FEATURES

E-Health Web PortalsDelivering Holistic Healthcare and Making Home thePoint of Care

• Linda E. Moody, PhD, MPH, BC, FAAN

E-health delivers healthcare services and education, via a Web portal, to older persons with chronic conditions andtheir caregivers and enables the patient's home to be the point of care. This growing industry is ripe for explorationby nurses who can empower the patient and caregiver to gain self-care and ooping skills. Advances in informationtechnology now make this dream a reality KEY WORDS: e-health. nurse informatics, point ot care, telehealth.telemedicine HntixrNurs fnu-i 2(

consumer, physician-by-physician, disease-by-disease, and region-by-region. Health IT has shown achallenged, but resilient, industry thai there is hopefor change, and that hope doesn't have to come fromthe top down but from the inside out. Heiilth IT is notabout better treatments for the ailing and ill among usor just for all of us who want toprevent or limit illnessin Its early stages. It is. ultimately, about treating theindustry itself, so that we not only have the bestscience, infrastructure, and professionals in the world,but also the best value, safety, and productivity.'

Digital environments in healthcare are catching upwith information technology (IT) applications inbusiness and education. With IT applications,decision-support systems can facilitate split-seconddecision making, wireless communications,monitoring systems run with computerized backbones,and computerized ordering and documentation:applications that were unimaginable a decade ago arebecoming fundamental to nursing and healthcarepractice. Although nurse informaticists work withcomputers and other technologies, technology is notthe essence of nursing informatics. HlTs are simplytools that can be adapted and applied electronically(automatically): hence, the term informaiics. toautomate the process of nursing and healthcare datacollection or reporting at any phase of the patient careprocess (assessment: evaluation of data within thecontext of care [decision-supporti: application ofinformation for interventions, such as evidence-basedcare: or development of decision-support systems andbest practice models)."'

Informatics tools include handheld devices, such asbar code scanners for medications or identification.

Recognized in 1992 by the American NursesAssociation, nursing informatics is a relativelynew nursing specialty that has expanded rapidly,applying new heahh information technologies(HIT) to better serve patients and improve safetyand quality.' Although it may seem strange topromote HIT in a journal embracing holism as theunderlying philosophy of patient care, principles ofholism are easily embedded in the design of e-hea!thprograms.

Nursing informatics has been diffused into alldimensions of nursing, from advanced nursepractitioner (NP) practice, home health, critical care,and emergency departments (EDs) to the use ofevidence-based support and decision making fornurses on clinical units. Nowhere is management andprocessing of health-related information moreimportant to ensure quality and patient safety than inhealthcare agencies.- Dr David Brailer. responsible torbuilding electronic health records (EHR) for theNational Health Information Infrastructure (NHII).has received widespread endorsement, including theNational Alliance for Health Information Technology,the eHealth initiative, and provider organizations andHIT vendors. Dr Brailer emphasizes the importance ofnationally adopting HIT:

Health IT can enable transfonnation of hcalihcare byallowing a better way to care—consumer-by-

From ilie College of Nursing. University ot"South Florida. Tampa.

Corresponding author: IJnda E. Mcody. PhO, MPH. BC. FAAN. College ofNursing. M tX 22. Univcrsily ol Stmlh norrda. Tumpa. FL .V16I2 (e-mail:Imoody <3' hsc.usf.edu).

E-Health Weh Portals 157

FIGURE 1. Mobile applications in healthcare.

persona] digital assistants (PDAs), or tabletpersonal cotnputers (PCs) that enable electronicdata collection or reporting at point of care:hospital bedside, outpatient clinic, or patient's home(Fig 1). Despite the digital divide slowly narrowing inthe older population, the use of e-health applicationsby nurses has enormous potential to enable elderlypersons with chronic conditions to itnproveself-man agement skills.-̂ -̂ symptom and interventionmanagement, and quality of life when point of carebecomes the patient's home.^ As vendors developmobile and user-friendly applications and Internetproviders make services more affordable, the potentialto apply e-health care, from Web-based healthinformation to full primary care services in thepatient's home, becomes less a fantasy and more areality.

By defining the scope of the relationshipbetween nurses and IT. nuising will playan essential role in the future direction of healthcareand. from thai participation, evidenee-basedknowledge will be gained when these domains worktogether.

TERMINOLOGY

E-health

A young, expanding field, e-health is an outgrowth oftelehealth or teletnedicine. The e-health subspeetaltyaims at the consumer or caregiver. applying a holisticview in which illness, especially chronic conditions.

affects the whole family. It differs from telehealth ortelemedicine in that e-health is Internet-based andincludes a range of services, nursing or healthcare,health education, and medication prescription or refillsvia e-preseribing." In conjunction, tele monitoringdevices may be used, via a Universal Serial Bus (USB)port on the patient's computer, to collect additionalphysiologic data (eg. blood pressure, pulse.temperature, weight, spirotnetry. blood glucose, andoxygen saturation level). Evidence-based guidelinescan be built into some systems to ensure the provideris following discipline standards. In a pilot study bythis author, the gold standard developed for chronicobstructive pulmonary disease (COPD) (AmericanLung Association) was used as the best practiceguideline.''

