Practicum Experience

Journal Assignment?Part 1

After reviewing the Practicum Weekly Resources, record responses to the following in your Journal:

1) What role does the nurse informaticist have in identifying and exploiting the use of disruptive technologies?

2) What strategies will you employ for keeping current with the latest trends and technologies in health information technology?

Journal Assignment?Part 2

Note: Each week, you are responsible for locating a scholarly journal article in the Walden Library related to your area(s) of interest. Include in your Journal the reference in proper APA format, and provide a BRIEFsummary of the article. (See below and attached PDF file)

Valley, T. S., & Fagerlin, A. (2016). Disruptive Technology. Can Electronic Portals Promote Communication in the Intensive Care Unit?. Annals Of The American Thoracic Society, 13(3), 309-310. doi:10.1513/AnnalsATS.201512-807ED

Journal Assignment?Part 3

Practicum Onsite Visits

Summarize the key activities of your visits to your Practicum site (as appropriate), including with whom you met, what you did, and what you gained from the experience.

Practicum Weekly Resources

Select a peer reviewed article published in the last 5 years from the Walden University Library related to disruptive technology. (See below and attached PDF file)

Schwamm, L. H. (2014). Telehealth: Seven strategies to successfully implement disruptive technology and transform health care. Health Affairs, 33(2), 200-6. Retrieved from

