Evaluation of Virtual Healthcare Visits

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8th Feb 2020 Health Reference this

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An increasing number of healthcare systems offer patients virtual visits for a variety of non-critical, acute conditions and chronic conditions. The virtual visits continue to increase patient satisfaction scores and decrease costs without affecting patient outcomes. Utilization of virtual visits is currently low but is sure to expand as patients learn about them and when to use them, as providers learn how to conduct them, and as technology on both sides, the patient’s as well as the provider’s, improves.

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What are Virtual Visits?

Virtual visits are provided using electronic communications (audio and/or visual) versus traditional in-person consultations (Abbott, et al., 2018). The internet is used to transmit data, allowing patients and providers increased flexibility to schedule initial and follow-up care visits. An additional benefit is that these virtual visits decrease insurance costs (Abbott, et al., 2018). Patients benefit because they no longer need to schedule as much time from work or travel for some healthcare visits (Abbott, et al., 2018). This is especially beneficial for patients that have trouble or are unable to leave home: they can still consult or visit with providers as needed for the appropriate situations or conditions.

Virtual visits decrease overhead costs, which helps allocate resources more to those who need in-person care while still providing care to all. This allows the provider to have consultations outside clinic hours, saving time for patients who need in-person examinations (Abbott, et al., 2018). Virtual visits enable greater patient access to different providers. Physical distance is easily overcome. They can be used to triage and direct patients to resources and further testing, if needed. But these advantages are still limited by Oklahoma law, e.g. a provider must be aware of the legal considerations due to licensure limits and the possible need for multiple licenses to be able to treat patients that are in different states than where the provider is located since the ability to consult and treat patients remotely is being utilized via the virtual visits, such as a patient being located in Oklahoma while the provider is located in Kansas or Missouri or vice versa, for example.

Role of Virtual Visits in Patient Health Outcomes

Virtual visits have the opportunity to improve patient outcomes by making it easier and faster for patients to see their healthcare provider. Utilization of virtual visits is limited both by the provider and by the patient because of unfamiliarity. Many patients do not know when they might use virtual visits and providers seem hesitant to recommend virtual visits to their patients. The unfamiliarity barrier can be overcome by learning about the benefits to virtual visits. When patients receive a virtual visit, research shows that patients view the care they receive to be as thorough as in-person consultations (McGrail, Ahuja, & Leaver, 2017). Providers are still able to order laboratory tests, diagnostic imaging tests, and prescribe medicine. From the provider perspective, known and unknown providers were equally likely to order laboratory testing, while known providers order fewer diagnostic imaging tests for a virtual visit than for an in-person visit or unknown providers, and they prescribe less medicine that unknown providers (McGrail, et al., 2017).

In managing chronic conditions or surgical follow-up consultations, patient outcomes of virtual visits have been shown to be equivalent to those of in-person follow-ups. With providers able to order testing electronically prior to the appointment, follow-up consultations had equivalent outcomes (Levine, Dixon, & Linder, 2018; Lin, McLaughlin, Zurawski, Kennedy, & Kabbani, 2018). Following patient conditions like chronic hypertension virtually actually improved systolic blood pressure by 56% versus a 52% improvement in those who had in-person follow-ups (Levine, et al., 2018). Likewise, virtual follow-up for chronic venous disease showed comparable outcomes to in-person follow-ups (Lin et al., 2018). After surgery for implantable cardioverter-defibrillators, patients were followed for years and found to have no significant difference in outcomes as measured by time to first shock after in the first five years post-implantation, by use of inappropriate therapies, and by survival at the seven year mark post-implantation, whether they were seen via virtual visits or in person (Dalouk, et al., 2017). Another study compared virtual post-surgical follow-up for multiple conditions that did not have delayed wound healing, did not need continuous testing for conditions for which surgery was performed, and did not have suspected or previous diagnosis of malignancy; it demonstrated comparable outcomes and significant increase in patient satisfaction while also allowing for patients who needed in-person visits fewer delays in being seen (Healy, Tully, Flannery, & Flynn, 2018). It is significant to note that recovery was comparable, patients’ perception of care received was amplified, and there were quick response times. Levine, et al. (2018) also found that the virtual follow-ups reduced utilization of in-office primary care. This has the added cost benefit of reducing costs associated with ancillary staff and reducing facility costs for the providers while also reducing travel expenses and time for the patients (Abbott, et al., 2018). Virtual initial consultations can help expedite additional diagnostic testing and follow-ups with other specialists (Abbott, et al., 2018).

