D.25 VHA CLINIC BASED TELEHEALTH OPERATIONS 1.pdf

D.25 VHA CLINIC BASED TELEHEALTH OPERATIONS 1

36C25922R0102

1. Introduction to Synchronous Telehealth

1.1. What To Know

The Office of Connected Care Telehealth Manual contains policies, procedures, and guidance related to telehealth. It also guides readers through the steps of fully implementing, managing, and evaluating a telehealth program. This Synchronous

Telehealth Manual serves as an appendix to the Telehealth Manual. It contains

Synchronous Telehealth-specific business, technical, and clinical process information that either adds to or differs from the guidance in the Telehealth Manual.

Synchronous Telehealth is a real-time interactive videoconferencing. Synchronous

Telehealth visits are conducted in the hospital, the clinic, and the home or another non-

VA setting.

Resources for different telespecialties can be found in specific specialty supplements available on the Veterans Health Administration Telehealth Services intranet site.

1.2. Roles and Responsibilities

Telehealth services work together to create a seamless experience for the patient. When creating a Synchronous Telehealth program, you will want to become familiar with the following roles and learn who fills each role for your facility:

• Facility Telehealth Coordinator.

• Telehealth Clinical Technician.

• Telepresenter(s).

• Teleprovider(s).

• VISN Telehealth Program Manager.

1.3. Locations of Care

Providers can deliver care from any safe, private, and professional location. The driver for the business, technical and clinical is the patient location. The typical locations are: in the hospital, in the clinic, at home, and non-VA sites.

1.3.1. In the Hospital

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Providers may need to consult specialists at other VA hospitals. Telehealth technologies help physicians and other medical professionals at different locations connect to discuss patients’ health care to develop a care plan. The telehealth program currently available in VA hospitals is the National TeleStroke Program. See the Telehealth intranet site for pilot and established teleconsultation programs.

1.3.2. In the Clinic

Providers can make diagnoses, manage care, and perform checkups virtually in the clinic and non-VA sites, such as community-based outpatient clinics. These services are provided in Synchronous Telehealth visits, where the provider is at a different location from the patient. A video visit in the clinic often requires the support of a Telehealth

Clinical Technician or another telepresenter at the patient site to assist in assessing the patient.

1.3.3. At Home

Synchronous Telehealth at home enhances the accessibility of care and enables the patient and the provider to connect through videoconferencing, such as through VA

Video Connect. The patient may be at any location of their choosing, not necessarily in their home, at the time of the telehealth visit. Therefore, special considerations related to privacy and safety must be discussed with the patient to ensure that standards are consistent with those that typically apply in telehealth visits. For instance, if a patient is joining a VA Video Connect visit from their car, considerations would include whether the patient is parked, not driving or in a moving car, and where the patient is located in case of an emergency.

1.3.4. Non-VA Locations

1.3.4.1. Telehealth Emergency Management

Telehealth Emergency Management uses Synchronous Telehealth to provide patients with clinical care following a disaster or emergency.

For more information, including how to volunteer, consult the Telehealth Emergency

Management intranet page.

1.3.4.2. ATLAS

ATLAS (Accessing Telehealth through Local Area Stations) enhances the accessibility of

VA care and helps bridge the digital divide by establishing convenient, comfortable, and https://vaww.telehealth.va.gov/clinic/spc/tnuro/tstrk/index.asp http://vaww.telehealth.va.gov/ http://vaww.telehealth.va.gov/pgm/tem/index.asp http://vaww.telehealth.va.gov/pgm/tem/index.asp private locations in which patients can connect with their VA providers through video appointments. These locations, known as ATLAS sites, are in select communities where patients often have long travel times to VA facilities or poor connectivity at home.

For more information on ATLAS, please visit the ATLAS intranet page.

2. Getting Started

For any Synchronous Telehealth program, some essential elements must be considered and decided on at the start of the process. These essential elements may be found in the New Telehealth Deployment Checklist.

For more information on how to plan and properly set up a telehealth program, please consult Section 6, Getting Started, and Section 7 of the Telehealth Manual.

2.1. Gaining Approval for Initiatives Using Synchronous

Telehealth

For new national telehealth programs using Synchronous Telehealth, there are two levels of approval: one at the local level and one at the national level.

Note: This approval process is not needed for providers using VA Video Connect into the home.

Local-level approval, including notifying the facility’s Telehealth Advisory Board, is required for all uses of Synchronous Telehealth. A Synchronous Telehealth program with local-level approval assumes responsibility and liability for all services and technology within that program.

