36C24419R0074-018.pdf

VHA Office of Connected Care vaww.telehealth.va.gov www.telehealth.va.gov

VA Video Connect Supplement

September 2018

Attachment P

VA Video Connect Supplement – September 2018 Page i

Table of Contents

1. VA Video Connect Overview

2. Program Planning & Development

2.1 Considerations

2.2 Documenting the Agreement

2.3 Policy

2.3.1 State Licensing Concerns: Anywhere-to-Anywhere Telehealth

2.3.2 Privacy

2.3.3 Ryan Haight Act (Guidance for Controlled Substances)

2.4 Telehealth by Employees in Training

2.5 Transitioning Providers when Veterans Geographically Relocate

2.6 VHA Directive 1230 - Outpatient Scheduling Processes and Procedures

2.7 VHA Directive 1231 - Outpatient Clinic Practice Management

2.8 VHA Directive 1232, Consult Processes and Procedures 1232(1)

3. VA Video Connect Consults, Scheduling and Workload

3.1 Consults

3.2 Intrafacility Scheduling

3.2.1 VA Video Connect Scheduled Visits

3.2.2 VA Video Connect On-Demand Visits

3.3 Interfacility Scheduling

3.4 Current Procedural Terminology, International Classification of Diseases & Managerial

Cost Accounting Office Codes

4. Technology

4.1 Provider Initial Set-up

4.2 Patient Initial Set-up

4.2.1 VA-Issued Tablets for Veterans

5. VA Video Connect Visit

5.1 Notifications

5.2 Entering the VA Video Connect Session

5.3 Conducting the VA Video Connect Visit

5.4 VA Video Connect Support

6. Risk Management: Emergency Procedures

6.1 Optimizing Your VA Video Connect Experience

7. Training

8. Resources

Appendix A: Chief Consultants and Directors Endorsement of VA Video Connect Supplement ...... A-1

VA Video Connect Supplement – September 2018 Page ii

Contributions and Support

We wish to acknowledge the many contributions of Telehealth Staff. For assistance in implementing VA Video Connect contact the VA Video Connect Implementation Team.

Updates to guidance that occur after document signature, if any, can be found at the view the VA Video Connect Supplement Update Log on the Telehealth Intranet Site.

Attachment P mailto:VVC_Implementation_Team@va.gov https://vaww.infoshare.va.gov/sites/telehealth/docs/vvc-upd-lg.docx https://vaww.infoshare.va.gov/sites/telehealth/docs/vvc-upd-lg.docx

VA Video Connect Supplement – September 2018 Page 1

1. VA Video Connect Overview

VA Video Connect enables Veterans to meet with their VA healthcare providers, in a virtual medical room, using encrypted video to ensure the session is secure and private. As part of VA’s optimization of the clinic access initiative and the expansion of telehealth services into the home and other non-VA settings, VA Video Connect (VVC) is offered as an alternative to an in-person visit. VA Video Connect allows Veterans to see and talk to their health care team from anywhere, making VA healthcare more convenient and reducing travel times for Veterans. The Anywhere to

Anywhere regulation authorizes the provision of care regardless of provider and patient location.

Refer to the VHA Telehealth Intranet Site for more information on the Anywhere to Anywhere telehealth rule.

There are two primary uses of VA Video Connect in telehealth: VA Video Connect On-Demand

Video Visits created for appointments within the next 12 hours and VA Video Connect Scheduled

Video Visits created in advance for future appointments. VA Video Connect Scheduled Visits are subdivided into Intrafacility and Interfacility.

VA Video Connect On-Demand Video Visit: An unscheduled visit.

• Used as a follow-up to a previous visit (i.e. face-to-face, VA Video Connect On-Demand

Video Visit, or VA Video Connect Scheduled Video Visit)

• Used as an alternative to canceling a face-to-face visit (e.g. the Veteran is no longer able to make a previously scheduled visit)

VA Video Connect Scheduled Video Visit (Intrafacility): A visit between a provider and a

Veteran.

• Offered in advance as an alternative to a face-to-face visit

VA Video Connect Scheduled Video Visit (Interfacility): A visit between a provider and a

Veteran.

• Offered in advance as an alternative to a face-to-face visit

VA Video Connect can be conducted through temporary links, which are emailed to the Veteran and provider prior to the visit, or through static links, which are paired with a VA-issued tablet that is supplied to the Veteran.

Temporary links are used for Veterans whose Telehealth Management Platform (TMP) patient record is set to “allow emails”. Temporary links are generated as part of the request for the visit.

For VA Video Connected On-Demand Video Visits, the temporary link expires 12 hours after the time of request. For VA Video Connect Scheduled Video Visits, the temporary link expires 12 hours after the scheduled visit time.

http://vaww.telehealth.va.gov/pgm/a2a/index.asp

VA Video Connect Supplement – September 2018 Page 2

Static links are used for Veterans whose TMP patient record is set to “do not allow emails”. Static links are linked to a specific VA-issued tablet. The static link is generated when the tablet is ordered and does not expire. See section 4.2.1 for more information on VA-issued tablets.

The purpose of the VA Video Connect Supplement is to provide guidance for implementation and monitoring of care to Veterans via telehealth technology. The supplement includes business, clinical, and technical standards, and identifies resources that support safe, quality care through

VA Video Connect.

This Supplement is intended to be used in parallel with the Telehealth Manual from VHA

Telehealth Services, and, as appropriate, the Telehealth Management Platform Supplement and the Home Telehealth Operations Manual. It contains links to additional training, tools and resources which ensure individuals are able to successfully implement and manage VA Video

Connect programs. This supplement is intended to be used alongside specialty supplements for care under those service lines.

