INTRODUCTION

The field of medicine during the recent years has made an explosion in collaboration with the
field of technology. When considering medicine and technology separately they have proved to
be strong enough to stand alone as different science helping the economic growth of our
country.In today's health care environment, the health care workers have to be flexible,
innovative and informative, able to solve complex client problems by utilizing the best available
resources. For this, newer technologies are being introduced day by day and it has grown to such
an extent that it can be termed and treated as a separate field.
Advances in telecommunication and technologies are revolutionizing education and health
services globally, including the provision of nursing services. Decreasing time and distance,
these advances increase access to health and healthcare, especially to underserved populations
and those living in rural and remote areas. They help to manage the demand for services, ensure
more effective use of human and health resources and facilitate education and research activities.
Communication technology now also enables nurses to deliver health care in rural and remote
locations, and areas without health care services.
The 21st century global nursing paradigm was developed with the help of technology to meet the
needs of services that have distance, physical and cost limitations. Telenursing has many ways to
facilitate the patient's need for nursing care and/or in managing management and conducting
distance education that is more efficient and can reduce costs. Telehealth, telemonitoring,
telepsychiatry are part of Telenursing which can be done as the remote care for patients who
need fast help such as themonitoring services for sufferers of chronic disease; monitoring of
medication adherence for type 2 diabetes mellitus and COPD patients; care education for
mothers and families who have premature babies; remote care for post-cataract surgery patients;
and prevention of major depression in people living with HIV/AIDS by utilizing digital
technology for teleconfigured videos.

TELE-HEALTH
The World Health Organization (WHO, 2016) defines telehealth as-
“Delivery of health care services, where patients and providers are separated by distance.
Telehealth uses information and communications technology (ICT) for the exchange of
information for the diagnosis and treatment of diseases and injuries, research and evaluation, and
for the continuing education of health professionals. Telehealth can contribute to achieving
universal health coverage by improving access for patients to quality, cost-effective, health
services wherever they may be. It is particularly valuable for those in remote areas, vulnerable
groups, and aging populations.”

-Tele-health is defined as "the use of electronic information and telecommunication technologies

to support long-distance clinical health care, patient and professional health related education,
public health and health administration" (Hutcherson, 2002,)

Tele health is such a field where the delivery of health-related services and information via
telecommunications via technologies.

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Telehealth encompasses:
-Tele-medicine
-Tele-nursing
It may include any or all of the following:
 Consultation
 Assessment/monitoring
 Diagnosis
 Treatment
 Transfer of information
 Client education
 Professional development

TELEMEDICINE
The term ‘telemedicine’ derives from the Greek word ‘tele’ meaning ‘at a distance’ and the
present word ‘medicine’ which itself derives from the Latin ‘mederi’ meaning
‘healing’.Telemedicine has numerous definitions, it is a phrase first coined in the 1970s by
Thomas Bird, referring to health care delivery where physicians examine distant patients through
the use of telecommunication technologies.

According to WHO
Telemedicine is the delivery of health care services where distance is a critical factors by all
health care professional using information and communication technology for the exchange of
valid information for diagnosis and treatment and prevention of disease and injuries, research
and continuing education of health Care providers all in the interest of advancing the health of
individual and their community.

According to Willams
Telemedicine is defined as any health care provided to patient via technology across a distance. It
also otherwise defined as the use of advance technologies to exchange health information and
provide health care services across geographic area, time, social and culturalbarriers.

-REGISTERED MEDICAL PRACTITIONER ‘A Registered Medical Practitioner [RMP] is a

person who is enrolled in the State Medical Register or the Indian Medical Register under the
Indian Medical Council Act 1956.’ [IMC Act, 1956]

Background/Evolution
Care at a distance (also called in absentia care), is an old practice which was often conducted via
post. There has been a long and successful history of in absentia health care which, thanks to
modern communication technology, which has evolved into modern telemedicine.
In its early manifestations, African villagers used smoke signals to warn people to stay away
from the village in case of serious disease. In the early 1900s, people living in remote areas in
Australia used two-way radios, powered by a dynamo driven by a set of bicycle pedals, to
communicate with the Royal Flying Doctor Service of Australia.

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 The practice of Telemedicine started first at Boston, USA in 1967. In India, telemedicine
practice was initiated at Lucknow and Chennai at 1997. In Kerala, the first unit of telemedicine
was established at Medical College Trivandrum in 2003. The first Ayurvedic telemedicine center
was established in India in the year 2007 by PartapChauhan, a well-known Indian Ayurvedic
doctor.

Evolution of Telemedicine in India

o 1996: Deployment of First Indigenously Developed Hospital Information System Software by
CDACNoida at SGPGIMS, Lucknow, UP
o 1999: Indigenous Development of Telemedicine Technology and Pilot Deployments by DeitY,
MCIT, Government of India at AIMS, New Delhi, PGIMERChandigarh and SGPGIMS
Lucknow
o 2000: SATCOM based Telemedicine Deployment byISRO at Apollo Hospitals, Aragonda
o 2001: First telemedicine network between three institutions AIIMS-New Delhi, PGI Chandigarh
and SGPGI-Lucknow, First National Conference on Telemedicine was held and a Scientific
Body for promotion of Telemedicine in the Country Telemedicine Society of India, was formed
o 2001-2003: Major Medical Institutions (Government and Corporate) initiated Telemedicine
activities and deployed hospital information system
o 2003-2004: Deployment of SATCOM based TM nodes across the country by ISRO for Tele-
education and Tele-consultation services
o 2005: MoHFW constituted Indian Task Force forTelemedicine
o 2006: Planning Commission approved budget for e-Health including Telemedicine in the 11th
Five Year Plan School of Telemedicine and Biomedical Informatics (STBI) was set up at
SGPGIMS, Lucknow by Government of UP PHFI was awarded Grant-in-aid to have MoHFW
'Healthy India' Website for Health Education from 2007-08 to 2012-13
o 2007: STBI at SGPGIMS, Lucknow was made National Resource Centre for Telemedicine and
Biomedical Informatics by DeitY Government of India MoHFW, Government of India supported
Tele-ophthalmology Project In many parts of the country MoHFW, Government of India
supported Onco-NET Project
o 2009: MoHFW, supported National Rural TMNetwork with 7 25-50 Lakh to start the pilot
projects on Telemedicine
o 2010: National Medical College Network Project Conceived. SGPGIMS was made National
Resource Centre for Telemedicine by MoHFW, MCTS Launched by MoHFW, GoI.
o 2012: EMR/EHR Standards by Expert Group ofMoHFW establishment
o 2013: Initiation of Process of establishment of NMCN with Open Tender Basis.

Objectives
o To provide quality care to the people who are residing in remotest areas.
o To reduce the cost of health care services.
o To save the time wasted by both providers and patients in traveling from one geographic
location to another to avail services on time.

Technology and Equipment for Telemedicine

• Internationally, technology standards are laid down by Technology Development Board
under the International Telecommunication union(ITU).

