WEBVTT 00:00:05.070 --> 00:00:06.320 position:50% align:middle - [Dr. O'Hara] Hi, everyone. 00:00:06.320 --> 00:00:14.410 position:50% align:middle Today we're going to talk about looking at...Brendan brought up the National Workforce Study, 00:00:14.410 --> 00:00:18.760 position:50% align:middle and today we're going to focus on the telehealth side of things there. 00:00:18.760 --> 00:00:26.260 position:50% align:middle So, starting with a little background, I think a term like telehealth can mean a whole lot 00:00:26.260 --> 00:00:29.970 position:50% align:middle of different things in different contexts. 00:00:29.970 --> 00:00:33.600 position:50% align:middle So today I'm defining it here. 00:00:33.600 --> 00:00:38.940 position:50% align:middle Telehealth is the provision of nursing services or communication with a patient or client located 00:00:38.940 --> 00:00:43.630 position:50% align:middle somewhere different from the provider's location, via phone or electronically. 00:00:43.630 --> 00:00:46.270 position:50% align:middle This is going to be a very broad definition of telehealth. 00:00:46.270 --> 00:00:53.870 position:50% align:middle We're going to capture things, not only something that would be a full remote visit 00:00:53.870 --> 00:00:59.030 position:50% align:middle with the provider, something that would show up in insurance claims data, 00:00:59.030 --> 00:01:04.760 position:50% align:middle but it's also going to involve a nurse picking up the phone when a patient has a question or 00:01:04.760 --> 00:01:06.070 position:50% align:middle something like that. 00:01:06.070 --> 00:01:12.410 position:50% align:middle So that's going to be important to look at here, and it's going to really capture kind of a wide range 00:01:12.410 --> 00:01:18.910 position:50% align:middle of how nurses are using this technology in their day-to-day practice. 00:01:18.910 --> 00:01:25.650 position:50% align:middle So Brendan talked a lot about how, you know, COVID happened, things changed, 00:01:25.650 --> 00:01:28.000 position:50% align:middle and now we're in a different place than we were before. 00:01:28.000 --> 00:01:31.840 position:50% align:middle So I want to talk about that a little bit with regard to telehealth. 00:01:31.840 --> 00:01:41.370 position:50% align:middle So this graph here from the Assistant Secretary for Planning and Evaluation's Office of Health Policy kind 00:01:41.370 --> 00:01:53.360 position:50% align:middle of shows that before, looking at Medicare claims, this yellow line represents in-person visits, 00:01:53.360 --> 00:01:57.460 position:50% align:middle blue represents all visits, red represents telehealth visits. 00:01:57.460 --> 00:02:03.360 position:50% align:middle If you look before the pandemic, the yellow and blue lines are basically overlapping. 00:02:03.360 --> 00:02:05.840 position:50% align:middle There's very little telehealth overall. 00:02:05.840 --> 00:02:12.550 position:50% align:middle And then something happened in March 2020, and you can see, everything drops off, 00:02:12.550 --> 00:02:15.710 position:50% align:middle but telehealth jumps up substantially. 00:02:15.710 --> 00:02:21.180 position:50% align:middle A hundred times as much telehealth visits were going on once the pandemic hit. 00:02:21.180 --> 00:02:25.860 position:50% align:middle But then again, we see telehealth starts to wane, in-person visits come back up. 00:02:25.860 --> 00:02:28.690 position:50% align:middle But we see it's different than it was. 00:02:28.690 --> 00:02:35.330 position:50% align:middle Telehealth is still here in a way that it wasn't before the pandemic, whether this is regulatory changes, 00:02:35.330 --> 00:02:40.840 position:50% align:middle whether this is providers and patients who were hesitant to use these technologies before the pandemic, 00:02:40.840 --> 00:02:45.770 position:50% align:middle experienced them hands on during the pandemic and went, "I can live with this. 00:02:45.770 --> 00:02:52.080 position:50% align:middle This is adding convenience to my life," or other tools that I didn't have before. 00:02:52.080 --> 00:02:58.450 position:50% align:middle And to show that this is not just more telehealth after the pandemic but really how telehealth works 00:02:58.450 --> 00:03:03.910 position:50% align:middle is different, I want to show some data, again, from the Office of Health Policy. 00:03:03.910 --> 00:03:06.740 position:50% align:middle Here is before the pandemic. 00:03:06.740 --> 00:03:11.990 position:50% align:middle In 2019, telehealth visits were largely rural. 00:03:11.990 --> 00:03:22.670 position:50% align:middle So 0.2% of all rural visits in CMS were telehealth visits, and the less than 0.1% of urban visits billed 00:03:22.670 --> 00:03:26.390 position:50% align:middle to Medicare were telehealth visits. 00:03:26.390 --> 00:03:33.030 position:50% align:middle So if telehealth was happening, it was more likely to happen in rural areas. 00:03:33.030 --> 00:03:35.950 position:50% align:middle But then, you know, 2020, things jumped up. 00:03:35.950 --> 00:03:39.230 position:50% align:middle You notice this urban column jumped up a lot higher. 00:03:39.230 --> 00:03:48.790 position:50% align:middle And we can see, even as the pandemic started to wane, we start to see that now in the urban areas, 00:03:48.790 --> 00:03:50.830 position:50% align:middle telehealth is more likely. 00:03:50.830 --> 00:03:55.280 position:50% align:middle More visits in urban areas are telehealth than before. 00:03:55.280 --> 00:04:02.520 position:50% align:middle So this really shows that COVID not only was an acute thing that, you know, 00:04:02.520 --> 00:04:05.710 position:50% align:middle changed all of our lives for many years, but our lives are different now. 00:04:05.710 --> 00:04:08.610 position:50% align:middle The status quo is different than it was. 00:04:08.610 --> 00:04:16.770 position:50% align:middle So what this study aims to look at is, if telehealth changed, 00:04:16.770 --> 00:04:22.260 position:50% align:middle if the way we use telehealth in nursing changed during the pandemic, how did that happen? 