Nationally approved telehealth programs have gone through the quality, implementation, and development process with the national telehealth teams, including, but not limited to, vetting of technology and equipment, identification of the clinical pathways, and creation of a specialty supplement that will be published on the

Telehealth intranet site. As this statement suggests, national-level approval is a complex process than is local approval. See Section 2.1.2., Enterprisewide Designation and

National Approval, of this manual for more information.

2.1.1. Local-Level Approval

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Once a Telehealth Services Business Plan/Needs Assessment is completed, the proposed local Synchronous Telehealth programs must be sent to the facility, and the VISN level for approval. This initial approval will provide the program with the ability to begin development in local facilities and is considered “local-level approval.” For more information on establishing a telehealth program or local-level approval, see Section 6, Getting Started, of the Telehealth Manual.

Once the facility and the VISN have approved a program, the VISN will send an email notification to the Office of Connected Care National Synchronous Telehealth Lead and the national telehealth Quality and Training Division. This email will qualify as notification of the new initiative and will be presented to the Telehealth Advisory Board for awareness, tracked for follow-up; and reviewed for progress, data, and quality evaluation.

The email will include:

1. The program name.

2. A short statement about the clinical purpose of the program.

3. The stop codes used for workload capture.

4. A description of the clinical pathway(s) and consult process in place (if possible).

5. A list of the equipment being used.

6. A list of the approved or unapproved video and software programs being used.

7. An indication of what data, images, or video will be incorporated into the medical record when the service or program is used.

8. An explanation of how security is managed.

9. A list of the metrics used to measure success.

The Telehealth Services Needs Assessment/Business Plan should be attached to the email.

VISNs are encouraged to share information on new Synchronous Telehealth services and best practices with others on VISN Leads Council calls. The VISN Leads Council will review new programs under “new business” during scheduled calls.

This sharing of new initiatives and local best practices is intended to spread awareness and does not guarantee that a new, locally established Synchronous Telehealth program will be moved to national implementation.

National data will be reviewed by the Office of Connected Care/Telehealth Services and the national office of Telehealth Services. National staff may reach out to local programs to verify what Synchronous Telehealth credit stop codes are being used on the local https://vaots.blackboard.com/bbcswebdav/xid-694055_1 https://vaots.blackboard.com/bbcswebdav/xid-510063_1#6-getting-started https://vaots.blackboard.com/bbcswebdav/xid-510063_1#6-getting-started http://vaww.telehealth.va.gov/about/contact/index.asp#async http://vaww.telehealth.va.gov/about/contact/index.asp#qt https://vaww.infoshare.va.gov/sites/telehealth/gb/Home.aspx https://vaots.blackboard.com/bbcswebdav/xid-694055_1 https://vaww.infoshare.va.gov/sites/telehealth/gb/VISN%20Telehealth%20Leads%20Council.aspx program to evaluate whether the program meets the intent for new Synchronous

Telehealth programs and is in line with national quality measures and Conditions of

Participation guidelines. Local programs will provide documentation of standard operating procedures or policies for new Synchronous Telehealth programs upon request and collaborate with the below-national-level process if deemed appropriate.

2.1.2. Enterprisewide Designation and National Approval

The process for obtaining enterprisewide designation and national approval is as follows:

1. The national Quality Operations team identifies a need for national standardized guidance, documentation, and training. Identification may occur through one or more of the following avenues:

o A VISN or facility with a Synchronous Telehealth program plan contacts the

Quality and Training email group at VHA_10P8_TH_DIQ@va.gov, contacts the National Synchronous Telehealth Lead, or shares information during

VISN Leads Council calls.

o VHA Support Service Center data indicates the use of Synchronous

Telehealth codes for new specialty clinics.

o Leadership and specialty office priorities or strategic planning reveals the need.

o A need emerges through Conditions of Participation discussions and data.

2. The Quality Operations team collaborates with representatives from VISNs, facilities, stakeholders, and other objective subject matter experts to modify or develop

Connected Care specialty supplements with applicable implementation and operational guidance.

3. Any technology used in the program is checked against the Blanket Purchase

Agreement. Any program technology that is not on the Blanket Purchase

Agreement is submitted to the Telehealth Advisory Board’s Technology Committee for approval.

4. The national specialty office should also approve the technology that is specific to a particular specialty (e.g., cardiac monitors).