Urgent care settings also lend themselves to virtual visits for certain patients. An emergency room in New York City dedicated a room to virtual visits so that some of the less acute or critical patients could be seen after being triaged by nurses. This let more critical patients to utilize the emergency room resources (McHugh, Krinsky, & Sharma, 2018). Patient satisfaction increased when the low acuity patients were steered to the virtual visits because, among other factors, this decreased the length of stay for both the patients who utilized the virtual visits and the lower-acuity patients who decided against using the virtual visits (McHugh, et al., 2018; Ahnood, Souriti, & Williams, 2018). When virtual visits were utilized for non-urgent or non-chronic conditions, follow-up evaluation and management visits were comparable to those of in-person visits and self-reporting of the ending of symptoms was comparable, as well (Gordon, Adamson, & DeVries, 2017).

Providing Virtual Visits

As technology improves and point-of-care ultrasound is more readily available, virtual visits may take the place of a large proportion of in-person visits (Lin, et al., 2018). The provider must be able to conduct assessments, think critically and creatively, be comfortable with technology, and be prepared to act as advocates for those with limited access to care (Rutledge, et al., 2017). They must also be prepared to and to lobby for funding, reimbursement, and continued research into developing telehealth technologies (Rutledge, Haney, Bordelon, Renaud, & Fowler, 2014; Rutledge, et al., 2017). They need to educate their patients about when virtual visits can and should be utilized, such as with a poster (Integris Health, Inc., 2018). Providers should also be prepared to use virtual visits with other providers for complex medical patients for care coordination (Cady, et al., 2015). Providers need to be aware about the legal issues of providing care via virtual visits as patients could be located across state lines (or even across international borders) where licensure does not extend. Providers include the healthcare systems that implement telehealth, including virtual visits, who have a vested interest in reducing costs in ways that do not negatively impact patient outcomes and increase patient satisfaction. They also have a role in promoting utilization of the virtual services as well as reimbursement for the care that they provide through virtual services including virtual visits.

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Advanced practice registered nurses (APRNs) have a unique position as one of the providers of healthcare and, specifically, virtual visits. APRNs combine the medical knowledge with the aspects of the bedside nurse, particularly knowing and caring for the patient. This knowing and caring is traditionally achieved through the physical presence of the nurse, and through verbal communication (Nagel, Pomerleau, & Penner, 2013). The physical distance that exists when providing care via virtual visits presents a barrier to the traditional form of knowing and caring for patients. Video virtual visits can help overcome the distance barrier because non-verbal behavior and the surrounding environment can be observed (Nagel, et al., 2013). In fact, it could be even more beneficial that the environment can be observed because APRNs can learn more about their patients’ environments that they could in a traditional clinical environment and, thus, know the patient (Nagel, et al., 2013). Knowing a patient’s environment often aids in providing appropriate recommendations for care. Different features involved in virtual visits might lead an interviewer to have different questions. There is a different quality of observation of the environment/surrounding that changes the senses utilized, such as smell, temperature, and feel, that are not able to be used during virtual visits that would be during in-person visits and so require creativity.

In any situation, a provider must be skilled in taking a history of the patient’s current medical issue (Muhrer, 2014). As part of taking a history, the provider must word questions so as not to lead answers and give patients adequate time to answer without filling the silence (Muhrer, 2014). This is even more important during virtual visits due to lack of physical contact. Muhrer (2014) declared that APRNs were more thorough physicians in taking a full history, including socioeconomic and cultural factors in addition to the medical and were less likely to “prescribe medical therapy unless indicated through a relevant history” (p. 34).

