolation due to the pandemic, even more older adults have learned how to navigate and become proficient using devices and platforms like Zoom, Skype, and telehealth platforms. This increased engagement with technology is encouraging, but challenges should be anticipated with older patients. The likelihood of embracing the use of technology is dependent on skill level and comfort in using devices. Older individuals may experience difficulties due to sensory and motor changes with the normal aging process, including a decline in memory, visual acuity, hearing, dexterity, and fine motor control. Attention to identifying and addressing these difficulties can facilitate the use of telehealth to increase healthcare access and improve outcomes among the elderly population.8 For the older patient, in particular, it may be helpful to have support staff telephone the patient prior to the visit to walk through the process of connecting to the virtual waiting room, test the connection, and answer any questions or concerns. This may help reduce anxiety, potential frustration, and demonstrate support. In a systematic review on the use of ehealth and mhealth for primary prevention and health promotion among adults age 50 years and older, findings indicated the successful use of such tools is dependent on motivation and the support received.21

During the telehealth visit, it is essential to create a personal presence to establish rapport and foster the provider–patient relationship. Important strategies include awareness of the camera’s position, maintaining eye contact, and looking directly into the camera. Body positioning should be closer to the camera or leaning into the camera and have an appropriate microphone and a clear video.5,22 An effort should be made to ensure the visit is personal, engaging, and warm, creating a positive virtual experience by asking questions and alleviating any concerns.

The American College of Obstetricians and Gynecologists (ACOG) and the Women’s Preventive Services Initiative support the use of telehealth for some aspects of preventive health visits.23,24 The virtual preventive services visit may include obtaining relevant health history, review of systems, identifying risk factors, and appropriate health counseling with referrals as needed and an in-person appointment scheduled at a future date for the complete physical examination. Examples of recommended preventive services for older women that can be done via telehealth include anxiety and depression screening; alcohol, substance, and tobacco use screening and counseling; risk assessment for BRCA 1/2 testing; fall prevention counseling; review of needed immunizations and cancer screening appointments; and urinary incontinence screening.23,24 Much of menopause symptom assessment and management can also be accomplished via this venue. Limited, small-scale studies suggest telehealth visits in the United States have been effective in the care of patients with chronic disease.5 Chronic health condition management components that can be implemented in a telehealth visit include review of relevant history and medications, ongoing education and counseling, follow-up of lab and diagnostic test results, medication adjustments, and refills for nonscheduled medications. Examples of chronic health conditions that may be considered for ongoing management through telehealth visits for older women include hypertension if patient has access to blood pressure cuff, dyslipidemia, anxiety and depression, urinary incontinence, and pessary management.25,26

Reimbursement considerations for telehealth

Before the pandemic, the Centers for Medicare & Medicaid Services (CMS) billing criteria for telehealth services and reimbursement were restrictive, including which specific patient settings and diagnoses were covered. Lack of significant reimbursement from Medicare, Medicaid, and commercial insurance plans posed a substantial obstacle to the widespread adoption and use of telehealth in practice.2 In 2020, the coronavirus public health crisis facilitated the expansion of allowed telehealth services on a limited basis under the Coronavirus Preparedness and Response Supplemental Appropriations Act and section 1135 waiver to improve safe access to virtual visits and healthcare.5 Medicare loosened restrictions to allow for better access to care. This broadened Medicare telehealth services and the range of qualified providers to include physicians, nurse practitioners, clinical psychologists, and licensed clinical social workers.27,28 This was necessary to ensure beneficiaries received their healthcare benefits and had remote access to healthcare from their home while keeping in compliance with the guidelines from the Centers for Disease Control and Prevention on social distancing to reduce the risk of Covid-19 transmission.

Some of the notable changes in telehealth policy for the duration of the public health emergency have included: coverage for all traditional Medicare beneficiaries regardless of geographic location or originating site; a pre-existing patient relationship not required to provide a telehealth visit; acceptable platforms including FaceTime, Skype, and standard communication technologies; audio-video or audio-only telehealth visits billed the same as in-person visits; and additional billing codes for mental health services and cardiac monitoring added to the approved telehealth procedures list.29

These changes have allowed for beneficiaries to receive telehealth services in any healthcare facility including a physician’s office, hospital, nursing home, or rural health clinic as well as from their homes, with CMS reimbursement for these telemedicine visits equal to the in-person visit reimbursement.5,28,30 Most commercial insurers have followed Medicare reimbursement rates for telehealth, increasing reimbursement to in-person visit levels, and expanded the practitioners who can provide telehealth services to include not only physicians and nurse practitioners but also clinical nurse specialists, certified registered nurse anesthetists, clinical psychologists, and clinical social workers within the provided guidelines.30