00:04:22.260 --> 00:04:25.370 position:50% align:middle What does it look like now? 00:04:25.370 --> 00:04:30.330 position:50% align:middle Who makes up the telehealth nursing workforce now? 00:04:30.330 --> 00:04:36.060 position:50% align:middle How much does the use of telehealth in nursing differ based on the nurse's position, 00:04:36.060 --> 00:04:38.640 position:50% align:middle their professional profile? 00:04:38.640 --> 00:04:47.630 position:50% align:middle And I'm also going to look a little bit about how interstate practice is affected by the NLC. 00:04:47.630 --> 00:04:52.870 position:50% align:middle So the methods we're going to use today. 00:04:52.870 --> 00:04:54.860 position:50% align:middle Brendan mentioned this study earlier. 00:04:54.860 --> 00:04:58.090 position:50% align:middle If you were in the other room, you heard a lot about it. 00:04:58.090 --> 00:05:08.650 position:50% align:middle The NCSBN performed the 2022 National Nursing Workforce Study or Survey that came out this last April, 00:05:08.650 --> 00:05:21.230 position:50% align:middle and what we did was look at a sample of RNs and LPNs across all of the jurisdictions in the United States, 00:05:21.230 --> 00:05:24.920 position:50% align:middle states and territories excluding Puerto Rico. 00:05:24.920 --> 00:05:36.070 position:50% align:middle And we looked at a variety of different questions using the National Center of Nursing Workforce Centers' 00:05:36.070 --> 00:05:42.270 position:50% align:middle minimum dataset, using questions about COVID-19, using questions about travel nursing, and importantly, 00:05:42.270 --> 00:05:44.690 position:50% align:middle today, we talked about telehealth questions. 00:05:44.690 --> 00:05:49.650 position:50% align:middle Here, I've given you, just to look at, the questions about telehealth that I'm going to be 00:05:49.650 --> 00:05:56.240 position:50% align:middle focusing on today just to kind of give you a chance to get used to what I'm talking about. 00:05:56.240 --> 00:06:03.340 position:50% align:middle So the big question here is to get how much telehealth nurses data, we asked them to estimate what percentage 00:06:03.340 --> 00:06:08.650 position:50% align:middle of their work time do they provide nursing services to a patient or client in a different location 00:06:08.650 --> 00:06:10.720 position:50% align:middle via phone or electronically. 00:06:10.720 --> 00:06:18.250 position:50% align:middle So again, like I mentioned earlier, compared to the Office of Health Policy's Medicare 00:06:18.250 --> 00:06:21.510 position:50% align:middle claims data, this data is going to be broader. 00:06:21.510 --> 00:06:27.880 position:50% align:middle It's going to capture all the ways a nurse communicates with a patient that's not in their location 00:06:27.880 --> 00:06:30.000 position:50% align:middle via phone or electronically. 00:06:30.000 --> 00:06:36.320 position:50% align:middle We also asked what percentage of this remote communication was across state borders, 00:06:36.320 --> 00:06:42.990 position:50% align:middle and we asked them to select modes of communication they use to provide nursing services remotely: 00:06:42.990 --> 00:06:48.330 position:50% align:middle electronic messaging, virtual ICU, telephone, email, and video call. 00:06:48.330 --> 00:06:51.590 position:50% align:middle These all differ how much people use them. 00:06:51.590 --> 00:06:57.140 position:50% align:middle Telephone is used a ton, 96% or so of people doing telehealth use telephone, 00:06:57.140 --> 00:06:58.490 position:50% align:middle at least some of the time. 00:06:58.490 --> 00:07:05.280 position:50% align:middle Whereas virtual ICU, we're looking at more like 8%. 00:07:05.280 --> 00:07:16.310 position:50% align:middle But continuing the methodologies, we weighted the respondents based on jurisdiction, age, 00:07:16.310 --> 00:07:20.020 position:50% align:middle and gender, based on formal nonresponse bias analysis. 00:07:20.020 --> 00:07:26.060 position:50% align:middle And for the telehealth questions we're looking at here, we received almost 23,000 registered nurses responding 00:07:26.060 --> 00:07:33.680 position:50% align:middle to these questions and a little over 18,000 licensed practical nurses. 00:07:33.680 --> 00:07:39.250 position:50% align:middle So we're going to get into the results, starting at looking at the demographics 00:07:39.250 --> 00:07:41.650 position:50% align:middle of telehealth providers. 00:07:41.650 --> 00:07:46.400 position:50% align:middle This histogram, it's a lot to look at, you don't really need to understand all of it, 00:07:46.400 --> 00:07:53.570 position:50% align:middle but what I've got here is the percentage of time a nurse spent doing telehealth versus the count 00:07:53.570 --> 00:07:55.460 position:50% align:middle on the y-axis. 00:07:55.460 --> 00:08:01.860 position:50% align:middle And so you can see, there's a wide variety of amounts of telehealth people are doing. 00:08:01.860 --> 00:08:07.210 position:50% align:middle You're almost as likely to spend 10% to 20% of your time on telehealth as 90% to 100% of your 00:08:07.210 --> 00:08:10.220 position:50% align:middle time on telehealth. 00:08:10.220 --> 00:08:13.650 position:50% align:middle You notice, there's a huge spike at the top here. 00:08:13.650 --> 00:08:17.480 position:50% align:middle This is nurses who spent 0% of their time on telehealth. 00:08:17.480 --> 00:08:21.640 position:50% align:middle And if you look, this is actually a logarithmic scale. 00:08:21.640 --> 00:08:28.500 position:50% align:middle While it looks like these are maybe twice as high on first glance as the nurses in 1% to 10%, 00:08:28.500 --> 00:08:33.010 position:50% align:middle that's actually almost an order of magnitude. 00:08:33.010 --> 00:08:40.100 position:50% align:middle About 10 times as many nurses do 0% telehealth than do 1% to 10%. 