Given the availability of technology for educational purposes,

The APN-PLACE Telehealth Education Network: Legal and Regulatory Considerations Patty Schweickert, DNP, FNP-BC; Karen S. Rheuban, MD; David Cattell-Gordon, MDiv, MSW; Richard L. Rose II, CTC, CWTS; Lynn L. Wiles, PhD, MSN, RN, CEN; Karen E. Reed, MA, CDE; Kathryn Ballenger Reid, PhD, FNP-C, CNL; Christianne Nesbitt Fowler, DNP, RN, GNP-BC; Tina Haney, DNP, CNS, RN; and Carolyn Rutledge, PhD, FNP-BC Telehealth technology can enhance nursing clinical education by allowing for virtual site visits, preceptor support, preceptor education, and student oversight. The Advance Practice Nurse-Preceptor Link and Clinical Education (APN-PLACE) Telehealth Education Network is a new and innovative video communication system that connects schools of nursing to preceptors and clinical practice sites. Specific areas of focus include preceptor education and support, student assessment, and clinical experiences when implementing a telehealth education network. As with in-person, or traditional, clinical education, it is important to consider the legal and regulatory issues related to the use of telehealth programs in clinical education. This article presents a telehealth preceptor support network and provides an overview of the associated legal and regulatory issues surrounding its use in advanced practice registered nurse clinical education. Keywords: Advanced Practice Registered Nurses, APRN, APRN education, clinical education, preceptor education, telehealth technology, virtual classroom Given the availability of technology for educational purposes, nurses are on the cusp of a new era in nursing clinical education. Indeed, it is possible to address barriers to nursing faculty and preceptor shortages by enhancing student clinical education using telehealth technologies. A telehealth educational network is a robust video communication system connecting schools of nursing to clinical practice sites and preceptors. For the purposes of this article, a preceptor is defined as an advanced practice registered nurse (APRN) who assists in the clinical education of the APRN student in the clinical arena. Although APRNs can be precepted by physicians, this article will focus on APRN preceptors (i.e., nurse practitioners, nurse midwives, and clinical nurse specialists). As with clinical service, telehealth eliminates geographic boundaries in education and offers new opportunities to use technology in the clinical education of advanced practice nursing students. Background The overwhelming burden of caring for a patient population that is increasingly chronically ill and aging comes at a time when the United States is experiencing severe primary health care workforce shortages. These issues are compounded in rural regions, where shortages of health care professionals and long distances to access care create additional barriers and health care disparities (Douthit, Kiv, Dwolatzky, & Biswas, 2015). The demand for primary care physicians will far exceed the supply; therefore, APRNs should be positioned to fill this gap (Health Resources and Services Administration [HRSA], 2013). However, schools of nursing face many challenges in meeting the increased demand for APRN graduates who are ready for practice. According to an American Association of Colleges of Nursing (AACN) report (2017), in 2016, schools of nursing turned away over 60,000 qualified applicants to undergraduate and graduate nursing programs as a result of faculty, clinical site, and clinical preceptor shortages. New models of APRN clinical education should be explored to address such barriers to increasing rates of practiceready new graduates. Complex issues in clinical nursing education can only be addressed with a multifaceted approach. Evolving paradigms of clinical education including academic-practice partnerships, integrative models, new models of clinical preceptorships, and the use of simulation are being developed and evaluated. To address the bottleneck in nursing clinical education, targeted initiatives have been developed with some success, such as those offering fellowships and loan forgiveness and programs designed to improve schools of nursing admissions capacity (AACN, n.d.; Beal, 2012). Additionally, exploring new models of clinical preceptorship, including the Integrated Clinical Preceptorship and the Team Modified Clinical Teaching Associate Model, have been introduced (Nordgren, Richardson, & Laurella, 1998; Brathwaite & Lemonde, 2011). Although these components are important for www.journalofnursingregulation.com 47

