D.10 FACILITY TELEHEALTH CLINICAL.docx

D.10 ATTACHMENT 36C25622R0004 FACILITY TELEHEALTH CLINICAL

DEPARTMENT OF VETERANS AFFAIRS

VETERANS HEALTH ADMINISTRATION

G.V. (Sonny) MONTGOMERY VA MEDICAL CENTER Medical Center Policy Number: F-11PC-79 January 20, 2017

FACILITY TELEHEALTH CLINICAL, BUSINESS, AND TECHNICAL OPERATIONS POLICY

I. PURPOSE: To establish safe and effective clinical, business and technical guidelines for Clinical Video Telehealth (CVT) and Store and Forward (S&F) services. Application of telehealth technologies will:

A. Increase access to healthcare, including primary care, specialist consultations and patient education;

B. Improve continuity and coordination of care, across the continuum of care;

C. Reduce wait times for access and treatment;

D. Provide alternatives to long-term institutional care.

Home telehealth (HT) and Store and Forward (S&F) services are covered in detail in separate policies and/or standard operating procedures (SOP) documents.

II. POLICY: The goal of all telehealth modalities is to provide safe and effective health care through increased access to services to all Veterans including those in remote areas and to provide education, medical and/or specialized services not available on site.

III. DEFINITIONS:

A. Telehealth Technologies: Information technology-based tools that collect clinical indices in the form of vital signs, disease management data, still images and live video from an originating site where the Veteran is located. These data are sent via secure telecommunications networks to a remote site where they are received, reviewed and assessed by clinicians. Telehealth technologies enable a range of healthcare services to be provided that cross the usual constraining boundaries of geographic distance, time, and social and/or cultural borders.

B. Clinical Video Telehealth (CVT): Use of real-time interactive video conferencing, sometimes with supportive peripheral technologies, to assess, treat, and provide care to a Veteran remotely.

C. Store and Forward Telehealth (SFT): Use of technologies to acquire and store clinical information (e.g. data, image, sound and video) that is then forwarded to or retrieved by a provider at another location for clinical evaluation.

D. Home Telehealth (HT): Use of electronic communication devices to assist in the delivery of health care services to the Veteran’s residence.

E. Memorandum of Understanding (MOUs): Agreement between participating facilities, defining the expectations of both the providing facility and the receiving facility, with regard to credentialing and privileging of providers.

F. Credentialing and Privileging for Telehealth services: Unless telehealth services are provided by VHA practitioners beyond their own VHA health care system (e.g., regional or national specialty referrals, Vet Centers, homeless shelters) there are no special or additional credentialing and privileging considerations for telehealth practitioners. However, where VHA telehealth services are provided by VHA practitioners beyond their own VHA health care system (e.g., regional or national specialty referrals, Vet Centers, homeless shelters) there are additional credentialing and privileging considerations due to the unique circumstances around linking two or more sites for telehealth services. If a provider is delivering services to a different VA station or to a non-VA site, they MUST be credentialed and privileged at both sites or both sites must agree in an MOU to abide by the credentialing and privileging of one designated station, while complying with VA and the Joint Commission regulation, including exchange of information and quality monitoring. In any circumstance where a provider is delivering care to a different VA station or non-VA site, the local credentialing and privileging office must determine the appropriate course of action at each site.

G. Teleconsulting: Typically a one-time visit whereby the distant consultant recommends diagnosis and treatments to the proximate provider requesting the consult, but the "consultant" does not assume care of the Veterans nor write orders. The proximate treating clinician maintains ultimate responsibility of the Veteran rather than the distant consulting clinician. The practitioner providing only teleconsultation services must be appointed, credentialed, and privileged at the site at which the practitioner is physically located when providing teleconsultation services.

H. Telemedicine: Provision of care by a licensed independent health care provider that directs, diagnoses, or otherwise provides clinical treatment delivered using electronic communications and information technology when distance separates the provider and the Veteran.