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• The basic telecommunication connectivity between the patient and the doctor may be a
wired one or a wireless one.
1. Wired: Telephone line, ISDN line, internet, cable connection.
2. Wireless: Satellite connection, wireless internet.
Once the connectivity is established between the patient and the doctor at a distance, hardware
and software equipments for data, audio and video transmission are needed.
Necessities of Telemedicine
• PIR (Personal Information Record).
• PHR (Personal Health Record).
• EMR (Electronic Medical Record).
• DICOM (Digital Imaging and Communication in Medicine).
• PACS (Picture Archival and Communication System).
• AES (Advanced Encryption Standard).

Types of Telemedicine
-Real Time (Synchronous)
 Real time telemedicine could be as simple as a telephone call or as complex as robotic
surgery.
 It requires the presence of both parties at the same time and a communication link
between them that allows a real time interaction to take place.
 Video-conferencing equipment is one of the most common forms of technologies used in
synchronous telemedicine.
 There are also peripheral devices which can be attached to the computer or the video
conferencing equipment which can aid in an interactive examination. For instant, a tele-
otoscope allows a remote physician to 'see' inside a patient's ear; a tele-stethoscope allows
the consulting remote physician to hear the patient's heartbeat. Medical specialties
conducive to this kind of consultation include psychiatry, family practice, internal
medicine, rehabilitation, cardiology, pediatrics, obstetrics, gynecology, neurology and
pharmacy.

-Store and Forward Telemedicine (asynchronous)

 Store and forward telemedicine involves acquiring medical data (like medical images, bio
signals) and then transmitting this data to the doctor or medical specialist at convenient
time for assessment offline.
 It does not require the presence of both parties at the same time. Dermatology (cf:
teledermatology), radiology and pathology are the common specialties that are
conductive to asynchronous telemedicine.
 A properly record Medical Record preferably in electronic form should be a component
of this transfer.
 Telemedicine is most beneficial for population living in isolatedcommunities and remote
regions and is currently being applied in virtually all medical domains.
 Specialties that use telemedicine often use a 'tele' prefix; for example, telemedicine
applied by radiologists is called Teleradiology. Similarly telemedicine as applied by
cardiologists is termed as telecardiology, etc.

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Methods of Transmission in Telemedicine
1. Store-and-forward
2. Remote monitoring
3. Interactive services
i) Store-and-forward telemedicine: Involves acquiring medical data (like medical images, bio
signals, etc.) and then transmitting this data to a doctor or medical specialist at a convenient time
for assessment offline. It does not require the presence of both the parties at the same time.
Dermatology (cf: teledermatology), radiology, and pathology are common specialties that are
conducive to asynchronous telemedicine

ii) Remote monitoring, also known as self-monitoring/testing This method is primarily used for
managing chronic diseases or specific conditions, such as heart disease, diabetes mellitus, or
asthma. These services can provide comparable health outcomes to traditional in-person patient
encounters, supply greater satisfaction to patients, and may be cost-effective.

iii) Interactive telemedicine services provide real-time interactions between patient and provider,
to include phone conversations, online communication and home visits. Many activities such as
history review, physical examination, psychiatric evaluations and ophthalmology assessments
can be conducted comparably to those done in traditional face to face visits. In addition,
“clinician-interactive” telemedicine services may be less costly than in-person clinical visits. The
first interactive telemedicine system, operating over standard telephone lines, for remotely
diagnosing and treating patients requiring cardiac resuscitation (defibrillation) was developed
and marketed by Med Phone Corporation in 1989 under the leadership of its president and
founder, S.EricWachtel.

Types of Connectivity
• Point-to-Point: communication: In networking, the Point to Point Protocol (PPP), is a
data link protocol commonly used to establish a direct connection between two nodes over
terrestrials and satellite link, e.g. SGPGIMS, Lucknow is connected to the medical colleges of
Orissa through point to point connectivity via satellite link and District Hospital, Rae Bareli via
fiber optic cable network.
• Point-to-multipoint communication is a term that is used in the telecommunication field
which refers to communication which is accomplished via a specific and distinct type of
multipoint connection, providing multiple paths from a single location to multiple locations, e.g.
two District Hospitals of Uttaranchal state are linked to SGPGIMS via ISDN link.

REQUIREMENT SPECIFICATION
a. Nodal Hospital:
A patient getting treated
 A doctor

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  A remote telemedicine console having audio-visual and data conferencing facilities.
b. Referral Hospital:
 An expert/specialised doctor
 A central telemedicine server having audio-visual and data conferencing facilities

THE DATA:
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  Data related to a patient’s personal information, Data related to a patients’
medical information, Data for patient management in Telemedicine, Data related
to the doctor, Data for system management.

PERSONNEL INVOLVED:
Referral end:
 A group of specialist doctors.
 System administrator.
 Studio technician.

Nodal end:
 A group of general physician.
 System administrator.
 Data entry operator.
 Studio technician.
 Patients.

Patient’s Personal Information:

 Patients ID, Name, Sex

Patient’s Medical Information:
 Textual, Plain Text, Structured Document, Image, Graphics, Video,Vector.

Data Related to the Doctors:

 Doctor’s personal information.
 Unique Identification key.

Data for System Management:

 Users ‘list, Password file, Log files

APPLICATIONS OF TELEMEDICINE
1. Telehealth care: It is the use of information and communication technology for prevention,
promotion and to provide health care facilities across a distance. It can be divided in the
following activities:
• Teleconsultation
• Telefollow-up
2. Tele-education: Tele-education should be understood as the development of the process of
distance education (regulated or unregulated), based on the use of information and
telecommunication technologies, that make interactive, flexible and accessible learning possible
for any potential recipient.

3. Disaster management: Telemedicine can play an important role to provide healthcare

facilities to the victims of natural disasters such as earthquake, tsunami, tornado, etc. and man-

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 made disaster such as war, riots, etc. During disaster, most of the terrestrial communication links
either do not work properly or get damaged so a mobile and portable telemedicine system with
satellite connectivity and customized telemedicine software is ideal for disaster relief.

4. Telehome health care: Telemedicine technology can be applied to provide home health care
for elderly or underserved, homebound patients with the chronic illness. It allows home
healthcare professionals to monitor patients from a central station rather than traveling to remote
areas chronically ill or recuperating patients for routine check-ups. Remote patient monitoring is
less expensive, more time savings, and efficient methodology. Telehome care virtual visits might
lead to improved home health care quality at reduced costs, greater patient satisfaction with care,
increased access to health care providers and fewer patients needing transfer to higher, more
costly levels of care. A Computer Telephone Integrated (CTI) system can monitor vital functions
of patients twenty-four hours a day and give immediate warnings.

Technology Used & Mode of Communications

Multiple technologies can be used to deliver telemedicine consultation. There are 3 primary
modes: Video, Audio, or Text (chat, messaging, email, fax etc.) Each one of these technology
systems has their respective strengths, weaknesses and contexts, in which, they may be
appropriate or inadequate to deliver a proper diagnosis. It is therefore important to understand
the strengths, benefits as well as limitations of different technologies. Broadly, though
telemedicine consultation provides safety to the RMP from contagious conditions, it cannot
replace physical examination that may require palpation, percussion or auscultation; that requires
physical touch and feel. Newer technologies may improve this drawback.