FIGURE 1 The Advance Practice Nurse-Preceptor Link and Clinical Education (APN-PLACE) Model Academic Schools of Nursing APN PLACE Preceptors & APN Students Telehealth Community Partners addressing nursing shortages, it is time to consider new designs in the current APRN clinical education model that use technology to address both faculty and preceptor shortages and support all nursing programs and students exponentially as part of a multifaceted approach. An innovative strategy to address faculty and preceptor shortages is a telehealth education network to enhance the current one-on-one preceptorship model. Video technology can be used as a tool to assist in communication, teaching, oversight, and mentoring of preceptors and students in clinical practice sites. Telehealth uses telecommunications technology, digital devices, and information to provide patient consultation and care, remote monitoring, and education (Rutledge et al., 2017). Telehealth is growing rapidly, as evident by the 200 items of state legislation presented in 44 states during 2017 to expand or modify telehealth services (Center for Connected Health Policy, 2017). Telehealth will be pervasive throughout all facets of care in the near future because of its usefulness to health care as a universal strategy to address the dramatic challenges in the cultural landscape of our nation s health care system. For nursing to respond, it must be able to produce well-educated, expert APRNs in adequate numbers to meet demands, especially in rural communities. The longstanding one-on-one apprentice model of nursing clinical education relies on practitioners volunteering their time and independently developing expertise to precept students. With today s complexity of care, time requirements, and competitive demands, this model has resulted in widespread preceptor shortages and is not sustainable. The one-to-one preceptorship model should be rethought and redesigned for the 21st-century technological age. The purpose of this article is to present an overview of a new and innovative telehealth education network, Advanced Practice Nurse-Preceptor Link and Clinician Education (APN- PLACE), along with the legal and regulatory issues related to its use in APRN clinical education. Overview: APN-PLACE Telehealth Education Network The APN-PLACE network was developed to address faculty and clinical preceptor shortages. It provides education and support to preceptors, assesses student performance in clinical settings, provides students with an opportunity to use telehealth for patient encounters, and exposes students to telehealth technology (Figure 1). Faculty at schools of nursing use live Web videoconferencing and medical peripherals which are pieces of diagnostic equipment such as a digital stethoscope to connect more frequently with students in practicum sites without the burden of travel, increasing the efficiency of each faculty member. The network also allows for preceptor support and education, which can increase the number of preceptors and improve their skills. These changes shift the model from one in which faculty communicate, teach, and mentor students and preceptors only through in-person contact to one where faculty can connect, observe, and educate students and preceptors frequently, easily, and spontaneously using live videoconferencing. APN-PLACE is a HRSA-funded preceptor education program that links rural and underserved clinical practice sites with schools of nursing using telehealth. APN-PLACE is a collaboration between the University of Virginia Center for Telehealth and Old Dominion University School of Nursing. Other academic schools of nursing are invited to join as determined by their alignment with goals of the program, which are to establish a telehealth education network to provide preceptor training with synchronous faculty and peer support to increase, diversify, and place APRN students in rural and underserved clinical sites with expert APRN preceptors. By employing secure, advanced telehealth technologies, APN-PLACE can deliver innovative training and communications via virtual classrooms. A variety of telehealth platforms are used at schools of nursing and clinical sites for the virtual site visits and virtual classroom including: a conference room with videoconferencing equipment, a mobile cart with peripherals such as stethoscopes and otoscopes, a dedicated telehealth examination room, a mobile box, or simply a handheld mobile device. Preceptor Education and Support Advanced communications technologies enable preceptors to be educated and supported by faculty via the telehealth network through the virtual classroom. Preceptors are the link that enables 48 Journal of Nursing Regulation

students to translate didactic learning to hands-on knowledge and skills, thereby providing preceptors access to training and education related to precepting APRN students, live support, discussion, and interaction with schools of nursing faculty. Additionally, peer support networking with other preceptors, clinicians, and educators is also possible through the telehealth network, which allows preceptors to discuss issues and ideas for enhanced preceptor student experiences. The support and education the network provides fill the gap between preceptors and faculty and may serve to address preceptor shortages by improving preceptor proficiency and willingness of the preceptor to precept. Student Assessment Observing and communicating with the student in the practicum site is a faculty requirement, adding important guidance in the clinical arena (Patton & Lewallen, 2015). The telehealth network enables nursing faculty to remotely conduct site visits and to assess student performance in clinical settings at almost any time, and as frequently as needed or desired. The use of peripherals, or digital diagnostic equipment such as stethoscopes, otoscopes, ophthalmoscopes, and dermatology cameras, allow faculty to see and hear clinical findings at the same time the students observe