Enhancing Utilization of Virtual Visits

Providers and their staffs who learn how to conduct virtual visits are more likely to encourage their patient to use virtual visits too. The providers must become more familiar with how virtual visits are conducted and when they are appropriate. One way of training providers and their staffs is through simulated practice. After a simulated virtual visit, Doctor of Nursing Practice (DNP) students expressed that this method of learning was valuable, they could utilize creative assessment means that were not considered in face-to-face encounters, and that it was both useful and practical (Rutledge, et al., 2014). These same students participated in an 8-hour immersion clinical that helped them practice and also connect with other providers utilizing telehealth. Interactive telehealth modules showed available resources for clinicians and patients, which helped students identify potential barriers for patients and ways to overcome those barriers (Rutledge, et al., 2014). Experiential methods solidify the didactic learning, including assessment (Rutledge, et al., 2017). Competencies must be developed for educational programs that address telehealth and virtual visits (Rutledge, et al., 2017). From a logistical standpoint, virtual visits are better suited for people who utilize single payer systems, such as the VA, and/or have shared electronic medical records so that information can be readily shared and accessed among providers (Abbott, et al., 2018). Licensure compacts can help with legal issues dealing with providing care over state lines; making access to care is even more available and so that providers do not need multiple licenses to cover not only the state that they reside/work in but also those around them. Once providers learn how to conduct virtual visits, they are better suited to encourage their patients to use virtual visits. The information can be easily shared during an in-person visit or with simple tools such as flyers or posters in the office (Integris Health, Inc., 2018).

Healthcare systems can also benefit from investing in telehealth because savings can occur when healthcare systems invest in virtual visits, both for the provider (as an individual and as a company) and the patient. In one example, the Veterans Affairs healthcare system (VA) had 65% cost savings after it mandated that all VA hospitals and community-based outpatient clinics incorporate telehealth, including virtual consultations between primary providers and specialists that started in 2009 (Abbott, et al., 2018). VA’s include travel reimbursement in their costs for patients. That inclusion must be considered when looking at the 65% savings provided by utilizing virtual consultations between the primary provider and specialists and using virtual visits with the patients who needed surgery until the multidiscipline preoperative visit for surgical general anesthesia clearance or until the procedure visit for non-general anesthesia procedures (but that portion of the savings would be on the patient side when not dealing with a VA system) (Abbott, et al., 2018).

Conclusions

Virtual visits have the potential to be cost-effective solutions to the overburdened physical access to providers. They allow those with limited means of physically going to healthcare sources to be able to be seen. They are a viable and efficient solution for follow-up visits, minor acute issues, and for following chronic conditions. They increase access when providers are educated in how to conduct virtual visits with patients and then implement that training. Patients and providers both reap benefits of virtual visits; each saves time and cost. Further, patient satisfaction is elevated. Even though establishing a trusting relationship between a provider and patient may be more challenging during an initial virtual visit, the data suggests that patient care is not compromised and satisfaction is improved. Because of their equivalent effect on patient outcomes while reducing costs, virtual visits are worth investing in and utilizing, both as a patient and as a provider.

An increasing number of healthcare systems offer patients virtual visits for a variety of non-critical, acute conditions and chronic conditions. The virtual visits continue to increase patient satisfaction scores and decrease costs without affecting patient outcomes. Utilization of virtual visits is currently low but is sure to expand as patients learn about them and when to use them, as providers learn how to conduct them, and as technology on both sides, the patient’s as well as the provider’s, improves.

What are Virtual Visits?

Virtual visits are provided using electronic communications (audio and/or visual) versus traditional in-person consultations (Abbott, et al., 2018). The internet is used to transmit data, allowing patients and providers increased flexibility to schedule initial and follow-up care visits. An additional benefit is that these virtual visits decrease insurance costs (Abbott, et al., 2018). Patients benefit because they no longer need to schedule as much time from work or travel for some healthcare visits (Abbott, et al., 2018). This is especially beneficial for patients that have trouble or are unable to leave home: they can still consult or visit with providers as needed for the appropriate situations or conditions.

Virtual visits decrease overhead costs, which helps allocate resources more to those who need in-person care while still providing care to all. This allows the provider to have consultations outside clinic hours, saving time for patients who need in-person examinations (Abbott, et al., 2018). Virtual visits enable greater patient access to different providers. Physical distance is easily overcome. They can be used to triage and direct patients to resources and further testing, if needed. But these advantages are still limited by Oklahoma law, e.g. a provider must be aware of the legal considerations due to licensure limits and the possible need for multiple licenses to be able to treat patients that are in different states than where the provider is located since the ability to consult and treat patients remotely is being utilized via the virtual visits, such as a patient being located in Oklahoma while the provider is located in Kansas or Missouri or vice versa, for example.