2. Program Planning & Development

Contact your Facility Telehealth Coordinator to discuss development and implementation of a VA

Video Connect program for your facility. VA Video Connect is compatible with multi-disciplinary care teams and sites should consider including other disciplines that may be involved in the program (e.g., Diabetes, Wound Management, Amputation or Prosthetics Clinics). Using shared resources and experiences from other disciplines is extremely helpful for any telehealth program.

Each VISN has a telehealth infrastructure to support all telehealth operations (e.g., VISN

Telehealth Leadership, Health Information Specialists, Clinical Engineers, Office of Information and Technology, Facility Telehealth Coordinators and Telehealth Clinical Technicians).

While Credentialing and Privileging is not needed for Intrafacility telehealth, it is required for

Interfacility telehealth. Review the Telehealth Manual and Telehealth Management Platform

Supplement for important guidance prior to implementing a VA Video Connect Platform.

2.1 Considerations

The clinician’s goal is to utilize telehealth technology to provide optimal patient care and minimize risk. Therefore, exercising clinical judgment at the time of the request for care is imperative for making appropriate decisions regarding patient selection for any modality of care. Providers should consider the following factors when considering the use of telehealth for a given patient:

• Veteran and/or caregiver consents and is able to participate in telehealth visit

• Veteran is medically and emotionally stable, as deemed by the attending physician responsible for the Veteran’s care

• Veteran is able to communicate needs and has the ability to understand clinical recommendations

Attachment P http://vaww.infoshare.va.gov/sites/telehealth/docs/cbt-ops-manual.docx http://vaww.infoshare.va.gov/sites/telehealth/docs/tmp-spp.pdf http://vaww.infoshare.va.gov/sites/telehealth/docs/ht-ops-manual.pdf http://vaww.infoshare.va.gov/sites/telehealth/docs/cbt-ops-manual.docx http://vaww.infoshare.va.gov/sites/telehealth/docs/tmp-spp.pdf http://vaww.infoshare.va.gov/sites/telehealth/docs/tmp-spp.pdf

VA Video Connect Supplement – September 2018 Page 3

• The telehealth visit has the ability to meet the Veteran’s clinical needs

• Veteran has access to a home/mobile device with a webcam and microphone o The Veteran may choose to use their own home/mobile device o If the Veteran does not have a personal device, a VA-issued device may be requested for the Veteran

• Veteran has internet access via one of the following:

o 4G cellular connection (suitable for cellular-enabled mobile devices)

▪ WiFi connection with sufficient connection speed for video call (suitable for mobile devices or computers) o Hardwired Ethernet connection (preferable for computers)

2.2 Documenting the Agreement

The Telehealth Service Agreement (TSA) specifies and governs the details of operations regarding the interfacility telehealth services between providing and receiving facilities. A Telehealth Service

Agreement is required for Interfacility VA Video Connect Scheduled Visits.

TSAs are not needed for Intrafacility VA Video Connect Scheduled Visits. If the Telehealth

Management Platform (TMP) is being used to schedule VA Video Connect appointments, see the

Telehealth Management Platform Supplement for guidance.

The TSA outlines the variables and responsibilities for safe and effective telehealth service delivery. Among the variables identified in the TSA are those which relate specifically to the proxy privileging process for Interfacility telehealth providers, including:

• A list of providers who are privileged at the provider facility to render interfacility telehealth services for the specific telehealth application

• Identification if telehealth service will be Teleconsultation, Telemedicine, or both

• Specific quality management and patient safety plans and variables, including provider performance indicators for the particular telehealth service, and

• Provide methodology and identify variables for FPPE/OPPE data exchange

• One (1) TSA will be in place for each telehealth service, signed by providing and receiving service chiefs as well as FTCs

A Memorandum of Understanding is required to be in place for interfacility telehealth.

A Workload Coding and Business Rules document outlines when a Telehealth Service Agreement is needed as part of VA Video Connect.

2.3 Policy

All care delivered through telehealth must adhere to existing VHA and Medical Center policies.

Refer to the rest of this section for a description of pertinent policies.

Attachment P https://vaww.infoshare.va.gov/sites/telehealth/docs/tmp-spp.pdf http://vaww.infoshare.va.gov/sites/telehealth/docs/vvc-wrkldcrdt.docx

VA Video Connect Supplement – September 2018 Page 4

2.3.1 State Licensing Concerns: Anywhere-to-Anywhere Telehealth

Popularly known as Anywhere to Anywhere, Rule FR 21897 is published in the Federal Register regarding provision of telehealth care by VA providers. The rule clarifies VA health care through the use of telehealth, notwithstanding any State laws, rules, licensing, registrations, or certification requirements to the contrary when the VA provider and VA beneficiary are located in the United

States, Territories and possessions of the United States, the District of Columbia, or the

Commonwealth of Puerto Rico.

Additionally, section 38 USC 1730C (popularly known as the VA Mission Act) was added to the

United States Code which establishes the same authority.

As a result of the Anywhere to Anywhere Rule and VA Mission Act, VA providers may deliver care by telehealth without limitations resulting from state licensure. VA providers are now empowered to provide care to Veterans located anywhere in United States territory, with the caveats in the

Anywhere to Anywhere ruling.

Further information may be found on the Anywhere to Anywhere Telehealth Intranet Site.

2.3.2 Privacy

The Privacy Office maintains a repository of documents which provide privacy guidance. This repository, including VHA Directive 1605 – VHA Privacy Program. These resources can be helpful for ensuring privacy protocols are adhered to.

The Telehealth Program Office requires a high level of privacy and confidentiality in regard to all telehealth visits. The Telehealth Quality Manager establishes how the interaction with the office of

Quality, Safety and Value affects telehealth and oversees development of processes to ensure telehealth is in compliance with privacy requirements.