Telehealth

Telehealth. considered the use of home-monitoringsystems by nurses, may be designed to provide homehealthcare nursing services to tnonitor chronicdiseases, such as diabetes. A video monitoring systemmay be used in conjunction with the monitoringdevice at both ends of the system, permitting videoand voice interaction between nurse and patient andadding a personal touch.

Telemedicine

Telemedicine usually refers to the remote monitoringof health data (eg, monitoring electrocardiographic[ECGl data in patients with congestive heart failure)fiom the patient at home to the healthcare agencyprovider, usually a physician or NR There may or maynot be interaction between patient and provider; forexample, when ECG data are abnormal, the patientmay be called by the physician, who then initiatesfurther treatment.

Web portal

A Web portal is a secure intranet systemspecifically designed and customized for the specialneeds of a designated group of people or patients. Tomeet the Health Insurance Portability andAccountability Act (HIPAA) requirements, a Webportal requires a secure socket layer (SSL) for securityand a unique identification (ID) and password for allusers and providers.'' A subscription fee may berequired.

Hoi isTic- NURSING PRACTICE • JULY/AUGUST 2005

THE DRIVING FORCE

The case for adopting e-health (with or withoutlelemonilorini:) in the home setting is morecompelling than ever. One important driving forcebehind Ihe movement toward the digital healthcare ageis the dramatic increase in our elderly population, whoprovide an endless consumer base. In addition,electronic technology is now more functional andaffordable and there is a national mandate to controlhealthcare costs, influencing even the most skepticalhealthcare decision makers to accept new modes ofcare delivery.'" Finally, add the most severe nursingshortage to date, and the formula is complete. In thenext decade, the greatest demand for e-health serviceswill come from Internet-savvy baby boomers whoexpect to have online access to services, includingbanking, shopping, and healthcare.

better-informed consumer, but also direct consumerinvolvement regarding care decisions.

• Accuracy and privacy: Through technology that com-plies with federal laws governing privacy and securityof health information, privacy, security, and quality ofeleetronic medical records could be improved overpaper records. Under HIPAA. patients may autho-rize certain nonroutine uses and disclosures of theiridentifiable records: misuses of individually identifi-able health information, including e-health records,are punishable by law.

With e-health, an SSL is used with Ihe Internet,and. to protect privacy, the patient or caregiver isprovided with a unique ID and password. A totallyEHR model has been proposed, which indicates theuniqueness of each type of record and the common,shared data elements that are mostly demographic andfinancial.'^

BARRIERS TO E-HEAITH

Three major obstacles exist to the adoption ofe-health in some areas of the United States; {I)Although reimbursement fore-health, telecare. andtelehealth visits varies by .state, there is more activitynow at the federal level to work toward a nationalreimbursement process for all states and levels ofreimbursement for varied types of e-visits. dependingon the level of the provider. (2) Digital e-preseriptionsignatures also vary by state; currently, only 23 statespermit e-prescribing. Elderly persons can requestconvenient home delivery once their local pharmacyreceives the e-prescription from their healthcareprovider. Electronic signatures are acceptable to theJoint Commission on Accreditation of HealthcareOrganizations; however, there is no nationalstandard." (3) Privacy and security must be respectedand providers must comply with HIPAA. Enacted in1996.'- the Act has been revised numerous times andis often misinterpreted by providers, patients, andmedical records stafl.

Strategies

The NHII Strategic Plan proposes 2 strategies forresolving these issues^

Consumer involvement: Secure personal healthrecords, maintained by the patient and his or herphysician, insurer, or others, give the patient unprece-dented access and control. This not onlv means a

GOMS

Although the e-health field varies widely, the commongoal is to provide patient-centric'' or holistic eare thatincludes Internet-based services and support forpatients with chronic conditions. In addition, a trulypatient-centric service includes the management ofmedications, symptoms, emotional support, and healthinformation and education for the patient andearegiver (eg. spouse, relative, or partner). Thechronically ill and their caregivers (about 35% ofonline health consumers) have (he greatest potential toaffect and be affected by Internet healthcareprovision.'' Many individuals living with a chronicillness actively incorporate e-health management intotheir daily lives.-̂ '•* Because they may not know whichWeb sites provide accurate information, patients andcaregivers need customized Web portals that providepull-down menus or links to credible healthinformation Web sites designed to help with specificconditions or problems. In addition, guided use ofcredible. Web-ba.sed support groups provides a levelof peer support that enables many elderly to forestallor prevent admission to a nursing home or hospital.The American Heart Association (AHA) provides anexample of a Web site developed for older adults withcongestive heart failure (http://www.americanheart.org/presemer.jhtmr?identif)er=3()06028). TheNational Library of Medicine (NLM) developedguidelines for credibility, accessibility, and readabilityof Web sites in healthcare and special Internet pages

E-Health Web Portuh

»••««• •»!-?»