STRENGTHS AND LIMITATIONS OF VARIOUS MODES OF COMMUNICATION

MODE STRENGTHS LIMITATIONS

VIDEO: Closest to an in person-consult, real time Is dependent on high quality internet
Telemedicine facility, interaction connection at both ends, else will lead to a
Apps, Video on chat  Patient identification is easier sub optimal exchange of information
platforms, Face time etc.  RMP can see the patient anddiscuss with Since there is a possibility ofabuse/ misuse,
the caregiver ensuring privacy of patients in video consults
Visual cues can be perceived is extremely important
 Inspection of patient can becarried out

AUDIO:  Convenient and fast Non-verbal cues may be missed

Phone, VOIP, Apps etc.  Unlimited reach  Not suitable for conditions that require a
 Suitable for urgent cases visual inspection (e.g. skin, eye or tongue
 No separate infrastructurerequired examination), or physical touch
 Privacy ensured  Patient identification needs to be clearer,
 Real-time interaction. greater chance of imposters representing the
real patient
TEXT BASED: Convenient and quick Besides the visual and physicaltouch, text-
Specialized Chat based  Documentation& Identification may be based interactions also miss the verbal cues
Telemedicine Smartphone

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Apps, SMS, Websites, an integral feature of the platform Difficult to establish rapport with the
messaging systems e.g.  Suitable for urgent cases, or follow-ups, patient.
WhatsApp, Google second opinions provided RMP has enough Cannot be sure of identity of the doctor or
Hangouts, FB Messenger context from other sources the patient
No separate infrastructure required
 Can be real time

ASYNCHRONO US: Convenient and easy to document Not a real time interaction, so just one-way
Email Fax, recordings etc.  No specific app or downloadrequirement context is available, relying solely on the
Images, data, reports readily shared articulation by the patient
No separate infrastructurerequired  Patient identification is document based
More useful when accompanied with test only and difficult to confirm
reports and follow up and second opinions  Non-verbal cues are missed
 There may be delays because theDoctor
may not see the mail immediately

ADVANTAGES OF TELEMEDICINE
The main objective of telemedicine is to cross the geographical barriers and provide healthcare
facilities to rural and remote areas (health for all) so it is beneficial for the population living in
isolated communities. Besides this other advantages of telemedicine are:
 Eliminates distance barriers and improve access to quality health services.
 In emergency and critical care situations where moving a patient may be undesirable
and/or not feasible.
 Facilitates patients and rural practitioners’ access to specialist health services and
support.
 Lessens the inconvenience and/or cost of patient transfers.
 Reduces unnecessary travel time for health professionals.
 Reduces isolation of rural practice by upgrading their knowledge through tele-education
or tele-CME.

-Benefits for Patients

* Improved Access: For over 40 years, telemedicine has been used to bring health care
services to patients in distant locations. People at remote areas get top class medical facility from
reputed hospital. Not only does telemedicine improve access to patients but it also allows
physicians and health facilities to expand their reach, beyond their own offices. Hospital can
spread their reach in remote villages and serve people without much investment or without the
infrastructure. Given the provider shortages throughout the world-in both rural and urban areas-
telemedicine has a unique capacity to increase service to millions of new patients.

* Cost Efficiencies: Reducing or containing the cost of health care is one of the most
important reasons for funding and adopting Telehealth technologies.Telemedicine has been
shown to reduce the cost of healthcare by reducing travel cost and save time and increase

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efficiency through better managementof chronic diseases, shared health professional staffing,
reduced travel times, and fewer or shorter hospital stays.

* Improved Quality: Studies have consistently shown that the quality of health care
services delivered via telemedicine as good those given in traditionally person consultations. In
some specialties, particular in mental health and ICU care, telemedicine delivers a superior
product, with greater outcomes and patient satisfaction. Doctors can tater new technology by
connecting foreign hospital.

* Patient Demand: Consumers want telemedicine. The greatest impact of

telemedicine is on the patient, their family and their community. Using telemedicine
technologies reduces travel time and related stresses for the patient. Over the past
15 years, study after study has documented patient satisfaction and support for
telemedical services. Such services offer patients the access to providers that might
not be available otherwise, as well as medical services without the need to travel
long distances.
* Reduce hospitalization and saves time of health care provider
* Provide patients satisfaction

-Benefits for Doctors

• Excellent opportunity to share knowledge between physicians all over the world.
• Joint consultation with expert physicians and surgeons for the better management of
complicated cases.
• Local doctors can be updated the anytime.
• Medical education in form of teleconferencing.

-Benefits for Government

• Reduced rush to medical facilities in cities.
• Improved monitoring facilities at rural centers.
• Increased reliance on government health care system

-Impact on Education
• Faculty members keeping in touch with classes while attending conferences.
• Guest lecturers brought in classes from other institutions.
• Faculty members participating in thesis defenses at other institutions.
• Administrators on tight schedules collaborating on budget preparation from different
parts of campus.
• Researchers answering questions about grant proposals from agencies or review
committees.
• Student interviews with an employer in other cities.
• Teleseminars.

BARRIERS IN TELEMEDICINE PRACTICE

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The practice of telemedicine: Through transmission of digitized data, audio, video and images
are getting popular all over the world as it provides hitherto unavailable access to tertiary level
specialist healthcare even in geographically remotest areas without displacement of the patient,
physician or the equipment.
a. Physician/patient acceptance: Physicians and patients have unique technological resources
available to improve the patientphysician relationship. It has been found that patients have no
difficulty in accepting telemedicine program. The survey conducted by SGPGIMS tele follow-up
program for the patients of Orissa state revealed that 99% patients were satisfied with using
telemedicine technology. In almost all the cases the patients are more than happy and satisfied as
they do not have to travel 1500 km to show their diagnostic reports to their doctors. In tele-
consultation, they were also happy that they get the specialist consultation and their cases has
been seen by some expert doctors. However, some resistance is seen amongst doctors. Doctors in
government sector tend to look upon telemedicine as an additional duty or workload. Therefore,
there is sometimes fear that telemedicine is likely to reduce their practice. They need to realize
that this technology enhances their reach and exposure and is only likely to increase their
practice further.

b. Availability of technology at a reasonable cost: It is myth that to establish a telemedicine

platform is an expensive. The basic system needs hardware, software and telecommunication
link. In all the areas there is a significant reduction in the prices. Most of these costs are well
within the reach of most of the hospitals, and can be recovered by nominal charge to the patients
and students in case of tele-education which would be much less than the physically traveling.

c. Accessibility: Although information technology has reached in all corners of the country but
the accessibility of people living in remote and rural areas to the nearest health center (PHCs,
CHCs or district hospital) may not be easy due to poor infrastructure of road and transport. It
may be possible that the available telemedicine system in the health centers may not function
because of the interruption in power supply.