5. The Quality Operations team collaborates to develop synchronous consult guidance and standardized consult templates, as needed.

A consult template request should be submitted to the National Clinical Template

Workgroup for national standardization of terms and rollout to the field for implementation.

6. After the program is approved through the Telehealth Advisory Board, the supplement is published and announcements are made to the field.

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7. Training and competency guidance is developed.

8. The Quality Management team makes any needed additions to the Conditions of

Participation standards, the review process, and the National Quality Data

Scorecard to reflect the new program.

9. Synchronous services will be nationally approved when the specialty supplements are published by the Quality and Training Division.

10. The final steps in the national standardization rollout include sustainment activities, such as marketing, additional training sessions, and forums.

Note: The different services within a program may need to reach different steps to be included in the national specialty supplements.

2.1.3. Established Programs

A list of current telehealth specialty programs can be viewed under the Specialty tab on the Telehealth intranet site. The supplement for each specialty, as well as additional related documents, is available on the specialty’s page on this site. For specific details on a specialty consult, please refer to the specialty’s manual.

Note that programs that wish to establish group visits must confer with the local regional counsel to ensure that there is patient consent for group participation and that considerations regarding VA or patient recording of visits are addressed.

2.2. Credentialing and Privileging

For information on credentialing and privileging, see Section 6.6.2, Credentialing and

Privileging, of the Telehealth Manual.

2.3. Space Resources

Facilities must ensure that space resources and alternate worksites follow the guidelines in Section 6.4, Space Resources, of the Telehealth Manual.

Other space requirements vary by type of visit. Factors influencing space requirements include the need for specialized equipment, technology, and lighting; the participation of multiple patients in a visit (for group visits); the need for a chaperone for some specialties; and the participation of family members and caregivers in an appointment.

When clinically appropriate, VA Video Connect can be used to minimize space issues.

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3. Setting Up Synchronous Telehealth

For full information on setting up a telehealth program, see Section 7, Setting Up

Telehealth, of the Telehealth Manual.

3.1. Teleconsultation Versus Telemedicine

Teleconsultation is defined as the provision of advice on diagnosis, prognosis, or therapy by a licensed independent provider to another licensed independent provider using electronic communications and information technology to support the care provided:

1. where distance separates the participants and

2. where hands-on care is delivered at the patient site by a licensed independent health care provider.

Telemedicine is defined as providing care by a licensed independent health care provider who directs, diagnoses, or otherwise provides clinical treatment using electronic communications and information technology when distance separates the provider and the patient.

3.2. Clinic Setup

When determining how to set up your clinic, be sure to follow national and local policies. For full details on naming conventions and general stop codes, see Section 7.2, Clinic Setup, of the Telehealth Manual.

Specialty primary stop codes for telehealth visits are the same as those for in-person visits. The managerial cost accounting CHAR4 codes further define the costs of outpatient encounters, enabling an analyst to identify care provided under specific clinics across stop codes and sites. Codes can be used locally and nationally.

For further assistance, contact local managerial cost accounting staff and see the

Managerial Cost Accounting Office intranet page.

3.2.1. In the Home and Non-VA Locations

In the home, all specialties and providers should have individual clinics set up with a credit stop code of 179 for Telehealth Visits Into the Home documentation, a stop code https://vaots.blackboard.com/bbcswebdav/xid-510063_1#7-setting-up-telehealth https://vaots.blackboard.com/bbcswebdav/xid-510063_1#7-setting-up-telehealth https://vaots.blackboard.com/bbcswebdav/xid-510063_1#72-clinic-setup https://vaots.blackboard.com/bbcswebdav/xid-510063_1#72-clinic-setup http://vaww.dss.med.va.gov/programdocs/pd_oident.asp not associated with a patient copay. For further assistance, contact local managerial cost accounting staff and see the Managerial Cost Accounting Office intranet page.

3.2.2. In the Clinic

Synchronous Telehealth visits use secondary stop codes to represent the type of telehealth modality used for the visit and the location of the patient and the provider.

For further assistance, contact local managerial cost accounting staff and see the

Managerial Cost Accounting Office intranet page.

3.2.3. In the Hospital

Synchronous Telehealth visits must follow national guidelines for documenting inpatient visits by specialty care staff per VHA Handbook 1907.01, Health Information

Management and Health Records.

For further assistance, contact local managerial cost accounting staff and see the

Managerial Cost Accounting Office intranet page.