All VA telehealth visits are completed through the Clinical Enterprise Video Network (VA’s private encrypted video network) for connecting VAMC telehealth providers by video with Veterans at

CBOCs or other VAMCs. Whether the Veteran is receiving care via a VA Video Connect Scheduled

Video Visit or VA Video Connect On-Demand Video Visit, all methods are on the private encrypted video network. One can ensure the session is encrypted and private by locating the padlock icon on the screen.

Although not common, the course of treatment may indicate the necessity of video or photographic recording as part of treatment. When video or photographic recording is done as a part of telehealth treatment, VA Form 10-3203 - Consent for Production and Use of Verbal or

Written Statements, Photographs, Digital Images and/or Video or Audio Recordings, must be completed prior to the recording in order to obtain written consent from the patient. This form should be kept as part of the patient electronic health record.

Attachment P https://www.gpo.gov/fdsys/pkg/FR-2018-05-11/pdf/2018-10114.pdf http://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title38-section1730C&num=0&edition=prelim http://vaww.telehealth.va.gov/pgm/a2a/index.asp http://vaww.vhaco.va.gov/privacy/Laws.htm http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=5456 http://www.va.gov/VAFORMS/medical/pdf/vha-10-3203-fill.pdf http://www.va.gov/VAFORMS/medical/pdf/vha-10-3203-fill.pdf

VA Video Connect Supplement – September 2018 Page 5

Veterans may choose to record sessions without obtaining the consent of the provider. Providers are recommended to conduct all sessions under the assumption that they are being recorded.

While a memo was released on Dec 14, 2017 regarding patient recording on clinical encounters, it has been since rescinded. Refer to the Patient Recording of Clinical Encounters Memo - Rescinded for more information.

2.3.3 Ryan Haight Act (Guidance for Controlled Substances)

The Ryan Haight Online Pharmacy Consumer Protection Act, (Public Law 110-425, 122 Stat.

4820-4834) enacted on October 15, 2008, states that no controlled substance may be delivered, distributed, or dispensed over the Internet (which includes the use of TeleMental Health and VA

Video Connect) without a valid prescription. The VHA is developing formal policy that will articulate the requirements of providers concerning this law. In the interim, the VHA National

Telehealth Office has issued guidance to providers to advise them on best practices to ensure their compliance with the law. The Ryan Haight Act 10N Memo outlines this information. The

January 2016 Ryan Haight guidance advises what a VA provider must do to satisfy the requirements of the Ryan Haight Act concerning the prescribing of controlled substances when the provider and patient are not in the same location. For physicians prescribing FDA approved schedule III and IV controlled substances to treat opioid addiction there are additional requirements.

Registration with the Drug Enforcement Agency

All VHA clinics will be registered with the Drug Enforcement Agency. Guidance is provided for how to submit an application through the Drug Enforcement Agency registration site, including selecting the appropriate clinics from the Drug Enforcement Agency’s comprehensive list of VHA clinics. The Telehealth Management Platform also records which patient care sites are Drug

Enforcement Agency registered and sends that information to a Teleprovider upon scheduling at that site.

Per federal law, providers must complete one in-person medical evaluation of a patient before they can prescribe, renew, or refill controlled substances.

An exception to the in-person requirement applies to providers who have been requested to cover for a provider who is unavailable. As long as the unavailable provider has conducted at least one in–person medical evaluation of the patient within the previous 24 months, the covering provider may prescribe, refill, and renew controlled substances for the unavailable provider’s patients.

State Prescription Drug Monitoring Programs

VHA Directive 1306, known as The Querying State Prescription Drug Monitoring Program, was distributed in October 2016. It establishes responsibilities requiring VHA healthcare providers to query State Prescription Drug Monitoring Programs to support safe and effective prescribing of

Attachment P https://vaww.infoshare.va.gov/sites/telehealth/docs/vvc-rcr.pdf http://www.deadiversion.usdoj.gov/fed_regs/rules/2009/fr0406.pdf http://vaww.infoshare.va.gov/sites/telehealth/docs/rha-mmoclnc.pdf http://vaww.infoshare.va.gov/sites/telehealth/docs/rha-gdnce.docx https://vaww.infoshare.va.gov/sites/telehealth/docs/th-mat.pdf https://vaww.infoshare.va.gov/sites/telehealth/docs/th-mat.pdf http://vaww.infoshare.va.gov/sites/telehealth/docs/rha-atcmnt.pdf https://apps.deadiversion.usdoj.gov/webforms/ http://vaww.infoshare.va.gov/sites/telework/HT%20Expansion%20and%20Survey/TDEA/default.aspx http://vaww.infoshare.va.gov/sites/telework/HT%20Expansion%20and%20Survey/TDEA/default.aspx https://internalcrm.crm15.xrm.va.gov/TMP https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3283

VA Video Connect Supplement – September 2018 Page 6 controlled substances. This Directive encourages facilities to establish local policy and procedures to identify delegates who are authorized to query the Prescription Drug Monitoring Program database on behalf of a controlled substance prescriber, where state laws permit the use of delegates.

Refer to VHA Directive 1306 for more information or contact the Office of Patient Care Services at

VHA10P4FStaff@va.gov.