them, which in turn helps faculty to understand the student s knowledge and techniques. As problems are identified, faculty can more readily provide follow-up virtual site visits. A telehealth network can help improve student learning through the faculty s increased access and communication to the clinical practice site. By way of the virtual site visit, faculty can connect to APRN students in the practice site using live videoconferencing technology. Videoconferencing enables more frequent, consistent assessment of the student in the practice arena than would otherwise be possible through in-person site visits. Clinical Experiences Using Telehealth Telehealth is becoming an important tool in health care delivery, especially for those living in geographically isolated regions. It is essential that APRNs gain experienced perspective and skills using these technologies. The telehealth network provides students with an opportunity to use telehealth for patient encounters and to apply telehealth evidence-based practice strategies in care delivery. Preceptors and students can gain experience and confidence using the technologies in the telehealth network. Nurses trained in standards-based applications of telehealth can help minimize health care disparities through use of this new service delivery model. The telehealth network also provides expanded opportunities for the facility to use telehealth in care delivery, which allows the student to participate as part of the practicum experience. APN-PLACE helps enable the nursing telehealth role to be actualized by providing telehealth knowledge, hands-on skills, and delivery of care using telehealth technology. Exposure to Telehealth Technology The infusion of technology into health care creates a growing role for nurses to integrate and use telehealth technologies in nursing practice. APN-PLACE Telehealth Network places telehealth technologies, including medical peripherals, in schools of nursing and in the practice setting for use in the virtual site visit, preceptor education, preceptor support, and patient care. Students and preceptors are educated in how to use the technology, including gaining a nuanced approach to telehealth practice, telehealth etiquette, and translating in-person care to the virtual environment. Regulatory Requirements for a Telehealth Network It is imperative that APRNs are cognizant of the legal and regulatory issues that would impact such practice, as telehealth adds a new layer of laws and regulations specific to use of this technology in clinical education. The following section presents an overview of the laws and regulations that govern the use of the APN-PLACE Educational Network in APRN clinical education. The regulations and requirements governing the practice of telehealth include each state s Nurse Practice Act (NPA). Both educators and students should be versed in legal and regulatory aspects of using telehealth in APRN clinical education in order to understand whether traditional in-person educational requirements are changed when using telehealth. Laws and regulations that govern innovative technology usually develop after clinical applications are demonstrated and scope of application is clarified (Brous, 2016). This finding is also true for incorporating a telehealth education network into APRN nursing education. The laws and regulations governing the use and implementation of the APN-PLACE network align with those that govern in-person education and fall into three areas: nursing regulations, federal regulations, and technology regulations. Nursing Regulations Practice is considered to take place where the patient is and/or where the student is located. If students are in a different state from the instructor, the faculty needs a license in the state where the student is practicing. This may require faculty to have multiple licenses. The exception to this are states that are part of the Nurse Licensure Compact (NLC), which is an agreement between states that recognizes and accepts the nursing license from another state. Faculty in these states only require one license as long as the student is located in another NLC state; otherwise, the faculty need an additional license. Telehealth clinical education aligns with the state boards of nursing (BONs) laws and regulations. BONs regulate practice, licensure, discipline of nurses, and compliance with their regulations. BONs also approve nursing education programs, ensuring that the program includes the knowledge and skills nurses need to practice safely and competently. Providing care www.journalofnursingregulation.com 49

