Telehealth and Telemonitoring Versus Face-to-Face Visits Among Patients

Final Research Proposal on “Telehealth and Telemonitoring Versus Face-to-Face Visits Among Patients Diagnosed with Amyotrophic Lateral Sclerosis (ALS)”
Your Name
Subject and Section
Professor’s name
Date
Abstract
This research focuses on the needs of patients diagnosed with ALS at the University of Chicago Medicine Hospital. The researcher shall utilize outcome measures, such as the ALSFRS-r, to compare the patients’ functionality when using telemedicine versus an in-clinic visit.
Section A: Organizational Culture and Readiness Assessment
The University of Chicago Medicine provides excellent nursing care, thereby improving patient outcomes. The facility also enhances nurses’ job satisfaction with benefits, proper compensation, and excellent management, making it a magnet hospital, where there are a reduced nurse turnover rate and suitable grievance solution CITATION Uni182 \l 13321 (McHugh, 2018). Additionally, the institution was named one of the best teaching hospitals for three consecutive years CITATION Uni181 \l 13321 (University of Chicago Medicine, 2018). The Organizational Culture and Readiness Scale for System-Wide Integration of Evidence-Based Practice (OCRSIEP) was used to assess the organization’s readiness level.
Organization Readiness Level
The institution has an excellent organizational readiness to fulfill its competitiveness in the field of medicine. It offers specialties such as otorhinolaryngology, oncology, gastroenterology, gastrointestinal surgery, nephrology, gynecology, and urology, documented in the U.S. News and World Report Rankings as the finest in the country. Other leading specialties include neurology and neurosurgery, geriatrics, and orthopedics CITATION Unind \l 13321 (University of Chicago Medicine, n.d.). Additionally, the Joint Commission accredits the institution and has various recognized centers, including the Comprehensive Stroke Center. It also provides a website and a phone number that the patients can contact anytime. The website can be easily navigated, and it provides information on the services and proofs of excellence of the institution CITATION Unind1 \l 13321 (University of Chicago Medicine, n.d.). Lastly, based on the OCRSIEP scale, the administration is committed to using evidence-based practice (EBP), which is implemented in the said specialties.
Staff and Resource
The institution recruits excellent staff who are well-trained. They are also given opportunities for certifications, further studies, and promotions. Examples of these include full tuition reimbursement for BSN and MSN graduates and 75% reimbursement after graduating from a doctoral degree CITATION Unind2 \l 13321 (Universtiy of Chicago Medicine, n.d.). Despite excellent staff and resource quality, one issue reported by the patients is difficulty in communication, especially among the transgender and people of color population, where the patients believe that those opposite of their personality receive better care than they do. The organization currently encourages its staff to attend conferences and read journals concerning this matter to eliminate gender bias and discrimination (Rattini, 2019). The OCRSIEP assessment revealed that the organization has competent nursing staff who are highly skilled and committed. However, they had a low score on cultural readiness.
Project Facilitators and Barriers
The COVID-19 pandemic allows the organization to showcase its full potential. The current project of the organization aims to eliminate COVID-19 health disparities through the help of machine learning. Once perfected, it plans to share the system globally for the benefit of many people. It invited expert researchers in data science and artificial intelligence, public health experts, policy analysts, and economists to construct a computational tool that improves the detection and diagnosis of COVID-19. Some of whom are Research Assistant Professor Anna Hotton, MD, Ph.D., Maryellen Giger, and Aditya Khanna, Ph.D. (Mitchum, 2020).
The project also received adequate funding from the organization and other private and government partners, including the $5.4 Million funds from the Digital Transformation Institute. In August 2020, the project encountered an issue with data collection that has yet to be resolved. This problem generates difficulty with disease detection and virtual illustration of the possible events during the pandemic and low mortality and morbidity prediction. To counter this, the researchers aim to gather 2.7 million on Chicago Population to analyze the factors on the present-day health disparities (Mitchum, 2020).
Based on the OCRSIEP scores, the institution is sufficiently prepared to use new technology to facilitate new projects. The users are also proficient in navigating the systems used for the projects, and they formulate models based on research incorporate this to the experts’ opinions.
