Education and Practice

Journal of Telemedicine and Telecare

0(0) 1–4
Primary-care registered nurse telehealth ! The Author(s) 2020
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DOI: 10.1177/1357633X20940142
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Susan Watkins and Judy Neubrander

Abstract
Coronavirus disease 2019 (COVID-19) has drastically changed health-care delivery models within primary-care settings.
Primary-care providers are limiting routine care face-to-face office visits while triaging COVID-19 symptomatic patients
to hospital emergency rooms. Primary-care providers are rapidly adopting telehealth modalities for care provisions
during this unprecedented pandemic to allow practices to continue delivering primary care while preventing community
spread of COVID-19. Federal legislation has responded to emergent public-health needs by removing barriers that have
impeded widespread adoption of telehealth modalities. This legislation has omitted professional registered nurses (RNs)
from delivering reimbursable telehealth services, which is problematic for primary-care practice. RNs historically have
led telehealth service delivery and should therefore be included in new legislation as eligible health professionals per-
mitted to provide reimbursable telehealth services. RNs improve quality outcomes in primary care within innovative
team-based care models and are essential clinicians capable of providing ongoing care coordination and disease man-
agement for patients needing to stay on track with their usual care needs.

Keywords
Telecare, telehealth, telemedicine, telenursing
Date received: 8 April 2020; Date accepted: 11 June 2020

Accelerated Virtual Care Demand

The coronavirus disease 2019 (COVID-19) pandemic
has accelerated the demand for health-care delivery
systems to enhance virtual care accessibility modalities
that promote cost-effective, high-quality and person-
centred care. The COVID-19 public-health recommen-
dations to minimize community viral spread are
consequently devastating the financial viability of
non-essential businesses, along with essential
community-based health-care entities.1 Primary-care
practices, although essential, have been required to
reserve face-to-face visits for emergent care needs,
along with encouraging patients with symptoms consis-
tent with COVID-19 to stay at home or seek emergency
room care.1 The COVID-19 pandemic has resulted in
primary-care practices experiencing significant staffing
furloughs, reduced visit capacity and decreased revenue
from face-to-face visits.1 Moreover, since many
primary-care practices still operate within fee-
for-service reimbursement models that reward practi-
tioners based on face-to-face office visit volumes to
generate revenue, primary-care providers (PCP) are
concerned about the financial viability of their practice
during this unpredictable pandemic.1 Telehealth
modalities for delivering virtual health visits have
attracted significant attention by primary-care practices
during this unprecedented pandemic, although tele-
health has been an approved and reimbursable service
through the Center for Medicare and Medicaid Service
(CMS) since 1997.2
Prior to the COVID-19 pandemic, less than 10% of
PCPs had adopted telehealth technology to conduct
virtual visits for reasons including complicated technol-
ogy, patient confidentiality and reimbursement
obstacles.3 As a result of the COVID-19 pandemic,
CMS has expanded telehealth reimbursement through
the Coronavirus Aid, Relief, and Economic Security
(CARES) Act as an emergent response to the health-
care market’s access and financial sustainability
Mennonite College of Nursing at Illinois State University, USA
Corresponding author:
