D.26 VHA CLINIC BASED TELEHEALTH OPERATIONS 2.pdf

D.26 VHA CLINIC BASED TELEHEALTH OPERATIONS 2

36C25922R0102

1. Introduction to Asynchronous Store and

Forward Telehealth

Asynchronous Store and Forward Telehealth within the U.S. Department of Veterans Affairs is defined as the use of technologies to asynchronously acquire and store clinical information (e.g., data, image, sound, or video) that is then forwarded to or retrieved by a health care professional at another location for clinical evaluation. The Asynchronous Store and Forward Telehealth model of care in the VA uses a recognized or nationally approved clinical pathway utilizing

VistA imaging or other approved secure vendor data collection or imaging interface. Nationally standardized Asynchronous Store and Forward Telehealth programs also involve program-specific requirements that are identified in the telespecialty supplements.

This appendix to the Telehealth Operations Manual gives guidance on Asynchronous Store and

Forward Telehealth business, technical and clinical processes that are either in addition to or different from the guidance in the Connected Care Telehealth Manual. Additional resources can be found on the Asynchronous Telehealth intranet page. Program-specific requirements are found on the Specialty tab of the Veterans Health Administration Telehealth Services intranet site. (NOTE:This is an internal VA website that is not available to the public.)

2. Obtaining Program Approval

There are two levels of approval: one at the local level and one at the national level. Services can be locally approved telehealth programs or working toward nationally approved telehealth programs.

Local level approval, including notifying the Telehealth Advisory Board, is required to use

Asynchronous Store and Forward Telehealth. An Asynchronous Store and Forward Telehealth program that has local level approval assumes the responsibility and liability for 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 technology and equipment, identifying pathways, and creating of a specialty supplement that will be published on the VHA Telehealth Services intranet site.

National level approval is a more complex process. See the Enterprise-Wide Designation and

National Approval section for more information.

2.1. Local Level Approval

Once the Asynchronous Store and Forward Telehealth Business Plan/ Needs Assessment is completed, you will send the proposed local Asynchronous Telehealth programs to the facility http://vaww.telehealth.va.gov/ http://vaww.telehealth.va.gov/ https://vaots.blackboard.com/bbcswebdav/library/LibraryContent/Asynchronous/async_th_manual/asynchronous-manual.html#22-enterprisewide-designation-and-national-approval https://vaots.blackboard.com/bbcswebdav/library/LibraryContent/Asynchronous/async_th_manual/asynchronous-manual.html#22-enterprisewide-designation-and-national-approval and VISN Telehealth level for approval. This initial approval provides the program the ability to begin development in local facilities and is considered local level approval.

Once the facility and VISN have approved, an email notification will be sent by the VISN the

Telehealth Program Manager to the OCC Telehealth National Lead for Asynchronous Telehealth

(NOTE:This is an internal VA website that is not available to the public.) and the National

Telehealth Quality and Training. (NOTE:This is an internal VA website that is not available to the public). This email will qualify as notification of the new initiative and will be presented to the Telehealth Advisory Board (NOTE:This is an internal VA website that is not available to the public.) for awareness, tracked for follow-up, and reviewed for progress, data, and quality evaluation.

Use this form to send in the email Asynchronous New Program Email Notification Form.

This email will include:

1. Program Name.

2. Provide a short statement about the clinical purpose of the program.

3. Attached the Telehealth Business Plan/ Needs Assessment.

4. Stop codes used for workload capture.

5. Clinical pathway(s)-consult process in place (as possible).

6. What equipment is being used.

7. How the data/image/video is incorporated into the medical record.

8. Use of Telereader or other approved program.

9. Explain how they are managing the retained camera images/data security.

10. Metrics they are using to measure success.

Established local Asynchronous Telehealth programs will have VISN level approval. VISNs are encouraged to share new Asynchronous Telehealth services and best practices with others on

VISN Lead Council calls. The VISN Leads Council (NOTE:This is an internal VA website that is not available to the public.) will review new Asynchronous Telehealth programs during the

“new business” portion of scheduled calls.

