D.16 Asynchronus Telehealth Manual.pdf

VHA Connected

Care/Telehealth vaww.telehealth.va.gov www.telehealth.va.gov

Connected Care/ Telehealth Manual

November 2018

D.16 Asynchronous Telehealth Manual 36C24621R0068

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Table of Contents

1. Overview

1.1 Background

1.2 Purpose

2. How to use this Telehealth Manual

3. Introduction to VA Telehealth

3.1 Synchronous Telehealth

3.2 Asynchronous Telehealth

3.3 Remote Monitoring Home Telehealth

3.3.1 Low Acuity/Low Intensity Telehealth

3.4 Other VA Office of Connected Care Solutions

3.4.1 Annie

3.4.2 My HealtheVet

3.4.3 Mobile Apps

4. Telehealth Organization

4.1 Office of Health Informatics (OHI)

4.1.1 Mission

4.1.2 Vision

4.2 Connected Care

4.3 Telehealth Staffing

4.3.1 Telehealth Executive Director

4.3.2 Telehealth Deputy Director

4.3.3 Synchronous Lead

4.3.4 Asynchronous Lead

4.3.5 Remote Monitoring Home Telehealth Lead

4.3.6 National Technology Manager

4.3.7 Quality and Training Director

4.4 VISN Roles and Responsibilities

4.4.1 VISN Director

4.4.2 VISN Chief Medical Officer (CMO)

4.4.3 VISN Telehealth Program Manager

4.4.4 VISN Quality Manager

4.4.5 VISN Telehealth Analyst

4.4.6 VISN Telehealth Technology Manager

4.5 Facility Organization

4.5.1 Facility Director

4.5.2 Facility Chief of Staff

4.5.3 Facility Quality Manager

4.5.4 Facility Telehealth Coordinator (FTC)

4.5.5 Facility Telehealth Technology Manager

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4.5.6 Supervisory Telehealth Clinical Technician (TCT)

4.5.7 Lead Telehealth Clinical Technician (TCT)

4.5.8 Telehealth Clinical Technician (TCT)

4.5.9 Telepresenter

4.5.10 Imager

4.5.11 Teleprovider/Reader

4.5.12 Clinical Champion

4.5.13 Lead Care Coordinator

4.5.14 Care Coordinator

4.5.15 Preceptor

4.5.16 Scheduler

5. Policy

5.1 Anywhere-to-Anywhere Telehealth

5.2 Memorandum of Understanding

5.3 Credentialing and Privileging

5.4 Telehealth Teleworking

5.5 Privacy

5.5.1 Information Security’s Role in Privacy

5.5.2 Privacy for Groups

5.6 Ryan Haight Act (Guidance for Controlled Substances)

5.6.1 Registration with the Drug Enforcement Agency

5.7 State Prescription Drug Monitoring Programs

5.8 Telehealth by Employees in Training

5.9 Transitioning Providers when Veterans Geographically Relocate

5.10 VHA Directive 1230 - Outpatient Scheduling Processes and Procedures

5.11 VHA Directive 1231 - Outpatient Clinic Practice Management

5.12 VHA Directive 1232 - Consult Processes and Procedures

6. Planning and Developing

6.1 Needs Assessment

6.2 Business Case Development

6.3 Budget Development

6.4 Feasibility and Sustainability

7. Gaining Approval

7.1 Memorandum of Understanding

7.2 Telehealth Service Agreement

7.2.1 Interfacility Telehealth Service Agreement

7.2.2 Intrafacility Telehealth Service Agreement

8. Clinic Set Up

8.1 Consults

8.2 Naming Conventions

8.3 Stop Codes

9. Scheduling

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9.1 Store-and-Forward Telehealth

9.2 Packages to Assist with Scheduling

9.2.1 Telehealth Management Platform

9.2.2 Scheduling Manager App

9.2.3 Patient Viewer App

9.2.4 VA Video Connect Manager (VVC) App

9.3 Scheduling Process

10. The Telehealth Visit

10.1 Clinical Environment and Space

10.2 Guidelines for a Successful Telehealth Visit

10.2.1 Virtual Teams

10.2.2 Clinical Video Telehealth Groups

10.2.3 Store-and-Forward Telehealth Visit

10.3 Veteran Engagement

10.3.1 Prior to the Visit

10.3.2 Informed Consent

11. Documenting and Closing the Encounter

11.1 Workload Validation and Identification of Orphans

11.2 Documentation

11.2.1 Copy and Paste in Telehealth Documentation

11.3 Closing the Encounter

11.3.1 Closing the Provider Side

11.3.2 Closing the Patient Side

11.4 Interfacility Documentation

12. Technical Infrastructure

12.1 Telehealth Management Platform Inventory Management

12.2 Denver Logistics Center (DLC)

12.3 National Telehealth Technology Help Desk (NTTHD)

13. Staff Training

13.1 Staff Competencies

13.2 Orientation

14. Quality Management

14.1 Conditions of Participation

14.1.1 External Accreditation

14.2 Performance Improvement

14.3 Telehealth Data Management

14.4 Telehealth Workload Data Cube

15. Risk Management

15.1 Medical and Mental Health Emergencies

15.1.1 Emergencies for Clinic-Based Telehealth

15.1.2 Emergency Procedures for VA Video Connect

15.2 Infection Control and Reusable Medical Equipment (RME)

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16. Information Outreach

16.1 Describing Telehealth Services

16.2 Customers

16.3 Program Promotion

16.4 Evaluation

17. Resources

Appendix A: Chief Consultants and Directors Endorsement of Telehealth Manual .............................. A-1

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Acknowledgement

We would like to thank the entire Telehealth Services team for their contributions and many revisions and reviews. For questions, please contact the quality and training team at VHA_10P8_TH_DIQ@va.gov.

mailto:VHA_10P8_TH_DIQ@va.gov

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Document Version History

Responsible Office

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

Administration (VHA), VHA Office of Health Informatics: Connected Care/Telehealth. Proposed changes to this document should be submitted to VHA_10P8_TH_DIQ@va.gov. To see if there is any have been updates after the most recent revision, view the Telehealth Manual Update Log on the Telehealth Intranet Site.