For more information on coding for telehealth visits, refer to the Telehealth Clinic Set-

Up and Coding Guidance and the Managerial Cost Accounting Office program documents.

3.3. Technology

Technology needs may vary, depending on the type of telehealth visit (i.e., hospital, clinic, home, or other non-VA location). The technology should suit the purpose of the visit. Before purchasing technology, please consult the list of approved technologies on the Telehealth Equipment and Technologies SharePoint site.

If the technology you wish to purchase is not listed, there are steps you can take to gain approval for the purchase and use of the technology. For more information on obtaining approval of the technology, visit the Telehealth Technology Approval Process intranet page. Use the New Technology Request Form for a new piece of telehealth technology or for a technology that is being used locally but has not been nationally approved. For equipment that has not been nationally approved, local sites assume full responsibility and liability for any issues with the equipment’s use during a telehealth visit.

3.3.1. VA Video Connect Technologies

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VA Video Connect enables patients to meet virtually with their VA care team in a virtual medical room. VA Video Connect uses encrypted video to ensure that each session is secure and private. It enables patients to see and talk to their health care team from anywhere, including from their home and other non-VA locations. This makes VA health care more accessible and reduces travel times for patients, especially those in rural areas with limited access to VA facilities.

VA Video Connect NOW can be used in an “instant,” also known as ad hoc, visits, or scheduled visits.

For more guidance on VA Video Connect, consult the VA Video Connect Supplement and the VA Video Connect for Providers, VA Video Connect for Coordinators, VA Video

Connect for Schedulers, VA Video Connect Groups, VVC NOW, and Virtual Care

Manager intranet pages.

ATLAS is part of VA’s Anywhere to Anywhere initiative. For more information on ATLAS, please visit the ATLAS intranet page.

3.3.2. Clinical Peripherals into the Home

Currently, peripherals into the home, can only be used with a VA-issued iPad or iPhone.

The peripherals currently available are blood pressure monitors, heart rate monitors, weight scales, stethoscopes, blood glucometers, pulse oximeters, spirometers, thermometers, and pedometers. A provider can use the Digital Divide Consult Process to order a VA-issued tablet for the patient during VA Video Connect visits. Several peripheral devices have been approved for use with a VA-issued tablet, including

Remote Patient Monitoring – Home Telehealth tablets. These peripheral devices can also be ordered through a Digital Divide Consult.

VA-issued peripherals can be used across telehealth care modalities (e.g., Remote

Patient Monitoring – Home Telehealth and Synchronous Telehealth care can use the same peripheral).

3.4. Synchronous Consult Pathway

The Synchronous Telehealth consult pathway is described below and shown in Figure 1.

After determining that a telehealth consult is needed:

1. The referring provider will initiate, or collaborate with a receiving provider through, a telehealth consult.

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2. The receiving provider will notify and provide information to the telehealth staff for both the patient and the provider sites.

3. The receiving provider must prepare for the appointment, following guidelines laid out in the Telehealth Service Agreement and, if applicable, for non-VA care, the memorandum of understanding.

If the receiving provider does not use the Telehealth Management Platform, appointment needs and resources should be tracked using local processes to prevent overbooking and secure the needed resources.

4. Progress notes should be written, and the steps should be completed to close the provider-side encounter. These steps will result in the sending of a Computerized

Patient Record System (CPRS) alert to indicate that results are available in the Joint

Legacy Viewer/VistA Web.

5. The patient-side encounter should then be closed and coded following the

Telehealth Service Agreement.

6. The telehealth team consult is then closed.

The receiving provider may determine that an in-person visit is required. In this case, a telehealth visit may still be useful to the receiving provider to obtain information from the patient before the in-person visit. After the in-person visit, the receiving provider may opt to conduct follow-up visits by telehealth.

Figure 1: Synchronous Telehealth Consult Pathway

4. Patient Engagement

There are numerous tools available to promote patient engagement with their health care. These include equipment, test calls, toolkits, and mobile apps.

4.1. Patient Equipment

VA equipment may be available for patients using VA Video Connect. A unique aspect of the VA Video Connect app is that patients can use their own internet-enabled devices or a VA-loaned device (as described in the Digital Divide Consult Process standard operating procedures).

4.2. Test Calls

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It is crucial for patients and providers who are new to telehealth to complete a test call.

This will help prevent technology failures and user errors when it is time for the first VA

Video Connect visit.

Several patient-facing documents include information on test calls. These documents include the VA iPad Setup Quick Reference and the VA iPhone Setup Quick Guidance.