00:08:40.100 --> 00:08:49.610 position:50% align:middle And so to break things up so you don't have to think about that giant histogram for the rest of the talk, 00:08:49.610 --> 00:08:52.100 position:50% align:middle I kind of split this into three groups. 00:08:52.100 --> 00:08:56.800 position:50% align:middle Nurses who spend 0% of their time doing telehealth, that orange spike here, 00:08:56.800 --> 00:09:00.660 position:50% align:middle make up about 49% of our sample. 00:09:00.660 --> 00:09:07.630 position:50% align:middle Nurses who spend up to 25% of their time doing telehealth is this green group. 00:09:07.630 --> 00:09:11.290 position:50% align:middle I call them the nurses that do some telehealth. 00:09:11.290 --> 00:09:18.090 position:50% align:middle And this blue group is nurses who do more than 25% of their time is spent doing telehealth. 00:09:18.090 --> 00:09:20.580 position:50% align:middle These people do a lot of telehealth. 00:09:20.580 --> 00:09:24.750 position:50% align:middle And I'm going to maintain these colors throughout the next couple of slides. 00:09:24.750 --> 00:09:27.930 position:50% align:middle So orange is none, blue is a lot, green is some. 00:09:27.930 --> 00:09:35.540 position:50% align:middle So we're going to start looking at the demographics, see how these different groups differ from each other, 00:09:35.540 --> 00:09:38.560 position:50% align:middle who's doing that practicing. 00:09:38.560 --> 00:09:41.960 position:50% align:middle Looking at age first, I've got some histograms based on ages, 00:09:41.960 --> 00:09:47.760 position:50% align:middle and I think your first impression should be those three blobs look almost exactly the same. 00:09:47.760 --> 00:09:49.890 position:50% align:middle And that's kind of what I want you to be getting. 00:09:49.890 --> 00:09:58.940 position:50% align:middle The black lines represent the median ages for the different groups, and you can see that the nurses who 00:09:58.940 --> 00:10:06.710 position:50% align:middle do a lot of telehealth have slightly higher median age than the other groups, but this is really small. 00:10:06.710 --> 00:10:17.030 position:50% align:middle Effectively, there's no real age difference based on how much telehealth you do. 00:10:17.030 --> 00:10:21.860 position:50% align:middle I also looked at the self-reported gender. 00:10:21.860 --> 00:10:27.430 position:50% align:middle And you can see here, looking especially at the nurses who do no telehealth, 00:10:27.430 --> 00:10:36.820 position:50% align:middle that nurses who self-identify as female are less likely to do no telehealth, 48% versus 52%, 00:10:36.820 --> 00:10:39.720 position:50% align:middle which means they're more likely to do telehealth. 00:10:39.720 --> 00:10:48.180 position:50% align:middle So female nurses are slightly more likely to be doing telehealth than male or non-binary-identifying nurses. 00:10:48.180 --> 00:10:58.290 position:50% align:middle Looking at race, we can see that White nurses are the least likely to do a lot of telehealth, 00:10:58.290 --> 00:11:03.470 position:50% align:middle and nurses who identify as multiracial are least likely to do telehealth of the racial categories we had here. 00:11:03.470 --> 00:11:12.840 position:50% align:middle Black and Asian nurses are particularly likely to be doing telehealth. 00:11:12.840 --> 00:11:23.130 position:50% align:middle If you look, it's, you know, about 56% and 53% of them are doing telehealth at all. 00:11:23.130 --> 00:11:27.930 position:50% align:middle And you also can notice, for especially the Black nurses, 00:11:27.930 --> 00:11:31.010 position:50% align:middle there's sort of a dumbbell distribution. 00:11:31.010 --> 00:11:39.120 position:50% align:middle Nurses of color are both more likely to do a lot of telehealth, and they're less likely to do 00:11:39.120 --> 00:11:40.270 position:50% align:middle just some telehealth. 00:11:40.270 --> 00:11:43.460 position:50% align:middle We'll talk about this dumbbell distribution several times. 00:11:43.460 --> 00:11:46.900 position:50% align:middle We'll see that time and time again. 00:11:46.900 --> 00:11:50.640 position:50% align:middle For example, here, with the Latino and Hispanic nurses, looking at ethnicity, 00:11:50.640 --> 00:12:01.800 position:50% align:middle we can see that Hispanic nurses are both a little bit more likely to do telehealth overall, 00:12:01.800 --> 00:12:07.970 position:50% align:middle they're less likely to do no telehealth, and they are more likely to do a lot of telehealth. 00:12:07.970 --> 00:12:16.500 position:50% align:middle So we get kind of a similar trend that we saw with the Black and Asian nurses on the last slide. 00:12:16.500 --> 00:12:20.910 position:50% align:middle Interestingly here, we really see this dumbbell distribution when we look at nurses who practice 00:12:20.910 --> 00:12:26.130 position:50% align:middle in urban locations versus rural locations. 00:12:26.130 --> 00:12:32.890 position:50% align:middle Urban nurses are both more likely to do a lot of telehealth than rural nurses and more likely to do no 00:12:32.890 --> 00:12:34.790 position:50% align:middle telehealth than rural nurses. 00:12:34.790 --> 00:12:44.450 position:50% align:middle So this is really emblematic of there's something heterogeneous going on in the group of urban nurses. 00:12:44.450 --> 00:12:49.600 position:50% align:middle There are some that are doing a lot of telehealth and some that are doing no telehealth, 00:12:49.600 --> 00:12:55.990 position:50% align:middle which suggests that we might want to dive in deeper and try to understand who are these different types 00:12:55.990 --> 00:13:00.100 position:50% align:middle of nurses that show this big gap in the urban workforce. 00:13:00.100 --> 00:13:07.340 position:50% align:middle We can also look at license type, and if we look at license type, 00:13:07.340 --> 00:13:14.560 position:50% align:middle we see that advanced practice registered nurses are more likely to do telehealth overall than either 00:13:14.560 --> 00:13:17.420 position:50% align:middle registered nurses or licensed practical nurses. 