d. Reliability: Some healthcare professionals have doubt about the quality of images transmitted
for tele-consultation and tele-diagnosis. In tele-radiology, tele-dermatology the quality of image
(color, resolution, field of view, etc.) should be of international standards to avoid any wrong
interpretation and misdiagnosis. The delay in transmission of data may be of critical importance
in tele-mentoring and robotic surgery and have to be reduced to the minimum.
e. Funding/reimbursement issues: There should be a format to calculate the investment and
recurring cost of the telemedicine system. The insurance companies have to decide whether the
cost of tele-healthcare should be reimbursed or not.

f. Lack of trained manpower: Telemedicine is a new emerging field, there is lack of training
facilities with regards to application of IT in the field of medicine. Most of the healthcare and IT

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professionals are not familiar with the terms commonly used in telemedicine such as HIS, EMR,
PACS, etc. Telemedicine is also not the part of course curriculum of medical schools.

g. Legal and ethical: Telemedicine technology has been proved and established and its
advantages and benefits are well-known but still many healthcare professionals are reluctant to
engage in such practices due to unresolved legal and ethical concerns. In case of a cross-border
tele-consultation which country’s litigation laws will be applied in case—those of the country in
which the patient is living or those of the remote physician?

h. Privacy and security concerns: There are many issues that should be considered regarding the
security, privacy and confidentiality of patient data, in telemedicine consultations. How are
patients’ rights of confidentiality of their personal data ensured and protected? How to ensure
security of the data and restrict its availability to only those for whom it is intended and who are
authorized and entitled to view it? How to prevent misuse and even abuse of electronic records in
the form of unauthorized interception and/or disclosure?

GUIDELINES FOR TELEMEDICINE IN INDIA

The professional judgment of a Registered Medical Practitioner should be the guiding principle
for all telemedicine consultations: An RMP is well positioned to decide whether a technology-
based consultation is sufficient or an in-person review is needed. Practitioner shall exercise
proper discretion and not compromise on the quality of care. Seven elements need to be
considered before beginning any telemedicine consultation:
1. Context
2. Identification of RMP and Patient
3. Mode of Communication
4. Consent
5 .Type of Consultation
6 .Patient Evaluation
7. Patient Management

1. Telemedicine should be appropriate and sufficient as per context.

o The Registered Medical Practitioners should exercise their professional judgment to
decide whether a telemedicine consultation is appropriate in a given situation or an in-
person consultation is needed in the interest of the patient.
o They should consider the mode/technologies available and their adequacy for a diagnosis
before choosing to proceed with any health education or counseling or medication.
o They should be reasonably comfortable that telemedicine is in the patient’s interest after
taking a holistic view of the given situation.
Complexity of Patient’s health condition: Every patient/case/medical condition may be
different, for example, a new patient may present with a simple complaint such as headache

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while a known patient of Diabetes may consult for a follow-up with emergencies such as
Diabetic Ketoacidosis. The RMP shall uphold the same standard of care as in an in-person
consultation but within the intrinsic limits of telemedicine.

2. Identification of the registered medical practitioner and the patient is required

- Telemedicine consultation is should not be anonymous: both patient and the RMP need to
know each other’s identity.
-An RMP should verify and confirm patient’s identity by name, age, address, email ID, phone
number, registered ID or any other identification as may be deemed to be appropriate. The RMP
should ensure that there is a mechanism for a patient to verify the credentials and contact details
of the RMP.
- For issuing a prescription, the RMP needs to explicitly ask the age of the patient, and if there is
any doubt, seek age proof. Where the patient is a minor, after confirming the age, tele
consultation would be allowed only if the minor is consulting along-with an adult whose identity
needs to be ascertained.
-An RMP should begin the consultation by informing the patient about his/her name and
qualifications.
- Every RMP shall display the registration number accorded to him/her by the State Medical
Council/MCI, on prescriptions, website, electronic communication (WhatsApp/ email etc.) and
receipts etc. given to his/her patients.

3. Mode of telemedicine
- Multiple technologies can be used to deliver telemedicine consultations. All these technology
systems have their respective strengths, weaknesses and contexts in which they may be
appropriate or inadequate in order to deliver proper care.
- Primarily there are 3 modes: Video, Audio or Text (chat, images, messaging, email, fax etc.).
Their strengths, limitations and appropriateness as detailed in Section 2 need to be considered by
the RMP.
-There may be situations where in order to reach a diagnosis and to understand the context better;
a real-time consultation may be preferable over an asynchronous exchange of information.
Similarly, there would be conditions where an RMP could require hearing the patient speak,
therefore, a voice interaction may be preferred than an email or text for a diagnosis. There are
also situations where the RMP needs to visually examine the patient and make a diagnosis. In
such a case, the RMP could recommend a video consultation. Considering the situation, using
his/her best judgment, an RMP may decide the best technology to use to diagnose and treat.

4. Patient consent
-Patient consent is necessary for any telemedicine consultation. The consent can be Implied or
explicit depending on the following situations:
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- If, the patient initiates the telemedicine consultation, then the consent is implied
- An Explicit patient consent is needed if: A Health worker, RMP or a Caregiver initiates a
Telemedicine consultation.
-An Explicit consent can be recorded in any form. Patient can send an email, text or audio/video
message. Patient can state his/her intent on phone/video to the RMP (e.g. “Yes, I consent to avail
consultation via telemedicine” or any such communication in simple words). The RMP must
record this in his patient records.

5. Exchange of information for patient evaluation

- Patient’s Information - An RMP would use his/her professional discretion to gather the type
and extent of patient information (history/examination findings/Investigation reports/past records
etc.) required to be able to exercise proper clinical judgment. - This information can be
supplemented through conversation with a healthcare worker/provider and by any information
supported by technology-based tools.
- If the RMP feels that the information received is inadequate, then he/she can request for
additional information from the patient. This information may be shared in real time or shared
later via email/text, as per the nature of such information. For example, an RMP may advise
some laboratory or/and radiological tests to the patient. In such instances, the consult may be
considered paused and can be resumed at the rescheduled time. An RMP may provide health
education as appropriate at any time.
- Telemedicine has its own set of limitations for adequate examination. If a physical examination
is critical information for consultation, RMP should not proceed until a physical examination can
be arranged through an in-person consult. Wherever necessary, depending on professional
judgment of the RMP, he/she shall recommend:
- Video consultation
- Examination by another RMP/ Health Worker
- In-person consultation

6. Types of consultation: first consult/ follow-up consult.

There are two types of patient consultations, namely, first consult and the follow-up consult.
An RMP may have only a limited understanding of the patient seeking teleconsultation for the
first time, when there has been no prior in-person consultation. However, if the first consult
happens to be via video, RMP can make a much better judgment and hence can provide much
better advice including additional medicines, if indicated. On the other hand, if a patient has been
seen in-person earlier by the RMP, then it is possible to be more comprehensive in managing the
patient.
 First Consult means the patient is consulting with the RMP for the first time; or the
patient has consulted with the RMP earlier, but more than 6 months have lapsed since the
previous consultation; or the patient has consulted with the RMP earlier, but for a
different health condition

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  Follow-Up Consult(s) means the patient is consulting with the same RMP within 6
months of his/her previous in-person consultation and this is for continuation of care of
the same health condition.
However, it will not be considered a follow up if: There are new symptoms that are not in the
spectrum of the same health condition and/or RMP does not recall the context of previous
treatment and advice.