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

After six months of new asynchronous services, the site will share the new initiative, if not already shared, on the VISN Leads Council call. The program will be reviewed to determine if national implementation and development are the best fit and sustainable or if a local level process is a better fit for the new initiative.

National Data will be reviewed by the Office of Connected Care/Telehealth Services and

National Office of Telehealth Services. Staff may reach out to local programs to verify what the

Asynchronous Telehealth credit stop codes are being used for and to request information on their local programs to evaluate whether the program is meeting the intent of new Asynchronous http://vaww.telehealth.va.gov/about/contact/index.asp#async http://vaww.telehealth.va.gov/about/contact/index.asp#qt http://vaww.telehealth.va.gov/about/contact/index.asp#qt https://dvagov.sharepoint.com/sites/VHA-Telehealth/gb/Home.aspx https://vaots.blackboard.com/bbcswebdav/xid-605341_1 https://dvagov.sharepoint.com/sites/VHA-Telehealth/gb/VISN%20Telehealth%20Leads%20Council.aspx

Telehealth and is in line with national quality measures and Conditions of Participation guidelines. (NOTE:This is an internal VA website that is not available to the public.) Local programs will provide documentation of standard operating procedures or policies upon request for new Asynchronous Telehealth programs as well as collaborate with the national level process described below, if deemed appropriate.

2.2. Enterprisewide Designation and National Approval

1. The national Knowledge Management team will identify a need for national standardized guidance, documentation, and training by any of the following avenues:

o Contact from VISNs or facilities with an Asynchronous Store and Forward Telehealth program plan through the Quality and Training email group, contact from the National Asynchronous Telehealth Lead (NOTE:This is an internal VA website that is not available to the public.), or information shared during the VISN Leads Council calls.

o VHA Support Service Center data indicating the use of Asynchronous Store and Forward Telehealth codes for new specialty clinics.

o Identified leadership and specialty office priorities or strategic planning.

o Conditions of Participation discussions and data.

2. The Knowledge Management team will then collaborate with representation from VISNs, facilities, stakeholders, and other objective subject matter experts to modify or develop

Office of Connected Care/Telehealth Services specialty supplements, with applicable implementation and operational guidance.

3. The Knowledge Management team will apply to the Telehealth Advisory Board’s

Technology Committee (NOTE:This is an internal VA website that is not available to the public.) for technology approval or grandfathering in the program, if not already obtained, and to determine future technology standardization. Future technology will be included in a Blanket Purchase Agreement, if not already present.

o Technology that is specific to a certain specialty (e.g., cardiac pacer monitors) should also be approved by the national specialty office.

4. The Knowledge Management team will collaborate with clinical provider and reader subject matter experts, Health Informatics Specialists, and Clinical Application

Coordinators to develop asynchronous consult guidance, as needed, and standardized consult templates, if necessary. In some cases, a consult template request must be submitted to the National Clinical Template Workgroup for national standardization of terms and rollout to the field for implementation.

5. After the program is vetted and shared through Quality and Training and VISN Leads and approved through the Telehealth Advisory Board, the Knowledge Management team will then publish the standardized supplement operations manual and announcements will be made to the field through the VHA Telehealth Services intranet site, (NOTE:This is an internal VA website that is not available to the public.) VISN Leads Council call, forums, emails, and so on.

6. Training, along with competency guidance, if needed, will be drafted by the Knowledge

Management team and finalized in collaboration with the Implementation and Quality teams.

http://vaww.telehealth.va.gov/quality/data/index.asp http://vaww.telehealth.va.gov/quality/data/index.asp mailto:VHA12CCCONNECTCAREACADEMY@va.gov http://vaww.telehealth.va.gov/about/contact/index.asp#async https://dvagov.sharepoint.com/sites/VHA-Telehealth/gb/Technology%20Committee.aspx https://dvagov.sharepoint.com/sites/VHA-Telehealth/gb/Technology%20Committee.aspx mailto:VHANationalClinicalTemplateWorkgroup@va.gov https://vaww.telehealth.va.gov/

7. The Knowledge Management team will make any additions needed to the Conditions of Participation standards, review process, and Virtual Care Scorecard to reflect the new program as appropriate. This may include the addition of criteria and evidence to the standards and data elements to the Virtual Care Scorecard.