Susan Watkins, Mennonite College of Nursing at Illinois State University,
203 Edwards Hall Campus Box 5810, Normal, IL 61790, USA.
Email: smwatk2@ilstu.edu
2 Journal of Telemedicine and Telecare 0(0)
concerns.4 Along with the CARES Act, the Creating
Opportunities Now for Necessary and Effective Care
Technologies (CONNECT) for Health Act of 2019
(CONNECT Act) will be proposed in 2021 in order
to reduce Medicare telehealth obstacles within the
Social Security Act.5 The CONNECT Act could also
renounce complicating telehealth live-video, asynchro-
nous store-and-forward, and originating patient/pro-
vider site and service modality requirement obstacles
that have hindered widespread adoption of telehealth
services in primary care.5 These legislation efforts are
significant benefactors to increasing widespread adop-
tion of telehealth within primary-care practices to allow
providers the capability of providing essential health-
care services for acute illness and chronic disease man-
agement.1 However, registered professional nurses were
omitted as eligible providers of reimbursable telehealth
services within both of these Acts.4,5 This is a signifi-
cant oversight, as CMS has permitted other non-face-
to-face registered nurse (RN) services to be billed and
reimbursed under the supervising PCP to support
chronic care management (CCM) and transitional
care management (TCM).4 These approved non-
face-to-face RN remote care services were influential
to the US health-care system considering that CMS
approval for reimbursement often signifies an interven-
tion’s potential for widespread utilization.6
TCM services were originated in 2013 by CMS to
support beneficiaries transitioning from a hospital or
skilled nursing facility (SNF) to a community setting
during the first 30 days after discharge.4 TCM was the
first service that could be ordered by the PCP and
supported by auxiliary personnel, such as RNs who
provide the services directly face-to-face or non-
face-to-face as a therapeutic care coordination service
under the ‘incident to’ benefit with PCP supervision.4
CCM services were originated by CMS in 2015 to qual-
ifying beneficiaries having a minimum of two chronic
diseases that increase risk of exacerbation and mortal-
ity and who are established with a supervising PCP and
a comprehensive care plan.4 The original CCM service
in 2015 included up to 20 minutes per month of care
coordination and disease self-management support
provided by a RN directly supervised by the PCP.4 In
2017, CMS increased payment under CCM for com-
plex service delivery for consenting beneficiaries, which
includes moderate to high-complexity medical decision
making, and 60 minutes additional clinical staff time
each month supervised by the PCP for disease self-
management support.4 These complex CCM services
can be delivered by the RN as face-to-face or non-
face-to-face for consenting beneficiaries under the
orders and supervision of the PCP to assist patients
with care coordination and disease management.4
The CMS TCM and CCM provisions had a signif-
icant impact on widespread adoption for RNs support-
ing non face-to-face reimbursable telehealth nursing
services.6 CMS TCM and CCM provisions will need
to be expanded within state policies to increase nation-
al implementation of telehealth platforms.2 Telehealth
nursing services have become an essential team-based
primary-care chronic disease management and care
coordination commodity that supports population
health improvement efforts in the USA.6 Evidence sug-
gests telenursing services provide patients with addi-
tional accessibility and support for disease symptom
monitoring and disease self-care guidance.7 Evidence
also supports a positive link between telenursing and
improved diabetes glycaemic control.8 International
evidence further supports telenursing as a safe, effective
and high-quality remote access service for health
care.9–11
Telehealth nursing practice leverages technology-
based communication platforms to provide distant
nursing services to patients,12,13 including consultation,
assessment, monitoring, treatment and patient educa-
tion.14,15 Telehealth nursing accessibility reduces travel
requirements, unnecessary provider visits and emergen-
cy room unitisation while maintaining quality and effi-
ciency16,17 associated with improved patient outcomes
and reduced health-care costs.2,18 Neither the CARES
or CONNECT Act legislation contain professional
RNs as an eligible provider of telehealth services.5
Instead, the proposed eligible health professionals
within these Acts are: ‘physician assistant, nurse prac-
titioner, clinical nurse specialist, certified registered
nurse anesthetist, certified nurse-midwife, clinical
social worker, clinical psychologist, and registered die-
titian or nutrition professional’.5 Professional RNs are
key inter-professional team members within team-
based primary-care models to support complex chronic
