D.14 Tele-Dermatology-Specialty Supplement (tderm-spp).pdf

D.14 Tele-Dermatology-Specialty Supplement 36C24621R0068

VHA Office of Connected Care

TeleDermatology

Supplement

January 2020

TeleDermatology Supplement – January 2020 i

Contents

1. TeleDermatology Overview

2. Program Planning and Development

2.1 TeleDermatology Clinical Considerations

2.1.1 Primary Care Clinic Needs

2.1.2 Dermatology Service Needs

2.1.3 Organizational/Facility Needs

3. Types of TeleDermatology Care

3.1 General Criteria for TeleDermatology Patients

3.2 Patients’ Options Regarding TeleDermatology

3.3 Poor Candidates for TeleDermatology Services

4. TeleDermatology Clinical Pathway: Consults, Scheduling, and Workload

4.1 TeleDermatology Resources

4.1.1 Common Resources

4.1.2 Clinical Resources

4.1.3 Business Resources

4.2 Asynchronous/Store and Forward TeleDermatology Clinical Pathway

4.2.1 Consult and Scheduling Process

4.3 Synchronous/Clinical Video TeleDermatology Pathway

4.3.1 Consult and Scheduling Process

4.4 Current Procedural Terminology, Internal Classification of Disease and Managerial Cost Account Office Codes

4.5 Summary of Required Resources

5. Risk Management

6. Infection Control Considerations

7. TeleDermatology Additional Resources

Appendices ............................................................................................................................................................ A-1

Appendix A. Store and Forward TeleDermatology Models.............................................................. A-1

Appendix B. Chief Consultants and Directors Endorsement of TeleDermatology

Specialty Supplement ....................................................................................................................................... B-1

TeleDermatology Supplement – January 2020 ii

List of Tables Table 1. Summary of Care Provided through TeleDermatology

Table 2. Summary of Care Provided through TeleDermatology with Modalities

Table 3. Primary Credit Stop Codes

Table 4. Secondary Credit Stop Codes

Table 5. TeleDermatology Credit Stop Codes and Current Procedural Terminology Codes

Table 6. Clinical Guidance by Workflow

TeleDermatology Supplement – January 2020 iii

Document Version History Responsible Office

The development and maintenance of this document is the responsibility of the Veterans

Health Administration, Office of Health Informatics: Connected Care/Telehealth. Submit proposed changes to this document via email to VHA_10P8_TH_DIQ@va.gov.

Document Revision

Effective Date

Page Description

3 May

Reformatted to new TeleSpecialty template; deleted general information found in Telehealth Manual and other documents.

2 August

This supplement provides standard clinical guidance to implement and monitor the quality TeleDermatology delivered to Veterans via Telehealth technology.

1 August

TeleDermatology Operations Manual

Supplement developed and posted to

Telehealth SharePoint.

mailto:VHA_10P8_TH_DIQ@va.gov

TeleDermatology Supplement – January 2020 iv

Acknowledgments We wish to acknowledge in the following table the many contributions of the subject matter experts that have provided their technical expertise. They have made this manual possible. These subject matter experts continue to be available to guide those interested in setting up a TeleDermatology program.

Name Office

Dennis H Oh, MD, PhD Co-Lead, TeleDermatology, Office of Connected Care (10A7D)

Assistant Chief, Dermatology Service, San Francisco VA Health Care System

Martin A. Weinstock, MD, PhD Co-Lead, TeleDermatology, Office of Connected Care (10A7D)

Providence VAMC/Dermatology Chief

Emily Drucker Telehealth Coordinador, Syracuse VAMC

Claire Marty MN, RN, CNL Office of Connected Care (10A7D) /Telehealth Quality

VHA Office of Connected Care (10A7D) | Office Health Informatics

Sara DeRycke-Brawdy, MHCA Asynchronous Telehealth Lead

VHA Office of Connected Care (10A7D) | Office Health Informatics

Leonie Heyworth, MD, MPH Synchronous Telehealth Lead

VHA Office of Connected Care (10A7D) | Office Health Informatics

Bruce L. Jones Interim Deputy Director

Senior Supervisory Technology Program Analyst

VHA Office of Connected Care (10A7D) | Office Health Informatics

Rhonda Johnston, Ph.D., FNP-

BC, BC-ANP

Director, OCC Quality and Training

VHA Office of Connected Care (10A7D) | Office Health Informatics

TeleDermatology Supplement –January 2020 1

1. TeleDermatology Overview

The purpose of the TeleDermatology Supplement is to provide standard clinical guidance to implement and monitor quality delivery of dermatologic care to Veterans via Telehealth technology. This guidance provides enough detail for readers to gain an understanding of the issues to address in the development and management of TeleDermatology programs.

To establish a TeleDermatology clinic(s) use the TeleDermatology Supplement along with the following Veterans Health Administration Telehealth Services Manuals and

Supplements:

Common Telehealth Services’ policies and practices are provided in these documents:

• Connected Care/Telehealth Operations Manual

• Synchronous Clinical Video Telehealth Operations Manual

• Asynchronous Store and Forward Operations Manual

• Telehealth Management Platform

Note: The Clinical Video Telehealth and Store and Forward Operations Manuals are currently under development. Policies and practices found in the above manuals are not repeated in the TeleDermatology Supplement. This supplement contains links to additional training, tools, and resources necessary to successfully implement and manage

TeleDermatology programs. Use this supplement along with other TeleSpecialty

Supplements (e.g., TeleWound, TeleSurgery) for care under those service lines.