Role of Virtual Visits in Patient Health Outcomes

Virtual visits have the opportunity to improve patient outcomes by making it easier and faster for patients to see their healthcare provider. Utilization of virtual visits is limited both by the provider and by the patient because of unfamiliarity. Many patients do not know when they might use virtual visits and providers seem hesitant to recommend virtual visits to their patients. The unfamiliarity barrier can be overcome by learning about the benefits to virtual visits. When patients receive a virtual visit, research shows that patients view the care they receive to be as thorough as in-person consultations (McGrail, Ahuja, & Leaver, 2017). Providers are still able to order laboratory tests, diagnostic imaging tests, and prescribe medicine. From the provider perspective, known and unknown providers were equally likely to order laboratory testing, while known providers order fewer diagnostic imaging tests for a virtual visit than for an in-person visit or unknown providers, and they prescribe less medicine that unknown providers (McGrail, et al., 2017).

In managing chronic conditions or surgical follow-up consultations, patient outcomes of virtual visits have been shown to be equivalent to those of in-person follow-ups. With providers able to order testing electronically prior to the appointment, follow-up consultations had equivalent outcomes (Levine, Dixon, & Linder, 2018; Lin, McLaughlin, Zurawski, Kennedy, & Kabbani, 2018). Following patient conditions like chronic hypertension virtually actually improved systolic blood pressure by 56% versus a 52% improvement in those who had in-person follow-ups (Levine, et al., 2018). Likewise, virtual follow-up for chronic venous disease showed comparable outcomes to in-person follow-ups (Lin et al., 2018). After surgery for implantable cardioverter-defibrillators, patients were followed for years and found to have no significant difference in outcomes as measured by time to first shock after in the first five years post-implantation, by use of inappropriate therapies, and by survival at the seven year mark post-implantation, whether they were seen via virtual visits or in person (Dalouk, et al., 2017). Another study compared virtual post-surgical follow-up for multiple conditions that did not have delayed wound healing, did not need continuous testing for conditions for which surgery was performed, and did not have suspected or previous diagnosis of malignancy; it demonstrated comparable outcomes and significant increase in patient satisfaction while also allowing for patients who needed in-person visits fewer delays in being seen (Healy, Tully, Flannery, & Flynn, 2018). It is significant to note that recovery was comparable, patients’ perception of care received was amplified, and there were quick response times. Levine, et al. (2018) also found that the virtual follow-ups reduced utilization of in-office primary care. This has the added cost benefit of reducing costs associated with ancillary staff and reducing facility costs for the providers while also reducing travel expenses and time for the patients (Abbott, et al., 2018). Virtual initial consultations can help expedite additional diagnostic testing and follow-ups with other specialists (Abbott, et al., 2018).

Urgent care settings also lend themselves to virtual visits for certain patients. An emergency room in New York City dedicated a room to virtual visits so that some of the less acute or critical patients could be seen after being triaged by nurses. This let more critical patients to utilize the emergency room resources (McHugh, Krinsky, & Sharma, 2018). Patient satisfaction increased when the low acuity patients were steered to the virtual visits because, among other factors, this decreased the length of stay for both the patients who utilized the virtual visits and the lower-acuity patients who decided against using the virtual visits (McHugh, et al., 2018; Ahnood, Souriti, & Williams, 2018). When virtual visits were utilized for non-urgent or non-chronic conditions, follow-up evaluation and management visits were comparable to those of in-person visits and self-reporting of the ending of symptoms was comparable, as well (Gordon, Adamson, & DeVries, 2017).

Providing Virtual Visits

As technology improves and point-of-care ultrasound is more readily available, virtual visits may take the place of a large proportion of in-person visits (Lin, et al., 2018). The provider must be able to conduct assessments, think critically and creatively, be comfortable with technology, and be prepared to act as advocates for those with limited access to care (Rutledge, et al., 2017). They must also be prepared to and to lobby for funding, reimbursement, and continued research into developing telehealth technologies (Rutledge, Haney, Bordelon, Renaud, & Fowler, 2014; Rutledge, et al., 2017). They need to educate their patients about when virtual visits can and should be utilized, such as with a poster (Integris Health, Inc., 2018). Providers should also be prepared to use virtual visits with other providers for complex medical patients for care coordination (Cady, et al., 2015). Providers need to be aware about the legal issues of providing care via virtual visits as patients could be located across state lines (or even across international borders) where licensure does not extend. Providers include the healthcare systems that implement telehealth, including virtual visits, who have a vested interest in reducing costs in ways that do not negatively impact patient outcomes and increase patient satisfaction. They also have a role in promoting utilization of the virtual services as well as reimbursement for the care that they provide through virtual services including virtual visits.