I. Telehealth Service Agreement (TSA): Agreement between two or more clinical endpoints that specifies and governs the clinical, business, and technical details of operations of the telehealth services between receiving and providing facilities and/or community based outpatient clinics. The agreements may exist within one facility or between two or more facilities. They are developed by consensus; signed by service chiefs from involved services; reviewed or updated as changes are needed. The Telehealth Service Agreement outlines:

1. Roles and responsibilities of all participants;

2. Specific clinical, business, and technical operating procedures;

3. Adequate resources, including staffing, space, equipment, and connectivity which are identified/established at all sites.

J. Conditions of Participation (COPS): Reflect program processes (clinical, business, and technical) that are essential to the safe and effective provision of care. These standards are required for all telehealth programs operating within VHA.

K. Orphans: Can occur when a CVT or S&F visit has only a Veteran note or provider note; or if the wrong clinic is selected; or if clinics are not coded correctly. CVT and S&F encounters require both Veteran and provider notes for the visit in order to count towards the performance measure.

L. CODEC: Short for Coder-Decoder and is the heart of the Video TeleConferencing (VTC) system. It compresses the two-way audio and video streams so that they can be sent over the communications link and decrease bandwidth usage. The CODEC also provides the means to connect all devices used in a video teleconferencing system, such as cameras, microphones, and other system components.

M. Bandwidth: Ability to carry and transmit data from endpoint to endpoint. Bandwidth is important in CVT encounters because every facility has limited bandwidth. OI&T are the contacts for bandwidth questions.

N. Central Enterprise Video Network (CEVN): Provides telecommunications capability and clinical videoconferencing technologies for telehealth that are interoperable in a manner that is secure, reliable, of sufficient quality, cost-effective and readily, usable by staff.

O. Synchronous Telehealth: “Real time” provider and Veteran encounters. These encounters count as a face to face visit. A Veteran, who is required to pay co-pays for medical care, will be required to pay the co-pay for this type of telehealth visit.

P. Asynchronous Telehealth: Occurs when data or pictures are uploaded into a Veteran’s chart for review by a Provider at a later time.

Q. Distant Site (DS) /Remote/”Provider Site”/”Provider Side”: Location of the health care provider in a telehealth setting. This term may be applied to the facility/health care system from which a provider delivers care or a telehealth endpoint from which a provider delivers care; may be within the boundaries of one facility or health care system or cross facility/health care system boundaries as defined by VISTA/CPRS record system access.

R. Local/Originating Site (OS)/”Patient Site”/”Patient Side”: Location of the Veteran in a telehealth setting--the term may be applied to the facility/health care system at which the Veteran receives primary care or a telehealth endpoint at which a Veteran receives care.

S. The Facility Telehealth Coordinator (FTC): Develops, refines, implements, and evaluates a comprehensive strategic plan for the telehealth program in the facility. The FTC promotes program growth and integration of all telehealth modalities in the facility.

T. The Telehealth Clinical Technician (TCT): VA staff member that facilitates direct veteran care activities, employing one or more telehealth modalities (CVT, SF), operating within one or more of the TCT roles. The TCT manages clinical telehealth encounters across all telehealth modalities. The TCT has three major roles: the telepresenter, scheduler and the imager.

1. Telepresenter Role: The telepresenter role falls, by default, to the Veteran site TCT. If the nature of the clinical visit requires a wider scope of practice or another discipline (e.g. RN), this need is specified in advance in the Telehealth Service Agreement, as completed by the participating clinicians at the time the service is implemented.

2. Scheduler Role: The TCT is responsible for scheduling the CVT sessions, except Tele-Mental Health sessions/encounters

3. Imager Role:

(a). The imager has the skills to capture the image of a portion of a Veteran’s anatomy for purposes of Veteran care, enter the image into VISTA imaging, and alert a provider that will read/assess the image at a later time. This individual has been educated in the special skills necessary to the image capture, storage, and forwarding to the provider. The imager follows national guidelines and is responsible for the quality of the image captured and provided to the clinician reviewer.