alth? refers to the use of electronic services to support a
broad range of remote services, such as patient care, education, and
monitoring. Telehealth must be integrated into traditional ambulatory
and hospital-based practices if it is to achieve its full potential, including
addressing the six domains of care quality defined by the Institute of
Medicine: safe, effective, patient-centered, timely, efficient, and equitable.
Telehealth is a disruptive technology that appears to threaten traditional
health care delivery but has the potential to reform and transform the
industry by reducing costs and increasing quality and patient satisfaction.
This article outlines seven strategies critical to successful telehealth
implementation: understanding patients? and providers? expectations,
untethering telehealth from traditional revenue expectations,
deconstructing the traditional health care encounter, being open to
discovery, being mindful of the importance of space, redesigning care to
improve value in health care, and being bold and visionary.
n 1996 the Institute of Medicine (IOM)
defined telemedicine as ?the use of electronic
information and communications
technologies to provide and support
health care when distance separates
participants.?1 The terms telehealth and telemedicine
are often used interchangeably. However,
telemedicine typically describes direct clinical
services, while telehealth refers to a broad range
of health-related services such as patient care,
education, and remote monitoring.2
Given the current unsustainable trend in the
growth of medical expenditures, increasing value
in health care will require improvements in
quality as well as reductions in cost.3 The integration
of telehealth into traditional ambulatory
and hospital-based practices can help achieve
both goals.
The telehealth interventions that aremost likely
to achieve these goals will be those that address
the six dimensions of quality outlined by
the IOM in its landmark 2001 report, Crossing the
Quality Chasm?namely, health care that is safe,
effective, patient-centered, timely, efficient, and
equitable.4 As the IOM noted, ?health care is
undoubtedly one of the most, if not the most,
complex sectors of the economy. Sizable capital
investments and multiyear commitments to
building systems will be needed. Widespread
adoption of many information technology applications
also will require behavioral adaptations
on the part of large numbers of clinicians, organizations,
and patients.?4(p16)
Telehealth can complement traditional ambulatory
and hospital-based practices, which tend
to be provider-centric, by creating delivery systems
that are more patient centered and that use
technology to increase access and quality, decrease
cost, and help providers manage an
ever-increasing volume of information and relationships.
Over the past half-century, technological
innovations have increased convenience and
improved access for consumers. For example,
automated teller machines, self-service gas stadoi:
NO. 2 (2014): 200?206
?2014 Project HOPE?
The People-to-People Health
Foundation, Inc.
Lee H. Schwamm (lschwamm@ is executive vice
chair of neurology and
medical director of telehealth
at Massachusetts General
Hospital, in Boston. He directs
the Massachusetts General
Hospital and Partners
TeleStroke Network.
200 Health Affairs February 2014 33:2
by Rachel McCartney
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tions, drive-through windows at various businesses,
and vending machines are all examples
of ?disruptive innovations?5 that have provided
consumers with new and alternative ways to
more efficiently obtain goods and services.
These innovations are disruptive because they
have displaced prior ways of doing things. They
start by introducing, in an area of low profitability,
a product that is just good enough to satisfy
consumers but that has a much lower price than
the alternative. Eventually, these new products
improve enough so that they compete effectively
with established, more expensive products.
Health care, however, has remained a largely
local and synchronous service, meaning that patients
and providers must be in the same place
(local) at the same time (synchronous). Exhibit 1
compares this type of health care delivery with
delivery that is remote and asynchronous, which
the use of telehealth permits.
Seven Critical Strategies For Future
Health Care Delivery
Understanding Patients? And Providers? Expectations
?PATIENTS: The Internet has changed the way
in which people obtain information about health
and health care. Physicians, nurses, and other
professionals remain the preferred source of information
for most people when they have health
concerns, but online resources?including advice
from other patients?have become a significant
and increasingly accessed source of information
in the United States. Among the
74 percent of US adults who use the Internet,
80 percent have searched online for information
about health topics, 25?35 percent have read
commentaries about health or medical issues,
and 15?20 percent have found other people with
similar health concerns.6
Increasingly, adults with Internet access are
sharing their personal health experiences with
other people?a process that is facilitated by easy
access to communication tools such as social
network sites, discussion forums, and online reviews.
Patients are also forming online diseasebased
communities and often volunteer to participate
in clinical trials.7?10 For example, the
organization PatientsLikeMe was founded in
2004 as a ?health data-sharing platform?to
transform the way patients manage their own
conditions, change the way industry conducts
research and improve patient care.?11 The organization
recently announced the launch of Open
Research Exchange, an online platform to connect
patients with scientists involved in the early