Advanced practice registered nurses (APRNs) have a unique position as one of the providers of healthcare and, specifically, virtual visits. APRNs combine the medical knowledge with the aspects of the bedside nurse, particularly knowing and caring for the patient. This knowing and caring is traditionally achieved through the physical presence of the nurse, and through verbal communication (Nagel, Pomerleau, & Penner, 2013). The physical distance that exists when providing care via virtual visits presents a barrier to the traditional form of knowing and caring for patients. Video virtual visits can help overcome the distance barrier because non-verbal behavior and the surrounding environment can be observed (Nagel, et al., 2013). In fact, it could be even more beneficial that the environment can be observed because APRNs can learn more about their patients’ environments that they could in a traditional clinical environment and, thus, know the patient (Nagel, et al., 2013). Knowing a patient’s environment often aids in providing appropriate recommendations for care. Different features involved in virtual visits might lead an interviewer to have different questions. There is a different quality of observation of the environment/surrounding that changes the senses utilized, such as smell, temperature, and feel, that are not able to be used during virtual visits that would be during in-person visits and so require creativity.

In any situation, a provider must be skilled in taking a history of the patient’s current medical issue (Muhrer, 2014). As part of taking a history, the provider must word questions so as not to lead answers and give patients adequate time to answer without filling the silence (Muhrer, 2014). This is even more important during virtual visits due to lack of physical contact. Muhrer (2014) declared that APRNs were more thorough physicians in taking a full history, including socioeconomic and cultural factors in addition to the medical and were less likely to “prescribe medical therapy unless indicated through a relevant history” (p. 34).

Enhancing Utilization of Virtual Visits

Providers and their staffs who learn how to conduct virtual visits are more likely to encourage their patient to use virtual visits too. The providers must become more familiar with how virtual visits are conducted and when they are appropriate. One way of training providers and their staffs is through simulated practice. After a simulated virtual visit, Doctor of Nursing Practice (DNP) students expressed that this method of learning was valuable, they could utilize creative assessment means that were not considered in face-to-face encounters, and that it was both useful and practical (Rutledge, et al., 2014). These same students participated in an 8-hour immersion clinical that helped them practice and also connect with other providers utilizing telehealth. Interactive telehealth modules showed available resources for clinicians and patients, which helped students identify potential barriers for patients and ways to overcome those barriers (Rutledge, et al., 2014). Experiential methods solidify the didactic learning, including assessment (Rutledge, et al., 2017). Competencies must be developed for educational programs that address telehealth and virtual visits (Rutledge, et al., 2017). From a logistical standpoint, virtual visits are better suited for people who utilize single payer systems, such as the VA, and/or have shared electronic medical records so that information can be readily shared and accessed among providers (Abbott, et al., 2018). Licensure compacts can help with legal issues dealing with providing care over state lines; making access to care is even more available and so that providers do not need multiple licenses to cover not only the state that they reside/work in but also those around them. Once providers learn how to conduct virtual visits, they are better suited to encourage their patients to use virtual visits. The information can be easily shared during an in-person visit or with simple tools such as flyers or posters in the office (Integris Health, Inc., 2018).

Healthcare systems can also benefit from investing in telehealth because savings can occur when healthcare systems invest in virtual visits, both for the provider (as an individual and as a company) and the patient. In one example, the Veterans Affairs healthcare system (VA) had 65% cost savings after it mandated that all VA hospitals and community-based outpatient clinics incorporate telehealth, including virtual consultations between primary providers and specialists that started in 2009 (Abbott, et al., 2018). VA’s include travel reimbursement in their costs for patients. That inclusion must be considered when looking at the 65% savings provided by utilizing virtual consultations between the primary provider and specialists and using virtual visits with the patients who needed surgery until the multidiscipline preoperative visit for surgical general anesthesia clearance or until the procedure visit for non-general anesthesia procedures (but that portion of the savings would be on the patient side when not dealing with a VA system) (Abbott, et al., 2018).

