Where NewYork-Presbyterian, UCSF Health, Novant digital leaders stand on virtual nursing

Virtual nurses can relieve staffing shortages, keep aging nurses working longer, and cut down on administrative tasks for in-person nurses, hospital IT leaders told Becker's.

However, shifts in culture, reimbursements and technology will have to happen for virtual nurses to become widespread, the executives said.

Either way, virtual nurses are here, evidenced by some large health systems turning to the telehealth tool. Fifteen chief nursing informatics officers and digital executives shared their insights with Becker's about how they expect this to all play out. (In the first part of this series, clinical nursing leaders weighed in on the trend.)

Note: Their responses have been lightly edited for length and clarity.

Geeta Nastasi, RN. Chief Nursing Informatics Officer of NewYork-Presbyterian (New York City). In a few years from now, we'll look back and marvel at why we spoke of virtual nurses as a novelty. In some ways, it's moot to think about it in terms of pros and cons. Virtual nurses will become the norm in the same way telehealth has become an essential healthcare delivery mode — even though pre-pandemic there was hesitancy to embrace digital engagement as an alternative to face-to-face, empathetic human interaction.

With the exponential pace of digital transformation lending itself to the propagation of hybrid models of care to solve workforce challenges and meet the quadruple aim, virtual care is now irrevocably established as strategic to a sustainable, composable enterprise strategy. As the largest healthcare profession in the world, nurses must inevitably evolve to meet a digital future head-on where both our customers and our workforce will be. Gen Z, Gen Alpha and subsequent generations fully expect and embrace all things digital.

While the technology to scale up virtual nursing does exist, virtual nursing should not be viewed as a zero-sum game but as part of a diversified portfolio of digital programs that can deliver a total, connected, digital experience. Many organizations, like NewYork-Presbyterian, have rolled out virtual nursing but are carefully plotting large-scale expansion in terms of a virtual care framework to achieve a seamless, integrated approach.

Kay Burke, BSN, RN. Chief Nursing Informatics Officer of USCF Health (San Francisco). The benefits include:

— Recruitment and retention (ability to attract talent that wants to practice in alternative ways/diversifying care-delivery modalities can be particularly motivating, particularly as we continue to combat burnout).

— Operational efficiency (offloading tasks that do not need to be cared for by a direct-care registered nurse can speed up throughput and accelerate discharge).

— 'Virtual care for the caregiver' — virtual nursing models allow for seasoned nurses to virtually precept and mentor less experienced nurses just entering the workforce.

The technology isn't quite there, but we are close. With COVID enabling telehealth capabilities, broadly we are much closer than pre-pandemic. Cultural shifts are probably harder to change at this juncture than technological shifts. Nurses are not accustomed to team models, especially ones that have a virtual and an in-person registered nurse.

Amber Fencl. Senior Vice President and Chief Digital Health Officer of Novant Health (Winston-Salem, N.C.). Benefits include allowing for flexibility with support staffing needs and enabling bedside nurses to operate at the top of their license with patient experience, safety and quality of care in mind.

Virtual nursing programs may be effectively conducted with iPads in patient rooms or rooms can be outfitted with advanced technology for virtual communications via video and audio, also with ambient fall detection. Virtual nursing teams may be implemented for various support needs, including teletriage, admissions, discharge and patient education. For example, while bedside nurses perform physical assessments during admissions, virtual nurses can interact with patients via video to collect information such as medical history and medication regimen.

Another example of successful use of virtualization may be when there needs to be patient education delivered prior to discharge. A virtual nurse has planned capacity to deliver detailed patient education, with focus and precision, while the bedside nurse performs final in-room discharge activities like vitals and case management coordination.

Gretchen Brown, MSN, RN. Chief Nursing Informatics Officer of Stanford Health Care (Palo Alto, Calif.). There are potential benefits to make improvements on many fronts, for example: virtual observation of high-risk, low-incident patients; efficiency with the use of a virtual nurse completing an admission assessment, currently a disruptive event in a hospital nurse's day; improvements in patient satisfaction with the addition of virtual-nurse touchpoints for consultation before obtaining care at the emergency department.

The technical stacks are coming together to meet the need and be scalable. Our work will be to introduce this new way of receiving care to our patients and staff while making it "easy." For the business, we should envision the funding and reimbursement models to support these offerings long-term.

Virtual nursing could be leveraged for in-the-moment education and mentoring, which could be a win-win for novice to expert nurses offering new opportunities for our aging nursing workforce rather than losing them.

W. Jason Atkins, RN. Chief Nursing Information and Quality Officer of Emory Healthcare (Atlanta). Virtual nursing is a new care model that all healthcare organizations should be evaluating given the nationwide nursing shortages and prevalence of burnout in nursing. Depending on how it is implemented, virtual nursing can provide relief from the burden of specific tasks such as patient admission, discharges and education.

Advanced functions may provide a level of anticipatory care that is a second set of eyes on the patient to identify early clinical deterioration, prompt response to clinical-decision-support alerts, and proactive monitoring for safety risks such as falls, elopement and behavioral concerns. These functions may help improve nursing communication with patients, improve care transitions, reduce lengths of stay, reduce codes and intensive care unit days, and reduce readmissions.

Similar models have been effectively used in eICUs for over two decades and have much promise in noncritical-care environments. The technology is advancing quickly to utilize computer vision and machine learning to support virtual nursing care, and current audio-visual technology can be integrated into EMRs to provide seamless interaction with orders, clinical documentation, and predictive analytics which all support both the virtual RN and the bedside clinical RN.