(b). The imager also uses the VISTA system to check the Veteran in upon arrival and out at the conclusion of the visit, and documents their part of the visit activity in CPRS. The imager role falls, by default, to the patient-site Telehealth Clinical Technician. If the nature of the clinical visit requires a wider scope of practice or another discipline (e.g. RN), this need is specified in advance in the Telehealth Service Agreement, as completed by the participating clinicians at the time the service is implemented.

U. Program Support Assistant (PSA): Assists the TCT with scheduling and coordinating telehealth services of inpatients and outpatients to/from VISN to VISN, facility to facility, CBOC to CBOC, etc.

V. A Stationary Desk Top (e.g. EX90) Unit: Used for CVT encounters with the camera and codec built in. The EX90 is about the size of a desktop computer.

W. The Clinical (Total Exam) Cart: Cart with peripherals such as stethoscopes, otoscopes, cameras, ultrasound, and others designed to allow a clinician to examine a Veteran at a far site with staff to facilitate the exam on the (Veteran) ‘patient end’.

X. Consulting Provider: The provider who completes the request for telehealth activity; used interchangeably with remote, distant, or “provider side” provider. The provider is responsible for closing both (Veteran) ‘patient side’ and ‘provider side’ encounters.

Y. Referring Provider: The provider who initiates the request for telehealth activity; used interchangeably with “patient side” provider and “local provider”.

Z. Reader: In Store-and-Forward telehealth applications, the reader (typically a licensed independent practitioner) is located at a site distant to the Veteran and is responsible for viewing and interpreting digital images acquired by the Imager at the ‘patient/originating site’ and responding to those telehealth consult requests within three (3) business days.

AA. Interfacility Consult (IFC): A request generated within the CPRS system for care, usually specialty care, to be delivered by a provider who is privileged to practice at a different facility or health care system within the VA healthcare system. The consult request and the subsequent results of the request “travel” across facility VISTA/CPRS record system boundaries.

BB. Local Consult: A request generated within the CPRS system for care, usually specialty care, to be delivered by a provider who is privileged to practice at the facility or health care system at which the Veteran receives his/her primary care. The consult request and the subsequent results of the request remain with the facility VISTA/CPRS record system boundaries.

CC. Jabber (formerly MOVI): A software program designed to allow CVT encounter by the addition of a webcam to a desktop computer. Jabber software utilizes excessive bandwidth and the bandwidth use cannot be tracked. Veterans using Jabber to home must have high speed internet access and their own webcam.

IV. RESPONSIBILITIES:

A. Facility Telehealth Committee:

1. Provide guidance and coordinate local telehealth programming for all three telehealth modalities: CVT, S&F, and HT;

2. Assist with completed needs assessments regarding implementation and sustainment of a successful CVT and/or S&F program;

3. Serve in an advisory capacity;

4. Ensure telehealth services are integrated throughout the facility;

5. Evaluate facility needs regarding telehealth services;

6. Track growth and data; and

7. Evaluate performance measure criteria.

B. Associate Chief of Staff/Primary Care:

1. Has overall responsibility of all clinical services provided through the Telehealth program;

2. In conjunction with the Medical Center Director and the Chief of Staff, will insure all clinical staff providing telemedicine comply with applicable credentialing and/or privileging requirements, licensure requirements, practice within Scope of Practice or Collaborative Practice Agreement, maintain educational requirements, and maintain documentation of core competencies;

3. Provide oversight for the implementation and operation of all Telehealth programs developed in the facility.

C. Facility Telehealth Coordinator:

1. Supports the overall planning, development, implementation, management, and evaluation of the facility telehealth program under the direction of the Associate Chief of Staff/Primary Care and works collaboratively with internal and external stakeholders;

2. Works with clinical and administrative leadership and strategic planning to align telehealth program planning with facility needs and priorities to ensure goals and priorities are complementary and in congruence with the overall facility and VISN strategic plan;

3. Is knowledgeable of facility, VISN telehealth and national performance measures, growth targets, funding sources and methodologies, and works with all involved to ensure monitoring is in place to meet assigned goals and monitor appropriate obligation of funds;