Strategies for Facilitating Clinical Inquiry
Clinicians at the University of Chicago Medicine utilize external and internal evidence to test hypotheses and investigate vague clinical perceptions. They use evidence-based research to formulate a hypothesis and test this through observation via home technology. An example of this is the study designed by Joseph Kirsner, a Professor of Medicine, where the patients are provided an application to track their health concerns and signs and symptoms at home and analyze the results with the literature reports. Another example of this is the Thirty Million Words (TMW) initiative by Dr. Dana Suskind that tracks children’s needs with the cognitive-developmental problem at home (Mitchum, 2017).
Based on the OCRSIEP assessment, the organization is critical to using EBP in the clinical setting. Moreover, the clinicians are committed to improving the quality of care provided to the patients. The institution also utilizes fiscal resources, high-quality technology, and a broad spectrum of databases to conduct its studies.
In summary, the University of Chicago Medicine attained its superior status through a thorough assessment of the patients’, staff’s, and organizational needs and addressing its internal and external problems. Furthermore, the institution enhances its readiness levels by training its constituents, constructing specialty centers, incorporating research to practice, and choosing leaders who are experts in their fields.
Section B: Problem Description
Background of the Problem
The pandemic has presented many issues concerning the accessibility of health care. This is especially true for geriatric patients and those with conditions that require regular monitoring, such as Amyotrophic Lateral Sclerosis (ALS). Luckily, the advancements in technology led to telemedicine’s availability, but there are still concerns regarding the effectiveness of this approach compared to face-to-face hospital/clinic visits and medical consultations. The American Telemedicine Association raises its concern about possible issues with monitoring the quality and standard of care provided to the patients because it is different from the usual provision of health care needs (Nesbitt et al., 2012). The stakeholders involved in the study are the medical professionals and patients with ALS who are the ones that will be directly affected by the effects of the intervention.
PICOT Question
In patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) from the University of Chicago Medicine Hospital (problem), how can the use of telemedicine (intervention) compare to traditional in-person clinic visits (comparison) delay the negative impact on their functional status, reduce the frequency of hospital visits, and decrease mortality rates (outcomes), three months post-intervention?
Purpose and Project Objectives
This study aims to compare telemedicine’s effects with face-to-face medical consultations for the regular monitoring and management of patients with Amyotrophic Lateral Sclerosis (ALS) by the prevention of ALS-related complications in 3 months. The intervention includes digital speech analysis, remote ventilatory monitoring, self-reported ALS functional rating scale, neurological assessment through mobile applications, and videoconferencing telemedicine consultation (Bombaci et al., 2020). In addition to these, remote cognitive assessment, psychological counseling, and a nutritional status check will also be provided as part of the intervention for a holistic evaluation and treatment for ALS patients (De Lucia et al., 2020). Some of the possible ALS-related complications that are looked out for are aspiration, loss of function, weight loss, pressure ulcers, and lung failure.
Rationale
This research study will support the innovation of the current health care system involving adult geriatric nurse practitioners and other health care workers involved in the assessment and treatment of ALS patients. It will be beneficial in decreasing health risks for the health care providers, especially during the pandemic, while also increasing the accessibility of vital assessment and treatment for ALS conditions. This study’s relevance is not exclusive to the duration of the pandemic but is a clinical transformation that is applicable even years after.
The monitoring and management of ALS will also be revolutionized once telemedicine is proven to be a practical approach because of the level of involvement that the patient and caregiver have even with the assessments. A progressive disease such as ALS requires close monitoring and continuous access to multidisciplinary care, and the prevention of complications through telemedicine will significantly impact the quality of life of the patients. Previous studies were done on telemedicine, but adult geriatric nurses’ involvement in the monitoring and management of a condition such as ALS should be further explored. This will enable nurse practitioners to make sound clinical decisions, skillful assessments, and home programs for complication prevention.