In addition, local facilities should establish a test call program available to both patients and providers. Many facility telehealth program offices have individuals designated to assist in this effort, including VA staff or voluntary service members (once determined that the individuals are appropriately trained). In addition, the Office of Connected Care

Help Desk is available 24 hours a day, seven days a week. VA staff and patients can call the help desk at 866-651-3180.

Morning test calls are also useful to ensure the technology is working in and to the appropriate locations. The virtual team should also use test calls when connecting to non-VA sites and connecting to new locations or using new technology.

4.3. Veteran-Facing Tools and Resources

Connected Care aims to improve the health of Veterans by providing technologies that expand clinical care beyond the traditional office visit. You will find links to additional resources in the following subsections.

4.3.1. Toolkits

The VA Mobile site contains an outreach toolkit that includes VA App Store materials and VA online scheduling materials, available for download and printing, and several videos, which patients can view on the site.

4.3.2. Mobile Apps

Mobile apps are available to both patients and VA care teams. The VA App Store is located on the VA Mobile website. Mobile apps are often used in conjunction with patient visits to reinforce care decisions and healthy living choices.

5. Scheduling

As with all medical appointments, it is crucial to schedule a telehealth visit correctly. The telehealth visit may occur:

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• Within a facility or health care system, known as intrafacility telehealth.

• Between facilities or health care systems, known as interfacility telehealth.

• Between a VA facility or health care system and a non-VA setting.

• Between a VA facility or health care system and the patient’s home or mobile device.

The core of the VA scheduling system is VistA, an integrated Electronic Health Record information technology system created and used by VHA. It has approximately 200 application packages or modules. The VistA Scheduling module is designed to assist in the setup of outpatient clinics, scheduling of patients for clinic appointments, and collection of related workload data for reporting purposes. VA facilities have separate

VistA databases. Therefore, the scheduler will need to be granted access to the appropriate remote VistA system to schedule interfacility telehealth visits. Patient health records from other systems may be accessed through a Joint Legacy Viewer, which connects to the U.S. Department of Defense and other community health record systems.

Over the next 10 years, VA will move from its current Electronic Health Record system to a new Electronic Health System (Cerner) that will link with the Department of Defense’s patient records. This move will unify all VA facilities on one system.

Scheduling processes should be defined in the Telehealth Service Agreement when a telehealth program is set up.

5.1. Scheduling Solutions

5.1.1. Telehealth Management Platform

The Telehealth Management Platform is a national scheduling resource that interfaces with VistA. The Telehealth Management Platform enables telehealth programs to manage and schedule needed resources (e.g., rooms, technologies, users) and VISN

Clinical Resource Hubs.

For more information on the Telehealth Management Platform, please refer to the

Telehealth Management Platform Supplement and the Telehealth Management

Platform intranet page.

5.1.2. Virtual Care Manager

Virtual Care Manager enables providers and other VA staff to create, view, and join a VA https://vaots.blackboard.com/bbcswebdav/xid-514616_1 http://vaww.telehealth.va.gov/quality/tmp/index.asp http://vaww.telehealth.va.gov/quality/tmp/index.asp

Video Connect visit. When a VA Video Connect visit is created in Virtual Care Manager, an email containing a link to the visit is sent to the patient. Video visits may be created to start anywhere from 360 days in advance to up to 15 minutes before the current time.

Scheduling appointments in the Virtual Care Manager sends out the VA Video Connect link and requires a separate appointment to be scheduled in VistA. Providers and other staff should work with their clinic schedulers for VistA scheduling.

For more information, refer to the Virtual Care Manager intranet page. You can access the Virtual Care Manager app through the Virtual Care Manager page on the VA App

Store.

6. Before the Visit

For specific guidance on what happens before a Synchronous Telehealth visit, please consult the VA Video Connect and ATLAS pages on the Telehealth intranet site. For specialties, consult the specialty-specific Telehealth intranet pages to learn about any pre-visit requirements, such as imaging studies, laboratory tests, or vital signs.

The provider must establish the clinical criteria for a visit. The clinical criteria also must be defined in the Telehealth Service Agreement; however, Telehealth Service

Agreements are not needed for in-the-home appointments if those are considered intrafacility visits.