4. Conducts/assists with needs assessments, as necessary, as well as ongoing planning to continually identify new opportunities to expand and/or enhance existing telehealth program capabilities in conjunction with Veteran and facility needs. With particular emphasis on improving access to underserved populations including Veterans identified as “rural” and “highly rural;”

5. Serves as a consultant to the various clinical, administrative, and technical staff to assure support for the development of new telehealth modalities that meet Veteran/program needs and are compliant with local and national standards and expectations;

6. Ensures that telehealth programs establish and utilize appropriate VHA coding, workload reporting and data management systems and works with VISN telehealth lead, business manager and/or appropriate staff to set up systems for appropriate workload tracking and reporting;

7. Develops knowledge and expertise in the retrieval and analysis of telehealth related data from the various local, VISN, and VHA date sources;

8. Maintains a regular system of data validation and assures a mechanism for review of data accuracy

9. Collaborates with OI&T (Office of Information Technology), PC ADPAC, and biomedical engineering to ensure adequate local information systems technology infrastructure, bandwidth and technical support are in place to fully maintain the telehealth programs and ensure smooth and efficient Veteran encounters among all network telehealth sites;

10. Collaborates to ensure that clinical pathways, templates and DICOM and VistA configurations at Veteran and provider sites are appropriately established for each imaging consult when required for clinical pathways;

11. Collaborates to ensure that responsible individuals are designated at each patient site to coordinate equipment, space, scheduling, workload capture, and veteran management;

12. Ensures a systematic telehealth technologies inventory and equipment tracking process is in place and assists with equipment management/ procurement;

13. Develops an in-depth knowledge of Office of Telehealth Services (OTS) Conditions of Participations and ensures that the facility telehealth programs are compliant with these;

14. Ensures that TCTs complete training and maintain competencies;

15. Serves as the Chairperson of the Facility Telehealth Committee.

D. Telehealth Clinical Technician:

1. Ensures proper equipment is available/functioning for telehealth encounters;

2. Educates staff and Veterans regarding telehealth services and processes;

3. Troubleshoots equipment at the Veteran/technical level;

4. Basic maintenance of telehealth equipment;

5. Cleans telehealth equipment between Veterans per policy and manufacturer’s guidelines;

6. Collaborates with FTC and facility staff regarding equipment and technology needs for telehealth;

7. Facilitates Veteran’s encounters-both individual and group;

8. Trains existing staff regarding telehealth processes as needed;

9. Facilitates the scheduling process; Schedules CVT appointments and CVT rooms for use;

10. Collaborates with FTC regarding problem solving, process issues, data collection and/or other logistical issues;

11. Administers Veteran/provider satisfaction surveys;

12. Facilitates management of clinical pathway from consult to encounter closure;

13. Assists with clinical reminders;

14. Serves as a resource person regarding telehealth to facility staff.

E. Program Support Assistant (PSA):

1. Assists the TCT with scheduling and coordinating telehealth services of inpatients and outpatients to/from VISN to VISN, facility to facility, CBOC to CBOC, etc.;

2. Reviews each telehealth encounter planned for needed resources (e.g. video conferencing, clinical peripherals, tele-presenter, scheduling, medical equipment, telehealth environment) to ensure resources are appropriate and meet safety requirements for the Veteran telehealth encounter;

3. Maintains daily telehealth schedule to assist in scheduling rooms, Veterans, technology, and tele-presenters;

4. Assists the FTC as needed to ensure program development and compliance with local and VISN standards and expectations.

F. Service Chiefs:

1. Tracks the CVT training needs and competencies for providers and staff;

2. Ensures that all telehealth programs in their service meet the Conditions Of Participation (COP) -e.g. MOUs, Virtual Care Service Agreements (VCSA), clinic set up and scheduling, performance improvement, emergency and contingency plans are in place for every telehealth program.