Section C: Literature Support
Amyotrophic Lateral Sclerosis (ALS) is a neurodegenerative neuromuscular condition that affects thousands of people each year and purposed many studies about the various aspects of the disease. New information regarding medical assessments and interventions are continuously progressing, especially with the current need to explore another aspect of the condition due to sudden healthcare changes. In response to the current healthcare system with numerous precautions and restrictions, patients with conditions such as ALS are now forced to change their routine to adjust to the new normal, limiting them from attending their regular face-to-face multidisciplinary assessments for systems such as respiratory, neurological, psychological, speech, physical and occupational therapies. Both monitoring and management in patients with ALS are vital, resulting in the emergence of teleconsultation or telemedicine to address ALS patients’ needs without increasing the risk of contracting and spreading the COVID-19 virus. However, this method raises concerns regarding virtual medical consultations’ effectiveness compared to traditional and hands-on consultations. The purpose of this literature review is to examine the available research on the efficacy of telemedicine with comparison to traditional care and consultation in providing multidimensional care for patients diagnosed with amyotrophic lateral sclerosis.
Search Methods
The research databases used to find studies relevant to the research question are Science Direct, EBSCO Host, and PubMed. The keywords used are telemedicine, remote monitoring, nursing, amyotrophic lateral sclerosis, telehealth, ALS, neurodegenerative muscular conditions, ALS treatment, ALS monitoring, virtual consultation, and teleconsultation. The research studies are further narrowed down by the inclusion and exclusion criteria. The inclusion criteria are either male or female, with a diagnosis of amyotrophic lateral sclerosis and are receiving multidisciplinary care. The exclusion criteria used are comorbidities or conditions that mimic ALS. 5 studies’ symptoms are included to be part of the current research.
Research Evidence Summary: Population
Patients and caregivers are involved in the studies as there are patients with ALS whose quality of life and functions are heavily affected by the condition. The focus of the research are patients diagnosed with ALS who are receiving multidisciplinary care for their condition. The confounding factors such as other conditions or present comorbidities that may affect the study results were identified.
Research Evidence Summary: Intervention
Features of Telemedicine
Telemedicine utilizes video conferencing instead of telephone communication. This requires a stable internet connection to conduct health care assessments and care. The teleconsultation similar to stroke care with neurological evaluation will be demonstrated. The accessibility and cost-effectiveness of telemedicine will highly benefit ALS patients in providing quality multidisciplinary care for increased survival (Hobson et al., 2016). In addition to the complexity of the technology required in telemedicine, the program’s service and flow are also some of the aspects that need to be considered (Hobson et al., 2018). The assessments that are included in the remote consultation are neurologic, respiratory, physical, cognitive, psychological, and nutrition to provide holistic and multidimensional care to ALS patients.
Telemedicine in ALS patients
There is still a limited number of studies on telemedicine’s efficacy in the monitoring and treating ALS, but the currently available research supports telemedicine for the decrease of disease progression and number of hospital visits. An example of telemedicine is the study by Selkirk et al., where extensive remote consultations had proven to be beneficial to ALS patients even at remote locations (2017).
Research Evidence Summary: Comparison
Traditional consultations are face-to-face assessments where patients encounter the Neurologist, Pulmonology, speech, dietary, physical and occupational therapies. A research study exhibiting holistic and multidisciplinary care involves identifying impairments and disabilities, which dictates the patients’ interdisciplinary needs. A meeting with the stakeholders is also required to track possible changes (Selkirk et al., 2017).
Research Evidence Summary: Outcomes
The clinical outcomes are measured using the standard outcome measure for ALS patients, the ALSFRS-r (See Appendix Figures 2 and 3), which measures the patients’ functional status. This quick assessment of speech, swallowing, upper and lower body movement, and repetitive assessments can gauge ALS patients’ disease progression over some time (Selkirk et al., 2017). Other outcome measures that are monitored are the mortality rates of ALS patients due to complications. The hospitalization rate is also monitored if telemedicine influences the trend that is expected of ALS patients.
Validity Description
The research studies’ nature poses current challenges in the validity of the outcome measures used during the remote assessment. There are also possible barriers to the use of technology and the procedures’ regulation (Hobson et al., 2016). The internal validity of the research studies is challenged by selection bias and attrition. The participants cannot be blinded and randomized due to the nature of the intervention. Attrition rates are also standard in some of the studies due to non-compliance of the participants, and intention-to-treat analysis is used to address dropouts.
The results of the research studies that were gathered have excellent external validity due to the population’s specific characteristics focusing on ALS. Although, the studies’ sample size can still be increased to improve the generalizability of the results. The outcomes that were measured through virtual consultations are also highly applicable to other populations or settings.