6.1. Virtual Huddle

Synchronous Telehealth uses virtual huddles as a means of communication. It is a best practice for telehealth teams to meet regularly. During the regular meeting, or huddle, the team will discuss treatment plans and the flow for upcoming telehealth visits. This is also the time to verify information on the emergency contact list and ensure that primary and alternate phone numbers are current for that particular day.

6.2. Homework

Homework assignments for patients accompany some Synchronous Telehealth visits. In these cases, the homework will be sent from the patient to the teleprovider. If the patient cannot send secure messages, the Telehealth Clinical Technician will assist the patient to ensure that the teleprovider receives the homework. This process is conducted for any patient location.

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7. During the Visit

Although a Synchronous Telehealth visit can, in most instances, provide the same service as an in-person visit, there are some factors specific to telehealth visits that must be highlighted.

For guidance on what happens during a telehealth visit, including some of the important differences between a telehealth visit and an in-person visit, please refer to the VA

Video Connect, ATLAS, and specialty supplements.

The following sections provide some additional guidance.

7.1. Emergency Procedures

It is crucial to establish a local emergency plan.

Every facility is required to have a current emergency plan and conduct routine emergency drills. The emergency plan must cover different provider and patient locations, including hospitals, clinics, and home or other non-VA sites. The emergency plan is included in the Telehealth Service Agreement. It is also vital that a contingency plan is developed and practiced locally.

Staff involved in telehealth must have a clear understanding of the communication process and the team members’ roles and responsibilities. For more detailed information, see the Telehealth Clinical Emergency Plans Memorandum and attachments.

7.2. CAPS-Lock Process

The CAPS-Lock process, described below, should be used during every telehealth visit.

This process is very similar for telehealth appointments into the clinic and those into the home. The letters of the process name will help you remember the steps.

C – Consent: Obtain or confirm that verbal consent for telehealth has been documented. This is a one-time requirement for your service.

A – Address: Verify the location of the patient site to be able to direct emergency responders to the patient, if necessary, accurately. Verify the patient’s location within the clinic (room number) or the physical address of the patient when participating in a VA

Video Connect visit from their home or mobile device. If using VA Video Connect, you can place this information in the Enhanced 911 (Emergency #) feature.

https://vaww.telehealth.va.gov/pgm/vvc/index.asp https://vaww.telehealth.va.gov/pgm/vvc/index.asp https://vaww.telehealth.va.gov/pgm/atlas/index.asp https://vaww.telehealth.va.gov/index.asp https://vaww.infoshare.va.gov/sites/telehealth/docs/th-tsa-es.pdf https://vaots.blackboard.com/bbcswebdav/xid-596377_1 https://vaots.blackboard.com/bbcswebdav/xid-596376_1

P – Phone Numbers: Verify the primary and alternate phone numbers for the patient clinic site and the patient’s mobile/home locations for use in emergency and contingency plans.

S – Survey: Survey the environment and identify all participants in your room and the patient’s room. Confirm that camera and audio equipment are in the correct position.

Confirmation should be conducted for the home or the clinic. During a telehealth appointment into the clinic, if a Telehealth Clinical Technician or telepresenter will not be in the room during the visit, ensure that the patient and any other participant in the room with them know how to alert clinic staff in case of an emergency.

Lock: Lock the virtual medical room once all expected participants have arrived. If conducting a telehealth appointment into the clinic, be sure to minimize noise outside the clinic room by ensuring that the room’s door is closed and a sign is posted on the door indicating that a telehealth visit is in session.

7.2.1. Groups

For group appointments, on a group’s initial or only call, the provider may want to begin by having the patients introduce themselves. This will help to provide identification and build rapport. The patients participating in the group session may also assist in building rapport with each other. Patients might not all be physically in the same location, but allowing for patient interaction can help improving group cohesiveness.

7.3. Telepresenting

Telepresenters are used for at-home and other non-VA, in-the-clinic, and in-the-hospital appointments. For visits in the home and other non-VA locations, Synchronous

Telehealth may require a telepresenter only for initiating the connection. Other

Synchronous Telehealth visits (in the clinic or the hospital) may require the telepresenter to remain in the room to act as the teleprovider’s “eyes,” “ears,” “hands,” and “nose.”

Some Synchronous Telehealth visits may require the telepresenter to use telehealth peripheral devices. For home-based primary care visits, telepresenters perform a unique function, assisting with the examination through VA Video Connect.