7. Patient management: health education, counseling &medication.

If the condition can be appropriately managed via telemedicine, based on the type of
consultation, then the RMP may proceed with a professional judgment to:
* Provide Health Education as appropriate in the case
* Provide Counseling related to specific clinical condition
* Prescribe Medicines
-Health Education: An RMP may impart health promotion and disease prevention messages.
These could be related to diet, physical activity, and cessation of smoking, contagious infections
and so on. Likewise, he/ she may give advice on immunizations, exercises, hygiene practices,
mosquito control etc.
-Counseling: This is specific advice given to patients and it may, for instance, include food
restrictions, dos and don’ts for a patient on anticancer drugs, proper use of a hearing aid, home
physiotherapy, etc to mitigate the underlying condition. This may also include advice for new
investigations that need to be carried out before the next consult.

Legal aspects of telemedicine in India

In India, till now there was no legislation or guidelines on the practice of telemedicine, through
video, phone, Internet based platforms (web/chat/apps etc). The existing provisions under the
Indian Medical Council Act, 1956, the Indian Medical Council (Professional Conduct, Etiquette
and Ethics Regulation 2002), Drugs &Cosmetics Act, 1940 and Rules 1945, Clinical
Establishment (Registration and Regulation) Act, 2010, Information Technology Act, 2000 and
the Information Technology (Reasonable Security Practices and Procedures and Sensitive
Personal Data or Information) Rules 2011 primarily govern the practice of medicine and
information technology. Gaps in legislation and the uncertainty of rules pose a risk for both the
doctors and their patients.

Current Efforts
In India, telemedicine programs are actively supported by:
Department of Information Technology (DIT)
 Indian Space Research Organization(ISRO)
 NEC Telemedicine program for North-Eastern states
 Apollo Hospitals
 Asia Heart Foundation
 State governments

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  Telemedicine technology also supported by some other private organizations

DIT as a facilitator with the long-term objective of effective utilization / incorporation of

Information Technology (IT) in all major sectors, has taken the following leads in
Telemedicine.
Development of Technology:
 Initiation of pilot schemes-Selected Specialty, e.g., Oncology, Tropical Diseases and
General telemedicine system covering all specialties
 Standardization
 Framework for building IT Infrastructure in health

The telemedicine software system has also been developed by the Centre for Development of
Advanced Computing, C-DAC which supports Tele-Cardiology, Tele-Radiology and Tele-
Pathology etc. It uses ISDN, VSAT, and POTS and is used to connect the three premier Medical
Institutes of the country (viz. All India Institute of Medical Sciences (AIIMS), New Delhi,
Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), Lucknow and Post
Graduate Institute of Medical Education and Research (PGIMER), Chandigarh). Now it is being
connected to include Medical centers in Rohtak, Shimla and Cuttack.

-The telemedicine system has been installed in the School of Tropical Medicine (STM), Kolkata
and two District Hospitals. In West Bengal, two hospitals where telemedicine centers have been
established are the First Coronary Care Unit inaugurated in Siliguri District Hospital, Siliguri,
and West Bengal on 24 June, 2001 and BankuraSammilani Hospital, Bankura, West Bengal
inaugurated on 21 July, 2001. Apart from the project at STM, the Second Telemedicine Project
has been implemented by Webel ECS at two Referral Centers (Nil RatanSircar Medical College
and Hospital (NRS MC and H), Kolkata and Burdwan MC and H, Burdwan) and four Nodal
Centres (Midnapore (W) District Hospital, Behrampur District Hospital, Suri District Hospital
and Purulia District Hospital). The Project uses a 512 kbps leased line and West Bengal State
Wide Area Network (WBSWAN) (2 Mbps fiber optic link) as the backbone.

ISRO's telemedicine network has expanded to connect 45 remote and rural hospitals and 15
super specialty hospitals. The remote / rural nodes include the offshore islands of Andaman and
Nicobar and Lakshadweep, the mountainous and hilly regions of Jammu and Kashmir including
Kargil and Leh, Medical College hospitals in Orissa and some of the rural / district hospitals in
the mainland states.

TELENURSING
• Tele-nursing refers to the use of telecommunications and information technology for providing
nursing services in health care whenever a large physical distance exists between patient and
nurse, or between any numbers of nurses. As a field it is part of tele-health, and has many points

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of contacts with other medical and non-medical applications, such as tele-diagnosis, tele-
consultation, tele-monitoring, tele-care etc.

-The first documented evidence of Telenursing occurred in 1974 when Mary Quinn, RN,
provided remote nursing care to patients who were at Logan Airport. Ms. Quinn was an
employee of Boston Hospital's telemedicine centre. Many consider this to be the date when the
Telenursing industry was born.

-International Council of Nurses (ICN, 2009), Telenursing is-

“The use of telecommunications technology in nursing to enhance patient care. It involves the
use of electromagnetic channels (e.g. wire, radio, and optical) to transmit voice, data, and video
communications signals.”

Telenursing - is the delivery, management, and coordination of care and services provided via
telecommunications technology within the domain of nursing.
- (American Association of Ambulatory Care Nursing(AAACN), 2004)

Registered Nurse (RN) -a “Registered Nurse and Midwife” is defined as “an individual who has
completed minimum General Nursing and Midwifery (GNM) course or BSc in Nursing course
(BSc N) and has enrolled in the State Nursing Council or Indian Nursing Council under the
Indian Nursing Council Act, 1947”.

Registered Auxiliary Nurse & Midwife (R.ANM) - a “Registered Auxiliary Nurse and Midwife”
(R.ANM) or “Junior Health Assistant” is defined as “an individual who has completed the
Auxiliary Nurse Midwifery course and have enrolled in State Nursing Council and Indian
Nursing Council under the Indian Nursing Council Act 1947”.

OBJECTIVES:
 To deliver care and expertise
 For curative, preventive and rehabilitation
 For training and information

SCOPE:
These Telenursing practice guidelines will be published under the INC Act, 1947. These
guidelines are developed to enable nurses and midwives in India in adopting and utilizing the
Telenursing concept in their professional practice to provide optimal care.
 These guidelines are intended for Registered Nurses and Registered Auxiliary Nurse &
Midwives (RN&R. ANMs) under the INC Act 1947.
 These guidelines were developed based on the professional norms and standards of practice
recommended by the Indian Nursing Council, Trained Nurses Association of India, and the
International Council of Nurses. The review of other relevant telemedicine practice
guidelines was taken into consideration.
 Telenursing like telemedicine includes all channels of communication with the patient that
leverage Information Technology platforms, including Voice, Audio, and Text& Digital Data
exchange.

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 ▪ These guidelines also can be utilized to educate health care workers in various aspects to
update their knowledge.