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

9. Asynchronous services will be considered nationally approved when they are present in the specialty supplements on the VHA Telehealth Services intranet site. (NOTE:This is an internal VA website that is not available to the public.)

o Note that many services may be at varying stages of working through the process for being included in the national specialty supplements.

**Note that Asynchronous Telehealth programs and Asynchronous Telehealth workload credit are for new and novel uses of technology, and if it can replace the need for face-to-face care.

There are episodes of care that occur asynchronously and do not obtain telehealth credit. These include examples such as: radiology, X-rays, EKGs, and cardiac Holter monitors, as these may not be new/novel or able to replace a face-to-face visit. Contact the national lead for questions, and follow the notification processes above for new asynchronous services.

3. Credentialing and Privileging

3.1. Memorandum of Understanding

Establishing interfacility Asynchronous Store and Forward Telehealth services requires certain agreements to be in place. The first requirement is a memorandum of understanding (MOU).

This agreement determines resource sharing, including liability and Proxy Privileging. The

Memorandum of Understanding delineates authorized procedures in VHA. Refer to the

Connected Care Telehealth Manual and the Memorandum of Understanding for additional information.

An example of interfacility Asynchronous Store and Forward Telehealth services include:

• Specialty providers read study sent from another facility (VA Medical Center [VAMC] or community-based outpatient clinic belonging to other VAMC).

3.2. Telehealth Service Agreement

Telehealth Service Aagreements are needed for interfacility and intrafacility Asynchronous

Telehealth. A Telehealth Service Agreement includes point of care guidance, contacts, and procedures to effectively communicate to the entire Asynchronous Store and Forward Telehealth virtual team for every visit. The Telehealth Management Platform Supplement can provide information on how the process is managed and automated. Included in the Telehealth Service

Agreement are the specific clinic set-up and stop codes. The agreements provide contact https://vaww.telehealth.va.gov/ https://vaots.blackboard.com/bbcswebdav/xid-878815_1 https://vaots.blackboard.com/bbcswebdav/xid-510063_1 https://vaots.blackboard.com/bbcswebdav/xid-514616_1 information for the Clinical Application Coordinators and the Facility Telehealth Coordinators who are responsible for program administration.

4. Clinic Setup

Clinics serve as a mechanism for scheduling patients and connecting workload coding, charting, and other pertinent encounter information. Responsibility for establishing clinic setup varies by facility. See the Clinic Set-Up and Closing Same Site SFT Encounters guides for more information. See specialty supplements for information by specialty and modality.

Stop codes provide the standardization required to identify workload for all outpatient encounters, inpatient appointments in outpatient clinics, and inpatient professional services. A current list of stop codes can be found in the Clinic Set-Up document.

The most common Asynchronous Store and Forward Telehealth setup follows the guidance provided in the Clinic Set-Up document.

Copay information can be found on the Copay intranet site. (NOTE:This is an internal VA website that is not available to the public.) Copays can vary depending on the stop code and encounter information:

• There is no copay for the patient side asynchronous encounter in a clinic setup with a 694 credit stop code.

• It is of note that there is no copay for 718, TeleEye screening.

• It is of note that there is no copay for services paired with the credit stop code 189 for

Asynchronous Store and Forward Telehealth From Home with no VA staff involved.

• For Asynchronous Store and Forward Telehealth From Home with VA resources, such as an imager, follow the clinic-based pathways using 694 as a credit stop code on the patient side and clinic setup stop code 695/696 on the provider site.

• Discuss copay questions with your local business office staff, or reach out to the

Asynchronous Lead for more information, if your questions are not answered locally.