Specialty services considering new Telehealth programs should contact the following for assistance putting together the planning team: Veteran Integrated Service Network

Telehealth Manager or Lead, and/or the Facility Telehealth Coordinator. Using shared resources and experiences from other disciplines builds on the success of any Telehealth program.

TeleDermatology care may be offered to different locations and under different modalities using a variety of technology. Possible locations include Veteran Affairs Medical Centers, Community-Based Outpatient Clinic, and the Veteran’s home. Modalities include

Asynchronous Store and Forward Telehealth for consultation for new patients in clinic and direct care of established patients via mobile health technology, as well as, care of patients with Synchronous Clinical Video Telehealth.

2. Program Planning and Development

This section addresses topics a team should consider during the telehealth planning process. The guidance found in the Connected Care/Telehealth Operations Manual and https://vaww.infoshare.va.gov/sites/telehealth/docs/th-mnl.pdf https://vaww.telehealth.va.gov/quality/tmp/index.asp https://vaww.infoshare.va.gov/sites/telehealth/docs/th-mnl.pdf

TeleDermatology Supplement –January 2020 2

Telehealth Management Platform Supplement includes Service Line Approval, Team

Selection, Oversight Committees, Service Level Agreements (Telehealth Service

Agreements), Memorandums of Understanding and scheduling processes.

To effectively plan, deploy, and operate Telehealth programs, a basic infrastructure and oversight committee should be in place at the Veteran Integrated Service Network and

Veterans Affairs Medical Centers levels. This includes ensuring the appropriate roles and personnel are available to support the program.

The Connected Care/Telehealth Operations Manual contains the requirements to implement and maintain a Telehealth Program. These include but are not limited to:

1. Quality Management and the Conditions of Participation

2. Policies covering the Telehealth Program

3. Documentation required for implementation

4. Requirements for Credentialing and Privileging

5. Types and characteristics of services

6. Risk Management

7. Training

2.1 TeleDermatology Clinical Considerations

Assessing the need for TeleDermatology is extremely important to ensure the considerable time and resources involved in creating an effective program. The general considerations for performing a needs assessment are described in the Telehealth Manual.

However, specific needs for patients, the Primary Care clinic, the Dermatology service or section, and the Veterans Administration facility implementing TeleDermatology includes the following.

2.1.1 Primary Care Clinic Needs

Primary care values improved access to dermatology opinions and more rapid effective treatment of their patients’ dermatologic disorders. However, it is important to acknowledge in initial discussions as well as in formal Telehealth Service Agreements that

Store and Forward TeleDermatology requires primary care to adopt more responsibility than in the conventional referral process to dermatology clinic, in order to adequately deliver care to patients. One important early consideration will be to decide whether the primary care provider will be responsible for obtaining the entire patient history, or whether some history-taking will be delegated to the imager who will conduct a structured interview; this decision will determine which of two VA-approved store-and-forward teledermatology template sets will be used at your facility. These templates are found on https://vaww.telehealth.va.gov/quality/tmp/index.asp

TeleDermatology Supplement –January 2020 3 the master document library, with accompanying TeleDermatology Templates User Guide and a Clinical Application Coordinator or Health Information Specialist (CAC/HIS) guide.

• SFT TeleDermatology Text Template – Provider Optional

• SFT TeleDermatology Text Template – Provider Required

• TeleDermatology Template – Referring Provider to Imager – Text Template -

Required Fields

• TeleDermatology Template – Referring Provider to Imager – Text Template -

Optional Fields

Enhanced efficiency and minimization of needed travel may result if some primary care providers or appropriate associated staff perform dermatologic procedures, such as cryotherapy and biopsies, and possibly surgical procedures. The ability to do dermatologic procedures at primary care clinics can significantly expedite care for patients. Primary care providers' interest in doing procedures requires consideration in the planning phase to decide how the appropriate training of primary care providers or others will occur, and the integration of such procedures into the provider’s time schedule.

2.1.2 Dermatology Service Needs

Store and Forward TeleDermatology is a potential solution for a Dermatology Service or

Section needing to optimize the use of its existing staffing to:

1. Provide access

2. Evaluate remote patients

3. Triage patients into its clinics

4. Serve as a means of pre-operative evaluation for those services which are referral centers for dermatologic surgery (see Model E in Appendix A)

5. Provide post-appointment or post-operative follow-ups via Store and Forward or

Clinical Video Telehealth

2.1.3 Organizational/Facility Needs

The most important potential benefit of TeleDermatology is improved access to care for

Veterans’ skin disorders. Assessment of access is the most important part of a need’s assessment. Other benefits that should be included in a need’s assessment include:

1. Reduced costs/increased efficiency, including Community Care costs for dermatology. (Many Veterans may no longer need in-person dermatology evaluation/input to achieve resolution of skin issue.)