Exclusions: The guidelines exclude

the following:
▪ Data management systems involved; standards and interoperability.
▪ Use of digital technology and artificial intelligence to carry out specific nursing procedures
(Insertion of intravenous infusions, conducting deliveries, etc).
▪ Provide for consultations out of the professional boundaries
▪ Provide for tele-consultations outside the jurisdiction of India

QUALIFICATIONS REQUIRED TO PRACTICE TELE NURSING

-Registered Nurses are entitled to provide Telenursing consultation to patients from across India
both in private and public health establishments.
-Registered Nurses who practice Telenursing shall uphold the same professional and ethical
norms, laws and clinical standards consistent within the scope of professional organizations (i.e.,
as outlined in various policy documents such as the Indian Nursing Council Act, Code of ethics
and professional standards for nurses in India and position statements by Trained Nurses
Association of India).

TECHNOLOGY USED IN TELE NURSING PRACTICE

Telenursing has evolved as an important branch of telemedicine. The essential technology tools
required for Telenursing include:
-Dedicated Office Mobile /Landline number and Email ID: It is preferable to consider having a
dedicated work phone/ office mobile line number/ professional social media account/Email ID to
provide Telenursing services. This helps the nurses in communicating with their clients
effectively.
-Internet Connection Secure and dependable internet connectivity is a prerequisite for a
successful Telenursing experience. A range of healthcare-related activities such as video
conferencing, accessible health care records, emails, uninterrupted communications, and so on,
are largely based on network performance. However, Wi-Fi technology has improved a lot. Yet
individuals have to remember not to move away from the range of the router.
-Computer system: A computer system comprises of two major elements namely hardware and
software. Computer hardware is the collection of physical parts that can be recognized easily
such as a keyboard, monitor, mouse, etc. In contrast, computer software is a set of instructions to
perform specific operations. For example, computer programs, online documentation, digital
media, etc. However, both computer hardware and software require each other, and neither can
function independently.
- Hardware: The most common types of hardware used in Telenursing consultations include,
desktop and laptop computers and tablets.
-Desktop computer:A desktop computer is a personal computer, consisting of a Central
Processing Unit (CPU), keyboard and a mouse. This type of computer is not portable due to its
size and power requirements.
- Laptop computer: A laptop computer has the same hardware components but is integrated into
a single portable unit.

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- Tablets and mobile devices: Tablets, such as iPads, are often used in emergency services and
other healthcare areas. Health care professionals (doctors and nurses) were the early adopters of
tablets and smartphones due to their portability and advanced features. The majority of health
care consumers are also able to use mobile phones effectively for video and audio conferencing
with health care providers. Mobile technology allows an instant connection between the
consumers and healthcare professionals to provide convenient care regardless of the location.
-Software: Nurses may choose software applications that are simple, easily adaptable, and can
provide uninterrupted communication with their clients. It is also important to choose the
software applications which are most commonly used by the general public. Telemedicine
practice guidelines (2020) and telepsychiatry operative guidelines (2020) also suggested the use
of social media such as WhatsApp, Skype, Facebook, and so forth which are popular among the
general public.
-Digital camera: Digital camera technology allows a simple, inexpensive Telenursing
experience. It is an essential component of Telenursing consultations. Thus, it is essential to have
high-end, high-resolution digital cameras as they allow nursing professionals to take clear
images and share them with specialists at different locations. The way nurses present themselves
on camera is extremely important during video consultations. Therefore, the camera has to be
placed at eye-level. Active listening and maintaining eye contact (looking at the camera) is
important to build rapport with the patients. If nurses are taking notes on history collection or
complaints, it is necessary to keep the patients informed, lest that behavior be mistaken as
distraction on part of the nurse.
-Infrastructure: The infrastructure of the teleconsultation room should create an environment
that allows nursing professionals to use technology in offering care to patients in remote areas.
-Location: The room should be set up in a quiet location to avoid noise exposure. It is important
to remember that, sound can be easily picked up by microphones and create difficulty in hearing
for the remote participants. Preferably, the room should be situated away from noisy hallways,
waiting rooms or restrooms and air-conditioners, to enable better sound quality. If possible, it is
wise to select a windowless room to obtain better image quality and ensure privacy. Rooms with
windows should have curtains or screens.
-Room size: The teleconsultation room should be large enough as it affects the camera’s field of
view. This distance between the two walls may vary according to the type of clinical service
being provided. Sometimes nurses would like to focus on the full view of the patient or only the
relevant body part. So, the nurses need to select the room size accordingly.
-Room design: The room should be designed in such a way to allow the nursing staff to enter and
exit easily without disrupting the consultation process. There should be a facility to indicate any
technical problems that exist during Telenursing consultation.
-Location of windows: The clients or nursing professionals should not sit with their back against
the window as this causes backlighting and reduces image quality. If this is not possible, curtains
should be fixed to reduce the backlighting effect. It is also recommended to use light blue or light
grey colours on the walls to reduce the impact of lighting.

GUIDELINES FOR TELENURSING PRACTICE

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Telenursing consultations need to be structured to provide optimal care to the patients. The
following elements need to be considered before beginning any Telenursing consultation
(adopted from telemedicine guidelines, 2020).
1. Context
2. Identification of RN and Patient
3. Mode of Communication
4. Consent
5. Assessment and communication of the patient related information with RMP
6. Patient Management
7. Professional accountability and responsibilities of the registered nurse

-Consent:Registered nurses should exercise their clinical skills and professional judgment to
decide whether a Telenursing consultation is appropriate in a given situation or an in-person
consultation is needed in the interest of the patient. In this phase, the RN should make a cursory
assessment of the patients and communicate with the RMP. After discussing with the RMP, the
RN helps patients in deciding what type of care they need. Standard protocols need to be
developed to help the RN in making decisions for the patients. However, protocols won’t replace
the training on Telenursing. Whatever the context or situation, the registered nurse should uphold
the same standard of care as an in-person consultation.

-Identification of the registered nurse and the patient:

 In Telenursing consultation, both patients and nurses need to know each other’s identity.
 Nurses should verify and confirm the patient’s identity by name, age, gender, address, email
ID, phone number, registered ID, or any other identification as may be deemed to be
appropriate. There should be a checklist or a form to acquire the details of the patients.
 The RN should ask for valid documents to confirm their age, height, and weight of the
patients and explain to them the necessity of the same for prescribing medications by the
RMPs. The nurses should confirm that adults are present with children during
teleconsultation (below 18 years of age).
 The RN should obtain consent from the patient/family member to transmit the patient
relateddata to the RMPs and other health team members.
 The RN should display the registration number accorded to him/her by the State Nursing
Council/Indian Nursing Council, in all electronic communication (WhatsApp/ email, etc.)
and receipts.

-Mode of Telenursing
 The most commonly used modes of communication are Video, Audio, or Text (chat, images,
messaging, email, fax, etc.).
 Mode of communication should be based on the patient’s symptoms and preferences of the
health care providers. There may be situations where a real-time consultation would be better
to understand the context than an asynchronous exchange of information by the RN to the
RMP. Therefore, the mode of technology can be decided by the health care providers
depending upon the situation and patients’ needs.