5. Clinical Pathways

5.1. Teleconsultation vs. Telemedicine

Teleconsultation is defined as the provision of advice on a diagnosis, prognosis, and/or therapy from a licensed independent provider to another licensed independent provider using electronic communications and information technology to support the care provided when distance separates the participants, and where hands-on care is delivered at the site of the patient by a licensed independent health care provider.

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Telehealth (telemedicine) is the use of electronic information or telecommunications technologies to support clinical health care, patient and professional health-related education, public health, or health administration at a distance.

Note that a crucial consideration in making a distinction between consultation and care is that teleconsultation occurs when the consultant involved recommends diagnoses, treatments, and so on to the consulting provider requesting the consult, but does not actually write orders or assume the care of the patient. If the consultant diagnoses, writes orders, or assumes care in any way, this constitutes “care” and requires privileges.

See VHA Directive 1232 – Consult Processes and Procedures and the Connected Care

Telehealth Manual for additional information on consults.

The Asynchronous Store and Forward Telehealth clinical pathways provide guidance for the field to understand the necessary steps to consider when developing Asynchronous Store and

Forward Telehealth programs. Please see the specialty services supplements and documents on the intranet site for Clinical Application Coordinators guides that exist for specific services.

5.2. One Consult Pathway

1. An initial consult is generated by the initiating provider and is sent to the technician to capture images/data.

2. The technician meets with the patient to capture the requested image/data.

3. The technician updates/forwards/alerts the consult to the specialist provider to read and provide a diagnosis or recommendations to the initiating provider. Note that this will not work for interfacility consults.

4. The specialist provider enters their analysis and recommendations into the patient record.

5. The specialist provider closes the consult.

6. The initiating provider is notified that the consult has been completed.

7. Naming conventions for a one consult process should indicate that consult is for the entire process, and not just for the imaging/data capture or just for the read.

Figure 1: 1 Consult Pathway Process https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3230

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5.3. Two Consult Pathway

1. An initial consult is generated by the initiating provider and is sent to the technician to capture data/images.

2. The technician meets with the patient to capture the requested image/data.

3. The technician closes the initial consult.

4. A second consult is generated by the technician and sent to the specialist provider to read and provide a diagnosis or recommendations to the initiating provider.

5. The specialist provider enters their analysis and recommendations into the patient record.

6. The specialist provider closes the second consult.

7. The initiating provider is notified that the second consult has been completed.

8. Naming conventions for the two consult pathway must be considered. Please see specialty supplements for any direction on naming conventions. For example, names should make logical sense, indicating the first consult is for the capturing of the image/data and upload, and the second consult is for the reading/interpretation of the image/data.

Figure 2: 2 Consult Pathway Process

CONSULT PAT

An initial consult is generated by the initiating provider and is sent to the technician to capture data/images.

CONSULT PAT

An initial consult is generated by the initiating provider and is sent to the technician to capture data/images.

5.4. Asynchronous Store and Forward Telehealth From

Home

Mobile apps are currently in the process of being developed and piloted for Asynchronous Store and Forward Telehealth. The My VA Images app is an example of a patient-facing app for

Asynchronous Store and Forward Telehealth to the home.

The Asynchronous Store and Forward Telehealth From Home clinical pathway (below) uses a web-based app for the patient to collect images or data. An exception is Asynchronous Store and

Forward Telehealth From Home that uses VA resources, such as an imager; these follow the

Two Consult Pathway.

1. After determining the need for Asynchronous Store and Forward Telehealth From Home, the specialist may order the use of a web-based app to collect the data/images for review by a specialist.

2. The data can be retrieved remotely by the provider. Ultimately the provider/specialist reads the data/information, documents findings, and treatment recommendations.

6. The Asynchronous Store and Forward

Telehealth Clinic Visit

VHA and the Telehealth Services are committed to providing a health care environment that supports respect for patients and protects their right to autonomous, informed participation in health care decisions. These essential elements of quality health care are noted below. They establish a process for informing patients about telehealth options and obtaining their consent prior to treatment.