2. Improved waiting times, overall or for a subset addressed by TeleDermatology

3. Reduced travel for Veterans https://vaww.infoshare.va.gov/sites/telehealth/docs/tderm-usrgde.docx https://vaww.infoshare.va.gov/sites/telehealth/docs/tderm-CAC-impgd.docx https://vaww.infoshare.va.gov/sites/telehealth/docs/tderm-tplt-po https://vaww.infoshare.va.gov/sites/telehealth/docs/tderm-tplt-rqd https://vaww.infoshare.va.gov/sites/telehealth/docs/tderm-tmplt-rqd.txml https://vaww.infoshare.va.gov/sites/telehealth/docs/tderm-tmplt-rqd.txml https://vaww.infoshare.va.gov/sites/telehealth/docs/tderm-tmplt-opt.txml https://vaww.infoshare.va.gov/sites/telehealth/docs/tderm-tmplt-opt.txml

TeleDermatology Supplement –January 2020 4

4. Greater convenience for Veterans

In some cases, TeleDermatology may offer some flexibility, allowing Dermatology positions at facilities that are difficult to fill or retain to be redistributed to centers where recruitment and retention of a TeleDermatologist reader are less problematic.

For support with these activities, consult the Subject Matter Experts identified in the

Acknowledgement section of this supplement and available on the TeleDermatology

Intranet page.

3. Types of TeleDermatology Care

This section describes care available through TeleDermatology. TeleDermatology care is offered to different locations and under different modalities. The two modes of

TeleDermatology in use in the Department of Veterans Affairs are Asynchronous Store and

Forward Telehealth and Synchronous Clinical Video Telehealth TeleDermatology. Store and

Forward TeleDermatology most commonly involves a referring primary care clinic capturing images (photographs) of the patient’s skin and elements of medical history for transmission to a consultant Dermatologist (reader). The reader formulates a diagnostic impression and recommended treatment/management plan for the patient, which is implemented by primary care.

Clinical Video Telehealth uses the transmission of live video from both the patient site and the dermatologist’s site, with the dermatologist responsible for both assessment and implementation of treatment/management plans. While Store and Forward and Clinical

Video Telehealth each have certain distinct advantages, Store and Forward is by far the predominant form of TeleDermatology due to its lower cost, lower bandwidth usage, greater efficiency, and greater flexibility.

Telehealth visits can provide two types of services:

1. Teleconsultation: the TeleDermatologist does not assume responsibility for patient care, and they do not write orders or prescriptions. The consult is completed by providing guidance and advice to a referring provider on management. The referring provider can decide to implement or not implement the guidance and advice provided by the TeleDermatologist.

2. Telemedicine: the TeleDermatologist is responsible for writing orders, prescriptions, and other aspects of care. The referring provider may or may not assume responsibility for the ongoing treatment of the condition. In either case, the level of participation with the patient by the specialist should be well-documented in the medical record. The practice of using Store and Forward TeleDermatology to allow dermatologists to care for patients directly offers potential benefits, but also https://vaww.telehealth.va.gov/clinic/spc/tderm/index.asp https://vaww.telehealth.va.gov/clinic/spc/tderm/index.asp

TeleDermatology Supplement –January 2020 5 involves additional responsibilities and oversight, and extends the process beyond the usual Teleconsultative role to Telemedicine.

It is critical that Teleconsultation (currently the predominant approach) and Telemedicine are clearly separated. It is also important that clear boundaries and limits of responsibilities are defined in the Telehealth Service Agreement (TSA).

Table 1. Summary of Care Provided through TeleDermatology lists services offered via

Store and Forward TeleDermatology. This table also lists the available modalities for each service. The roles of the primary care provider, imager, site Dermatologist, and

TeleDermatologist reader are specified. See the Telehealth Manual and Home Telehealth

Manual for further information on applying Clinical Video Telehealth and Home Telehealth modalities to TeleDermatology.

Note: Clinic-based Telehealth encounters can be within a facility or health care system

(intrafacility), between facilities or health care systems (interfacility), or the Veteran patient may be located at a non-Veterans Affairs clinical setting.

Table 1. Summary of Care Provided through TeleDermatology

Model Referring Clinician

Imager TeleDermatologist Reader Procedures

TeleDermatologist Prescription

A – Surrogate

Store and

Forward Supported

TeleDermatology

Primary Care Provider through a Surrogate

Surrogate Surrogate Surrogate

B – Direct Referral Store and Forward TeleDermatology

Primary Care Provider

Imager Privileged Primary Care Provider

Primary Care Provider

C - Teletriage Primary Care Provider

Imager Dermatologist Primary Care Provider

D – Follow-up Dermatologist Imager Dermatologist Dermatologist

E - Pre-surgical Evaluation

Dermatologist at Site A

Imager Dermatologist at Site B

Dermatologist at Site B

F – Telemedicine:

New Patients

Primary Care Provider

Imager N/A TeleDermatologist reader

G – Direct Care:

Follow-up

Dermatologist Patient N/A TeleDermatologist reader https://vaww.infoshare.va.gov/sites/telehealth/docs/th-mnl.pdf https://vaww.infoshare.va.gov/sites/telehealth/docs/ht-ops-manual.pdf https://vaww.infoshare.va.gov/sites/telehealth/docs/ht-ops-manual.pdf

TeleDermatology Supplement –January 2020 6

3.1 General Criteria for TeleDermatology Patients

All patients are eligible for dermatologic care in the Veterans Health Administration.

3.2 Patients’ Options Regarding TeleDermatology

Every patient should be informed he/she hasthe option of being referred to the conventional dermatology clinic, though longer travel and wait times for an appointment may be involved. Patients not giving verbal informed consent to participate in the

TeleDermatology process may opt for conventional dermatology clinic or, if eligible per the

Mission Act, referred to a community provider.

3.3 Poor Candidates for TeleDermatology Services

• Patients requiring a complete skin examination by a dermatologist.