2.4 Telehealth by Employees in Training

Guidance for employees who are in training is provided through VHA Handbook 1400.09 –

Education of Physicians and Dentists, VHA Handbook 1400.04 – Supervision of Associated Health

Trainees and VHA Handbook 1400.01 – Resident Supervision. Questions or concerns should be directed to the Office of Academic Affiliations. Handbooks 1400.04 and 1400.01 provide direction on Real-time Videoconferencing and Videophone as well as telehealth care, including:

Real-time Videoconferencing and Videophone (Per VHA Handbook 1400.04)

“In situations where the supervising practitioner and trainee are present at a VA medical facility delivering telehealth care to a Veteran remotely, trainee-provided care is acceptable in all circumstances where VA standards permit the supervising practitioner to deliver care remotely.

Requirements for the presence of the supervising practitioner are the same as for clinic-delivered care and must correspond to documented graduated levels of responsibility. Real-time videoconferencing or use of a videophone must not be used to substitute for appropriate supervision, for instance, in situations where the trainee is with the Veteran in a remote setting such as a Community Based Outpatient Clinic and the supervising practitioner is at the parent VA medical facility with videoconferencing or videophone connectivity. Certain VA facilities in very rural settings and offer specialized training in the utilization of telehealth services. Programs may request special consideration of their telehealth training programs from Office of Academic

Affiliations. Consultation with specialists via remote connections may be handled as any outpatient consultation would be conducted.”

Telehealth Care, Including Telemental Health (Per VHA Handbook 1400.04)

“Telehealth care is provided by supervising practitioners and trainees to Veterans using virtual technologies such as home-messaging devices or interactive voice response telephone systems.

Individual or group care may also be provided by clinical video teleconferencing in a location desired by the Veteran or at a Community Based Outpatient Clinic. Virtual care is often supplemented by telephone support with Veterans. Such an arrangement is acceptable in all circumstances in which VA standards permit the supervising practitioner to deliver care remotely.

Trainees who are assigned responsibility for home telehealth patients must receive orientation and training pertaining to emergency situations and consult with the supervising practitioner regarding any changes in a Veteran’s status or proposed changes in the treatment plan.

Supervising practitioners will provide general oversight of the home telehealth care provided by trainees, consistent with assigned graduated levels of responsibility.”

Attachment P http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3283 mailto:VHA10P4FStaff@va.gov http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3239 http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3239 http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3087 http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3087 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2847

VA Video Connect Supplement – September 2018 Page 7

Telemedicine and Telehealth (Per VHA Handbook 1400.01) “(a) Real-time Videoconferencing. In situations where the supervising practitioner and resident are present at a VA facility delivering telehealth care to a remote patient, resident-provided care is acceptable in all circumstances where VA standards permit the staff practitioner to deliver care remotely. The supervising practitioner must be in the general vicinity and available to the resident for direct supervision without delay, as if the patient were being seen in a clinic.

Real-time videoconferencing must not be used to substitute for appropriate supervision, e.g., in situations where the resident is with the patient in a remote setting (e.g., at a Community-Based Outpatient Clinic (CBOC)) and the supervising practitioner is at a parent VA facility with videoconferencing connectivity. Resident-provided care in remote settings without the on-site presence of a supervising practitioner is not acceptable. However, consultation with specialists via remote connections may be handled as any outpatient consultation would be conducted.

(b) Store and Forward Telehealth. In “store and forward” telehealth, the resident and supervising practitioner would not see the patient, except through examination of images or specimens (e.g., teleradiology films, teleretinal scans, or telepathology specimens). The resident reviews the material with or without the supervising practitioner present, and the supervising practitioner reviews the same material. The interpretations and reports on all images and pathology specimens must be verified by the supervising practitioner. In all instances, the resident must receive feedback on the resident’s interpretation of home telehealth for learning purposes.

(c) Home Telehealth. In home telehealth, the supervising practitioner and resident are delivering home care to a patient by videophone or in-home messaging devices. Such an arrangement is acceptable in all circumstances in which VA standards permit the supervising practitioner to deliver care remotely. Residents who are assigned responsibility for home telehealth patients must consult with the supervising practitioner regarding any changes in a patient’s status or proposed changes in the treatment plan. Supervising practitioners are expected to exercise general oversight of the home telehealth care provided by residents.”

2.5 Transitioning Providers when Veterans Geographically Relocate

Veterans who permanently relocate will benefit from establishing care with providers at their closest VAMC instead of continuing care with providers in their previous geographic area via telehealth. Establishing care at the closest VAMC will facilitate access to healthcare services including primary care, mental health services, and specialty care.

Clinical exceptions for maintaining care via telehealth are rare and will be addressed at the Service Chief level. Alternate clinical solutions will be considered prior to a patient continuing to receive care from their previous provider via telehealth. Any time-limited treatments should be completed before the patient relocates, when possible, instead of continuing them by telehealth.

2.6 VHA Directive 1230 - Outpatient Scheduling Processes and Procedures

It is VHA policy, per VHA Directive 1230 - Outpatient Scheduling Processes and Procedures, that

Veterans’ appointments are scheduled timely, accurately, and consistently with the goal of scheduling appointments no more than 30 calendar days from the date an appointment is deemed clinically appropriate by a VA healthcare provider or, in the absence of a Patient Indicated Date http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3218

VA Video Connect Supplement – September 2018 Page 8

(PID), 30 calendar days from the date the Veteran requests outpatient healthcare service. When scheduling telehealth appointments, the PID in the two appointments must match and be determined by the referring/ordering provider consistent with VHA scheduling and consult directives. Telehealth specific guidance may be found in the Telehealth Patient Indicated Date

(PID) Standard Operating Procedures.

2.7 VHA Directive 1231 - Outpatient Clinic Practice Management

VHA Directive 1231 - Outpatient Clinic Practice Management establishes policy for outpatient clinic practice management. This VHA directive establishes the requirements for clinic practice management capability, responsibilities, definitions, and processes for outpatient clinic practice management.