G. Clinical Champions:

1. Program development and support;

2. Marketing and outreach.

H. Facility Planner: Must submit all facility space requests to the Resource Executive Board (REB) for approval.

I. Providers:

1. Follows all applicable policies and procedures, regulatory and clinical standards while providing Telehealth services;

2. Communicates the need for special peripherals or room arrangements to CVT staff prior to the Telehealth session;

3. Ensures the comfort and safety of Veteran;

4. Ensures the privacy and confidentiality of the veteran while providing telehealth services;

5. Implements a “read back” process to verify orders transmitted via telehealth system;

6. Determines if interactive video is an appropriate means for providing the services required;

7. Responsible for closing both (Veteran) “patient-side” and “provider-side” encounters at the conclusion of the CVT visit;

8. Determines if the connection is of sufficient quality to diagnose, evaluate, or treat the Veteran appropriately;

9. Determines if the connection is of sufficient quality to adequately convey necessary information to the Veteran and/or referring health care provider;

10. Development of application specific protocols is the responsibility of Jackson VAMC departments and/or provider utilizing telehealth technologies;

11. Documents telehealth encounters and process the resulting records in accordance with Jackson VAMC policies, CVT guidelines, and standard clinic practices;

12. Responsible for follow up on the CVT consultant’s recommendations as appropriate.

V. PROCEDURES:

A. Quality Management:

1. Performance Improvement:

The Conditions of Participation require that each facility identify and monitor quality and performance indicators for all telehealth programs. Indicators may be related to clinical, business, or technology areas pertaining to telehealth including aspects of utilization, access, clinical outcomes, cost, quality of life, Veteran satisfaction, functional status or provider satisfaction. Whenever possible, indicators should be collected from data that is electronically available for reviewing and tracking.

2. Data and Performance Measures:

Data is collected from the Veteran, providers, staff workload, program performance and outcomes data. Quality indicators should be set with the purpose of monitoring and measuring performance and efficiency of telehealth practices.

B. Environment for CVT Encounters: Creating the clinical environment and using appropriate communication skills when utilizing telehealth is critical to a successful and safe encounter. Care must be taken to ensure that services are provided in an environment that can guarantee the safety, privacy and confidentiality of the Veteran. All provider-to-Veteran tele-consultations should be considered equivalent to a face-to-face 9 office visit and should therefore follow the same clinic procedures that are in place for face-to-face consultations.

C. CVT Etiquette:

1. Equipment images and audio must be clear;

2. It is essential that the Veteran sees the clinician consistently throughout the visit;

3. The Clinician needs to be able to visualize the Veteran’s face. Therefore, the Veteran should be asked to remove his hat or reposition the hat to allow the provider to visualize face;

4. The clinician should appear to be making eye contact with the Veteran. For example, computer monitors should be placed to the side for optimal Veteran viewing during the contact;

5. Speak naturally and clearly; don’t shout, use a normal speaking voice;

6. Be prepared;

7. Be camera conscious, keep the camera on the speaker and/or material presented;

8. Introduce all conference participants, and all staff in the room;

9. In a group conference speaking one at a time ensures understanding. The microphone should face toward the speaker;

10. Avoid distracting behavior such as side conversations and note passing, interrupting the speaker, finger tapping, paper shuffling, and whispering as the camera is sound activated.

D. Space:

1. Standard requirements for all clinical spaces such as an adequate space for special needs Veterans and/or employees to navigate using wheelchairs must be re-assessed with the addition of telehealth equipment to ensure it still meets accessibility standards;

2. For gender-specific procedures and examinations, clinics need to ensure that the clinical environment and spacing of the examination rooms, equipment, and female chaperones are considered (See VHA Handbook 1330.01 Health Care Services for Women Veterans);

3. Clinical video telehealth space for groups is dependent on the size of the group and the clinical application. Technology can include: document cameras, presenter software, interactive whiteboards, projectors, and large monitors.

E. Infection Control: All telehealth equipment should be cleaned according to manufacturer and facility guidelines for reusable, non-critical medical equipment. Refer to TH equipment cleaning standard operational procedure (SOP) for details.