in a virtual environment that transcends geographic boundaries must be congruent with state laws and regulations. As such, it becomes essential that professional licensure portability and multistate privileges be reconciled when using telehealth for education (Brous, 2016). The NLC currently allows faculty to conduct virtual education visits with APRN students within their state of licensure or with students outside their state as long as they are licensed in a compact state. However, faculty that do not reside in a compact state require a license in every state where students are located. The Advanced Practice Registered Nurse Compact (APRN Compact), currently in its early stages of adoption in many states, promotes uniform licensure requirements allowing for APRNs to have one multistate license in their home state with the privilege to practice in other APRN compact states, alleviating the barriers to using telehealth in practice and in clinical education across state lines. Federal Regulations When students work with faculty and preceptors in the practicum setting using telehealth to perform consults and deliver care, standards of practice and scope of practice as authorized by state laws (NPA) remain consistent with in-person practices. If faculty and students are located in different states, they must abide by the NPA and regulations of the state where the student is located. Students working with patients and providing direct patient care must practice in compliance with the Health Insurance Portability and Accountability Act (HIPAA), which establishes national standards and regulations of certain protected health information including electronic transmissions (U.S. Department of Health and Human Services, 2002). Privacy and security of medical records, information, and communications must be protected, whether the encounter is in-person, virtual, or via remote monitoring technologies. HIPAA laws are also used to implement safeguards such as data encryption and user authentication (Erickson, Fauchald, & Ideker, 2016). Informed consent is included under the HIPAA Privacy Rule (U.S. Department of Health and Human Services, 2002). In some states, informed consent for telehealth visits must be obtained, just as consents for other types of procedures and services may be required. In other states, consent may be implied or written into the general consent to receive care at a given facility. Faculty and preceptors should be familiar with their individual state s laws regarding telehealth informed consent in the virtual environment. To meet HIPAA requirements, it is also required to have experts in cyber security monitor all electronic transmissions of data and communications for telehealth (Brous, 2016). Medicare conditions of participation standards govern the process of credentialing and privileging of telehealth practitioners (Centers for Medicare and Medicaid Services, 2011). These standards require that distant site and originating site hospitals contractually agree to the process by which credentialing and privileging occur, either fully as with in-person services or by proxy with the sharing of quality data. The Joint Commission has adopted similar telehealth standards for licensed practitioners in both critical access hospitals and hospitals related to credentialing and privileging of those engaging in telemedicine practices (Joint Commission, 2012). Technology Regulations The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act and communications security related to telecommunication devices via the Federal Communications Commission (FCC), developed to provide guidance in the use of electronic medical records and other health care technologies, needs to be observed when using telehealth (U.S. Department of Health and Human Services, 2017). HITECH provides rules and regulations for protecting all forms of electronic health information and electronic communications from inappropriate disclosures. Therefore, in the use of telehealth, cyber security measures must be employed for ensuring privacy and security of protected health information, communications, and all electronic transfers of images and clinical data. Additionally, a HIPAA compliant telehealth platform is necessary in the telehealth education network to allow faculty to observe the student as they work with patients When using telehealth technology, FCC regulations regarding communication devices must also be observed. The FCC governs broadcast communications new technology safety and effectiveness (FCC, 2017). The Food and Drug Administration (FDA) issued guidance on mobile medical applications (apps), defining which apps and technologies require 510K clearance. The telehealth practitioner is advised to understand this guidance before using such apps in virtual practice (U.S. Food and Drug Administration, 2015). Conclusion Nursing is well positioned in scope of practice to respond to the current health care needs; however, improvement is needed to meet the current enrollment demands of APRNs if only traditional pedagogy and practices continue to be used. Currently, a perfect storm of factors present an opportunity to consider a new strategy in nursing education (Clabo et al., 2014). The increased demand for primary care services could be addressed by schools of nursing by increasing the numbers of applicants they admit and subsequently graduate. However, although the annual number of graduates from nurse practitioner programs has increased since 2004, most schools have reached their capacity (AACN, 2017). Without a change in the in-person model, schools of nursing may not be able to meet these demands and will have to continue to limit enrollment in APRN programs despite the substantive need. It is time to re-evaluate the effectiveness of the apprentice preceptorship model and consider using telehealth as a tool to 50 Journal of Nursing Regulation