Highlights include:

• Patient must be fully informed of the risks and benefits of telehealth services and procedures.

• Patient has the right to refuse telehealth services.

• Verbal consent is obtained from the patient by each clinical service prior to the initial telehealth appointment.

• In the event the telehealth session is part of a research study, written consent must also be obtained per VHA research guidelines. Refer to the VA Office of Research for more information.

6.1. Telepresenting

Telepresenting refers to the assistance of a remote clinician with a Veteran’s assessment using telehealth technology. Telepresenters also collect data and orient patients to the technology. They collect images and other data during the exam used to store and forward to specialists.

https://vaots.blackboard.com/bbcswebdav/library/LibraryContent/Asynchronous/async_th_manual/asynchronous-manual.html#53-two-consult-pathway

Depending on the skills and scope of practice needed for the telehealth encounter, telepresenting may be completed by a Licensed Independent Provider, Registered Nurse, Licensed Practical

Nurse, Telehealth Clinical Technician, or specialty certified technician such as an ophthalmic technician or audiology technician.

See the Connected Care Academy Telepresenting Community for more information.

6.2. Imaging

Imaging is the act of obtaining telehealth images, videos, or tests as part of an Asynchronous

Store and Forward Telehealth program. Examples include, but are not limited to, operating digital retinal and hand-held imaging systems to acquire nonsimultaneous stereoscopic images for retinal screening, and appropriate skin/lesion images for Dermatology. Similar to telepresenting, imaging may be completed by a wide range of clinicians and technicians, depending on the needs of the Asynchronous Store and Forward Telehealth service. See

Connected Care Academy for more information on imagers in the Dermatology and TeleEye

Care Specialties.

6.3. Staff Competencies

While telespecialites have specific competencies, all Asynchronous Store and Forward

Telehealth programs require the following technician and imager competencies:

• Captures clinical images or data of sufficient quality so that the specialist reader can make an accurate diagnosis and recommendation.

• Uses appropriate hygiene measures.

• Demonstrates images or data to the patient immediately following the imaging session, if possible and appropriate for the telespecialty.

• Deletes images and data from the device, software, and/or workstation.

• Takes appropriate quality assessment and quality improvement measures while the patient is in the examination room.

• Maintains equipment properly.

• The referring provider and the telepresenter must be constantly aware that they are the only intervention that takes place directly with the patient since the specialist reviewing the images or other data may not have contact with the patient until after the data/images are collected. The technician or imager can find or identify Veterans who meet screening/testing/clinical reminder requirements to assist the referring provider (e.g., by reviewing incoming patients that are due for a diabetic retinal screening). In other cases of Asynchronous Store and Forward Telehealth, the patients are referred by the primary care provider after review (e.g., TeleDermatology for teleconsultation). In telemedicine examples, a specialist may refer a patient to have an Asynchronous Store and Forward

Telehealth sleep study done, where the results come back to the same ordering provider for interpretation and that person provides the follow-up care.

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Asynchronous Store and Forward Telehealth staff training is available through VHA Telehealth

Services from the Office of Connected Care/Quality Management, Implementation, and

Development Division. VHA Telehealth Services provides training on business and technology as well as guidance to start a telehealth program. All the training is modular and developed for busy telehealth staff and providers.

To locate training for your specific telehealth role or specialty, go to the Asynchronous Store and

Forward Telehealth Training Plans by Role page.

1. Select Role and choose the correct role for your position.

2. Scroll down the page and locate the Training Plan.

3. Click on Begin the Training. This will bring you to your training plan and outlines which training applies to you.

A majority of telehealth training is located on the Training Management System (TMS). Open

TMS and place the course ID number into the search box. This will bring you to your training.

Some facilities and/or telehealth programs will assign training to your TMS My Learning

Assignments. Specialty supplements must also be consulted to determine required training. Some

Asynchronous Store and Forward Telehealth specialties will require, for certain roles, skills-based training provided by a Telehealth Preceptor.