F. Scheduling and Clinical Pathways: Scheduling has been identified as the single most powerful predictor of success in Clinical Video Telehealth. Scheduling management:

1. The scheduling system for visits should not differ from the system already in place for in-person visits in terms of telephone access number, personnel, etc. The facility TCTs or the PSA will be contacted to coordinate scheduling of CVT encounters and rooms at both the medical center and the CBOCs (excluding CVT sessions for Tele-Mental Health). Scheduling real-time telehealth clinics involves numerous resources:

(a). The Veteran (VistA);

(b). The provider (VistA);

(c). Female chaperones for gender-specific examinations and procedures;

(d). Rooms on both sides;

(e). Technology on both sides;

(f). Bandwidth;

(g).Telepresenter (if required); and (h). Identification of level of staff required for presentation- TCT, RN, etc;

G. Clinical Pathway: The Conditions of Participation require all telehealth programs to utilize a clinical pathway that includes registration of Veterans on remote Vista systems, scheduling, coding, consults, workload capture and documentation of care.

H. Clinical Protocols: Telehealth clinical protocol processes identify the variations in clinical practice when providing care with the use of telehealth technologies. Once identified, solutions to variations are recommended by the clinician panel of experts for the telehealth service; a technology algorithm is the developed and the necessary skills for the telehealth clinical technician and/or telepresenter identified.

1. Provider educates Veterans as to the expectation(s) of the telehealth services;

2. The ultimate responsibility for the Veteran and action taken as the result of the telehealth consultation remains with the referring provider at the originating site.

I. Clinical Video Telehealth Documentation and consent: The creation of encounter forms, progress notes and consult templates for telehealth clinic visits is essential.

1. Documentation:

(a). Encounter forms will include the location title for all visits (e.g. dermatology telehealth, surgery telehealth, SCI telehealth, TBI telehealth, etc.) and must have the appropriate telehealth encounter codes and modifiers;

(b). Routine visits that are not consult-specific visits will be closed with a progress note (e.g. surgical telehealth progress note, primary care telehealth progress note, etc); all services without specific telehealth note templates must ensure that “CVT visit” or “Telehealth visit” is indicated in the progress note for all Telehealth encounter notes;

(c). The consult template includes reasons for the specialty consult, location for the CVT visit, information regarding Veteran consent and/or Veteran suitability for telehealth interactions and other necessary information and diagnostics required for the specialist;

(d). Clinic-based teleconsultation or routine medical follow up encounter (Clinical Video Telehealth and Store and Forward) are either requested by remote facility providers using interfacility consults (IFC) or scheduled by the hub site providers as a part of an ongoing provider/Veteran medical care plan;

(e). IFCs will be closed with a consult report title consistent with specific types of service provided and standardize naming conventions;

(f). It is important to distinguish between “teleconsult” vs. “telemed”/ “CVT” in the clinic and/or hospital location title;

(g). The CPRS Clinical Applications Coordinator (CAC) will set up the IFCs.

2. Consent:

(a). The Veteran must be fully informed of the risks and benefits of telehealth services and procedures;

(b). Provider obtains verbal consent for telehealth services prior to the initiation of the telehealth clinic and documents consent in the chart;

(c). The Veteran has the right to refuse telehealth services;

(d). Verbal informed consent for telehealth services need only to be obtained at the commencement of the first treatment and/or care program and is not required for each individual telehealth session;

(e). If permanent video or photographic recording is used during the telehealth session then VA form 10-3203, Consent for Use of a Picture or Voice, must be used and written consent obtained from the Veteran;

(f). In the event that the telehealth session is part of a research study, then written consent must also be obtained per VHA research guidelines;

(g). Veterans who pay co-pays for face-to-face visits should be informed the co-pay will probably be required for a CVT visit.