disease management and care coordination efforts.19
RNs supply the largest health-care occupation20 and
are well positioned to assume more telehealth roles
while increasing revenue within pandemic-besieged pri-
mary care settings. The literature demonstrates that
RNs in team-based primary care partnerships are well
prepared to care for patients with chronic illness such
as congestive heart failure, diabetes and hypertension
utilizing telehealth modalities.21
Telehealth nursing scopes and standards were first
published in 2011 for ambulatory care RNs who pro-
vide evidence-based telehealth services in accordance to
American Academy of Ambulatory Care Nursing
guidelines.22 RNs have been utilizing e-visit tools, elec-
tronic health record portal platforms and digital mobile
remote monitoring technology within ambulatory care
settings to provide asynchronous chronic disease guid-
ance, care plan evaluation and disease self-management
Watkins and Neubrander
through enriched communication modalities to support
patients as active participants in their care between
provider visits.21,22 RNs also provide expert telehealth
services for triaging patients to the appropriate level of
care, utilising clinical judgement, algorithms and
evidence-based guidelines.22 The high-level RN knowl-
edge and skills of assessment paired with clinical deci-
sion expertise allow the RN to prioritise urgent care
needs, develop a plan of care in collaboration with
the multidisciplinary care team and provide supportive
patient education for treatment recommendations and
evaluation of care outcomes.22
RN telehealth supports population health, care
coordination, transitional care, disease self-
management support, wellness, symptom triage and
palliative care for patients and families.22 Modern
advancements in RN telehealth services using mobile
devices and digital technologies are consistent with the
CMS definition of ‘telemedicine’. CMS defines ‘tele-
medicine’ as utilizing virtual visit modalities to connect
with health professionals ‘to exchange health care
information in audio, video, graphic, or other format
for the purpose of providing improved health care serv-
ices’.23 RN-led telemedicine interventions have been
linked to improved disease self-management behaviors
associated with reduced HbA1C levels and decreased
blood pressure levels.24
The omission of RNs as eligible telemedicine health
professionals will intensify the unprecedented chal-
lenges primary-care providers are facing related to the
COVID-19 pandemic. It is essential for legislators to
recognize the urgent need for RNs to qualify as one of
the additional health professionals to provide
reimbursable telehealth services to mitigate pandemic-
associated health-care workforce shortages, accessibil-
ity to care and declining revenues associated with viral
public-health infection control. RNs are well posi-
tioned with the knowledge and skills to assist
primary-care providers to continue serving the vulner-
able patient populations who require high-quality coor-
dinated and ongoing chronic disease self-management
and transitional care services across the continuum of
care within patient-centred medical home models.24
Declaration of conflicting interests
The author(s) declare no potential conflicts of interest with
respect to the research, authorship and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial sup-
port for the research, authorship and/or publication of this
article: This project was supported by the Health Resources
and Service Administration (HRSA) of the U.S. Department
3
of Health and Human Services (HHS) as part of an award
totaling $2.729705m with 0% financed by non-governmental
sources. The contents are those of the authors and do not
necessarily represent the official views of, nor an endorsement
by, HRSA, HHS or the US government.
ORCID iD
Susan Watkins https://orcid.org/0000-0003-3119-8948
References
1. Primary Care Collaborative. Primary care and COVID-
19: week 2 survey, https://www.pcpcc.org/2020/03/26/pri
mary-care-covid-19-week-2-survey (2020, accessed 30
March 2020).
2. Neufeld JD, Doarn CR and Aly R. State policies influ-
ence Medicare telemedicine utilization. Telemed J E
Health 2016; 22: 70–74.
3. Peabody MR, Dai M, Turner K, et al. Prevalence and
factors associated with family physicians providing
E-visits. J Am Board Fam Med 2019; 32: 868–875.
4. Centers for Medicare & Medicaid Services. Chronic Care
Management Services, https://www.cms.gov/outreach-
and-education/medicare-learning-network-mln/mlnprod
ucts/downloads/chroniccaremanagement.pdf (2018,
accessed 5 May 2020).
5. Dizon R. Federal CONNECT Act seeks to expand access
to telehealth in Medicare. https://www.telehealthresource
center.org/federal-connect-act-seeks-to-expand-access-
to-telehealth-in-medicare/ (2020, accessed 2 April 2020).
6. Lister M, Vaughn J, Brennan-Cook J, et al. Telehealth
and telenursing using simulation for pre-licensure USA
students. Nurse Educ Pract 2018; 29: 59–63.