Conclusions

Virtual visits have the potential to be cost-effective solutions to the overburdened physical access to providers. They allow those with limited means of physically going to healthcare sources to be able to be seen. They are a viable and efficient solution for follow-up visits, minor acute issues, and for following chronic conditions. They increase access when providers are educated in how to conduct virtual visits with patients and then implement that training. Patients and providers both reap benefits of virtual visits; each saves time and cost. Further, patient satisfaction is elevated. Even though establishing a trusting relationship between a provider and patient may be more challenging during an initial virtual visit, the data suggests that patient care is not compromised and satisfaction is improved. Because of their equivalent effect on patient outcomes while reducing costs, virtual visits are worth investing in and utilizing, both as a patient and as a provider.

References

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  • Ahnood, D., Souriti, A., & Williams, G. (2018). Assessing patient acceptance of virtual clinics for diabetic retinopathy: a large scale postal survey. Canadian Journal of Ophthalmology, 53(3), 207-209. doi:10.1016/j.jcj0.2017.10.035
  • Cady, R. G., Erickson, M., Lunos, S., Finkelstein, S., Looman, W., Celebreeze, M., & Garwick, A. (2015). Meeting the needs of children with medical complexity using a telehealth advanced practice registered nurse care coordination model. Maternal Child Health Journal, 19(7), 1497-1506. doi:10.1007/s10995-014-1654-1
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  • Gordon, A. S., Adamson, W., & DeVries, A. (2017). Virtual visits for acute, nonurgent care: A claims analysis of episode-level utilization. Journal of Medical Internet Research, 19(2), e35. doi:10.2196/jmir.6783
  • Healy, P., Tully, R., Flannery, E., & Flynn, A. (2018). Virtual outpatient clinic as an alternative to an actual clinic visit after surgical discharge: A randomized controlled trial. BMJ Quality & Safety, 0, 1-8. doi:10.1136/bmjqs-2018-008171
  • Integris Health, Inc. (2018). Accessing health care. [Poster].
  • Levine, D. M.,Dixon, R. F., & Linder, J. A. (2018). Association of structured virtual visits for hypertension follow-up in primary care with blood pressure control and use of clinical services. Journal of General Internal Medicine, 33(11), 1862-1867. doi:10.1007/s11606-018-4375-0
  • Lin, J. C., McLaughlin, D., Zurawski, D., Kennedy, N., & Kabbani, L. (2018). Comparison of virtual visit versus traditional clinic for management of varicose veins. Journal of Telemedicine and Telecare, 0(0), 1-5. doi:10.1177/1357633X18787181
  • McGrail, K. M., Ahuja, M., & Leaver, C. (2017). Virtual visits and patient-centered care: Results of a patient survey and observational study. Journal of Medical Internet Research, 19(5), e177. doi:10.2196/jmir.7374
  • McHugh, C., Krinsky, R., & Sharma, R. (2018, September). Innovations in emergency nursing: Transforming emergency care through a novel nurse-driven ED telehealth express care service. Journal of Emergency Nursing, 44(5), 472-477.
  • Muhrer, J. C. (2014). The importance of the history and physical in diagnosis. The Nurse Practitioner, 39(4), 30-35. doi:10.1097/01.NPR.0000444648.e6
  • Nagel, D. A., Pomerleau, S., & Penner, J. (2013). Knowing, caring, and telehealth technology: “Going the distance” in nursing practice. Journal of Holistic Nursing, 31(2), 104-112. doi:10.1177/08980101122465357
  • Rutledge, C. M., Haney, T., Bordelon, M., Renaud, M., & Fowler, C. (2014). Telehealth: Preparing advanced practice nurses to address healthcare needs in rural and underserved populations. International Journal of Nursing Education Scholarship, 11(1). doi:10.1515/ijnes-2013-0061
  • Rutledge, C. M., Kott, K., Schweickert, P., Poston, R., Fowler, C., & Haney, T. (2017). Telehealth and ehealth in nurse practitioner training: Current perspectives. Advances in Medical Education and Practice, 8, 399-409.

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