Research Evidence Summary: Scientific Merit Related to the Problem
All the research studies that met the criteria are patients diagnosed with amyotrophic lateral sclerosis. The studies support telemedicine or online consultations in monitoring and managing ALS, mainly due to the multidisciplinary care that ALS patients require. The typical outcomes measured in the research studies include the progression of the disease, frequency of hospitalization, morbidity and mortality rates, and changes in respiratory function and functional status. Most of the research studies involving telemedicine are conducted during the COVID-19 pandemic, revealing how novel the virtual consultation is for conditions such as ALS. Telemedicine provides multidisciplinary care for ALS patients and is effective in reducing the frequency of hospitalizations and delaying disease progression measured through ALSFRS-r. The cost-effectiveness of remote or virtual consultations and monitoring, which appeals to ALS patients and families, is also highlighted in the studies. (See Appendix Table 1)
Section D: Solution Description
Solution
This intervention will improve the accessibility of multidisciplinary quality care given to ALS patients. In this research, telemedicine’s effectiveness as an intervention in monitoring and managing ALS will be studied, specifically regarding patient monitoring, symptom management, and disease progression.
In aiming for a patient-centered, multidisciplinary approach for ALS, the telemedicine for ALS will involve the following: subjective reporting, weight monitoring, and Revised Amyotrophic Lateral Sclerosis Rating Scale (ALSFRS-r), as done in the research studies of Wills et al., (2019) and Capozzo et al., (2020) involving telemedicine and remote ALS management. This will be executed through apps, calls, and video conferencing as proposed in the user-centered program of Hobson et al. (2018).
Selkirk et al. (2017) conducted a similar study to improve the specialized care that ALS requires. This set of assessments effectively monitors disease progression using the ALSFRS-r as an instrument to check the progression in ALS-caused impairments and disabilities.
Feasibility of intervention
In the study of Helleman et al. (2020), telemedicine’s feasibility to provide health care services for ALS patients was demonstrated. Previous studies’ barriers and limitations include lack of access to a stable internet connection, unavailable gadgets, and exclusion from insurance coverage.
In the study of Helleman (2020), the patient or caregiver’s training can conduct the assessments with proper supervision from a licensed physician or ALS registered nurse ensure objectivity and accuracy of the assessments. In addition to this, the ALSFRS-r is also a validated instrument that is self-administered.
A limitation of telemedicine as a multidisciplinary and regular part of an ALS patient is the cost (Andrews et al., 2020). Although telemedicine is promoted to be cost-effective and efficient in providing multidisciplinary care, telemedicine’s exclusion in the insurance coverage of patients poses as a barrier to health care.
Consistency with culture
The study setting will be at the University of Chicago Hospital, a known ALS clinic that offers multidisciplinary care for ALS patients. The team involved in providing holistic quality care to the patients includes neurologists, surgeons, cardiologists, pulmonologists, geneticists, orthotists, nurses, and social workers.
Expected Outcomes: P
The population will be patients diagnosed with ALS who are needing multidisciplinary care for ALS monitoring and management. It will also be noted whether the patient will be doing the telemedicine or if a caregiver will assist it.
Expected Outcomes: I
In telemedicine, a multidisciplinary team of specialists will conduct remote health consultations. This will be done through video conferencing, voice calls, and applications with the help of a multidisciplinary team for ALS.
Expected Outcomes: C
The face-to-face consultations will be the comparison group in the study. The routine assessments will be done in the University of Chicago Hospital by a team of ALS specialists.
Expected Outcomes:O
In telemedicine, the disease progression is the primary outcome to be monitored, using a validated instrument specialized for ALS patients, the ALSFRS-r, which is done once a month (Rooney et al., 2017). The minor outcomes that will be included in the study are nutritional status, cognitive function, psychological status, and frequency of hospitalizations. The same outcomes will be used for both face-to-face and telemedicine consultations.
Methods: Quality Care
The quality of care will be ensured by giving standardized tests and having the same set of medical staff who are licensed and skilled in their own ALS specializations.