00:13:17.420 --> 00:13:22.890 position:50% align:middle But you also notice, they're extremely likely to do some telehealth versus a 00:13:22.890 --> 00:13:24.360 position:50% align:middle lot of telehealth. 00:13:24.360 --> 00:13:28.230 position:50% align:middle PNs show this dumbbell distribution. 00:13:28.230 --> 00:13:36.420 position:50% align:middle They're more likely than RNs to be doing a lot of telehealth, and they're more likely than APRNs to be 00:13:36.420 --> 00:13:38.140 position:50% align:middle doing no telehealth. 00:13:38.140 --> 00:13:44.250 position:50% align:middle They're really unlikely to be doing some telehealth. 00:13:44.250 --> 00:13:49.620 position:50% align:middle So that's another dichotomous group. 00:13:49.620 --> 00:13:56.930 position:50% align:middle We can see that a high rate of APRN telehealth is largely driven by the nurse practitioners who make up a 00:13:56.930 --> 00:14:00.080 position:50% align:middle large proportion of the advanced practice registered nurses we have. 00:14:00.080 --> 00:14:08.850 position:50% align:middle Looking at APRN roles, we have the certified nurse practitioners, 00:14:08.850 --> 00:14:15.920 position:50% align:middle almost 50% of them are doing some telehealth, and three-quarters of them are doing any telehealth, 00:14:15.920 --> 00:14:18.570 position:50% align:middle either some or a lot of telehealth. 00:14:18.570 --> 00:14:28.270 position:50% align:middle But we can compare that to, for instance, the certified registered nurse anesthetists, who, 00:14:28.270 --> 00:14:31.970 position:50% align:middle three-quarters of them are doing no telehealth at all. 00:14:31.970 --> 00:14:39.350 position:50% align:middle And we can see here a different pattern for midwives, for instance, where 50% are doing some telehealth, 00:14:39.350 --> 00:14:43.240 position:50% align:middle but almost none are doing all telehealth or doing a lot of telehealth. 00:14:43.240 --> 00:14:50.800 position:50% align:middle So again, this is really showing, as you dial down to the particular professional profile 00:14:50.800 --> 00:14:57.560 position:50% align:middle of a nurse, the type of telehealth they're doing seems to differ, and we'll dive even deeper into that 00:14:57.560 --> 00:14:59.430 position:50% align:middle as we go forward. 00:14:59.430 --> 00:15:05.750 position:50% align:middle I'm going to kind of skip over a bit of this slide, but this is also looking at educational profile. 00:15:05.750 --> 00:15:12.040 position:50% align:middle If you look up here, DNP-prepared nurses and masters-prepared nurses are 00:15:12.040 --> 00:15:14.520 position:50% align:middle most likely to be doing telehealth. 00:15:14.520 --> 00:15:18.500 position:50% align:middle I think this largely falls into what we just talked about with APRNs. 00:15:18.500 --> 00:15:25.720 position:50% align:middle And so, now we've seen that there's these kind of heterogeneous pictures. 00:15:25.720 --> 00:15:32.360 position:50% align:middle As we look into the professional profiles of a nurse, we get kind of a different story about the 00:15:32.360 --> 00:15:33.920 position:50% align:middle telehealth they do. 00:15:33.920 --> 00:15:41.590 position:50% align:middle And so I wanted to look at...we asked questions about a nurse's primary title, their job title, 00:15:41.590 --> 00:15:45.570 position:50% align:middle their primary work setting, and their primary specialty, 00:15:45.570 --> 00:15:52.100 position:50% align:middle and I wanted to kind of look at each of those categories, see how much telehealth they're doing 00:15:52.100 --> 00:15:59.280 position:50% align:middle compared to nurses who don't have that title or don't have that specialty and how much of each 00:15:59.280 --> 00:16:01.430 position:50% align:middle modality they use. 00:16:01.430 --> 00:16:05.570 position:50% align:middle So, do certain types of nurses do more video calling? 00:16:05.570 --> 00:16:08.720 position:50% align:middle Do certain types of nurses do more telephone? 00:16:08.720 --> 00:16:11.060 position:50% align:middle More electronic messaging? 00:16:11.060 --> 00:16:16.250 position:50% align:middle And here, I'm going to talk about three different groups we can kind of pull out from this. 00:16:16.250 --> 00:16:23.590 position:50% align:middle And again, an individual nurse may kind of...they might have a title that's in one of my groups and a specialty 00:16:23.590 --> 00:16:25.300 position:50% align:middle that's in another group. 00:16:25.300 --> 00:16:34.330 position:50% align:middle I'm not really telling a story with no exceptions here, but these are, for lack of a better word, 00:16:34.330 --> 00:16:42.980 position:50% align:middle kind of stereotypes of types of telehealth practice that we can see and the types of providers who fall 00:16:42.980 --> 00:16:45.180 position:50% align:middle into those roles. 00:16:45.180 --> 00:16:48.230 position:50% align:middle So first, I want to talk about what I call the video callers. 00:16:48.230 --> 00:16:52.670 position:50% align:middle So these are registered nurses who are much more likely to use video calling than average, 00:16:52.670 --> 00:16:58.140 position:50% align:middle and they perform more types of telehealth, but they don't really differ on the other 00:16:58.140 --> 00:16:59.970 position:50% align:middle types of telehealth. 00:16:59.970 --> 00:17:06.370 position:50% align:middle And importantly, this group is extremely likely to do some but not a lot of telehealth. 00:17:06.370 --> 00:17:12.700 position:50% align:middle They use a lot of video calls, and they do telehealth, but not most of their day. 00:17:12.700 --> 00:17:19.540 position:50% align:middle And these are...APRNs tend to fall into this role, nurses whose title is APRN, 00:17:19.540 --> 00:17:25.130 position:50% align:middle and nurses in specialties like psych and mental health, family health, geriatric care and gerontology, 00:17:25.130 --> 00:17:30.870 position:50% align:middle and nurses in community health settings. 