• An example of a patient requiring an in-person exam by a dermatologist is one with numerous pigmented lesions that appear to violate the ABCDE rules (Asymmetry, Border, Color, Diameter, and Evolving) for normal nevi or are otherwise suspicious for malignancy (see INFORMED at visualdx.com/educational-resources) and are impractical to image individually. However, TeleDermatology may be an excellent adjunct system for tracking individual lesions or regions of skin in patients with high risk for melanoma.

• Store and Forward TeleDermatology is not appropriate for performing a complete skin exam. Routine complete skin exams can and should be performed by the primary care provider.

• Patients with skin symptoms without any visible skin abnormalities to be imaged.

An example is a patient with pruritus without primary or secondary lesions.

• Patients with skin findings which cannot be well imaged due to location or other issues.

• Patients with extraordinarily complex medical histories or with conditions that require detailed medical history beyond that conveyed in the consultation (e.g. due to suspicion of contact allergen) may be more appropriate for a face-to-face encounter or direct interview with CVT.

• Patients requiring immediate evaluation for life-threatening conditions.

• Unless there is an established mechanism, specified in the Telehealth Service

Agreement, for the referring clinician to alert the TeleDermatologist and agree to a same-day review of the images, Clinical Video Telehealth and Store and Forward TeleDermatology consultations are not suited for emergency consultations.

TeleDermatology Supplement –January 2020 7

• If TeleDermatology is not used for emergency consultations, a plan for patient care should be established in the Telehealth Service Agreements (e.g., paging the on-call dermatologist, referral directly to dermatology clinic or local urgent care/emergency department).

Table 2. Summary of Care Provided through TeleDermatology with Modalities lists services or diagnostic groups offered under TeleDermatology. This table also lists the available modalities (asynchronous, synchronous, and mobile app) for each service. Descriptions of the visit or service are also provided. See Telehealth Manual for further information on telehealth modalities.

Note: TeleDermatology encounters occur within a facility or health care system

(intrafacility), between facilities or health care systems (interfacility), or the Veteran patient may be located at a non-Veterans Affairs clinical setting.

Table 2. Summary of Care Provided through TeleDermatology with Modalities

Type of Visit/Service Modality Description of Visit/Service

Surrogate Supported

Dermatology/Model A

Asynchronous

Store and

Forward

Teleconsultation using a Surrogate provider at the patient site

Direct Referral Store and

Forward

TeleDermatology/Model B

Asynchronous

Store and

Forward

Common model where primary care provider refers patient to imager;

TeleDermatology Reader makes recommendations and primary care provider is responsible for follow-up, including some minor procedures.

Teletriage/Model C Asynchronous

Store and

Forward

Same as direct referral except any necessary procedures require referral by the primary care provider for a face to face dermatology clinic visit or with other appropriately credentialed provider.

Follow-up/Post-Op/Model D Asynchronous

Store and

Forward

A patient already established with a dermatology clinic. Follow-up images from the primary care provider are sent to a reader. The reader provides continuity of care via telemedicine by

TeleDermatology Supplement –January 2020 8

Type of Visit/Service Modality Description of Visit/Service ordering labs, medication, and education/advice.

Pre-Surgery/Model E Asynchronous

Store and

Forward

This allows for pre-surgical planning and evaluation without a face-to-face visit with the surgeon. Upon receiving images and other patient information, the surgeon decides if a face-to-face preliminary visit is needed prior to the surgery.

Telemedicine: New

Patients/Model F

Asynchronous

Store and

Forward

Referring clinic submits teledermatology consult just as in consultative teledermatology. However, the dermatologist at reading site assumes care, and is responsible for communicating findings and management plan with patient, ordering medications, labs, etc., and arranging follow-up.

Telemedicine: Established

Patients/ Model G

Asynchronous

Store and

Forward

Established dermatology patient’s follow-up by submitting interval history and photos via the My VA Images app.

Recommendations for care are then sent back to the patient via the Patient Viewer app by the TeleDermatology Reader

Telemedicine

TeleDermatology

Synchronous/

Clinical Video

Telehealth

Primary care provider places consult request for patient(s) with variety of skin issues; TeleDermatologist evaluates and cares for patient and determines appropriate follow-up.

For more detailed information regarding the different Asynchronous Store and Forward

Models listed in Table 2. Summary of Care Provided through TeleDermatology with

Modalities see Appendix A.

TeleDermatology Supplement –January 2020 9

4. TeleDermatology Clinical Pathway: Consults, Scheduling, and Workload

Consults and scheduling are key indicators of telehealth success. They allow for objective evaluations of workload and Veterans served by TeleDermatology. Tracking such measures helps the Veterans Health Administration identify which programs need additional funding and support to continue to provide quality care to Veterans.

Specific information regarding the need for pre-appointment laboratory and/or diagnostic studies should be spelled out as much as possible in the Telehealth Service

Agreements/Memorandums of Understanding. Facilities should consider whether these services will be available at or near the Veteran Site. If they will require the Veteran to travel to the Dermatology service’s location, consider using Teletriage to pre-plan the visit and maximize the scheduling of the trip.

Asynchronous Store and Forward Consult Process: All patients being considered for referral to TeleDermatology require an examination and evaluation from their primary care provider. Their primary care provider will then initiate a TeleDermatology consult based on their evaluation by placing a consult to the Imager.