The Telehealth Service Agreement provides details on the skills and scope of practice needed for a telehealth visit, regardless of the location. Depending on the skills needed for the telehealth visit, the telepresenter may be a Telehealth Clinical Technician, a licensed practical nurse, a registered nurse, or a licensed independent provider.

https://vaww.infoshare.va.gov/sites/telehealth/docs/th-tsa-es.pdf

For more information, please consult the Telehealth Telepresenter intranet page.

https://vaww.telehealth.va.gov/roles/prsntr/index.asp

7.4. Camera Etiquette

The patient’s experience in Synchronous Telehealth visits must be similar to the experience they would have in an in-person visit. Practicing good “camera etiquette” helps accomplish this goal. Camera etiquette can be achieved for any synchronous visit, no matter the provider or patient location.

Camera etiquette includes:

• Maximizing the clarity of video and audio transmission.

• Speaking clearly; using a consistent, regular volume; and avoiding speaking when someone else is talking.

• Avoiding side conversations and minimizing any interrupting or whispering.

• Minimizing note passing, finger tapping, and other distracting behaviors.

The teleprovider should:

• Look at the camera and maintain eye contact with the patient.

• Review their image with the self-view feature.

• Adjust the room’s lighting, their seat height, and the camera angle to optimize how they will appear in the patient’s view.

• Offer an explanation when they need to look away from the camera (e.g., “Let me look at your records”).

• Use the pan, tilt, and zoom features when using a desktop codec or connecting to a telehealth cart.

• Use presentation mode to share materials with the patient.

The telepresenter should:

• Ensure that the teleprovider and the patient have unobstructed views.

• Use the pan, tilt, and zoom features to give the provider an optimal view of the patient during the examination.

• Keep the camera focused on the speaker or the material being presented.

7.5. Synchronous Telehealth Groups

Telehealth staff are responsible for ensuring the following:

• Appropriate lighting and seating to maintain good video quality.

• Reduction of noise in the group environment.

• Review of terms of engagement at the beginning of the visit.

Before a group visit begins, patients must agree to the Group Telehealth Agreement.

Before beginning group visits in any location, see the Synchronous Groups intranet page and the VA Video Connect Supplement.

8. After the Visit

After the telehealth visit, there are a few important steps that must be taken to ensure that the telehealth visit is closed out correctly.

8.1. Documentation (Capture of Workload)

Providers must document information to from Synchronous Telehealth patient visits.

8.1.1. Interfacility Documentation

A key step for the patient-site provider in documenting an interfacility Synchronous

Telehealth visit is to ensure that the distant-site provider writes the full progress note or report in the patient-side VistA.

A pointer note in the provider-site VistA can be used. An example of a pointer note is, “The telehealth encounter was conducted with [name of patient] at [location of encounter] on [date of encounter]. Please see the Joint Legacy Viewer for progress notes, clinical reminders, and patient orders.” Also, a full note can be written in the provider note.

8.1.2. Interfacility Consults

One way for a provider to write a note or report in the patient-site VistA is to link the note to the interfacility consult. Linking the note to the interfacility consult records the progress note or report in the patient-site CPRS.

8.1.3. WebVRAM

Web VistA Remote Access Management (WebVRAM) enables telehealth program and hub health care providers to access authorized CPRS and VistA accounts from all over the country through a single web portal. WebVRAM is useful for telehealth providers who (1) need access to a remote CPRS where they do not have direct CPRS or VistA access and (2) wish to use the same menu options and keys that are in their home VistA https://dvagov.sharepoint.com/sites/vha-telehealth/docs/vvc-grp-toe.pdf http://vaww.telehealth.va.gov/pgm/vvc/groups/index.asp https://vaots.blackboard.com/bbcswebdav/xid-711085_1 https://webvram.va.gov/ user profile. Typical uses for WebVRAM include ordering and signing labs, notes, image orders, and medications (aside from controlled substances) in a remote CPRS.

Telehealth program or Clinical Resource Hub directors may approve and disapprove user account setup requests to use WebVRAM and are responsible for determining which remote VistA stations a provider will be granted access to.

For more guidance, please refer to the WebVRAM Management intranet page.

8.1.4. Group Documentation

Group notes, a companion to CPRS’s Notes tab, assists providers in documenting group sessions.

8.2. Closing the Encounter

Closing the encounter is the final step of the visit. Even if everything else is done correctly, if this step is neglected, neither the patient site nor the provider site will receive workload credit. The patient site must close its encounter using the appropriate procedure code. Please note that the primary diagnosis code at the patient site and the provider site must match.