00:17:30.870 --> 00:17:34.250 position:50% align:middle The next group I want to talk about is what I call the remote workers. 00:17:34.250 --> 00:17:38.220 position:50% align:middle These are the group who do a lot of telehealth. 00:17:38.220 --> 00:17:42.580 position:50% align:middle They are most likely to spend more than 25% of their time in telehealth. 00:17:42.580 --> 00:17:48.240 position:50% align:middle They actually do less video calls than average and less than that video caller group we just talked about, 00:17:48.240 --> 00:17:53.430 position:50% align:middle and they are more likely to use email and the telephone than nurses overall. 00:17:53.430 --> 00:17:58.390 position:50% align:middle And they're actually extremely likely to do interstate telehealth as well. 00:17:58.390 --> 00:18:08.630 position:50% align:middle And so these nurses have titles like case manager, consultant, and nurses who are in insurance claims and 00:18:08.630 --> 00:18:13.740 position:50% align:middle benefits tend to kind of fit into this type of pattern. 00:18:13.740 --> 00:18:22.610 position:50% align:middle And then, finally, the third group is what I call the frontline workers. 00:18:22.610 --> 00:18:26.910 position:50% align:middle This group is the group that doesn't do very much telehealth at all. 00:18:26.910 --> 00:18:32.950 position:50% align:middle These are the profiles that the majority of nurses at this profile tend not to do telehealth. 00:18:32.950 --> 00:18:37.690 position:50% align:middle They tend to do less of each of these, of emailing, less of electronic messaging. 00:18:37.690 --> 00:18:43.900 position:50% align:middle They tend to use slightly more virtual ICU systems than some of these other groups. 00:18:43.900 --> 00:18:49.610 position:50% align:middle And this is categories like staff nurses, hospital nurses, nurses in acute 00:18:49.610 --> 00:18:57.930 position:50% align:middle care/critical care, med-surg, emergency/trauma. 00:18:57.930 --> 00:19:01.670 position:50% align:middle These profiles here make up the majority of our dataset. 00:19:01.670 --> 00:19:05.600 position:50% align:middle The majority of nurses are in hospitals or staff nurses. 00:19:05.600 --> 00:19:13.110 position:50% align:middle And so we can kind of see here that, at the beginning of the talk, I showed you, you know, 00:19:13.110 --> 00:19:21.660 position:50% align:middle telehealth is up and RNs are spending...near majority of RNs are doing telehealth at all. 00:19:21.660 --> 00:19:26.660 position:50% align:middle But we also see that the largest group of RNs, these frontline workers, 00:19:26.660 --> 00:19:29.340 position:50% align:middle do less telehealth than everyone else. 00:19:29.340 --> 00:19:36.710 position:50% align:middle So if we separate the workforce and look at these individual types of practice profiles, we can see that, 00:19:36.710 --> 00:19:42.570 position:50% align:middle while the staff nurses may not have picked up that much more telehealth during the pandemic or might not do a 00:19:42.570 --> 00:19:50.340 position:50% align:middle ton of telehealth now, these other roles that exist, these other professional profiles are doing a lot 00:19:50.340 --> 00:19:53.550 position:50% align:middle of telehealth in a lot of different ways. 00:19:53.550 --> 00:19:57.510 position:50% align:middle Now, I just want to talk a little bit about interstate telehealth. 00:19:57.510 --> 00:20:03.620 position:50% align:middle So looking at these three profiles I saw, nurses who do no telehealth, some telehealth, 00:20:03.620 --> 00:20:07.670 position:50% align:middle and a lot of telehealth, it may come as no surprise that nurses who do no 00:20:07.670 --> 00:20:10.890 position:50% align:middle telehealth don't do interstate telehealth. 00:20:10.890 --> 00:20:15.600 position:50% align:middle This was a really, really edifying result when I got it out of... 00:20:15.600 --> 00:20:20.900 position:50% align:middle But we can also see, more interesting, if you do a lot of telehealth, 00:20:20.900 --> 00:20:29.430 position:50% align:middle you're about twice as likely than if you do some telehealth to do interstate telehealth. 00:20:29.430 --> 00:20:34.970 position:50% align:middle And this gets a little confusing, but I tried to dial down into who are these nurses who 00:20:34.970 --> 00:20:43.690 position:50% align:middle are doing a lot of telehealth and tend to do a lot of interstate telehealth. 00:20:43.690 --> 00:20:51.580 position:50% align:middle So what I looked at was the number of jurisdictions that nurses actively practice in, 00:20:51.580 --> 00:20:57.320 position:50% align:middle separating nurses who practice in three or fewer jurisdictions actively to more than three, 00:20:57.320 --> 00:21:01.680 position:50% align:middle and I looked at nurses who have multistate licenses, have an NLC license, 00:21:01.680 --> 00:21:04.780 position:50% align:middle and those who report not having an NLC license. 00:21:04.780 --> 00:21:11.900 position:50% align:middle What we see here, if we just focus on those who practice actively in three or fewer jurisdictions, 00:21:11.900 --> 00:21:13.140 position:50% align:middle you see a small boost. 00:21:13.140 --> 00:21:19.640 position:50% align:middle Having an NLC license makes you slightly more likely to do interstate telehealth. 00:21:19.640 --> 00:21:25.600 position:50% align:middle And unsurprisingly, maybe, if you practice actively in more than three states, 00:21:25.600 --> 00:21:30.000 position:50% align:middle you're more likely to do interstate telehealth than someone who doesn't practice in that many states. 00:21:30.000 --> 00:21:36.620 position:50% align:middle We can see here 15.6% versus 27.1% without the NLC license. 