Synchronous/Clinical Video Telehealth Consult Process: The primary care provider examines and evaluates the patient’s dermatological concerns. The primary care provider determines a consult to TeleDermatology is in the best interests of the patient, and then places a consult to dermatology for consideration for TeleDermatology visits. Depending upon the TeleDermatology Clinical Video Telehealth requirements outlined in the

Memorandums of Understanding, images may or may not initially be required.

Only providers may request consults to TeleDermatology. Primary care providers after examination and evaluation of the patient may have a registered nurse enter the consult request (if they have the correct keys), but the provider is still required to sign the consult request. If consults are not submitted from a provider, they will be refused.

4.1 TeleDermatology Resources

The structure of the TeleDermatology visit will vary depending on the Type of Visit/Service or Diagnostic Group provided.

4.1.1 Common Resources

TeleDermatology common resources are required and need documentation in the

Telehealth Service Agreements. Common resources include but are not limited to:

• Sites. The participating sites may be facilities, community-based outpatient clinics, Veterans Homes, or the patient’s location.

TeleDermatology Supplement –January 2020 10

• Clinics. The participating clinics and their health care providers should be known so that they can be trained, and appropriate clinic locations should be created to track their workload.

• Rooms. The actual space in which imaging and reading, or a CVT session, occur should ensure audio and visual privacy, possess adequate lighting, and be sufficiently spacious to accommodate the imaging technology. The rooms can be used for other purposes and need not be dedicated for teledermatology, but they should be readily available to avoid excessive wait times for patients.

• Technologies. Technology includes equipment required to conduct the visit. For example, visits typically require the presence of a computer work station, as well as appropriate imaging equipment that may or may not need to interface with that workstation. A Blanket Purchase Agreement (BPA) provides VISNs/Facilities access to approved Telehealth Technology. Prior to deployment in the field, all Telehealth

Technology is required to be evaluated and then placed onto the BPA. The Office of

Connected Care Telehealth Services has a process in place, as well as Subject Matter

Experts available for completing the technology evaluation. The Office of Connected

Care technology SMEs are located at the bottom of the Technology Intranet page.

Please visit the technology approval website at https://vaww.telehealth.va.gov/technology/approval.asp for information regarding the approval status for telehealth equipment, and information regarding the approval process. If the equipment currently used in your program has not been approved by Office of Telehealth Services, please contact the National Telehealth

Technology Manager with any questions.

• Consults. Teledermatology consults, whether they be SFT or CVT, will need to be readily identified by title and associated with the proper stop codes. However, they will typically utilize the common features of VistA/CPRS to allow tracking. The exceptions are store-and-forward teledermatology encounters directly with patients in the home which currently do not use the consult mechanism in VistA/CPRS.

4.1.2 Clinical Resources

The clinical staffing necessary for a teledermatology encounter include the referring provider (usually in primary care), the TeleDermatologist reader, and imaging staff.

Referring providers play a significant role in store-and-forward teledermatology encounters. They must not only initiate the consult by placing an imaging order, but they and their staff (e.g., PACT) are usually responsible for executing any recommendations in the teledermatology consult note.

Other clinical personnel serve as resources to directly support the referring provider in facilitating a teledermatology encounter. These include but are not limited to:

https://vaww.telehealth.va.gov/technology/approval.asp

TeleDermatology Supplement –January 2020 11

• TelePresenter (for CVT teledermatology)

• Imager (for SFT teledermatology).

In practice these roles may be fulfilled by Telehealth Clinical Technician or other trained imaging personnel which can include nursing staff. Refer to the Connected Care/Telehealth

Operations Manual for the standard role descriptions and competencies.

All board-certified dermatologists are qualified to serve as store-and-forward teledermatology readers and care for patients remotely via CVT modalities in VA.

Physician extenders such as nurse practitioners and physician assistants who work in dermatology may also serve in these roles with the approval of their Dermatology Chief.

4.1.3 Business Resources

Business resources include but are not limited to:

• Instructions for setting up clinic locations associated with proper stop codes (see below)

• Informatics templates

• Coding Guidance (see below)

• Clinic scheduling

• Scheduling support, for initial and follow-up appointments

• Consult management tools for tracking consults and workload

• Appropriate IT and CAC support

TeleDermatology consult management will follow VHA Directive 1232, Consult Processes and Procedures. For clinic set up, refer to the Clinic Set Up Guidance. Refer to the

Connected Care/Telehealth Operations Manual for detailed information regarding business requirements.

4.2 Asynchronous/Store and Forward TeleDermatology Clinical

Pathway

TeleDermatology Store and Forward specific requirements are:

• Veteran patient

• Referring Provider – typically a primary care provider - with access to the electronic health record

• Consultant dermatologist with access to the electronic health record

• Imager with access to the electronic health record

• Room in which to image patients ensuring privacy

• Imaging equipment

4.2.1 Consult and Scheduling Process

Consultative Store and Forward TeleDermatology uses a 2-consult process.

https://vaww.infoshare.va.gov/sites/telehealth/docs/th-mnl.pdf https://vaww.infoshare.va.gov/sites/telehealth/docs/th-mnl.pdf http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=3230 http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=3230 https://vaww.infoshare.va.gov/sites/telehealth/docs/clnc-stp.docx

TeleDermatology Supplement –January 2020 12

1. Primary care providers with imagers will need to provide the patient’s history so that images can be properly interpreted by the reader. Depending on which templates have been adopted by the local program, the primary care provider is required to provide a minimal history or a complete history. To ensure effective imaging and interpretation, the referring clinician needs to effectively communicate to the Imager the areas of concern to be photographed. This should include information regarding anatomic locations, and the need for dermatoscope images where applicable. Agreement on these processes should be developed and communicated to all involved staff.