2.8 VHA Directive 1232, Consult Processes and Procedures 1232(1)

It is VHA policy, per VHA Directive 1232 - Consult Processes and Procedures, to ensure timely and clinically appropriate care to all Veterans by standardizing and managing consultation processes.

The provider entering the consult (the “sending provider”) determines the Patient Indicated Date

(PID) in collaboration with the Veteran. The PID is the date care is deemed clinically appropriate.

The PID is determined based upon the needs of the patient and should be at the earliest appropriate date care is needed. The PID should not be used to indicate the latest appropriate date. The PID may not be changed by the receiving service due to lack of availability of appointments. The date may only be changed if it was entered in error (e.g., a future care consult with a PID of today). The date must either be manually entered into the consult order or generated through an order menu that includes the PID. The PID should be entered into the scheduling package when the appointment is made.

Though VHA Directive 1232 states that consults must be changed from a pending status within 7 calendar days, more recent guidance from the Office of Veterans Access to Care (OVAC) requires updating of consult status within 2 days. For more detailed information and guidance on consult requirements, review the Telehealth Business Basics for Success training.

3. VA Video Connect Consults, Scheduling and Workload

All VA Video Connect visits will require certain information and resources to be obtained prior to the actual encounter, including:

• The Veteran’s phone number

• The Veteran’s present location and address

• The Veteran’s emergency contact name and phone number

• Ensure the Veteran is in a private and safe place

• Contact information for local emergency services

Attachment P https://vaww.infoshare.va.gov/sites/telehealth/docs/pid-gde.docx https://vaww.infoshare.va.gov/sites/telehealth/docs/pid-gde.docx https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3296 http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3230 http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3230 http://go.va.gov/espl

VA Video Connect Supplement – September 2018 Page 9

3.1 Consults

Consults are not typically required for initiating VA Video Connect services. Most often VA Video

Connect visits are a way of bringing existing services to a location more convenient for the

Veteran. In the cases that new services are initiated using VA Video Connect please see guidance in the Supplement for the corresponding specialty.

3.2 Intrafacility Scheduling

Note that group visits into the home are not endorsed by the Office of General Council (OGC). All scheduling guidance is provided for individual home visits only.

3.2.1 VA Video Connect Scheduled Visits

Documentation requirements, workload and coding information for VA Video Connect Scheduled

Video Visits can be found in the Telehealth Patient Indicated Date (PID) Standard Operating

Procedures document.

VA Video Connect Scheduled Video Visits can be created directly though the Telehealth

Management Platform, through the Patient Viewer app, through the Scheduling Manager app or through the VA Video Connect Manager app. Note that the Scheduling Manager app is not integrated with VistA; any appointments booked through the Scheduling Manager must be separately entered in VistA.

When scheduling using the Scheduling Manager app, appointments must be separately booked in

VistA. The Scheduling Manager app is used to send out the virtual medical room link to the provider and the patient. Once the VistA System Enhancements (VSE) is completed, the Scheduling

Manager app will not be used.

After a VA Video Connect Scheduled Video Visit is created the provider and patient receive a link to a virtual medical room by email notification.

Providers with the Patient Viewer app may also join the virtual medical room directly from within

Patient Viewer app.

For guidance on how to create a VA Video Connect Scheduled Visit, refer to TMP Scheduling of VA

Video Connect and the Telehealth Management Platform Supplement.

For guidance on how to create a VA Video Connect Scheduled Visit through the Patient Viewer app, refer to the Patient Viewer app page, which includes a Patient Viewer Quick Start Guide and

Patient Viewer User Manual.

For guidance on how to create a VA Video Connect Scheduled Visit through the Scheduling

Manager app, refer to the Scheduling Manager app page, which includes a Scheduling Manager

Quick Start Guide and Scheduling Manager User Manual.

Attachment P http://vaww.infoshare.va.gov/sites/telehealth/docs/pid-gde.docx http://vaww.infoshare.va.gov/sites/telehealth/docs/pid-gde.docx http://vaww.telehealth.va.gov/quality/tmp/index.asp http://vaww.telehealth.va.gov/quality/tmp/index.asp https://vaww.infoshare.va.gov/sites/telehealth/docs/vvc-schd-ptnt.docx https://vaww.infoshare.va.gov/sites/telehealth/docs/vvc-schd-ptnt.docx http://vaww.infoshare.va.gov/sites/telehealth/docs/tmp-spp.pdf https://mobile.va.gov/app/patient-viewer https://mobile.va.gov/sites/default/files/PatientViewer-QuickStartGuide-508-1.1.pdf https://mobile.va.gov/sites/default/files/PatientViewer-UserManual-1.3.pdf https://mobile.va.gov/app/scheduling-manager https://mobile.va.gov/sites/default/files/Schedule%20Manager%20-%20Quick%20Start%20Guide%201.2_508.pdf https://mobile.va.gov/sites/default/files/Schedule%20Manager%20-%20Quick%20Start%20Guide%201.2_508.pdf https://mobile.va.gov/sites/default/files/Schedule%20Manager%20-%20User%20Manual%201.3_508.pdf

VA Video Connect Supplement – September 2018 Page 10

For guidance on how to create a VA Video Connect Scheduled Visit through the Scheduling

Manager app, refer to the Scheduling Manager app page.

Best practices dictate that an employee connects with the Veteran prior to the appointment time to verify the connection and allow the Veteran to ask initial questions.

3.2.2 VA Video Connect On-Demand Visits

A VA Video Connect On-Demand Video Visit is a request by a provider for a situation where a visit needs to occur immediately. The VA Video Connect On-Demand Video Visit is generated directly by the provider by using the “Video on Demand” shortcut on the provider’s desktop (which automatically routes through the Telehealth Management Platform). For more information about

VA Video Connect On-Demand Video Visits, refer to the VA Video Connect Intranet site.