improve faculty efficiency and connectedness to the preceptor and student. A telehealth network can minimize barriers experienced by nursing faculty and address preceptor shortages. Additionally, by using telehealth technologies, other models of preceptorship could be enhanced and supported. It is imperative that nursing educators as well as students be informed and proactive in the legal and regulatory telehealth arena as our nursing practice and nursing education are changed by the infusion of advanced technologies. References American Association of Colleges of Nursing. (2017). 2016-2017 Enrollment and graduations in baccalaureate and graduate programs in nursing reports. Retrieved from http://www.aacnnursing.org/store/productinfo/productcd/idsr_17enrollbacc American Association of Colleges of Nursing. (n.d.). Nursing faculty shortage fact sheet. Retrieved from http://www.aacnnursing.org/ Portals/42/News/Factsheets/Faculty-Shortage-Factsheet-2017.pdf Brathwaite, A. 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Retrieved from https:// www.cms.gov/medicare/provider-enrollment-and-certification/surveycertificationgeninfo/downloads/scletter11_32.pdf Clabo, L. L., Giddens, J., Jeffries, P., McQuade-Jones, B., Morton, P., & Ryan, S. (2012). A perfect storm: A window of opportunity for revolution in nurse practitioner education. Journal of Nursing Education, 51(10), 539 541. doi:10.3928/01484834-20120920-01. Douthit, N., Kiv, S., Dwolatzky, T., & Biswas, S. (2015). Exposing some important barriers to health care access in the rural USA. Public Health, 129(6), 611 620. doi.org/10.1016/j.puhe.2015.04.001. Erickson, C. E., Fauchald, S., & Ideker, M. (2015). Integrating telehealth into the graduate nursing curriculum. The Journal for Nurse Practitioners, 11(1), e1 e5. Federal Communications Commission. (2017). Wireless Devices and Health Concerns. Retrieved from https://www.fcc.gov/consumers/ guides/wireless-devices-and-health-concerns Health Resources and Services Administration. (2013). Projecting the supply and demand for primary care practitioners through 2020. Retrieved from https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projectingprimarycare.pdf The Joint Commission. (2012). Final Revisions to Telemedicine Standards. Retrieved from https://www.jointcommission.org/assets/1/6/ Revisions_telemedicine_standards.pdf Nordgren, J., Richardson, S. J., Laurella, V. B. (1998, May-June). A collaborative preceptor model for clinical teaching of beginning nursing students. Nurse Educator, 23(3), 27 32. Patton, C. W., Lewallen, L. P. (2015). Legal issues in clinical nursing education. Nurse Educator, 40(3), 124 128. doi:10.1097/ NNE.0000000000000122 Rutledge C. M., Kott, K., Schweickert, P. A., Poston, R., Fowler, C., & Haney, T. (2017). Telehealth and ehealth in nurse practitioner training. Advances in Medical Education and Practice, 8, 399 409. U.S. Department of Health and Human Services. (2017). HITECH Act. Retrieved from https://www.hhs.gov/hipaa/for-professionals/ security/laws-regulations/index.html U.S. Department of Health and Human Services. (2002). Summary of the HIPAA Privacy Rule. Retrieved from https://www.hhs.gov/sites/ default/files/privacysummary.pdf U.S. Food & Drug Administration. (2015). Mobile medical applications. Retrieved from http://www.fda.gov/medicaldevices/digitalhealth/ MobileMedicalApplications/default.htm Patty Schweickert, DNP, FNP-BC, is Program Director, APN- PLACE, University of Virginia Center for Telehealth, University of Virginia Health System; Adjunct Professor of Nursing, University of Virginia School of Nursing, Charlottesville and at Old Dominion University School of Nursing, Norfolk, Virginia. Karen S. Rheuban, MD, is a Professor of Pediatrics, and Senior Associate Dean for CME and External Affairs Director, University of Virginia Center for Telehealth, University of Virginia Health System. David Cattell-Gordon, MDiv, MSW, is Director of Telehealth, Director of Rural Network Development, Faculty Member with Public Health Sciences and Nursing, University of Virginia, Charlottesville. Richard L. Rose II, CTC, CWTS, is Telemedicine Engineer, Department of Telemedicine, University of Virginia Health System. Lynn L. Wiles, PhD, MSN, RN, CEN, is Assistant Professor of Nursing and Director of Technology and Simulation, Old Dominion University School of Nursing. Karen E. Reed, MA, CDE, is Director of the Division of Multicultural Health and Community Engagement, Virginia Department of Health, Richmond, Virginia. Kathryn Ballenger Reid, PhD, FNP-C, CNL, is Associate Professor of Nursing, University of Virginia School of Nursing. Christianne Nesbitt Fowler, DNP, RN, GNP-BC, is Associate Professor, Old Dominion University School of Nursing. Tina Haney, DNP, CNS, RN, is Assistant Professor in the DNP Program, Co-director of Adult Gerontology at Old Dominion University School of Nursing. Carolyn Rutledge, PhD, FNP-BC, is Professor and Associate Chair for Graduate Programs, and Director of Doctor of Nursing Practice Program, Old Dominion University School of Nursing. Advanced Practice Nurse-Preceptor Link and Clinician Education (APN-PLACE) is supported through a grant from the Health Resources and Services Administration (grant No. D09HP28668) and the Old Dominion University School of Nursing along with The University of Virginia Center for Telehealth. www.journalofnursingregulation.com 51