stages of research design.12 In addition, more
than 13,000 mobile health applications for consumers
were available from the Apple App Store
in 2012 at an average cost of only $3.21.13
Despite this increase in interest and activity,
patients remain concerned about their privacy
and the use of their medical information.14 Patients
need assurances that data derived from
applications such as telehealth monitoring will
be kept private and will be fully and meaningfully
integrated into their electronic health records.15
Exhibit 1
Time And Space Characteristics Of Health Care Delivery
Synchronous Asynchronous
Characteristics Requires transportation
Requires coordination
Requires physical proximity
Very high cost
Requires transportation
Does not require coordination
Displaces interactions in time
Moderate cost
Traditional health care examples Hospitalization
Traditional office visit
Pick up or drop off specimens, records
Perform blood tests before a visit
Characteristics Does not require transportation
Requires coordination
Displaces interactions in space
Moderate cost
Does not require transportation
Does not require coordination
Displaces interactions in time and space
Very low cost
Telehealth examples Virtual office or home visits
Continuous monitoring, remote care
Adding out-of-town parties to a visit
Telementoring to supervise procedures
Secure messaging
Skin lesion photograph review
Teleradiology interpretation
SOURCE Adapted from Mitchell WJ. E-topia: ?Urban life, Jim?but not as we know it.? Cambridge (MA): MIT Press; 1999. NOTES
Synchronous interactions must happen at the same time. Asynchronous interactions occur at different times for each party. Local
interactions require immediate physical proximity. Remote interactions occur with the parties at a distance.
February 2014 33:2 Health Affairs 201
by Rachel McCartney
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?PROVIDERS: Health care providers face
many challenges. The growth of managed
care, documentation requirements, malpractice
claims, consumerism and an erosion of trust
have changed the practice of medicine and affected
the patient-doctor relationship. Providers are
less and less satisfied with the amount of time
available for them to spend with patients, their
decision-making autonomy, and how much leisure
time they have.16 Evolving work ethics and a
desire for greater workplace flexibility are
among the many factors that are influencing
the number and nature of people who seek careers
in health care.16,17
Practitioners increasingly expect to be able to
use technical innovations and to have them produce
benefits for both patients and themselves.18,19
And, in fact, electronic systems that
intelligently aggregate and process data (for example,
tracking levels of blood glucose over
time) between patients? medical visits and that
provide decision support functions (such as
alerts for drug-drug interactions) and web-based
clinical diagnosis systems are helping make
practitioners more efficient and accurate.20
Providers also want easy access to reliable and
secure medical information from trusted sources.15
They want patient data to be easily integrated
into longitudinal health records, and they
want those records to be monitored and analyzed
to help prevent future disease events. In addition,
they want to be alerted when new treatment
options become available.
Telehealth applications are expected to make
all of this possible when they are effectively integrated
into existing practice models. But to facilitate
the use of online systems, providers must
have access to reliable, ubiquitous, and highquality
bandwidth. In 2010 the Federal Communications
Commission reported that more than
3,000 small provider groups across the country
faced a broadband connectivity gap that would
deny them such access.21
As telehealth provides greater access to care in
more geographical markets, some physicians
may feel financially threatened because patients
will be able to access care from other sources,
such as distant large health systems with sophisticated
telehealth portals. And as medical care
becomes more commoditized and more widely
available, new financial risks to providers and
organizations may emerge, including price competition
from providers in other parts of the
country or even other countries.
Untethering Telehealth From Traditional
Revenue Expectations It is unrealistic to
expect a rapid return on investment for many
telehealth applications. For example, a telehealth
consultation might be more efficient than
a face-to-face office visit, but it also might not be
reimbursed. At this point, telehealth applications
might best be viewed as important organizational
learning experiments. Returns on investment
should in general be considered a
long-term matter. They will likely be achieved
through reduced numbers of patients? visits to
?bricks and mortar? sites, increased sizes of patient
panels, and decreased numbers of high-cost
events such as hospitalizations.
The more that telehealth activities are directed
to populations associated with financial risk
(such as thirty-day readmission penalties or alternative
quality contracts), the less traditional
revenue will decrease. Payers provide scant reimbursement
for telehealth, and what limited payments
there are go mostly for delivering care to
underserved rural areas. Most initial telehealth
activities thus will be financed by providers.
In scenarios where telehealth activity is financed
by providers without external reimbursement,
setting financial incentives for telehealth
too high might encourage waste and overuse (for
example, repeated follow-up telehealth video
consultations when a single telephone call would
suffice instead) or stimulate adoption to such an
extent that providers would have insufficient
time for traditional in-person visits. Alternatively,