VA Video Connect On-Demand Video Visits are created through a desktop application which uses the Telehealth Management Platform as a background application.

When generating the VA Video Connect On-Demand Video Visit, the provider (or the provider’s scheduler) enters the patient’s email address and the provider’s email address. The Telehealth

Management Platform then automatically generates virtual medical room links and emails these links to the patient and the provider. No notifications are sent to schedulers for VistA scheduling, as this is considered an “unscheduled” visit

Virtual medical rooms created for VA Video Connect On-Demand Video Visits expire 12 hours after being created. If the requested visit will not be completed within 12 hours, a VA Video Connect

Scheduled Visit must be used instead. Refer to the VA Video Connect Intranet site for additional information.

Note: When a VA Video Connect On-Demand Video Visit is used to replace a face-to-face visit, the face-to-face visit must be canceled. After the face-to-face visit has been canceled, the VA Video

Connect On-Demand Video Visit can be created in the VistA Clinic using the 179 stop code. If the visit is to a non-VAMC site, a 648 stop code may be used. This information is detailed in the

Telehealth Business Rules for VA Video Connect document.

3.3 Interfacility Scheduling

To create an interfacility VA Video Connect Scheduled Video Visit, the appointment must be created in the Telehealth Management Platform as a clinic-to-clinic visit. When creating the appointment, the scheduler will only enter the provider clinic and the patient clinic. Then, on the date of the appointment, a VA Video Connect On-Demand Video Visit is manually generated.

Even though the virtual medical room is generated as part of the VA Video Connect On-Demand

Video Visit, the visit is treated as an interfacility VA Video Connect Scheduled Visit.

Attachment P https://mobile.va.gov/app/scheduling-manager http://vaww.telehealth.va.gov/pgm/vvc/index.asp http://vaww.telehealth.va.gov/pgm/vvc/index.asp http://vaww.infoshare.va.gov/sites/telehealth/docs/vvc-wrkldcrdt.docx

VA Video Connect Supplement – September 2018 Page 11

Refer to the Telehealth Patient Indicated Date (PID) Standard Operating Procedures for additional guidance on scheduling Interfacility visits.

Note that when scheduling interfacility telehealth appointments, the scheduler’s time zone is displayed. This may differ from the Veteran’s time zone.

3.4 Current Procedural Terminology, International Classification of

Diseases & Managerial Cost Accounting Office Codes

Refer to Integrated Outpatient Code Editor Specifications for guidance regarding the use of telehealth modifiers. Per the specifications, modifier 95 is provided for Synchronous Telemedicine Service. VA Video Connect Scheduled visits should be created using the appropriate primary stop code for the type of care being offered.

Secondary stop codes are as follows:

1. 179 – Real Time Clinical Video Telehealth to Home - Provider Site

2. 648 – Real Time Clinical Video Telehealth with Non-VAMC Location - Provider Site

3. 679 – National Center Real Time Clinical Video Telehealth to Home - Provider Site

Refer to the VA Video Connect Intranet site for additional guidance.

4. Technology

VA Video Connect is simple to use, with quick guides available for both Providers and Veterans.

Provider Quick Guides:

• VA Video Connect iOS Devices Quick Guide for Providers

• VA Video Connect Chrome Quick Start Guide

• VA Video Connect Internet Explorer Quick Start Guide

Veteran Quick Guides:

• VA Video Connect iOS Devices Quick Guide for Veterans

• VA Video Connect Android Devices Quick Guide for Veterans

• VA Video Connect Chrome Quick Start Guide

• VA Video Connect Internet Explorer Quick Start Guide

Patients connect to the virtual medical room from their preferred device. Providers must use their

GFE to connect to the virtual medical room. Connecting to the virtual medical room at the scheduled date and time is accomplished using email scheduling confirmation or iCal reminder.

Refer to the VA Video Connect Intranet site for additional guidance on the VA Video Connect set-up and visit.

Attachment P http://vaww.infoshare.va.gov/sites/telehealth/docs/pid-gde.docx https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9892.pdf http://vaww.telehealth.va.gov/pgm/vvc/index.asp https://vaww.infoshare.va.gov/sites/telehealth/docs/vvc-ios-pro.docx https://vaww.infoshare.va.gov/sites/telehealth/docs/vvc-chr-qck.docx https://vaww.infoshare.va.gov/sites/telehealth/docs/vvc-ie-qck.docx https://vaots.blackboard.com/bbcswebdav/institution/CVT/tmp/email-link/vvc-ios-vet.docx https://vaots.blackboard.com/bbcswebdav/institution/CVT/tmp/email-link/vvc-drod-vet.docx https://vaww.infoshare.va.gov/sites/telehealth/docs/vvc-chr-qck.docx https://vaww.infoshare.va.gov/sites/telehealth/docs/vvc-ie-qck.docx

VA Video Connect Supplement – September 2018 Page 12

4.1 Provider Initial Set-up

Provider requirements for connecting to a virtual medical room:

• Computer or other VA Issued Device

• VA-issued devices o Personal computer o Laptop o Government Furnished Equipment (GFE) smartphone (i.e. iPhone)

▪ VA GFE iOS devices should have “Good for Enterprise” installed and the user’s VA email account should be enabled o GFE Tablet (i.e. iPad)

▪ VA GFE iOS devices should have “Good for Enterprise” installed and the user’s VA email account should be enabled

• Internet Connection

• Webcam plus Microphone o Note that many devices have an integrated webcam and microphone

Google Chrome is the preferred web browser for accessing a virtual medical room. Most VA computers use Internet Explorer-11(IE-11); regardless if Google Chrome or Microsoft Internet

Explorer is used, an initial camera and microphone configuration is necessary. Chrome allows for screen sharing, IE-11 does not allow for screen sharing.