J. Workload capture and data management

1. It is critical that all activity for telehealth be coded correctly in order to monitor clinical activity and to undertake routine outcome measurements that ensure clinical quality;

2. The Veteran side and provider side of the encounter must have the same primary code;

3. The secondary credit stop for clinic based telehealth is determined by the location of the Veteran and the provider, and indicates a clinical video telehealth or store and forward telehealth encounter;

4. Clinical Video Telehealth cannot be coded as Store and Forward Telehealth and vice versa; 5. For CVT, the provider should code and close both the provider and the Veteran end encounters to ensure both notes occur on the same day and have the same primary code to prevent orphans;

6. Specific clinic locations/titles need to be set up prior to the implementation of any telehealth visits;

7. Staff at both the ‘provider side’ and ‘patient side’ of the encounters needs to be informed of the correct clinic location/title to use to ensure appropriate workload capture and avoid “orphans”.

K. Billing and Co-pays: All telehealth clinical video telehealth visits are billable to the third party insurance but there are differences from state-to-state. Co-pays for Veterans are appropriate and are coordinated with MAS Service. (for details see VHA Directive 2011-022).

L. Equipment Management: Telehealth equipment and technical support requires collaboration between the Telehealth program, Biomedical Engineering Departments and the Office of Information & Technology (OI&T).

1. Central Enterprise Video Network: All CVT equipment is registered with the Clinical Enterprise Videoconferencing Network (CEVN) by OI&T to track usage, warranty, and replacement;

2. Troubleshooting Pathways and Infrastructure: A technical support pathway ensures that adequate planning and technical supports are in place and available in the event technical difficulties occur while conducting telehealth encounters. Since Clinical Video Telehealth is a synchronous event, most problems will require immediate action from technical support staff in order to avoid interruptions or cancellations of the encounter. The facilitator initiates trouble-shooting process when technology issues occur. (Refer to Telehealth Emergency/Contingency Plan Policy for details).

M. Technology Procurement/Purchasing: After determining existing telehealth and administrative equipment is fully utilized, a list should be developed for all necessary technical equipment and peripheral devices needed for the telehealth program, with the following guidelines:

1. Identify the correct funding appropriation, (IT vs. Medical Services), which can be used to purchase telehealth equipment;

2. Use the national Blanket Purchase Agreement (BPA) for purchasing equipment to eliminate delays in the purchasing process;

3. All CVT systems must have the following components:

(a). Hardware:

1. Input devices to capture sound and pictures (cameras and microphones);

2. Output devices to generate sounds and pictures (monitors and speakers);

3. Peripheral equipment, if appropriate;

4. Transmission media to carry the audio and video signals.

(b) Software:

1. Capable of high level computing functions;

2. To convert signals from analog to digital;

3. To filter noise and clean-up both audio and video signals;

4. To code and decode data (CODEC);and

5. To synchronize audio and video components.

N. Veteran Education:

1. Veteran and Caregiver. Veterans should be oriented to the telehealth program environment and understand their rights, responsibilities and telehealth policies. The orientation and education touches on each of the following areas:

(a). Access: by providing a telehealth endpoint closer to where the Veteran lives, there is greater access to specialty care;

(b). Quality: studies measuring quality of telehealth compared to inpatient visits indicate no significant perception of difference;

(c).Veteran Satisfaction: surveys gathered after each telehealth encounter show a high level of satisfaction, particularly as it relates to cost and improved access.

O. Staff Competencies:

1. The competency of the staff refers not only to their usual clinical positions, but also to a level competence in applying those skills in a telehealth setting;

2. A minimum level of technical competence must be achieved by all staff;

3. The technical competence of the TCT staff must also be extended to meet the operational and maintenance requirements of videoconferencing technologies, telehealth peripheral equipment, and accompanying connectivity requirements;

4. Telehealth Training Centers:

(a). The Sunshine Training Center provides education and training for Home Telehealth (HT). Home Telehealth (HT) training requirements are covered in the HT program policy. The training algorithm supplied by the Office of Telehealth Services is followed to meet training requirements for HT.

(b). The Rocky Mountain Telehealth Training Center (RMTTC) provides training for CVT;

(c). Boston Telehealth Training Center (BTTC) provides training and consultation for Store and Forward programs.