-Patient consent:

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 Patient consent is necessary for teleconsultation. The consent can be implied or explicit
depending on the following situations:
 If the patient initiates the telemedicine consultation, then consent is implied (the patient has
initiated the consultation).
 Explicit patient consent is needed if:
 A Registered Nurse, Health worker, Registered Medical Practitioner (RMP) or a family
member initiates a Telemedicine consultation.
 Explicit consent can be recorded in any form. The patient can send an email, text, or an
audio/video message or consent form. The patient also can state his/her intent on phone/video
to the registered Nurse (e.g. “Yes, I consent to avail consultation via Telenursing” or any such
communication in simple words) and this must be saved in the patient’s records.

-Assessment and communication of the patient related information with RMP:

 Registered nurses must collect adequate patient-related information to communicate with the
RMP which enables the RMP to make appropriate decisions for the patient.
 Patient’s Information ▪ The RN should collect patients’ history based on protocols and
guidelines (SOPs). Auxiliary Nurse Midwives (ANMs) and other community health workers
(ASHAs, Anganwadi teachers, etc.) may not have adequate capacity to analyze the patient’s
problems. Hence, they need to undergo a brief training on identification of the patient’s
problems and how to communicate the same with the RMP in the higher centre such as
Primary Health Centre or Community Health Centre.
 The RN should make a detailed assessment of the patients based on the written protocols.
This information can help the RMPs to rule out emergencies and positive patient outcomes.
 If in case physical examination or in-person consultation is critical for the patient, RN should
facilitate the same with the RMP.
 The registered nurse should maintain all patient records including case history, investigation
reports, images, treatment prescribed by the doctors, and care offered by nursing
professionals, etc.

-Patient management: clinical care, health education& counselling, medication

Nursing management of the patient includes:
 Clinical care
 Providing information and Health Education related to the disease condition
 Offering necessary Counselling related to specific clinical condition; and/or
 reinforcing about treatment regimen as prescribed by the doctor

-Professional accountability and responsibilities of the registered nurse

 Nursing Ethics, Data Privacy & Confidentiality:
Principles of nursing ethics, including professional norms for protecting patient privacy and
confidentiality as per the INC Act, shall be binding and must be upheld and practiced.
 Registered Nurse would be required to fully abide by the Indian Council Act 1947
(Professional Conduct, Etiquette and Ethics) and with the relevant provisions of the IT
Act, Data protection and privacy laws, or any applicable rules notified from time to time
for protecting patients’ privacy and confidentiality and regarding the handling and
transfer of such personal information regarding the patient. This shall be binding and
must be upheld and practiced.
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  Registered Nurses will not be held responsible for breach of confidentiality if there is
reasonable evidence to believe that the patient’s privacy and confidentiality have been
compromised by a technology breach or by a person other than RN. The RNs should
ensure that a reasonable degree of care is undertaken while hiring such services.
 Misconduct:
The registered nurses are legally liable if their actions wilfully compromise patient's care
or privacy and confidentiality, or violation of prevailing laws.
Some examples of misconduct in Telenursing practice include:
 RNs insisting on Telemedicine, when the patient is willing to travel to a facility
and/or requests an in-person consultation.
 RNs misusing patient images and data, which are especially private and sensitive (e.g.
RN uploads an explicit picture of the patient on social media etc).
 RNs issuing prescription. RNs giving inappropriate advice out of their professional
boundaries.
 RNs are not permitted to solicit patients for Telenursing through advertisements or
inducements.

Types of Telenursing Services

There are many different types of nursing services can be provided remotely. The basics of
the nursing process – assessment, planning, intervention, and evaluation of outcomes – still
apply. The only difference is that the care is provided remotely, rather than in person.
The following are some of the services which lend themselves Telenursing:

 Triage. As already mentioned, Telenursing is used extensively at call centers for

triage to determine the severity of a patient’s condition and advise accordingly.

 Pre-operative. Pre-operatively the nurse can complete that part of the patient
assessment, which doesn’t require physical presence, including personal details
and a full medical history. Based on the information obtained, further laboratory
and other investigations can be ordered, and plans can be made in advance to
meet particular needs once the patient is admitted.

 Home care during illness or recovery. Patients who either do not require
hospitalization or are recovering at home after an illness or surgery can be
monitored, advised, and educated via Telenursing. Through video calls, a nurse
can, for example, assess wound healing and teach wound care. Astudy found that
telephone calls with specially trained nurses significantly reduced the level
of anxiety in patients with COVID-19 who were recovering at home.

 Consultations for minor ailments. Many minor conditions for which patients
routinely visit doctor’s rooms could be successfully diagnosed and treated via
remote consultations, particularly with the availability of video conferencing.
Examples are common pediatric conditions, uncomplicated allergic skin reactions,
and minor injuries.

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  Care for patients with chronic conditions. A significant growth area for
Telenursing is in the care and monitoring of the aged with chronic conditions.
Nurses can monitor these patients’ well-being through regular video conferences
as well as via digital monitoring devices. The nurse will also pick up on their need
for additional health services such as that of a dietician, physical therapist, or
optometrist, and then act as a coordinator between the patient and different health
services.

 Mental health care. Telehealth services are widely used for crisis intervention
and suicide prevention. Via Telenursing services, patients with mental health
and substance abuse problems can be evaluated regularly, and the nurse can also
be on call should the client face a problematic situation. This is particularly
valuable in areas where there is a shortage of mental health resources.

APPLICATIONS OF TELENURSING
 One of the most distinctive Telenursing applications in home care. For example patients
who are immobilized or live in remote area, citizens who have chronically ailments such
as COPD, diabetes, CHF or disabilitating diseases (Parkinson's disease, Alzheimer’s
disease) etc. may stay at home and be visited and assisted regulatory by a nurse via, video
conferencing, internet, video and phone, etc.Still other applications of home care are the
care of patients in immediate postsurgical situations, the care of wounds, handicapped
individuals etc. In normal home health care one nurse is able to visit up to 5-7 patients/
day but by using Telenursing one nurse can visit 12-16 patients in the same time.

 A common application of Telenursing is also used by call centres operated by managed

care organizations which are staffed by registered nurses who act as case managers or
perform patient triage. Information and counselling as a means of regulating patient
access and flow and decrease the use of emergency rooms.

 Telenursing can also involve other activities such as patient education, teleconsultation,
examination of results of medical tests, and assistance to physicians in the
implementation of medical treatment protocols.

 Telenursing has been used as a tool in home nursing, where immobilized patients, those
living in remote areas or those with chronic disease conditions may stay at home and be
visited and assisted regularly by a nurse via video-conferencing, Internet, video,
phone,etc.

 Telenursing can also provide opportunities for patient education, nursing teleconsultation,
and examination of results of medical tests and assistance to physicians in the
implementation of medical treatment protocols.

Potential applications of Telenursing may also include:

 Collaborating and mentoring by nurses around the globe
 Triage and counselling of patients by medical call centres.