setting the incentives too low might make
providers unlikely to adopt telehealth.
Lastly, online ?second opinion? and other telehealth
vendors might compete with hospitals:
They could lure providers employed by hospitals
away with offers of more-lucrative payments.
Deconstructing The Traditional Health
Care Encounter The traditional face-to-face office
or clinic visit is composed of many parts,
each of which must be analyzed to determine
its value. The resulting data can be used to reassemble
the parts of the health care encounter
into the future form that will replace the traditional
one. Wherever feasible, less costly solutions
that take advantage of telehealth?s capabilities
should be incorporated into the future form.
For example, securely collecting and combining
ahead of time information such as health
records, medical images, and medication lists
will be necessary for virtual visits. And doing
so would be more efficient than having providers
gather and organize this information during inperson
An approach known as value stream mapping
should be applied to the health care encounter in
both the outpatient and inpatient environments.
Value stream mapping is a Lean manufacturing
technique that is used to design and analyze the
flow of materials and information required to
deliver a service. Activities in the outpatient setting
that could benefit from it include appointOverview
202 Health Affairs February 2014 33:2
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ment scheduling, checking out after an office
visit, and filling prescriptions or orders. Activities
in the inpatient setting could include hospital
admission, discharge, and follow-up. After
these activities have been ?mapped,? they should
be adapted to use in telehealth. The participation
of information technology professionals in these
processes will be essential.
In addition, because many of the activities are
in administrative, legal, or workflow domains,
diverse staff expertise is required. Key items to
modify include contracts for professional services
and standards for competency to practice;
definitions of where visits can legally occur; regulations
governing the documentation of visits;
decision support reminders; billing and coding
procedures; and patient registration, visit scheduling,
and data collection. See the online Appendix
for the structure of the medical and administrative
team that one organization is using to
implement telehealth.22
Traditional medical documentation and communication
are largely confined to the paper or
electronic health record. Because mobile devices
are convenient and inexpensive, many providers
have begun to use them to send and receive text
and e-mail messages containing confidential and
important patient information. Health care organizations
should encourage the use of these
devices, with appropriate legal and privacy safeguards.
But most of the information exchanged
in this way is not currently captured in electronic
health records, and it should be. And unless providers
can enter medical information into patients?
records simply, using word processing
instead of performing complex tasks such as
categorizing the type or values of the information,
they are not likely to do so.23
Health care organizations should develop
mechanisms to allow providers to rapidly incorporate
user-friendly mobile technology into
their daily workflow. This would ease the burden
of medical documentation and communication.
Being Open To Discovery Many telehealth
innovations are designed to make care safer
and more convenient. Examples include secure
messaging, virtual video-based visits with providers,
and the use of digital or cell-phone cameras
to photograph rashes and skin lesions. Other
innovations will open up entirely new avenues
of care delivery in which patientsmay not even be
aware that health interactions are taking place.
Examples include the remotemonitoring of body
weight, physical activity, medication adherence,
and heart rhythms.
One example of a real-time, affordable, telehealth
application is TeleStroke. This is an online
system that uses interactive videoconferencing
and the acquisition and transfer of digital
images to allow experts at large urban centers
to evaluate acute stroke patients in community
and rural hospitals for the application of
time-critical, clot-dissolving intravenous medications.24
TeleStroke has already achieved mainstream
adoption because it commoditized and distributed
acute stroke expertise efficiently in a market
of underserved hospitals that were willing to
pay for it. It is a hospital-to-hospital rather than a
patient-to-provider relationship that has proved
to be financially sustainable with a short-term
return on investment.
Being Mindful Of The Importance Of Space
Space refers to both the physical and emotional
environments in which virtual encounters occur.
For example, if a person needs health care while
at work, his or her workplace may lack the facilities,
technology, privacy, and comfort needed to
conduct a telehealth encounter. Public, residential,
and commercial spaces might need to be
redesigned to include health kiosks or other appropriate
spaces for telehealth care. Similarly,
providers might need different environments
at home or at work to use these new services.
Telehealth encounters might help people
avoid traffic, anxiety, and wasted time. However,
they might also remove fundamental elements of
the in-person encounter, such as interacting
with medical assistants, nurses, and receptionists,
that are important for the effective functioning
of the office practice or for ensuring that key
health measurements or interventions occur.
To the extent that patients or providers feel
that a virtual visit lacks or interferes with the
human connection of a face-to-face visit, other