6.4. Scheduling for Clinic-Based Asynchronous Store and

Forward Telehealth

Unlike traditional in-person/face-to-face encounters, Asynchronous Store and Forward

Telehealth encounters require other resources such as the following:

• Patient (VistA).

• Technology at the patient side.

• Telepresenter or imager.

• Please note that you never schedule the providers side read/interpretation/or appointment.

• For Asynchronous Telehealth, the data or image is read asynchronously; these are not scheduled. The provider enters a note and encounter in the proper provider side clinic to do their documentation. This includes selecting the day and time of that read or interpretation (sometimes referred to as an add/edit).

7. VA Telereader Software

The TeleReader app (or the Cerner Application for those sites that have transitioned) provides a worklist for local or remote imaging studies that are waiting to be read and interpreted.

Asynchronous Telehealth that involves reading of Asynchronous images are encouraged to use the TeleReader app. See the user manual for more information on the TeleReader app. Cerner manual will be added as available.

https://vaots.blackboard.com/bbcswebdav/xid-606594_1

8. Documentation

The creation of encounter forms, progress notes, and consult templates for Asynchronous Store and Forward Telehealth clinic visits is essential. Some guidelines include the following:

• Use template notes to improve clinical efficiency and serve as a guideline(s) for appropriate health information collection.

• Include the location title in encounter forms for all visits (e.g., TeleDermatology, TeleEye

Care, TeleCardiology) and include the appropriate telehealth encounter codes and modifiers.

• Close routine visits that are not consult-specific visits with a progress note (e.g., Surgical

Telehealth Progress Note, Primary Care Telehealth Progress Note).

• Include health factors that integrate with clinical reminders, pertinent physical exam information and numeric data and include any patient education completed in progress note templates.

• Appropriately document procedures, apart from image acquisition (e.g., testing visual acuity or pupil dilation). Provide safety warnings for pupil dilation to the patient.

Additional information may be found in the TeleEye Care Supplement.

• Use the consult template, which includes reasons for the specialty consult, diagnosis codes for specialty care, information regarding patient consent and/or patient suitability for Asynchronous Store and Forward Telehealth interactions and other necessary information.

• It is of note that the coding for Asynchronous Store and Forward Telehealth is typically different than the coding for face-to-face care. See specialty supplements for specific diagnosis codes and Current Procedural Terminology (CPT) codes for Asynchronous

Store and Forward Telehealth. For more information, speak to local coding Health

Information Management (HIMS) departments.

8.1. Interfacility Documentation

One of the key steps in documentation is to ensure the distant site provider writes a progress note/report and links it to the interfacility consult (IFC). The originating patient site will also have a record of the progress note/report in the Computerized Patient Record System (CPRS), without having to view the progress note under the “Remote View” option in CPRS.

This is created because the provider has access to the patient site VistA through the credentialing and privileging process, allowing the provider to document the visit, write orders, and manage the care of the Veteran.

“Pointer notes” are an option that meet the requirements for telehealth and are a completed note on the patient side that includes the clinical reminders, orders, and so on with a corresponding pointer note on the provider side. These may be referred to as a follow-up note as well in

TeleEye screening to satisfy clinic reminders with interfacility TeleEye screening.

This is an example of a pointer note on the provider side:

https://vaots.blackboard.com/bbcswebdav/xid-638211_1

“The telehealth encounter was conducted with Veteran Z (name of patient) at Patient’s medical center (location of encounter) on (date of encounter). Please see Joint Legacy Viewer for progress note, clinical reminders, and patient orders.”

8.2. Closing the Patient Side Encounter

Follow these steps to close the encounter on the patient side:

1. Under the “visit,” select the proper imager clinic for the service and answer the “service-connected condition” and any other pertinent or required questions. Selecting the primary care clinic will result in “orphans.”

2. Select the appropriate diagnosis code for the service. See the specialty supplement for the specific service for more information.