2. Once the Imager has received the consult request, the patient will either be a walk-in or will have an imaging appointment scheduled for them. The Imager will transmit the referring provider’s medical history, supplement it if required by conducting a structured interview, take the requested images, and ensure the quality of the images before loading them into VistA Imaging or other approved software program. The

Imager will then document the visit and close the consult. The Imager will submit a consult to the appropriate Dermatology Service TeleReader program.

3. The dermatologist will access the consult via Telereader, and review the images and history provided. This may take place on a different day than the acquisition of the images. The dermatologist then creates a visit for the reading encounter; completes the consult with recommendations of care to the referring provider. Notification of completion of the consult is sent to both the Imager and the referring provider. The primary care provider is responsible for initiating treatment and education for the patient.

Timeliness of reading the images from the Imager to the TeleReader/Dermatologist is of utmost importance. The time to read an image/data for asynchronous/Store and

Forward telehealth is measured by monitoring the number of consults pending and completed at 3, 7, and 30 business days from the date of the patient side imaging encounter entry to the date of the reader side encounter entry. VA requires

Asynchronous/Store and Forward telehealth consults to be completed within 7 days.

Asynchronous/Store and Forward telehealth images must absolutely be read 30 business days or less. Telehealth encounters will match up at 30 business days. If images or data are not read or interpreted within 30 business days, they are forever unmatched or forever an orphan.

4.3 Synchronous/Clinical Video TeleDermatology Pathway

Clinical Video Telehealth encounters are synchronous events, and the scheduling aspects of the clinical pathway have heightened importance. Clinic-based Telehealth encounters can be within a facility or healthcare system (intrafacility), between facilities or healthcare

TeleDermatology Supplement –January 2020 13 systems (Interfacility), or the Veteran may be located at a non-Veterans Affairs clinical setting.

The scheduling of Clinical Video Telehealth visits is more complicated than scheduling traditional in-person medical visits. However, at a minimum, the scheduling system for visits should not differ from the system already in place for in-person visits in terms of a telephone access number, personnel, etc. Scheduling real-time Telehealth clinics requires coordination of several resources:

• Veteran (VistA)

• Provider (VistA) – Referring, and dermatologist

• Rooms at both sites

• Technology at both sites

• Bandwidth

• TelePresenter (as required)

• Scheduler

4.3.1 Consult and Scheduling Process

TeleDermatology via Clinical Video Telehealth is best suited to a one consult process. The

Clinical Video Telehealth visit is initiated by a consult request, usually from the Veteran’s primary care provider. Clinical Video Telehealth visits lend themselves to practically all dermatologic conditions. The consult should indicate the area needing evaluation and patient history as related to the condition and any contributing factors.

It is recommended that visit templates and any pre-visit requirements, such as laboratory tests or other studies, are identified in the Telehealth Service Agreements/Memorandums of Understanding. Store and Forward of images may be incorporated for follow-up of dermatologic conditions. The dermatologist is often providing Telemedicine care via

Clinical Video Telehealth and is therefore responsible for ordering medications and treatments as required. The dermatologist will close the consult, and a notification will be sent to the primary care provider. The primary care provider will then have access to it either through Computerized Patient Record System Consults or as a Computerized Patient

Record System progress note (for follow-up visits).

The role of the TelePresenter may vary. For a review of the history and interval history, the

TeleProvider and Veteran should suffice (see Clinical Guidance by Diagnostic Condition in

Table 2. Summary of Care Provided through TeleDermatology with Modalities). The

TelePresenter is trained and has mastered the competencies to help perform the examination as needed, in addition to positioning the camera appropriately and using the peripheral for certain parts of the examination. If clinical or other factors indicate, the dermatology provider may request a credentialed TelePresenter assist with the visit.

TeleDermatology Supplement –January 2020 14

Depending on the complexity of the patient’s issues, the TeleProvider may decide a face-to-face visit will better serve the patient.

Note: When documenting clinic-to-clinic appointments, be sure to obtain the patient’s verbal consult and chart at the beginning of the visit: “Visit conducted by clinical video telehealth. Patient verbal consent obtained. Location/emergency number confirmed.”

4.4 Current Procedural Terminology, Internal Classification of Disease and Managerial Cost Account Office Codes

To ensure workload credit, clinics must be set up with the appropriate telehealth secondary credit stop codes. Detailed information on clinic set-up is available in the

Telehealth Manual. Refer to the Telehealth Manual regarding coding and documentation, including the use of Telehealth modifier 95 for closing out a Clinical Video Telehealth encounter if required by individual facilities. In all other ways, Clinical Video Telehealth and Store and Forward Telehealth should use the same primary stop code (304).

TeleDermatology current procedural international Current Procedural Terminology and

Internal Classification of Disease codes will follow face to face coding processes and policies. In addition, Telehealth modifier 95 will be used for Synchronous/video visits (i.e., Clinical Video Telehealth) and GQ modifier (used to support services delivered via asynchronous telecommunications systems) for Synchronous Store and Forward

Telehealth visits. Some Current Procedural Terminology codes are listed for Store and

Forward only and are current as of publication date of this supplement.

All new telehealth programs must contact their local Health Information Management

System, /coding office to ensure all stop codes, Internal Classification of Disease, and

Current Procedure Terminology codes are the most current. Table 3. Primary Credit Stop

Codes shows the Dermatology Primary credit stop codes and descriptions.