meaningful benefits may be lost as well. For example,
patients may be reluctant to volunteer
information about sexual dysfunction if they
do not feel that they are in a safe, private environment
that is conducive to discussing very
personal matters.
Organizations must make informed choices
about when to replace an in-person interaction
with a remote human-to-human or human-tomachine
virtual interaction. It remains to be determined
whether the virtual visit can reliably
reassemble and provide the necessary attributes?such
as registration functions, vital sign
measurement, laboratory monitoring, physical
examination, diagnostic assessments, therapeutic
recommendations, and postvisit coordination
of care?at a lower cost than a face-to-face
visit. However, the growth of online social networks
suggests that consumers are open to alternative,
lower-cost, and very convenient ways of
interacting with others.
Redesigning Care To Improve Value In
Health Care Telehealth innovations should be
February 2014 33:2 Health Affairs 203
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designed to increase the quality of care. To the
extent possible, they should be aligned with the
IOM?s six dimensions of quality.4
?SAFE: Telehealth must also contribute to preventing
injuries from care. For example, the use
of digital pill counters to electronically monitor
adherence to a medication regimen can prevent
harm from medication errors.25 Coupling these
pill counters with smart software agents or apps
that can alert physicians, pharmacists, or nurses
when a patient fails to take a pill could produce
substantial improvements in patient safety.
Under current models, reimbursement of traditional
care delivery is limited to providers? episodic
and infrequent observations and interactions
with patients. However, it is likely that
reimbursements will become available for more
frequent or continuous monitoring of patients
with specific, well-defined conditions as these
interactions are demonstrated to be inexpensive
and to improve health outcomes. Examples of
interactions likely to be reimbursed might include
the early detection of unfavorable heart
or brain rhythms that precede heart attacks or
seizures26 and patterns of movement and acceleration
that precede injurious falls.
?EFFECTIVE: Telehealth should provide services
based upon scientific knowledge and avoid
services that are not likely to be of benefit. Telehealth
alternatives to traditional care should not
be embraced simply because they are intuitively
appealing or because they can collect large quantities
of data. Instead, they must deliver evidence-based
New scientific research will be needed to
achieve this goal and prove that telehealth interventions
are at least as effective as their traditional
counterparts. For example, despite promising
preliminary data,27 randomized trials have
not yet confirmed the impact and efficacy of remote
monitoring for improved outcomes in
congestive heart failure.28 In fact, recent analyses
of telemonitoring studies in heart failure have
produced conflicting results.29?31 Such interventions
must undergo the same processes of discovery,
hypothesis testing, and evaluative research
as those used in traditional care delivery.
?PATIENT-CENTERED: Telehealth should deliver
care that is respectful and responsive to
individual patients? preferences, needs, and values
and that includes patients? values in clinical
decision making. Telehealth applications, particularly
virtual visits, have great potential to
meet patients? needs and respond to their preferences
and values. Many organizations now allow
patients to view their medical notes or results
online, upload information, and share their
records with others.
Virtual home visits are especially desirable for
patients who live far from medical care or have
limited mobility.32 They also permit the addition
to the visit of remotely located relatives or caregivers,
which could increase compliance with
health care instructions and support more effective
shared decision making.
?TIMELY: Telehealth should reduce wait times
and delays that can be harmful for patients. Telehealth
interventions could increase access to important
health information between traditional
visits and permit the earlier detection of adverse
health trends.
An example of this is when a remote monitoring
program detects a failure to adhere to a
health maintenance intervention?such as
weight gain in a patient with congestive heart
failure and poor medication adherence25 in a
patient with epilepsy or diabetes33?and prompts
the provider to adjust the medication or arrange
for a visit. The result could be the avoidance of a
medical crisis requiring hospitalization.
?EFFICIENT: Telehealth should avoid waste?
in particular, of equipment, supplies, ideas, and
energy, such as that needed to fuel a trip to a
provider?s office. Replacing in-person visits with
remote monitoring and virtual encounters has
the potential to dramatically reduce the use of
transportation, real estate, and energy, while
saving hours of missed work by patients and the
caregivers who accompany patients on traditional
office visits. Monetizing these savings and using
them to reduce overall health care spending
will require new economic models of cost sharing
among providers, insurers, and patients.
?EQUITABLE: Telehealth should deliver care
that does not vary in quality because of the personal
characteristics of the patient or provider,
including sex, race or ethnicity, geographic location,
and socioeconomic status. Telehealth has
tremendous potential to improve health inequities
related to these characteristics.
However, a major risk of telehealth is that low
socioeconomic status or other factors might increase
health disparities among patients who
have limited technology literacy or access. To
the extent that telehealth is embraced by the