(d). Clinical Video Telehealth Training Requirements for providers and clinicians:

The required courses are available in TMS and are revised as needed by the Office of Telehealth Services. Additional optional CVT training courses are available in TMS. 1. The courses are available on the following link: http://vaww.infoshare.va.gov/sites/telehealth/cvtntc/docs/cc-trng-ovrvw.docx

2. TCT education and training requirements are located in TMS and are revised by the Office of Telehealth Services as warranted; http://vaww.infoshare.va.gov/sites/telehealth/cvtntc/docs/tct-trng-ovrvw.docx

3. PSA education and training requirements for scheduling are located on the VISN 16 SharePoint site. All other training relevant to CVT is located in TMS.

4. Operation of videoconferencing equipment;

5. Use of peripheral devices for use with videoconferencing equipment;

(e). Store and Forward Telehealth Training Requirements. Training includes both web-based and face-to-face training by a trained SFT Master Preceptor. The required Store-and-Forward training is located in TMS. Training is also located and updated by the Office of Telehealth Services on their website.

1. Store and forward telehealth applications for teleretinal imaging require the following training:

a. ocular anatomy primer;

b. Overview of diabetes and diabetic retinopathy;

c. Common non-diabetic but related eye findings;

d. Image acquisition techniques and clinical and technology processes using non-mydriatic retinal cameras;

e. Image triage;

f. Quality assurance for DICOM and image deletion;

g. Overview of Conditions of Participation.

h. Patient education.

i. Telehealth operations, coding, encounters.

j. Camera trouble shooting and maintenance.

k. Electronic resources.

l. Web Based courses.

2. The training for teledermatology is similar to that of teleretinal Imaging, with both hands-on and an in-person component. The required teledermatology training is located in TMS. Training is also located and updated by the Office of Telehealth Services at:

http://vaww.infoshare.va.gov/sites/telehealth/sftntc/btcdocs/Forms/AllItems.aspx P. New Program Implementation: Implementation of telehealth programs occurs in stages:

1. Develop standardize and maintain the organizational, clinical, technical and business infrastructure as a foundation to all telehealth development and operations;

2. A “Needs Assessment” helps identify the health care needs of Veterans that telehealth can address appropriately, safely and cost-effectively, ensuring a thorough analysis of cost/benefit and sustainability; 3. Completing the Conditions of Participation while developing telehealth programs helps to determine suitable telehealth clinical, business, and business/management processes to meet the identified healthcare needs;

4. Design, implement and manage telehealth programming to meet identified health care needs;

5. Practice continuous quality improvement processes to optimize telehealth operations at all levels of the organization;

6. For complete guidelines to implement a new CVT program go to:

http://vaww.infoshare.va.gov/sites/telehealth/docs/cbt-ops-manual.docx Q. Risk Management

1. The referring provider must have license to assume full responsibility for the veteran and be able to interpret/implement the results of the telehealth consultation. This is to include the provision of prescriptions, ordering of tests, or making arrangements for further consultations or surgical intervention as may be the case;

2. The Provider should evaluate the Veteran for clinical appropriateness for telehealth services prior to initiation of this form of treatment. Veterans with a known history of impulsive violence, impulsive suicidal behavior, aggressive behavior, or untreated Substance Use Disorder generally should be seen face-to-face first;

3. Veterans should only be seen for telehealth encounters during normal clinic hours for patient and staff safety;

4. All telehealth programs are required to have contingency plans in case of technical problems, as well as an emergency plan for medical or environmental emergencies.

VI. REFERENCES:

a. VHA Office of Telehealth Services Clinic Based Telehealth Operations Manual: Clinical Video Telehealth, Store and Forward Telehealth 9/2012;

b. VISN DIRECTIVE 10N19-28, February 21, 2007;

g. TH Oversight Committee Policy CEB-11PC-23, November 16, 2012.

VII. FOLLOW UP RESPONSIBILITY: Associate Chief of Staff, Primary Care VIII. RESCISSION: None.

/s/ David M. Walker, MD, MBA, DFAPA Medical Center Director EXPIRATION DATE: January 20, 2022 RESPONSIBLE OFFICE: Primary Care Services (11PC) 16