As a best practice, it is recommended that each facility establish processes so that Veterans, new to VA Video Connect, can complete a non-clinical test call prior to their first visit to ensure they are prepared and able to effectively use the technology before connecting with their provider. It is also recommended that providers glean a good understanding of the steps involved in connecting, turning up the volume and other items associated with using the device.

The National Telehealth Technology Help Desk (NTTHD) has established a similar test call service in their operations. Veterans can call the NTTHD and ask for a test call; however, it is recommended that this be used as a back-up service to the facility process.

If this backup process is used, then the Veteran’s appointment must be scheduled with the assumption that the Veteran will have a successful test call with NTTHD unless the Veteran informs the facility otherwise. This is essential to ensure the Veteran is seen within the appropriate timeline as indicated by the Patient Indicated Date (PID).

VA Video Connect quick guides are available for both Google Chrome and Internet Explorer.

4.2 Patient Initial Set-up

Veteran requirements for connecting to a virtual medical room:

• Computer, VA Issued Device, smartphone or tablet o Smartphone or tablet must have either iOS (i.e. iPad and iPhone) or Android operating system

• Internet Connection

Attachment P https://vaww.infoshare.va.gov/sites/telehealth/docs/vvc-chr-qck.docx

VA Video Connect Supplement – September 2018 Page 13

• Webcam plus Microphone o Note that many devices have an integrated webcam and microphone

• Access to an active email address

• Internet Browser, e.g. Microsoft Internet Explorer or Google Chrome o Guide: Configuring Internet Explorer for VA Video Connect o Guide: Use Chrome without making it the Default Browser o Google Chrome is the recommended browser for Android devices

• VA Video Connect iOS App if using iOS Device (e.g. iPhone, iPad)

It is imperative to ensure that patients can effectively use VA Video Connect in their preferred location to connect with the VA prior to an initial clinical encounter. Multiple pathways are available to assist patients with setup and testing of VA Video Connect to ensure it works correctly:

• VA facility staff and volunteers trained on using VA Video Connect can assist patients with managing a VA Video Connect test visit and provide technical support, particularly for patients as they come to the facility and/or are being scheduled for their VA Video Connect

Scheduled Video Visit.

o VA Video Connect App Toolkit is available to VA facility staff and volunteers on the

VA intranet and contains posters, videos, fact sheets, and guides.

• VA Mobile App store available on the Internet provides the VA Video Connect app, automated testing option, and quick guides:

o Link to download the free iOS VA Video Connect app from the App Store.

o Link to VA Video Connect test site to test whether a personally owned device is compatible with VA Video Connect. The National Telehealth Technology Help Desk

(NTTHD) will assist with any difficulties with the test visit.

o An Android Device quick guide and iOS Device quick guide.

• NTTHD is fully staffed and ready to assist patients with their initial VA Video Connect set

up. NTTHD hours of operation are Monday - Saturday, 7 am - 11 pm ET and available at toll free at 866-651-3180. Alternate phone # is: 703-234-4483.

• “How to” VA Video Connect videos are available for patients to view on the Internet:

o Overview

▪ VA Mobile App store provides an overview of VA Video Connect.

▪ What is a Virtual Medical Room?

▪ A Virtual Medical Room Encounter o Detailed

▪ How to Connect VMR using Android

▪ How to Connect VMR using iOS

▪ TeleMental Health with VMR

4.2.1 VA-Issued Tablets for Veterans

Veterans who do not have an email address or do not have a tablet require a VA-issued tablet in order to use VA Video Connect. The need for a VA-issued tablet is identified by a provider, who

Attachment P https://vaww.infoshare.va.gov/sites/telehealth/docs/vvc-cfgie.pptx https://vaww.infoshare.va.gov/sites/telehealth/docs/vvc-chrmndflt.pptx https://vaww.connectedhealth.va.gov/Communications/SitePages/VVC_ToolKit.aspx https://mobile.va.gov/app/va-video-connect#AppDescription https://itunes.apple.com/us/app/va-video-connect/id1224250949?mt=8 https://care.va.gov/vvc-app/?name=Patient&join=1&media=1&escalate=1&conference=testwaitingroom@care.va.gov&pin=5678 https://vaots.blackboard.com/bbcswebdav/institution/CVT/tmp/email-link/vvc-drod-vet.docx https://vaots.blackboard.com/bbcswebdav/institution/CVT/tmp/email-link/vvc-ios-vet.docx https://vaww.infoshare.va.gov/sites/telehelpdesk/default.aspx https://mobile.va.gov/app/va-video-connect#AppDescription https://vaots.blackboard.com/bbcswebdav/institution/videos/vmr/what-is-vmr/video.html https://vaots.blackboard.com/bbcswebdav/institution/videos/vmr/vmr-encounter/video.html https://vaots.blackboard.com/bbcswebdav/institution/videos/vmr/acess-vmr/video.html https://vaots.blackboard.com/bbcswebdav/institution/videos/vmr/access-vmr-ios/video.html https://vaots.blackboard.com/bbcswebdav/institution/videos/vmr/tmh-vmr/video.html

VA Video Connect Supplement – September 2018 Page 14 enters a consult requesting the VA-issued tablet for a Veteran. The tablets are requisitioned through the Remote Order Entry System (ROES) by a designee who oversees the ordering process and completes the provider consult with the appropriate information. Facility Telehealth

Coordinators are responsible for overseeing the tablet process and ensuring providers and

Veterans receive the appropriate education on use of VA-issued tablets.