23
  Telediagnostics (not only basic tele-ECG, but more advanced nursing diagnostics, as
well).
 Nursing care for soldiers on or near the battlefield
 Assisting and training nurses in developing countries
 Nursing teleconsultation, both before and after admission to a hospital
 Support to home care
 Monitoring in risk pregnancies, home-bound seniors, the physically disadvantaged, etc.
 Support to nursing second opinion services
 Case management, personal health tutoring and follow-up of chronic and post-acute
patients Emergency nursing, paramedic rescue
 Remote intensive care monitoring (e-ICU)
 Tele-rehabilitation
 Tele-education for patients, particularly for informedconsent
 Healthcare plans audits
 Support to nursing research.

Telehealth nurses should have good communication skills.She must be good listener and critical
thinkers. She should be capable of judging and understanding patients' problem.

Legal, Ethical and Safety Issues

Telenursing is freight with legal, ethical and regulatory issues as it happens with Telehealth as a
whole. In many countries interstate and inter country practice of Telenursing is forbidden. The
attending nurse must have a license both in her state/country or residence and in the state/country
where the patient receiving telecare is located. Legal issues such as accountability and
malpractice, etc. are also still largely an unsolved and difficult to address. In addition there are
many considerations related to patient's confidentiality and safety of clinical data.
1. Assess appropriateness of tele health for patients' ability and status.
2. Know equipment
3. Evaluate reliability and effective use of equipment
4. Infection control
5. Information safety
6. Compliment with nurse judgment

Role of Tele Health Nurse

1. Nurse presenter-ambulatory.
2. Nurse Case manager-i.e. diabetes care.
3. Public health nursing
4. Health coach
5. Tele-ICU nursing.
6. Clinical tele-health co-ordinator, e.g. Nurse Clinician/ presenter.
7. Planning tele health program i.e., speciality consultations in rural/village/PHC/Hospital.
8. Co-ordinate scheduling clients.
9. Evaluating and preparation of equipment.
10. Assessing clients.
11. Presenting patient.

24
 12. Facilitating remote exam.
13. Documentation.
14. Follow up care.

Advantages of Tele Nursing

1. Nurses can help more clients in less time due to the fact that there is no travel involved
for the nurse. Fewer nurses are required to reach more people.
2. Emergency room visits and hospitalizations may decrease as patients don't have to wait
as long to be "seen". Patients can be monitored more closely. Providers can collaborate
more easily via the use of technology, saving both money and time. Tele nursing can
improve patient compliance to prescribed care. Patients who are discharged early from
the hospital can be monitored at home for complications.
3. Telehealth nursing focuses on patients' long-term well. Self-management and health.It
promotes accessibility of nursing care in remote areas
4. Nurses can assist with patient retention
5. Increased health care employment opportunities.
6. Economic in terms of money, material and time.
7. Decrease on-call hours for healthcare providers
8. Offer versatility for use during any time interval including ground-the-clock, weekend, or
afterhours care.
9. Telehealth nurses' versatility includes the ability to guide patients to bed visits, clarify
appropriate treatment options, educate about self-care at home, and assist with
appointment scheduling
Disadvantages of Tele Nursing
1. Decreased face-to-face interaction.
2. Security of data.
3. Risk of decreasing quality of care- Increase liability.
4. Concerns with maintaining confidentiality.
5. Likelihood of technology failure.
6. Dehumanizing effects.
7. Knowledge base of nurse.
8. Inability for patients to use equipment.
9. Malfunctioning of equipment.

Future of Telenursing
The applications of telemedicine for nurses include the following:
1. Patient Consultations: These can range from a simple follow-up session after a
procedure, topatient education as part of a disease management program, to more
involved consultations that involve diagnosis and treatment.
2. Remote Monitoring: Devices used by the patient at home can collect and transmit
medical data to clinicians for interpretation so a medical intervention can be planned.
3. Education and Career Opportunities: Skills and competencies required by traditional
bedside nursing. You'll still be performing nursing assessments and taking on the role of
patient advocate. It's just technology adds another piece to the puzzle-you should be
skilled with health care information technology (HIT). It's an added bonus if you can help
to design or refine technologybased delivery model.

25
 CONCLUSION:

Normally, doctors and other health care providers care for their patients in person at a facility such
as a medical office, clinic, or hospital. But thanks to computers, smartphones, and other new
digital technologies, medical professionals can now diagnose, treat, and oversee their patients' care
virtually.Telehealth is defined as the delivery of health care services at a distance through the use
of technology. It can include everything from conducting medical visits over the computer, to
monitoring patients' vital signs remotely. Its definition is broader than that of telemedicine, which
only includes the remote delivery of health care. Telehealth also includes the training and
continuing education of medical professionals.

Using technology to deliver health care has several advantages, including cost savings,
convenience, and the ability to provide care to people with mobility limitations, or those in rural
areas who don't have access to a local doctor or clinic. Telehealth has become even more essential
during the coronavirus (COVID-19) pandemic. Fears of spreading and catching the virus during
in-person medical visits have led to a greater interest in, and use of, technology to provide and
receive health care.

26
RELATED JOURNAL

1.Snoswell CL, Taylor ML, Comans TA, Smith AC, Gray LC, Caffery LJ
Determining if Telehealth Can Reduce Health System Costs: Scoping Review
J Med Internet Res 2020;22(10):e17298
doi: 10.2196/17298PMID: 33074157PMCID: 7605980

Conclusions:Health services considering implementing telehealth should be motivated by

benefits other than cost reduction. The available evidence has indicated that although telehealth
provides overwhelmingly positive patient benefits and increases productivity for many services,
current evidence suggests that it does not routinely reduce the cost of care delivery for the health
system.

2.Afik, A., &Pandin, M. G. R. (2021). Telenursing as a new nursing paradigm in the 21 century:
A literature review.
Nursing is a part of health services that serves individuals, groups and communities. In this 21st
century the need for nursing services has changed rapidly and in a complex manner. Physical
limitations, is on should to be considered, while the implementation and maintenance of patient-
centered service infrastructure still have to be recked. The aim of this literature review is to
identify the role of telenursing in nursing services for patients. This language method uses
literature reviews which are summaries of 10 articles in the publication years of 2019, 2020, and
2021 on 3 search databases, namely Scopus, Science Direct, and SAGE. This review used the
new Joanna Briggs Institute and Prisma. The eligibility of these studies were from its title,
abstract, research methodology, results, and discussion. The results of the review were presented
in narrative form. The results of a review of 10 articles found that the form of nursing services
with telenursing could prove long-distance service, time efficiency and funding allocation, but in
terms of quality it had been not satisfactory related to its physical implementation of nursing
service. Conclusion: The nursing paradigm in the 21st century global era has been developedwith
the help of technology to meet the needs of distance efficiency and cost limitations. Thus,
telenursing is a solution to answer these challenges.

3.Khemapech, I., Sansrimahachai, W., &Toachoodee, M. (2019). Telemedicine–meaning,

challenges and opportunities. Siriraj medical journal, 71(3), 246-252.

4.Sakinah, S., Nurdin, S.(2020). Telenursing and self-management among patient with
hypertension.Malahayati International Journal of Nursing and Health Science, vol 03, no.2,
September 2020

BIBLIOGRAPHY:
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