Note: Coding staff validates all billable encounters, and will append modifiers as appropriate (GQ and 95).

Table 3. Primary Credit Stop Codes

Primary Credit Stop Codes Description 304 Records patient visits for consultation, evaluation, follow-up, and/or treatment provided by a physician trained in skin disease. Includes provider and support services.

Table 4. Secondary Credit Stop Codes lists the secondary credit stop codes and the documentation of patient visit descriptions. It includes the Store and Forward digital telehealth information. Store and Forward is the use of electronic communications and information technology to provide and support health care when time and distance

TeleDermatology Supplement –January 2020 15 separate the participants. The patient’s site (usually a technologist) captures, stores, and forwards images for later review by an interpreting provider. During Store and Forward visits, there is an asynchronous transmission of clinical data from one location to another.

The interpretation of data by the provider does not occur simultaneously with the patient's encounter.

Table 4. Secondary Credit Stop Codes

Secondary Stop Codes Description

Store and Forward from Home –

Provider Site

Records workload at the provider site (distant site) for the reading of Store and Forward digital telehealth information where the patient site

(originating site) is the patient’s home. Use of this

Stop Code is limited to those programs that use approved IT/technology platforms and clinical pathway standards as delineated by Veterans

Health Administration Telehealth Services. There is no corresponding patient site telehealth encounter. Currently, this code is for use to document dermatologist evaluations of encounters where the patient submits history and images using the My VA Images app. It should be associated with clinic locations which include the title, “DERM-TELEMED MOBILE SFT”

Real-Time Clinical Video

Telehealth – Patient Site

Records at the patient’s site (originating site), real-time clinical video telehealth care provided to patients. Both the patient and provider must be present during the real-time video session. This secondary code can be attached to any primary

Stop Code related to the workgroup provides telehealth consultations.

Real-Time Clinical Video

Telehealth – Provider Site (Same

Division/

Station)

Records at the provider site, Real-Time Clinical

Video Telehealth care provide to patients where the site of the patient and the site of the provider share the same division or the Station

Number/Company Code, such as in the case of a

TeleDermatology Supplement –January 2020 16

Community-based Outpatient Clinic and its parent station.

Examples: Clinical Video Telehealth conducted when the patient and provider are both located/assigned to the same division/campus but in separate physical locations, when a provider is teleworking from the division where the patient is located and recording workload at the same division where the patient is located or between a

Veterans Administration Medical Center and a

Community-Based Outpatient Clinic belonging to the specific Veterans Administration Medical

Center.

Example: The patient is seen at the Denver VA, and the provider is also assigned to the Denver VA, but is working from an off-campus location (such as their home in another state). Telehealth is the use of electronic communications and information technology to provide and support health care when distance separates the participants. Both the patient and provider must be present during the real-time video session.

Store and Forward - Patient Site

Records at the patient site (originating site), the capturing of data used in a Store and Forward procedure enables provision of care to a patient.

This secondary code may be attached to any primary Stop Code related to the workgroup providing the telehealth session (e.g., Store and

Forward imaging for teleretinal screening or teledermatology).

For telehealth occurring real time/live such as telemental health video teleconferencing, use Stop

Code 690 for the patient site.

695 Records at the provider site (distant site), Store and Forward care provided for patients where the

TeleDermatology Supplement –January 2020 17

Store and Forward - Provider Site (Same Division/Station) site of the patient and the site of the provider have different company codes (a.k.a. Station Numbers, a.k.a. STA-3). This secondary code may be attached to any primary Stop Code related to the work group providing the telehealth session (e.g., review of Store and Forward images for teleretinal screening or teledermatology).

(For telehealth occurring real time/live such as telemental health video teleconferencing, different station, use Stop Code 693 for the provider site).

Store and Forward - Provider Site (Different Division/Station)

Records at the provider site (distant site), Store & Forward telehealth care provided for patients where the site of the patient and the site of the provider have different company codes (a.k.a.

Station Numbers, a.k.a. STA-3). This secondary code may be attached to any primary Stop Code related to the workgroup providing the telehealth session (e.g., review of Store & Forward images for teleretinal screening or teledermatology). Store & Forward Telehealth is the use of electronic communications and information technology to provide and support health care when time and distance separates the participants. Images are captured, stored and forwarded by the patient’s site for later review/interpretation by a provider.

During this type of telehealth visit, there is an asynchronous transmission of clinical data from one location to another. The interpretation of data by the provider does not happen simultaneously with the patient's encounter. (For telehealth occurring real-time/live such as telemental health video teleconferencing, different station use Stop Code 693 for the provider site).

Table 5.TeleDermatology Credit Stop Codes and Current Procedural Terminology Codes lists the TeleDermatology Program models (A – G), primary and secondary credit stop codes, and Current Procedural Terminology codes.