7. Gidora H, Borycki EM and Kushniruk AW. Effects of
telenursing triage and advice on healthcare costs and
resource use. Stud Health Technol Inform 2019; 257:
133–139.
8. Yang S, Jiang Q and Li H. The role of telenursing in the
management of diabetes: a systematic review and meta-
analysis. Public Health Nurs 2019; 36: 575–586.
9. Bikmoradi A, Masmouei B, Ghomeisi M, et al. Impact of
tele-nursing on adherence to treatment plan in discharged
patients after coronary artery bypass graft surgery: a
quasi-experimental study in Iran. Int J Med Inform
2016; 86: 43–48.
10. Goudarzian M, Fallahi-Khoshknab M, Dalvandi A,
et al. Effect of telenursing on levels of depression and
anxiety in caregivers of patients with stroke: a random-
ized clinical trial. Iran J Nurs Midwifery Res 2018; 23:
248–252.
11. Graversen DS, Christensen MB, Pedersen AF, et al.
Safety, efficiency and health-related quality of telephone
triage conducted by general practitioners, nurses, or
physicians in out-of-hours primary care: a quasi-
experimental study using the Assessment of Quality in
Telephone Triage (AQTT) to assess audio-recorded tele-
phone calls. BMC Fam Pract 2020; 21: 84.
4 Journal of Telemedicine and Telecare 0(0)
12. Allen M, Aylott M, Loyola M, et al. Nurses: extending
care through telehealth. Stud Health Technol Inform
2015; 208: 35–39.
13. Kumar S and Snooks H. Telenursing. London: Springer,
2011, p.200.
14. Reierson IÅ, Solli H and Bjørk IT. Nursing students’
perspectives on telenursing in patient care after simula-
tion. Clin Simul Nurs 2015; 11: 244–250.
15. Sevean P, Dampier S, Spadoni M, et al. Bridging
the distance: educating nurses for telehealth practice.
J Contin Educ Nurs 2008; 39: 413–418.
16. Lustig TA. The role of telehealth in an evolving health care
environment: workshop summary. Washington, DC:
National Academies Press, 2012, pp.1–26.
17. Moehr JR, Schaafsma J, Anglin C, et al. Success factors
for telehealth– a case study. Int J Med Inform 2006; 75:
755–763.
18. Edirippulige S. Readiness of nurses for practicing tele-
health. Stud Health Technol Inform 2010; 161: 49–56.
19. United States of Representatives. Office of Law Revision
Counsel United States Code 42 Section 1115A(b)(2)(B) of
the Social Security Act 42 U.S.C. 1315a(b)(2)(B), https://
uscode.house.gov/view.xhtml?req=telehealth+service
s&f=treesort&fq=true&num=17&hl=true&edition=
prelim&granuleId=USC-prelim-title42-section254c-14
https://uscode.house.gov/browse.xhtml (2020, accessed
8 March 2020).
20. Health Resources and Services Administration. The
future of the nursing workforce: national- and state-
level projections, 2012–2025, http://bhpr.hrsa.gov/health
workforce/supplydemand/nursing/workforceprojections/
nursingprojections.pdf (2014, accessed 20 March 2020).
21. American Academy of Ambulatory Care Nursing.
Position paper: the role of the registered nurse in ambu-
latory care, https://www.aaacn.org/sites/default/files/
documents/PositionPaper.pdf (2017, accessed 2
February 2020).
22. American Academy of Ambulatory Care Nursing.
Telehealth nursing practice, https://www.aaacn.org/prac
tice-resources/telehealth (2020, accessed 1 January 2020).
23. Centers for Medicare & Medicaid Services. Trump
administration provides financial relief for Medicare pro-
viders, https://www.cms.gov/newsroom/press-releases/
trump-administration-provides-financial-relief-medicare-
providers (2018, accessed 5 May 2020).
24. Massimi A, De Vito C, Brufola I, et al. Are community-
based nurse-led self-management support interventions
effective in chronic patients? Results of a systematic
review and meta-analysis. PLoS One 2017; 12: 1–22.