US health care system and becomes a major avenue
of care delivery, these disparities could rapidly
accelerate. Measuring and mitigating them
should be a major focus of health care and patient
advocacy organizations.
Being Bold And Visionary In 1925 the pioneering
science fiction publisher Hugo Gernsback
envisioned the ?teledactyl,? a device that,
fifty years in the future, would allow a doctor to
perform ?diagnosis by radio? (see the illustration
in the online Appendix).22 Gernsback?s
then-futuristic invention represents the kind of
innovative thinking needed in health care today
204 H ealth Affair s February 2014 33:2
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to adapt to the growing population of elderly
people and the looming shortage of providers.
For example, new solutions to the problem of
limited access to providers are needed to support
the full-scale implementation of accountable
care organizations and patient-centered medical
homes, as well as increased access to specialists
in the medical neighborhood. With sufficient
economies of scale, a pool of specialists could
be made available to provide information and
consultation on demand for referring primary
care providers who require more efficient methods
of managing large populations of patients.
Reducing delays in access to specialty care could
reduce primary care providers? reliance on highcost
medical testing and imaging and allow them
to intervene more swiftly to avoid further deterioration
in a patient?s condition.
Patients? virtual visits to the medical home
could decrease the use of urgent care clinics,
reduce hospital admissions and readmissions,
and even facilitate the return of ?house calls??
although they, too, would be virtual.32 Such visits
could also provide needed ongoing medical care
when transportation to the hospital is difficult or
impossible to obtain as a result of predictable
circumstances (such as financial hardship, medical
limitations, and distances) or unpredictable
circumstances (including weather, work demands,
restrictions on travel imposed by law
enforcement officials, and a family crisis).34
The implementation of telehealth technology
is analogous in many ways to that of the automated
teller machine (ATM).When it was introduced
in the 1970s, the ATM was an expensive,
clunky, unfriendly, and inflexible device capable
only of dispensing cash. What was then a financial
loss leader for banks has become an essential
component of financial institutions that is fully
integrated with global electronic banking records
and allows access to accounts and local currency
almost anywhere in the world.
This customer-centric innovation has become
one of the primary drivers of banking brand
choice among consumers today. In spite of initial
fears that it would reduce the size of the retail
banking workforce, the ATM has instead led to
more optimal matching of customers? needs to
providers and contributed to substantial growth
in the numbers of bank branches and tellers.35
Replacing traditional visits to a provider?s office
with virtual visits could free up needed space
for patients whose medical needs require them
to be seen in person. The same kind of replacement
could also apply to the episodic care of
patients and allow for more efficient use of
specialists, who will increasingly be in short supply.36
Or it could permit the aggregation of patients
with rare diseases across multiple accountable
care organizations to create sufficient
volume to sustain the practice of an expert subspecialist.
Remote consultations for second
opinions for patients with complex conditions
in underserved areas might increase providers?
revenue or the likelihood of optimal matching of
patients with specialty care providers.
These strategies could reduce the disparities
between urban and rural health care delivery by
increasing access to specialty care in areas that
are medically underserved in general, or access
to care for particular diseases. This principle
could be extended to improving the quality of
the work life of providers who are located in large
urban general and specialty hospitals by supporting
more efficient staffing models that
would enable providers to sleep at home but
remain available for virtual supervision of critical
in-hospital events as needed.
Relentless innovation is a crucial driver in creating
value across all industries, and health care is
no exception. Telehealth is a disruptive innovation
that is changing health care, and its
influence is likely to increase rapidly. Reconceptualizing
the delivery of health care as a patientcentered
service that is responsive to the IOM?s
domains of quality4 will be critical to improving
the efficiency of the US health care system.
Guided by what is best for patients, telehealth
could help usher in a brave new world of health
care that is embraced by both patients and providers,
identifies new avenues of care delivery,
and improves the value of care by increasing its
quality while lowering its cost. ?
Lee Schwamm?s work was supported in
part by the Stroke and Traumatic Brain
Injury Telehealth Services (Grant
No. HHSH250200927063P). The author
gratefully acknowledges the
contributions of two Massachusetts
General Hospital colleagues: Sarah
Sossong, for her work defining the
hospital?s administrative approach to
implementation, and Elizabeth Mort, for
mentoring the author in the field of
quality improvement and measurement.
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22 To access the Appendix, click on the
Appendix link in the box to the right
of the article online.
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Amarenco P, Audebert HJ, Bakas T,
Chumbler NR, et al. A review of the
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206 H ealth Affair s February 2014 33:2
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