TeleDermatology Supplement –January 2020 18

Table 5. TeleDermatology Credit Stop Codes and Current Procedural Terminology

Codes

Type of Visit/Service Primary

Stop

Code

Secondary

Stop Code

Current Procedural

Terminology Code

Model A: Surrogate

Supported Dermatology

Model B:

Direct Referral Store and

Forward TeleDermatology

Model C: TeleTriage

Model D:

Follow-up/

Post-Op

Model E:

Pre-Surgery

Model F: Telemedicine:

New Patients

(Teleconsultation)

Asynchronous/

Store and Forward

304 694

Patient/Image Acquisition

Site

Decision Support System, 304694 for workload credit

Current Procedural

Terminology, 96999 with

Technical Component modifiers (visit with Imager only);

TC for Technical Component

For diagnosis Dx = Imager uses current diagnosis (i.e., ordering provider's preliminary Dx, e.g., 782.1 for

‘rash’)

Dermatologist/Image

Reading Site:

Decision Support System, 304695 or 304696 for workload credit

Current Procedural

Terminology, 99451 for

Interprofessional telephone/internet/electronic health record assessment & management service provided by a consultative physician, including a written report to the patient’s treating or requesting physician or other qualified health care

TeleDermatology Supplement –January 2020 19

Type of Visit/Service Primary

Stop

Code

Secondary

Stop Code

Current Procedural

Terminology Code professional, 5 minutes or more of medical consultative time.

For diagnosis Dx = dermatologist uses own diagnosis (e.g., 705.1 for ‘heat’)

Telemedicine: Established Patients Direct Care Follow-up

Model G Mobile App/ MY VA Images

304 189 Dermatologist Site:

Current Procedural

Terminology (99211-99215) may mostly use lower level as there is not a face-to-face visit

TeleDermatology Synchronous/ Clinical Video Telehealth

304 690

Patient Site:

Decision Support System, 304690 for workload credit

Current Procedural Terminology Q3014 for TeleDermatology encounters via live video/audio communications for the patient site/no modifier.

Telehealth Facility Fee For diagnosis Dx = Imager uses diagnosis (i.e., distant site dermatologist’s Dx)

Dermatologist Site:

Decision Support System, 304692 or 304693

Current Procedural Terminology clinical coding -use regular Evaluation and Management and/or Current

TeleDermatology Supplement –January 2020 20

Type of Visit/Service Primary

Stop

Code

Secondary

Stop Code

Current Procedural

Terminology Code

Procedural Terminology code for service provided, as if the clinic was conducted face to face but add GT modifier (real-time telehealth)

For diagnosis DX – dermatologist use their own diagnosis

Note: For further information about CPT codes, please direct questions to facility coding personnel for clarification and guidance. Coding staff validates all billable encounters and will append modifiers as appropriate (GQ and 95).

Note: The Imager closes the encounter and places themselves as the primary provider on the encounter form. This has been approved by the National Health Information

Management System as this is a non-billable/no-copay patient side clinic set up with relative value units (RVUs) of the imager staff type. This is also imperative for Image

Quality reports and the health factor tying to the Imager being the primary provider on the patient side encounter.

In the event VistA will not allow a user to add GT to the Current Procedural Terminology code, ensure the encounter is in a clinic with stop codes identifying telehealth.

See the Telehealth Manual and the MCAO Intranet page for more detailed information on stop codes, as well as, the Coding for Asynchronous Telehealth Care Memorandum-

01062020 for more detailed guidance.

4.5 Summary of Required Resources

Table 6. Clinical Guidance by Workflow lists the type of visit, service, or diagnostic group, resources (common, clinical, and business), and additional information.

Table 6. Clinical Guidance by Workflow

Type of Visit/

Service

Common

Resources

Clinical

Resources

Business

Resources

Additional

Information

Model A Telehealth clinical station

Imager with training for taking

Consult

Management

The Surrogate

Dermatologist is a http://vaww.mcao.va.gov/

TeleDermatology Supplement –January 2020 21

Type of Visit/

Service

Common

Resources

Clinical

Resources

Business

Resources

Additional

Information

Surrogate

Supported

Dermatology with exam camera.

dermatology

Images; Surrogate

Dermatologist patient history, physical exam, obtains images, submits consult, and provides care/treatment recommended by

TeleDermatologist;

clinical supplies and instruments for minor

Dermatological procedures.

Process

(2 consult); Clinic

Templates;

Scheduling

System; Coding;

Biopsy tracking system to track patient disposition.

midlevel, or higher practitioner trained and privileged in dermatology, dermatology procedures, and imaging. The

Community-based

Outpatient Clinic needs to commit to

Full-Time Employee

Equivalent required to staff this position.

Model B Direct

Referral Store and Forward

TeleDermatology

Telehealth clinical station with exam camera.

Imager with training for taking dermatology

Images; primary care physicians are responsible for follow-up care.

Consult

Management

Process (2 consult); Clinic

Templates;

Scheduling

System; Coding;

Biopsy tracking system to track patient disposition.

Primary Care

Providers may perform minor dermatologic procedures after training by dermatology

Service/Section and credentialing.

Model C

TeleTriage

Telehealth clinical station with exam camera.

Imager with training for taking dermatology

Images

Consult

Management

Process

(1 consult); Clinic

Templates;

Scheduling

System; Coding.

If a dermatologist reader determines a face-to-face appointment is needed, it will be documented in the recommendations of the closed

TeleDermatology Supplement –January 2020 22

Common

Resources

Clinical

Resources

Business

Resources

Additional

Information consult. Upon receipt of the closed consult, the primary care provider must submit an additional consult for a face-to-face appointment.

Model D

Follow-up

Telehealth clinical station with exam camera

Imager with training for taking dermatology

Images

Consult

Management

Process (initial consult for face-to-face visit is only the consult required by Patient site)

Clinic Templates for follow-up imaging appointments;

Scheduling

System; and

Coding.

The dermatologist follows the postoperative or post-procedure patient via telehealth imaging and provides remote care to the patient via telemedicine.