8.2.1. Closing the Provider Side

To close the encounter, follow these steps:

• If the diagnosis codes for the encounter are not prepopulated on the form, select the appropriate diagnosis codes from the encounter form or the patient problem list. The diagnosis for a telehealth encounter is the same diagnosis that would be used if the patient were in a physical office.

• Enter the procedure code, if applicable. This is the same procedure code that would be used if the patient were in the provider’s office.

• If displayed, select the Synchronous Telehealth modifier (95) from the box in the upper right of the form.

• In the “visit related to” section, answer the service-connected condition and any other pertinent or required questions.

• Digitally sign the note with the completed encounter form.

8.2.2. Closing the Patient Side

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

To close an interfacility into-the-clinic, into-the-home, or other non-VA encounter, follow these steps:

• In the “visit related to” section, answer the service-connected condition and any other pertinent or required questions.

• Select the appropriate diagnosis code that matches the diagnosis code from the provider side.

• If there is not yet a diagnosis code on the provider encounter form, work with the teleprovider to determine the code that is most like the code the provider might use (e.g., use “health maintenance” for a medical appointment).

• Enter Q3014 for the originating facility procedure code fee.

• Enter the provider as the primary provider if this is not autopopulated.

• Digitally sign the note with the completed encounter form.

For more information, please consult the Closing the Encounter presentation.

8.3. Workload Validation and Identification of Orphans

Synchronous Telehealth clinics are set up to receive workload credit. Sometimes, errors occur that result in the loss of this credit. Therefore, it is necessary to monitor the VHA

Support Service Center data cube in the Telehealth Dashboard and take any necessary action to resolve any “orphans.”

For Synchronous Telehealth visits in the clinic or the hospital, orphans may be created when the patient-side and the provider-side encounters do not match. Common reasons that encounters do not match are:

• Stop codes are not identical.

• Documentation is in a nontelehealth clinic.

• Encounter information is missing.

• A telehealth clinic was used to document a nontelehealth visit.

• More than one encounter or note was completed for a visit.

For more information about orphans, please refer to the Workload Troubleshooting and

Resolution Quick Guide and the Telehealth Dashboard in the VHA Support Service

Center capital assets databases.

9. Program Success Criteria

There are several ways to see how your Synchronous Telehealth program is doing.

https://vaots.blackboard.com/bbcswebdav/xid-52501_1 https://vssc.med.va.gov/VSSCMainApp/Defaultrsg.aspx https://vssc.med.va.gov/VSSCMainApp/Defaultrsg.aspx https://bioffice.pa.cdw.va.gov/default.aspx?bookid=d6941fb2-97e8-4634-aed5-e29cd00dc00e%7CispasFalse%7Creport53139be3-e0ca-4e54-ae1c-c392be47b6cd%7Cws4%7Cwsb0%7CisDisabledAnalyticsFalse%7CisDashboardPanelOnTrue https://vaww.infoshare.va.gov/sites/telehealth/docs/orp-trb-rsl.pdf https://vaww.infoshare.va.gov/sites/telehealth/docs/orp-trb-rsl.pdf https://bioffice.pa.cdw.va.gov/default.aspx?bookid=d6941fb2-97e8-4634-aed5-e29cd00dc00e%7CispasFalse%7Creport53139be3-e0ca-4e54-ae1c-c392be47b6cd%7Cws4%7Cwsb0%7CisDisabledAnalyticsFalse%7CisDashboardPanelOnTrue https://vssc.med.va.gov/VSSCMainApp/Defaultrsg.aspx https://vssc.med.va.gov/VSSCMainApp/Defaultrsg.aspx

For more information, please consult the Telehealth Manual.

10. Additional Resources

Additional resources can be found in the Telehealth Manual and on the Telehealth intranet site.

Appendix: Chief Consultants and Directors Endorsement of Synchronous Telehealth Manual

I have reviewed this Synchronous Telehealth Manual and approve of the content, guidance, and processes. I fully endorse the publishing of this supplement as a VHA standard guide for the implementation of Synchronous Telehealth.

Date:

Sara DeRycke

Asynchronous Telehealth Lead

Connected Care

Date:

Rhonda Johnston, Ph.D., BC-FNP, BC-ANP Director

Quality and Training Division https://vaots.blackboard.com/bbcswebdav/xid-510063_1 https://vaots.blackboard.com/bbcswebdav/xid-510063_1 http://vaww.telehealth.va.gov/ http://vaww.telehealth.va.gov/