Methods: Processes
The ALSFRS-r is a tool that measures speech, salivation, swallowing, handwriting, nutrition intake, handling food and utensils, hygiene and dressing, med mobility, ambulation, stair negotiation, orthopnea, dyspnea, and respiratory insufficiency did once a month (Rooney et al., 2017). The minor outcomes will be monitored using the following methods: Weighing once a week will monitor the patient’s nutritional status with ALS. This can also be used to detect a need for hospitalization in cases of sudden weight loss. The checking of the patients’ cognitive and psychological status will be assessed through subjective input and video conferences with specialists on the field.
Methods: Professional expertise
The multidisciplinary team that will handle both the regular and telemedicine consultation will receive a 3-day training and briefing of the study, which will enable objectivity and reliability in the execution and recording of data.
Outcome impact description: Quality care
Telemedicine will significantly improve the quality of care provided to ALS patients, with increased efficiency, especially in monitoring the disease’s progression and its effect on ALS patients’ quality of life. Telemedicine will promote patient-centered care that will best fit the patient’s unique and individual traits, also with consideration to their primary caregiver/s.
Outcome impact description: Processes
The urgent decision-making regarding hospitalizations and other procedures that the patient will need will be given promptly. In line with the changes in society and the environment, telemedicine will also be a safe, cost-effective, and efficient process for the patient, caregivers, and medical staff.
Outcome impact description: Professional expertise
Telemedicine will elevate nurses’ and other involved medical professionals’ skills by having a keen eye on the essential assessments done in remote consultations. The medical staff should be skilled in decision-making and identifying red flags to ensure patient safety and quality of care.
Section E: Change Model
Stetler Model of Evidence-Based Practice (EBP)
Model Assumptions
The Stetler Model assumes that internal factors, such as health providers utilizing EBP and the administrative regulations, and external factors, including protocols and research results, guide the implementation of EBPs (Indra, 2018).
Evidence of Suitability to the Project
Intervention
The model emphasizes the individual practitioner and how one can handle a particular situation. However, it can also be used in teams in the clinical setting. Notably, this model has been tested in neurological and psychiatric settings (Indra, 2018).
Scope of the Project
Hobson et al. (2016) state that telemedicine can improve patients’ quality of care with Amyotrophic Lateral Sclerosis (ALS) due to its cost-effectiveness, accessibility, and comprehensiveness of multidisciplinary approach even in the outpatient setting. Glenda (2019) proved the Stetler Model can be used in telehealth, which resulted in an improved quality of care through better patient education.
A Guide to Implementation
The Stetler Model has five phases. Phase I focuses on overall preparation. Phase II requires the authentication of the researched data. Phase III refers to data analysis by comparing the past and current evidence while considering the internal and external factors. Phase IV allows for modifications before the implementation, and Phase V assesses the factors that inflicted the most remarkable positive change to the practice (Indra, 2018).
Conceptual Model (See Appendix Figure 1)
Concepts related to Problem Solution
As discussed previously, the problem solution includes weight monitoring, subjective reporting, and the Revised Amyotrophic Lateral Sclerosis Rating Scale (ALSFRS-r). These shall provide remote access to ALS management through cellphone applications and the web via video conferences (Hobson et al., 2018). Like the planned solution, Humpfer (2019) integrated the Stetler model in asthmatic patients’ remote self-management, which proved to be efficient.
Processes and Interactions
Helleman et al. (2020) investigated the use of telemedicine to care for ALS patients. It is useful but with certain limitations, such as the need to train the caregiver, proper coordination with the health providers, and an objective assessment at home. The Stetler Model can eliminate the barriers by providing a facilitator who shall aid the caregivers via interactive problem solving and supportive contact (Lindsay et al., 2015).
Advancing Research and Clinical Practice Through Close Collaboration (ARCC) Model
Model Assumptions
It assumes that it is necessary to train EBP mentors to improve the nurses’ research and practice perspectives. Thus, resulting in a better EBP implementation (Kim et al., 2017).
Evidence of Suitability to the Project
Intervention
The ARCC Model emphasizes the holistic approach that is in line with the University of Chicago Hospital’s mission and vision, the ALS facility of choice, which aims to provide quality care via a multidisciplinary approach. Telemedicine in ALS management is relatively new, and there are only a few...