00:21:36.620 --> 00:21:41.850 position:50% align:middle But if you have an NLC license, you are twice as likely to do interstate telehealth if 00:21:41.850 --> 00:21:50.440 position:50% align:middle you practice in three or more states than if you don't, which is really kind of showing that there's some type 00:21:50.440 --> 00:21:55.680 position:50% align:middle of practice out there, there is maybe this remote worker type job which does a 00:21:55.680 --> 00:22:02.290 position:50% align:middle lot of interstate telehealth and a lot of telehealth, seems to really be fostered by having 00:22:02.290 --> 00:22:03.900 position:50% align:middle this multistate license. 00:22:03.900 --> 00:22:09.620 position:50% align:middle If you have a multistate license, you're way more likely to do interstate telehealth if 00:22:09.620 --> 00:22:11.580 position:50% align:middle you're practicing in more than three states. 00:22:11.580 --> 00:22:20.200 position:50% align:middle These seem to be sort of different types of jobs, those who do multistate licenses and work in more 00:22:20.200 --> 00:22:24.780 position:50% align:middle than three jurisdictions and those who don't. 00:22:24.780 --> 00:22:28.280 position:50% align:middle Just tying into that, interstate telehealth providers who practice in more 00:22:28.280 --> 00:22:35.610 position:50% align:middle than three states are actually twice as likely to have NLC licenses than RNs overall. 00:22:35.610 --> 00:22:44.820 position:50% align:middle So this is showing that the NLC license seems to be fostering this type of position that kind of seems 00:22:44.820 --> 00:22:55.160 position:50% align:middle to facilitate the ability to do interstate telehealth across a myriad of different states. 00:22:55.160 --> 00:23:04.170 position:50% align:middle Just to tie this to some pre-pandemic work on NLC and telehealth, Norris and Nandy looked at 2019 insurance 00:23:04.170 --> 00:23:11.820 position:50% align:middle claims data and found that the proportion of telehealth from out-of-state providers did not statistically 00:23:11.820 --> 00:23:15.590 position:50% align:middle significantly differ between NLC states and non-NLC states. 00:23:15.590 --> 00:23:20.690 position:50% align:middle So this is before the pandemic, and again, there's some confound because they're looking 00:23:20.690 --> 00:23:25.970 position:50% align:middle at insurance claims data and we're looking at kind of a wider net of telehealth. 00:23:25.970 --> 00:23:28.880 position:50% align:middle But our data seems to suggest that this may have changed since 2019. 00:23:28.880 --> 00:23:36.610 position:50% align:middle We see that having an NLC license as a nurse makes you more likely to do interstate telehealth. 00:23:36.610 --> 00:23:47.200 position:50% align:middle So we may be getting closer to...we may be finding a new status quo than what we saw before. 00:23:47.200 --> 00:23:50.340 position:50% align:middle Some limitations I just wanted to mention. 00:23:50.340 --> 00:23:53.530 position:50% align:middle Our telehealth questions, based on the way we did our survey, 00:23:53.530 --> 00:23:58.380 position:50% align:middle were limited to states that we surveyed via email or mail-out surveys. 00:23:58.380 --> 00:24:02.560 position:50% align:middle So there were five jurisdictions that were excluded from this listed here. 00:24:02.560 --> 00:24:12.180 position:50% align:middle And because this study was just looking at 2022, there's a limited ability to capture the change because 00:24:12.180 --> 00:24:21.930 position:50% align:middle we don't really have a clear baseline from before the pandemic of how different nurses were doing telehealth. 00:24:21.930 --> 00:24:24.380 position:50% align:middle My main takeaways I want to get here. 00:24:24.380 --> 00:24:30.480 position:50% align:middle Telehealth providers are more likely to identify as women, Hispanic, and as members of racial minorities. 00:24:30.480 --> 00:24:33.680 position:50% align:middle But they make up a heterogeneous group. 00:24:33.680 --> 00:24:39.180 position:50% align:middle The way an RN uses telehealth differs based on their specialty, title, and setting. 00:24:39.180 --> 00:24:45.240 position:50% align:middle I've talked about three groups here, our video callers who do some but not a lot 00:24:45.240 --> 00:24:50.560 position:50% align:middle of telehealth, our remote workers who do a lot of telehealth and a lot of interstate telehealth, 00:24:50.560 --> 00:24:57.060 position:50% align:middle and our frontline workers who don't do as much telehealth as the other types of nurses. 00:24:57.060 --> 00:25:04.140 position:50% align:middle And then, finally, RNs with multistate licenses are more likely to perform interstate telehealth. 00:25:04.140 --> 00:25:08.070 position:50% align:middle So, with that, I believe we have a few minutes for questions. 00:25:08.070 --> 00:25:10.000 position:50% align:middle Thank you all. 00:25:14.100 --> 00:25:14.710 position:50% align:middle - [Dr. Lyon] Thank you. 00:25:14.710 --> 00:25:16.170 position:50% align:middle This isn't really a question. 00:25:16.170 --> 00:25:16.970 position:50% align:middle It's an observation. 00:25:16.970 --> 00:25:21.830 position:50% align:middle Karen Lyon, executive officer in Louisiana. 00:25:21.830 --> 00:25:23.970 position:50% align:middle We've implemented the compact in '19. 00:25:23.970 --> 00:25:29.120 position:50% align:middle We did not grandfather our 70,000+ RNs. 00:25:29.120 --> 00:25:32.720 position:50% align:middle You have to apply to convert your single state to a multistate license. 00:25:32.720 --> 00:25:37.760 position:50% align:middle To date, about 21,000 of my active 67,000 nurses have done that. 00:25:37.760 --> 00:25:42.840 position:50% align:middle I'm not worried about the ones who have multistate licenses and that are doing telehealth because 00:25:42.840 --> 00:25:46.470 position:50% align:middle those RNs, they're fine. 00:25:46.470 --> 00:25:51.100 position:50% align:middle I'm worried about the ones who have single-state licenses and are engaging in virtual visits, 00:25:51.100 --> 00:25:55.900 position:50% align:middle telephoning to patients who they treat in Louisiana. 