Billing for telehealth services should be consistent with Medicare telehealth billing guidelines, and the remote visit should be done in a real-time, face-to-face video format. Providers should be diligent in reviewing modifications and updates to Medicare guidelines for telehealth services regularly, to keep abreast of crucial telehealth policies, practice, and billing regulations given that these modifications have been due to the Covid-19 pandemic and may be subject to change.4

Regulatory and legal telehealth practice considerations

Practice considerations include regulatory and legal implications related to telehealth such as Health Insurance Portability and Accountability Act (HIPAA) compliance, malpractice coverage, implementation cost, liability, and licensure, especially if providing multistate care. Regulations vary by state and frequently change, making it essential to stay updated with current requirements. Providers practicing telehealth should ensure they are compliant with state and federal regulations, providing care consistent with evidence-based practice guidelines. The ACOG committee opinion on implementing telehealth in practice offers insightful information on billing, licensure, security, and technology considerations.3

The Covid-19 pandemic has facilitated timely telehealth legislative changes allowing for convenient, cost-effective, and free applications such as Doximity, Doxy.me, Skype, FaceTime, and Zoom in place of expensive technology that was previously required.5,31 This presented many practices with the ease of entry for telehealth services. Although easily accessed, these platforms do not meet the prior HIPAA compliance requirements, so long-term practice implementation planning should include a secure software that meets HIPAA standards.

Doximity offers a convenient, free, easy-to-use platform for getting started offering telehealth visits. There is also an App for smartphone use. Upgrades are available at additional costs. This platform or one similar to it can provide an easy option to test the use of telehealth visits. Depending on regulations, and if changes are needed to ensure compliance with previous, more stringent regulations, a better decision may be made with some early experience and feedback from these types of options. This may aid in determining if the cost of implementation to meet prior restrictions would be worth the investment, while adding value to the practice and overall patient experience.

Conclusion

As technology continues to advance, becoming commonplace in daily life and work, the use of telehealth in clinical practice will likely be necessary as part of the comprehensive healthcare choices to meet patients’ needs and expectations. ACOG encourages practices that do not offer telehealth to begin strategizing how a telehealth platform could be integrated and offers guidance on implementing telehealth in practice that may be helpful to the WHNP.

A number of factors need to be considered in determining if the implementation of telehealth would be a worthwhile practice endeavor. To ensure successful telehealth implementation, practices must consider how to best manage the potential technologic, educational, behavioral, and financial barriers that may be encountered. A list of resources on telehealth is provided in the Box.

Box. Telehealth resources for guidance

ACOG FAQs for Obstetrician-Gynecologists, TelehealthA

ACOG Implementing Telehealth in PracticeB

ACOG Managing Patients Remotely: Billing for Digital and Telehealth ServicesC

AMA Telehealth Quick GuideD

Centers for Medicare & Medicaid Services List of Payable Telehealth ServicesE

Medicare Telemedicine Health Care Provider Fact SheetF

CMS.gov Waivers & Flexibilities for Health Care ProvidersG

Health Resources & Services Administration TelehealthH

Center for Connected Health Policy/The National Telehealth Policy Resource CenterI

National Consortium of Telehealth Resource CentersJ

American Telemedicine Association (ATA)K

Distant site practitioners who can furnish and get payment for covered telehealth services (subject to state law) are: • physicians • nurse practitioners • physician assistants • nurse-midwives • clinical nurse specialists • certified registered nurse anesthetists • clinical psychologists (CP) • clinical social workers (CSW) • registered dietitians or nutrition professionals.

Note: CPs and CSWs cannot bill Medicare for psychiatric diagnostic interview examinations with medical services or medical evaluation and management services. They cannot bill or get paid for current procedural terminology (CPT) codes 90792, 90833, 90836, and 9083.

More studies on patient outcomes with implementation of telehealth technologies in women’s healthcare, specifically the value of telehealth for the older female patient, are needed. As technology continues to play a significant role in healthcare delivery, however, integration of telehealth into practice may be very beneficial to provide convenient adjunct healthcare services in a women’s health practice. The WHNP is ideally situated to consider adding telehealth services for older women as part of preventive healthcare and chronic health condition management.

Kimberly L. Lynch is an adult nurse practitioner at Associated Physicians of Libertyville in Libertyville, Illinois, and faculty in the MSN program at Olivet Nazarene University and Indiana Wesleyan University. The author has no actual or potential conflicts of interest in relation to the contents of this article.

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Key words: telehealth, telemedicine, women’s health, older women