Tablets for Veterans are ordered by the VA and will come with a pre-installed static link. A Veteran with a VA-issued tablet is able to select the static link on their tablet to automatically join a virtual medical room. Providers join the virtual medical room by copying the static link from the tablet consult into a web browser.

Guidance is provided in the VA-Issued Tablet SOP, which covers the process for tablet requisition, generating the static link, scheduling and conducting the visit.

5. VA Video Connect Visit

5.1 Notifications

Depending on the type of visits, different parties will receive notifications regarding the creation of a visit. The different notifications sent for each visit are listed below:

• VA Video Connect On-Demand Visits – email notifications are sent to the provider and the patient

• VA Video Connect Scheduled Visits – email notifications are sent to the provider, patient, and the VistA scheduler

Email notifications are automatically sent by the Telehealth Management Platform, when appropriate. The Telehealth Management Platform also includes a link to the virtual medical room in scheduling email notifications. The email also provides the Teleprovider and Veteran with the ability to save the scheduling information to iCal.

5.2 Entering the VA Video Connect Session

To join a VA Video Connect session through an email link, refer to the appropriate following quick guides:

• VA Video Connect iOS Devices Quick Guide for Providers

• VA Video Connect Chrome Quick Start Guide

• VA Video Connect Internet Explorer Quick Start Guide

• VA Video Connect iOS Devices Quick Guide for Veterans

• VA Video Connect Android Devices Quick Guide for Veterans

• VA Video Connect Chrome Quick Start Guide

• VA Video Connect Internet Explorer Quick Start Guide

Attachment P https://vaww.infoshare.va.gov/sites/telehealth/docs/vvc-tbt-sop.docx https://vaww.infoshare.va.gov/sites/telehealth/docs/vvc-ios-pro.docx https://vaww.infoshare.va.gov/sites/telehealth/docs/vvc-chr-qck.docx https://vaww.infoshare.va.gov/sites/telehealth/docs/vvc-ie-qck.docx https://vaots.blackboard.com/bbcswebdav/institution/CVT/tmp/email-link/vvc-ios-vet.docx https://vaots.blackboard.com/bbcswebdav/institution/CVT/tmp/email-link/vvc-drod-vet.docx https://vaww.infoshare.va.gov/sites/telehealth/docs/vvc-chr-qck.docx

VA Video Connect Supplement – September 2018 Page 15

To join a VA Video Connect session through a static virtual medical room link, refer to the following quick guide:

• VA iPad Mini Introduction for Veterans

5.3 Conducting the VA Video Connect Visit

At the initial VA Video Connect visit the provider must ensure and document that the Veteran consents to the appointment being conducted via telehealth technology. At the start of each subsequent VA Video Connect visit the Teleprovider must document that the appointment is being conducted via telehealth. The Teleprovider must record the address of the Veteran’s current location during the appointment along with numbers the Veteran may be contacted at in the case of technology disruption. The Teleprovider must ask if there are others in the home or local area that may be contacted in an urgent situation. If so, the names and numbers of those persons must be documented. Finally, the local emergency phone number for the Veteran’s location must be obtained prior to commencing the appointment and a plan must be in place of how the appointment will continue in the case of technology failure.

If the Teleprovider will be late, procedures must be in place to notify the Veteran.

Refer to the VA Video Connect Intranet site for further guidance.

5.4 VA Video Connect Support

Similar to initial setup, multiple pathways are available to support users with VA Video Connect and provide technical assistance:

• The VA Video Connect test site is available for automated testing of audio and video connection.

• The National Telehealth Technology Help Desk (NTTHD) is fully staffed and ready to assist patients with VA Video Connect. NTTHD hours of operation are Monday - Saturday, 7 am -

11 pm ET and available at toll free at 866-651-3180. Alternate phone # is: 703-234-4483.

6. Risk Management: Emergency Procedures

In a medical or mental health emergency, the telehealth Provider who is located at a distant site from the Veteran is unable to provide direct assistance to the patient and must rely on others to respond safely and effectively. When equipment fails, a backup or contingency plan must be in place to support safe and effective patient care. It is essential that risk management policies and procedures are developed and practiced around contingency planning and emergency management of any VA Video Connect visit.

Attachment P https://vaww.infoshare.va.gov/sites/telehealth/docs/vvc-tbt-ltr.docx http://vaww.telehealth.va.gov/pgm/vvc/index.asp https://care.va.gov/vvc-app/?name=Patient&join=1&media=1&escalate=1&conference=testwaitingroom@care.va.gov&pin=5678 https://vaww.infoshare.va.gov/sites/telehelpdesk/default.aspx

VA Video Connect Supplement – September 2018 Page 16

Should an acute event happen to a Veteran during a VA Video Connect encounter, emergency procedures must be in place prior to the event. The procedures are addressed in the Telehealth

Service Agreement. For additional information on VA Video Connect Emergency Procedures please refer to the VA Video Connect Intranet site and the Telehealth Manual.

Since VA Video Connect occurs in a location other than a clinic, there are additional emergency procedures that are required. This includes knowledge and utilization of Emergency 911 (E911).

E911 is an emergency service and is only to be utilized in the event of an emergency or as deemed clinically appropriate. As a result, test calls to E911 are prohibited.

The E911 operator is not a traditional 911 operator. Rather, the E911 acts as a relay to the traditional 911 operator. The E911 operator is used to connect a provider with the appropriate emergency service for a Veteran. A key function of E911 services is to identify specific location information (e.g., floor or wing that the Veteran is located on) in addition to the Veteran’s address.

The E911 operator can then convey this detailed location information to a traditional 911 operator.

E911 is a service that providers can use to be routed to…