00:25:55.900 --> 00:26:01.490 position:50% align:middle For instance, this is a perfect example, Ochsner and MD Anderson in Houston now have a great 00:26:01.490 --> 00:26:05.320 position:50% align:middle partnership in Louisiana, and so we're treating all these Louisiana patients, 00:26:05.320 --> 00:26:07.350 position:50% align:middle but sometimes they have to go to Houston. 00:26:07.350 --> 00:26:11.930 position:50% align:middle And during that time that they're in Houston undergoing different tests or treatment, 00:26:11.930 --> 00:26:15.760 position:50% align:middle the nurses here in Louisiana are communicating with them and doing virtual visits and doing all 00:26:15.760 --> 00:26:18.620 position:50% align:middle these things, and they don't have a multistate license. 00:26:18.620 --> 00:26:21.190 position:50% align:middle They don't have a single-state license in Texas either. 00:26:21.190 --> 00:26:29.750 position:50% align:middle And so my problem is that we have to use a lot of time doing communication and education and marketing 00:26:29.750 --> 00:26:34.610 position:50% align:middle to make people, these nurses, especially RNs, understand what telehealth involves. 00:26:34.610 --> 00:26:39.560 position:50% align:middle And every time you make that telephone call, if you're in Louisiana and your patient is in Texas or 00:26:39.560 --> 00:26:44.130 position:50% align:middle Arkansas or Mississippi or Alabama, we're surrounded by compact states, 00:26:44.130 --> 00:26:50.830 position:50% align:middle you're doing telehealth and you must have either an MSL or a single-state license in those states. 00:26:50.830 --> 00:26:55.789 position:50% align:middle And that's not happening because I don't think they even understand that that's telehealth as follow-up. 00:26:55.789 --> 00:26:57.380 position:50% align:middle - One hundred percent. Yeah. 00:26:57.380 --> 00:27:01.880 position:50% align:middle And I think that's something that we're hoping to get at with the study is a lot of the other studies looking 00:27:01.880 --> 00:27:07.470 position:50% align:middle at telehealth are looking at really, you know, the things that any RN would go, 00:27:07.470 --> 00:27:10.750 position:50% align:middle "That was telehealth," but there's so much more. 00:27:10.750 --> 00:27:16.390 position:50% align:middle And you know, our numbers might be a little lower than they could be because people are not realizing they're 00:27:16.390 --> 00:27:18.800 position:50% align:middle doing telehealth when they are. 00:27:18.800 --> 00:27:20.400 position:50% align:middle - [Woman 1] Hey, Charlie, I have a question. 00:27:20.400 --> 00:27:25.970 position:50% align:middle Part of the way you described a provider that's more likely to do telehealth, 00:27:25.970 --> 00:27:30.900 position:50% align:middle a nurse that is of color that is...what was the other characteristic? 00:27:30.900 --> 00:27:32.020 position:50% align:middle Anyway. 00:27:32.020 --> 00:27:39.250 position:50% align:middle So I'm wondering, is there any additional thoughts that perhaps maybe that is the persona of the nurse that is 00:27:39.250 --> 00:27:45.730 position:50% align:middle possibly providing more access to care to the same population that they're serving? 00:27:45.730 --> 00:27:48.180 position:50% align:middle Is there any thoughts or anything around that? 00:27:48.180 --> 00:27:51.490 position:50% align:middle - Yeah, that's a really interesting question, and I think, you know, 00:27:51.490 --> 00:28:02.130 position:50% align:middle that's one of the big benefits of telehealth is that it allows for patients to be able to see a wider variety 00:28:02.130 --> 00:28:08.830 position:50% align:middle of providers, potentially based on their specialty, potentially seeing a provider that looks more like them 00:28:08.830 --> 00:28:12.880 position:50% align:middle who may not be in the geographical region. 00:28:12.880 --> 00:28:18.820 position:50% align:middle Unfortunately, we don't have any data on who you're providing the telehealth to when you're doing this, 00:28:18.820 --> 00:28:22.210 position:50% align:middle so I can't tell you that we're getting that result. 00:28:22.210 --> 00:28:25.430 position:50% align:middle But hopefully, there's something there. 00:28:25.430 --> 00:28:31.240 position:50% align:middle - It's kind of an aha moment for me because when you speak about just kind of the reference 00:28:31.240 --> 00:28:35.450 position:50% align:middle [inaudible 00:28:30] a nurse of color that is [inaudible 00:28:35]. 00:28:35.450 --> 00:28:43.360 position:50% align:middle I found that interesting that that is the person that kind of [inaudible 00:28:41]. 00:28:43.360 --> 00:28:45.970 position:50% align:middle - Absolutely, absolutely. 00:28:45.970 --> 00:28:50.230 position:50% align:middle - [Dr. Nikpour] Hi, Jacqueline Nikpour, University of Pennsylvania. 00:28:50.230 --> 00:28:51.960 position:50% align:middle Thank you so much for your presentation. 00:28:51.960 --> 00:28:57.790 position:50% align:middle So I'm a researcher, and my work is mostly in primary care and specifically 00:28:57.790 --> 00:29:04.620 position:50% align:middle redesigning primary care delivery models to elevate and expand the roles of nurses who are working 00:29:04.620 --> 00:29:11.000 position:50% align:middle in those settings, so registered nurses who are not APRNs or can be working at sort of an elevated level, 00:29:11.000 --> 00:29:16.130 position:50% align:middle doing things like chronic disease management, independent low-level patient visits for established 00:29:16.130 --> 00:29:20.770 position:50% align:middle follow-up routine things like getting an A1c screening or vaccination. 