FIGURE 2. An example of a preferred Web site for seniors.

(NIH Senior Health: http://www.americanheart.org/presenter.jhtml?identifier=30()6028). MedLinePlus isanother useful NLM site (http://medlineplus.gov/[Fig 2]). With a Web portal, approved healthcareeducation links can easily be added and customized tomeet the needs of the patient and caregiver.

THE FUTURE OF E HEALTH

It may be difficult for some to imagine howinformatics can be applied to clinical practice. The 2following e-health scenarios illu.strate how informaticscan be incorporated with technology and the Internetto deliver primary healthcare services by nurses andNPs in ways previously not considered possible. Thescenarios are based, in part, on the author's cliniealspecialty pulmonary practice and a funded grantdesigned to pilot test an e-heaith Web portal for COPDpatients. The names used in the scenarios arefietieious.

Scenario 1

Joe and Mary Smith live in a small, rural Florida townabout 45 miles from Joe's pulmonologist's urbanoffice. Joe. aged 82. has been diagnosed with severechronic bronchitis and emphysema (CBE) for longerthan 25 years, and he requires constant oxygen. In thelast year, he experienced 3 acute bronchitisexacerbations, requiring 3 ED visits. Mary, a small,frail hypertensive woman nearing age 80, has severerheumatoid arthritis and needs frequent doctor visitsfor chronic pain and joint swelling. Joe and Mary's 2sons live in Seattle and can only visit once a year. It is

extremely difficult for Mary to drive Joe to doctorappointments or ED care because she must help him inand out of the car and wheelchair and adjust his20-pound oxygen tank. The last ED visit occurred at12:00 PM. with a 6-hour wail before seeing aphysician: chest radiology, .sputum for culture andsensitivity, and blood gases were analyzed. After 2hours, a physician viewed the tests and placed Joe onantibiotics for 5 days, with instruction to increase hisfluids and continue his current bronchodilators. Hewas instructed to return in 2 or 3 days if his symptomsworsened.

Scenario 2

It is now 2010; Medicare and third-party payersreimburse in all states and allow NPs to e-prescribe inall states. Healthcare may be difficult to access, butcustomized e-health is available via an Internet Webportal.'"^ John, an 82-year-old white man withend-stage COPD, and his wife, Alice (his caregiver forlonger than 20 years), have used the Internet for about5 years, exchanging pictures of their grandchildrenand sending e-mails to family and friends. When theNP in John's pulmonologist's office (60 miles fromtheir home) suggests they sign up for the e-healthCOPD program, they jump at the chance (Fig 2)J TheNP trained John and Alice during a lhour office visit.In addition, they were given a training CD to use athome. Alice likes the joumaling feature: She can"blog" with other caregivers. John uses the Web portaleach day to record his symptoms and to read the Webportal news. Occasionally, he e-mails the NP toquestion the use of his nebulizer or request a refill.John has scheduled monthly virtual visits online withthe NP and has 2 office visits a year with his

FIGURE 3. Prototype e-health system, with the patientshome as point of care.

i 60 HOLISTIC NURSTNG PRACTICE • JULY/AUGL.ST 2005

physician. During the year before using e-health. Johnsaw his physician 13 times and had 3 ED visits: therehave been no ED visits in the last year.

NHII identifies 4 major collaborative goals, with 12strategies for advancing and focusing future effortstoward a fully digitized healthcare system in theUnited State.';.̂ Several states have formed regionalhealth information organizations to develop strategicplans for adoption of EHR and IT system.s. withprogres.s differing widely from state to state. Meetingthe national goal of having all healthcare agenciesfully digitized, including the use of e-health, by theyear 2010 remains to be seen.

In 2000. Cain and colleagues'^ accurately projectedthat the first stage would follow a shakeout by businesscategory, leaving only a few survivors in each e-healthniche; this near-term stage would be market-driven,with only tho.se players able to show an investmentreturn continuing to receive substantial venturecapital support. In addition, Cain predicted that alonger-term and more significant shift would occurfrom 2003 to 2005, as increasing numbers ofcompanies see the advantage of an online businessplatform. The accumulation of a critical mass ofhealthcare data and agreement on informationstandards will lead this stage. Certification of vendorsand e-health providers will provide additionalassurance to baby boomers who will create thedemand to receive e-health in the home whilemaintaining privacy and security.

As it becomes increasingly apparent that e-healtheffectively reduces healthcare costs, improves safetyand quality of care, and provides a return onhealthcare investment, it is important for nursing to

define its niche and play a major role in helpingpatients and caregivers recognize a return on theirhealth and quality of life.

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