3. Select the appropriate CPT code for the action. See the specialty supplement for specifics.

4. Enter the imager for the patient side encounter as the primary provider, if not autopopulated.

5. Digitally sign the form.

8.3. Closing the Provider Side Encounter

The specialist consultant does not require a separate appointment to review patient data and make a recommendation and diagnosis. It is recommended that the provider side appointment never be scheduled.

To close an encounter on the provider side, follow these steps:

1. If the diagnosis codes are not prepopulated, select the appropriate diagnosis codes from the form.

2. Enter the procedure code. See specialty supplements for details. Confirm with local

HIMS if the CPT code guidance is not in each specialty supplement. Note that CPT codes for Asynchronous Store and Forward Telehealth are not the same as face-to-face CPT codes.

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

4. Digitally sign the form.

9. Workload Validation and Identification of

Orphans

As telehealth continues to expand, it is imperative to monitor, manage, and track proper coding to ensure that the full workload is received for patient visits. All Asynchronous Store and

Forward Telehealth visits consist of a match of a patient site and provider site encounter. Visits must have identical primary stop codes and a secondary stop code that reflects the use of telehealth technology. If there is only one encounter that does not fall into the Asynchronous

Store and Forward Telehealth business rules, this encounter will be labeled an “orphan.”

Workload validation is essential in maintaining telehealth clinics and should be monitored regularly. Common causes of Asynchronous Store and Forward Telehealth orphans include:

• The primary stop codes in both visits are not identical.

• Documentation was created in a nontelehealth clinic.

• Encounter information is missing from one of the encounters (e.g., service connection, diagnosis code, CPT code).

• Reads/interpretations do not occur within 30 business days.

• The Asynchronous Store and Forward Telehealth patient visit documentation was completed after the provider visit documentation.

• Asynchronous Store and Forward Telehealth documentation on the patient side was not done first.

• A telehealth clinic was used for a nontelehealth visit in error.

• Multiple encounters/notes were completed for one visit.

• A visit was erroneously marked as historical.

• A credit stop code is incorrect on the clinic setup.

Orphans can be reviewed on the VHA Support Service Center (VSSC) (NOTE:This is an internal VA website that is not available to the public.) data cube in the Telehealth Workload

Data Cube.

For information regarding Asynchronous Store and Forward Telehealth orphans, go to the

Telehealth Dashboard (NOTE:This is an internal VA website that is not available to the public.)

in the VSSC Capital Assets Databases.

See the Orphan Troubleshooting and Resolution Quick Guide for more troubleshooting guidance.

10. Image Deletion Protocols

Images and data must be deleted from any device used. Specific instructions for image deletion are provided in service-specific trainings, technology manuals, and supplements. General procedures are as follows:

For non-USB connected devices:

• Delete images after each patient visit after the images are successfully uploaded to the patient record.

• Ensure latent drives do not contain images.

• Ensure sites have a local point of contact from clinical engineering or technical support if software configuration changes are needed that require administrative permissions.

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• Sites are recommended to develop a local standard operating procedure for expectations if images do not successfully transfer.

For USB connected devices:

• Delete images from the camera, camera media, and local workstation/folder, as applicable.

• When applicable, format storage media (e.g., SD cards) after each patient, in addition to deleting images.

• Sites are recommended to develop a local standard operating procedure for expectations if images cannot be uploaded the same day and remain on the camera, SD card, or computer workstation.

11. Emergency Procedures

For Asynchronous Store and Forward Telehealth involving teleconsultation, the provider side is not scheduled and the provider does not meet with the patient. The patient interacts only with the technician who captures the images or data. It is recommended that the technician working with the Veteran be mindful that some Veterans may have claustrophobia (a fear of dark confined places), be fearful of being alone with one person in the room, or have poor tolerance of staff standing behind them out of view. Reviewing the record for history/comments on the consults is helpful for avoiding disruption in the appointment and discomfort for the Veteran.