00:29:20.770 --> 00:29:26.400 position:50% align:middle All of these things that nurses are kind of taking on in addition to things like care condition, all of that, 00:29:26.400 --> 00:29:29.160 position:50% align:middle and some of the regulatory issues associated with that. 00:29:29.160 --> 00:29:36.500 position:50% align:middle And because we're in this era of team-based care where nurses are kind of taking on these different roles 00:29:36.500 --> 00:29:44.860 position:50% align:middle in primary care, including telehealth, I'm curious if, on your slide where you've got nurses who are 00:29:44.860 --> 00:29:50.640 position:50% align:middle in community health who are doing telehealth some of the time, you mentioned their title as APRNs, 00:29:50.640 --> 00:29:54.800 position:50% align:middle and so I'm curious if that... 00:29:54.800 --> 00:29:56.800 position:50% align:middle - I pressed the button too many times. 00:29:56.800 --> 00:29:58.770 position:50% align:middle This is going to go back to the top. 00:29:58.770 --> 00:30:01.410 position:50% align:middle - There was, I think, one slide you just passed that was APRNs. 00:30:01.410 --> 00:30:02.850 position:50% align:middle - Yeah, I know which slide you're talking about. 00:30:02.850 --> 00:30:07.190 position:50% align:middle - Are they all APRNs who were, as part of sample, doing community health? 00:30:07.190 --> 00:30:12.030 position:50% align:middle Did you see any registered nurses who are not APRNs doing telehealth in these settings? 00:30:12.030 --> 00:30:12.870 position:50% align:middle What did that look like? 00:30:12.870 --> 00:30:13.640 position:50% align:middle - Yeah. 00:30:13.640 --> 00:30:19.050 position:50% align:middle And I think this is a place where the way I'm presenting these profiles is a little bit 00:30:19.050 --> 00:30:20.740 position:50% align:middle confusing right now. 00:30:20.740 --> 00:30:30.830 position:50% align:middle But I think, here, what I'm kind of looking at is APRNs are more likely to be video callers than other titles, 00:30:30.830 --> 00:30:38.300 position:50% align:middle than like staff nurses or other things, and nurses in community health settings are more likely 00:30:38.300 --> 00:30:43.050 position:50% align:middle to be doing video calling than, say, hospital nurses and other settings. 00:30:43.050 --> 00:30:47.100 position:50% align:middle - So, when you say nurses in community health settings, you're specifically referring to APRNs? 00:30:47.100 --> 00:30:52.880 position:50% align:middle - No, I am talking about any title you have in community health settings. 00:30:52.880 --> 00:30:58.520 position:50% align:middle So these three categories are not meant to be overlapping inherently. 00:30:58.520 --> 00:31:04.840 position:50% align:middle So even though, you know, I haven't looked at the data, the cross-tabs completely, 00:31:04.840 --> 00:31:08.830 position:50% align:middle but it may be the case and probably is the case in some of these that, like, well, 00:31:08.830 --> 00:31:16.680 position:50% align:middle the staff nurses in hospitals who do acute care is, you know, a very close together Venn diagram. 00:31:16.680 --> 00:31:23.020 position:50% align:middle I think we may have some distinct Venn diagrams that are showing a similar profile of telehealth that can't 00:31:23.020 --> 00:31:25.370 position:50% align:middle be gleaned just looking at, yeah. 00:31:25.370 --> 00:31:26.410 position:50% align:middle - Got you. 00:31:26.410 --> 00:31:26.920 position:50% align:middle Okay. 00:31:26.920 --> 00:31:31.630 position:50% align:middle I'm curious because you've got...it's most likely that most people in these settings who are doing these video 00:31:31.630 --> 00:31:36.510 position:50% align:middle calls are APRNs, but I'd be curious if there's an increase in RNs doing telehealth over time, 00:31:36.510 --> 00:31:39.470 position:50% align:middle especially in community health centers that are very RN-driven, that kind of thing. 00:31:39.470 --> 00:31:40.310 position:50% align:middle - Absolutely. 00:31:40.310 --> 00:31:43.810 position:50% align:middle That's a really great question, something I want to look at now. 00:31:43.810 --> 00:31:45.060 position:50% align:middle - Thank you. 00:31:45.060 --> 00:31:47.350 position:50% align:middle - Thank you so much. 00:31:47.350 --> 00:31:53.260 position:50% align:middle - [Woman 2] I know you didn't provide types of services, but would it make more sense that those are 00:31:53.260 --> 00:32:02.100 position:50% align:middle providing sick visits or follow-up visits would be more telehealth than those providing well visits such 00:32:02.100 --> 00:32:04.840 position:50% align:middle as pediatrics who need, frequently, especially the first two years, 00:32:04.840 --> 00:32:09.830 position:50% align:middle frequent well-checks over adults who need a well-check maybe once a year with just follow-up visits 00:32:09.830 --> 00:32:10.800 position:50% align:middle or sick visits? 00:32:10.800 --> 00:32:11.880 position:50% align:middle - I think 100%. 00:32:11.880 --> 00:32:17.750 position:50% align:middle I think, again, these are the three questions I had to get the type of providing you're doing, 00:32:17.750 --> 00:32:23.290 position:50% align:middle but I'm hoping that nothing I'm presenting here is, like, surprising to anyone. 00:32:23.290 --> 00:32:25.320 position:50% align:middle You should look at those and go like, "Well, yeah, no. 00:32:25.320 --> 00:32:31.190 position:50% align:middle If you're an anesthetist, you should not be doing that via telehealth. 00:32:31.190 --> 00:32:33.710 position:50% align:middle That doesn't really make sense to me." 00:32:33.710 --> 00:32:39.410 position:50% align:middle And so I think that's sort of what we get. 00:32:39.410 --> 00:32:46.470 position:50% align:middle And again, the next steps are making those leaps and going like, "Okay, if you're this type of provider, 00:32:46.470 --> 00:32:49.610 position:50% align:middle you're probably doing this type of practice this much," and so on. 00:32:49.610 --> 00:32:51.990 position:50% align:middle So, yeah, thank you so much. 00:32:51.990 --> 00:32:54.129 position:50% align:middle I think we are out of time for this session.