Zafar Chaudry, MD. Senior Vice President and Chief Digital and Information Officer of Seattle Children's. Technology continues to improve fueled by the progress made during the pandemic. More importantly than the technology, organizations going down this path will need to rework their clinical processes and change the way in which their people work for success in this area.

Melinda Cooling, DNP, RN. Chief Clinician Executive of Digital Health at OSF HealthCare (Peoria, Ill.). There are nurses that can no longer manage the physical demands of bedside nursing but bring years of expertise to the care of patients. Virtual nursing allows you to bring their expertise to the patient and the healthcare team. It also allows them more flexibility.

But many times healthcare organizations can be very conservative, and we have to be able to get out of our own way to innovate and create new models of care. Safety is always the first priority, but we have to be willing to try new things. We don't have the financial or human resources to continue doing it the same way.

Erin Green, RN. Executive Director of Virtual Care at Froedtert Health (Milwaukee). Virtual nurses can provide benefits such as efficiency through more purposeful work assignments, improved response times, dynamic staffing, and enhanced collaboration and communication across the care team and care continuum.

The technology behind virtual nursing is still evolving, and while we have a robust menu of tools for audio-visual assessment and interaction, medical-record integration and resources that further support virtual nursing workflows remain a challenge. The use of virtual nursing also requires clear key performance indicators and metrics to measure its effectiveness and avoid misperceptions around its return on investment.

Michael Mainiero. Chief Digital and Information Officer of Catholic Health (Rockville Centre, N.Y.). Virtual nursing has the potential to transform patient care with our Epic EHR system at the forefront. With the orchestration of audio, video, vitals, and AI technology, nurses may become better supported to detect falls and other potential harm early.

The challenge is to scale this technology and implement it cost-effectively, balancing the health system's goals, supporting nurses, and improving patient outcomes.

Mohamed Salem. Executive Director of Digital IT Innovation at University of Miami Health System. The potential benefits for virtual nursing are to relieve burdens on the nursing staff. It allows nonclinical and urgent questions to be handled by a virtual nurse who can oversee a larger ratio of patients. This allows physical nurses to also oversee a larger ratio of patients.

This will largely benefit patients, since their questions and concerns are answered at a faster pace. Also benefits the patient because physical nurses can focus on more urgent clinical matters.

Some issues may be solved with natural language AI chatbots that may be able to answer a lot of questions and can adapt to a larger database of information as programs evolve and expand. If this is linked with infotainment platforms, they may be able to then automatically guide the patient to specific patient education or websites. These bots can also gather key information to feedback to nursing and other staff to help enhance the patient experience on gaps that are identified.

Thomas Graham, MD. Chief Innovation and Transformation Officer of Kettering (Ohio) Health. The concept of virtual nursing is one of the most exciting I am seeing evolve out of our post-pandemic facility and comfort with non-traditional provider interactions. This specific competency is "ambidextrous" — it helps patients get the right care at the right place and time and it supports the remainder of the nursing staff, extending them by unburdening many tasks and allowing them to concentrate on patient-focused care. This is another of the portfolio of virtual applications that will be the "next normal."

April Giard, DNP. Senior Vice President and Chief Digital and Innovation Officer of Northern Light Health (Brewer, Maine). Virtual nurse models effectively extend to ambulatory and home venues of care. Virtual nurses support patients at home through remote patient monitoring and virtual visits for chronic disease monitoring such as heart failure as well as recovery from acute illnesses. Across primary care, virtual nurses effectively close gaps in care, increasing quality to ensure patients receive the care they need to support optimal health. In addition to working with patients to close gaps in care, virtual nurses manage comprehensive patient chart prep to maximize a patient's provider visit.

Current tools and technology can support a successful virtual nursing program without spending large sums of money. For example, Microsoft Teams, Zoom and telehealth platforms can be used to communicate with the patient across multiple venues of care: acute, at home and ambulatory.

Julie Luengas, DNP, RN. Chief Nursing Informatics Officer of Stony Brook (N.Y.) Medicine. Virtual ICU nurses are able to provide continuous monitoring of patients and notify the bedside nurse of potential urgent issues. In addition, the virtual nurse is able to share expert knowledge to novice nurses for complex patient situations.

As the virtual nurse model of care expands across the county, connectivity and integration with the EHR will be an integral component for success.

Kathy Azeez-Narain. Chief Digital Officer of Hoag (Newport Beach, Calif.). Imagine those situations where you have an urgent question that can be easily answered by the nurse vs. needing to wait on the doctor. Similar to having telemedicine pathways to your physician, having certain cases handled by a nurse can lead to less wait time and better triaging while hitting the mark on quick and easy access to getting care. Beyond that, it gives the opportunity to offer skilled nurses a pathway to continue giving care in remote settings as they might be on the cusp of wanting to retire.

I also see it as an opportunity to supplant the world of "leave a message and the nurse will call you back." If I'm already going to be routed to the nurse then virtual care is ideal as it hopefully gets me to a resolution faster.

There is also the experience of using a virtual nurse in the hospital room — with a click of a button getting connected to a nurse on your screen can give nurses that are on the floor support to focus on the calls that need in-person help since not all calls need them to be in the room.

Teresa Niblett, DNP, RN. Chief Nursing Informatics Officer of TidalHealth (Salisbury, Md.). There are a lot of potential benefits to implementing a well-designed virtual nursing program in the acute-care setting. These include:

— Quicker and more efficient double-checks for the administration of blood products and high-risk medications.

— More time for in-person nursing staff to do thorough physical assessments and interventions.

— Improved ability to quantify "nursing inputs" to more accurately measure productivity which results in the desired outputs/outcomes.

The potential downsides include:

— Resources (time, money, space, technology, people) to get a quality program designed and implemented.

— Change management.

— Maintaining privacy.

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