For Asynchronous Store and Forward Telehealth involving telemedicine (e.g., technology-based eye care services), the provider may need to contact the patient with specific instructions, information, and recommendations tailored specifically to that encounter. It is recommended that the treating clinician at the patient site alert staff involved in the telehealth visit of any specific risks. For specific guidelines and/or recommendations for the safe and effective management of patients with severe immunosuppression, refer to the Centers for Disease Control and Prevention

(CDC) website and the local VAMC Infection Control Department.

It is recommended that all patients be managed with standard precaution. Standard precautions mean all patients are treated as if they have a transmissible bloodborne pathogen. Infection control procedures are followed and adhere to local policy. To ensure appropriate infection control guidelines are observed, refer to the local VAMC Infection Control Department and the

CDC website.

There may be a case when the imager finds an urgent issue to bring to the reader or primary care provider’s attention. The specialty-specific training will provide the technician with the information to identify when images are improperly done (e.g., when a TeleRetinal image looks incorrect). Follow local emergency protocols and the Telehealth Service Agreement for the specific service if the technician needs to notify a reader or the ordering provider about an issue.

If there is an emergency during the patient side imaging appointment, follow local emergency procedures for the site or facility.

http://www.cdc.gov/ http://www.cdc.gov/ http://www.cdc.gov/

12. Quality Management

Please refer to the Connected Care Telehealth Manual for full Quality Management guidance and the Conditions of Participation.

12.1. Asynchronous Store and Forward Telehealth

Benchmarks

12.1.1. Timeliness of Reads

The time to read an image/data for Asynchronous Telehealth is measured at three, seven, and 30 business days from the date of the patient side encounter entry to the date of the provider side encounter entry.

The benchmark for reads/interpretation of Asynchronous Telehealth is seven business days or less. The seven-day benchmark is the goal. The three-day benchmark is an optimal benchmark.

Asynchronous Telehealth images must be read within 30 business days. Telehealth encounters will match up to 30 business days. If images/data are not read or interpreted within 30 business days, they are forever unmatched or forever an orphan.

If an image was read in less than 30 days and there was an administrative error of documenting in the wrong clinic, discuss this with your local HIMS department to potentially work on having the encounter entered or moved to the correct clinic location. Encourage providers to use caution and always select the correct telehealth clinic location. Additional trainings for Facility

Telehealth Coordinators can be found on their training plan.

12.1.2. Image Quality

For those Asynchronous Store and Forward Telehealth programs that transfer images, the image quality health factors should be used in the reader’s template for the interpretation. These health factors should indicate if the image was adequate or inadequate for interpretation. The provider chooses the correct health factor to rate the image quality, and this data is tracked. See the specialty supplements for links to user guides on completing templates with health factors, along with information on monitoring image quality.

13. Laws, Regulations, and VHA Policies

All care delivered through telehealth must adhere to federal laws and regulations and national

VHA policy. Federal laws and regulations and national policies pertinent to telehealth can be reviewed in links listed on the Connected Care Telehealth Manual. Specific asynchronous links can be found here:

• The Use of Unlicensed Assistive Personnel UAP in Administering Medication https://vaots.blackboard.com/bbcswebdav/xid-705914_1

14.Additional Resources

Additional resources are as follows:

• TeleEyeCare Reader Training Plan

• TeleEyeCare Imager Training Plan

• Dermatology Reader Training Plan

• Dermatology Imager Training Plan

Appendix A: Chief Consultants and Directors

Endorsement of Asynchronous Store and

Forward Telehealth Manual

I have reviewed this Asynchronous Store and Forward Telehealth Manual and approve of the content, guidance, and processes. I fully endorse the publishing of this Supplement as a VHA standard guide for implementation of Asynchronous Store and Forward 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-1056866_1 https://vaots.blackboard.com/bbcswebdav/xid-1056867_1 https://vaots.blackboard.com/bbcswebdav/xid-878063_1 https://vaots.blackboard.com/bbcswebdav/xid-878058_1