Document

Revision

Effective Date Page Description

1 November 2018 N/A Initial Document Development.

mailto:VHA_10P8_TH_DIQ@va.gov https://vaww.infoshare.va.gov/sites/telehealth/docs/th-upd-lg.docx

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1. Overview

1.1 Background

Operating the nation's largest healthcare system, the Veterans Health Administration (VHA) uses a wide variety of communication and information technologies to ensure excellence in the health care it delivers to our nation's Veterans. New technologies are revolutionizing health care and the

Department of Veterans Affairs (VA) has been recognized as a leader in using these technologies to improve the quality of its care delivery. VHA uses health informatics, virtual environments, quality controls, case management, staff resources and human factors to improve the Veterans’ healthcare experience and access to care. Telehealth also expands healthcare capacity and improves Veterans’ health not just in the implementation of telehealth technologies but also in delivering quality healthcare services to Veterans.

The Veteran’s choice in how and where care is delivered is a major focus and guides telehealth programs’ operations. When clinically appropriate, Veterans should be offered telehealth as an option for appointments. Telehealth and its infrastructure support Veterans’ choice to obtain VA quality care from anywhere. One of the Veterans’ preferred locations for obtaining care is in their homes. VA Video Connect allows Veterans to have an outpatient telehealth visit with their provider via a smartphone, tablet, or computer. For more information on VA Video Connect see the VA Video Connect Intranet Site and the VA Video Connect Supplement.

VA has made significant progress to remove barriers and enhance the legal authority of VA healthcare professionals providing quality care through telehealth. Resulting from these efforts are a rule and code popularly known as “Anywhere to Anywhere”, which was published in the

Federal Register on May 11, 2018 and went into effect on June 11, 2018. Similarly, section 151 was added to 38 USC 1730C of the United States Code on June 6, 2018 and was effective on October 24, 2018. This law is also referred to as the VA Maintaining Internal Systems and Strengthening

Integrated Outside Networks (MISSION) Act of 2018 which establishes the same authority. This law and rule clarifies notwithstanding any provision of law regarding the licensure of health care professionals, a covered health care professional may practice the health care profession of the health care professional at any location in any State, regardless of where the covered health care professional or the patient is located, if the covered health care professional is using telemedicine to provide treatment to an individual. The provisions of this law shall supersede any provisions of the law of any State to the extent that such provision of State law are inconsistent. No State shall deny or revoke the license, registration, or certification of a covered health care professional who otherwise meets the qualifications of the State for holding the license, registration, or certification on the basis that the covered health care professional has engaged or intends to engage in activity covered by this law.

Further information on the rule is available on the Anywhere to Anywhere intranet page.

http://vaww.telehealth.va.gov/pgm/vvc/index.asp https://vaww.infoshare.va.gov/sites/telehealth/docs/vvc-spp.pdf http://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title38-section1730C&num=0&edition=prelim http://vaww.telehealth.va.gov/pgm/a2a/index.asp

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1.2 Purpose

This Telehealth Manual establishes standards and procedures to assist VA staff with the integration of Telehealth into routine health care for the benefit of patients, caregivers, families and practitioners. This integration of processes and procedures applies to both establishing a new program and operational standards for an existing Telehealth program. References and links to the relevant VHA Connected Care guidance are provided throughout this manual.

Telehealth leaders from all the Veterans Integrated Service Networks (VISN) comprised the development committee for this Operations Manual, with oversight and leadership from the

Quality and Training Division within Connected Care/Telehealth. The committee developed content with the underlying goal of providing the greatest amount of relevant information in the least amount of time. Key staff from VHA Telehealth Services completed final reviews prior to approval and publication.

2. How to use this Telehealth Manual

The Quality and Training Division, under Telehealth Services, developed this Telehealth Manual. It is meant to complement existing VHA clinical and administrative directives and guidelines. These directives and guidelines detail the prerequisites and critical success factors for providing services within the framework of the national, VISN or Veterans Affairs Medical Center (VAMC) strategic plans for telehealth. They assist VHA staff in integrating leading practices and agreed procedures of telehealth into routine care for the benefit of Veterans and practitioners. The content and tools provided within this Operations Manual serve as a resource to improve and expand the delivery of care via telehealth, and to ensure that the efficiency, quality, and sustainability of these services maximize the satisfaction of VHA communities of practice.

This manual describes tools and processes that assist in identifying variables between telehealth and traditional in-person/face-to-face health care. It provides details for the intended audience to gain an understanding of the complex components of developing and managing telehealth programs. This manual also contain links to additional training, tools, and resources that will complement other national, VISN and local requirements ensuring competency and the ability to successfully plan, deploy and manage telehealth programs.

TeleSpecialty Supplements are intended to be used in parallel with this manual, as provided by

Connected Care/Telehealth. These supplements complement existing VHA clinical and administrative directives and guidelines. The supplements are extensively vetted by national subject matter experts in the specific specialties. These documents are used when developing and managing any TeleSpecialty care or service within VHA. The TeleSpecialty Supplements may be found in the Telehealth SharePoint in the Master Telehealth Document Library, under the

Operations Manuals category.

https://vaww.infoshare.va.gov/sites/telehealth/docs/Forms/AllItems.aspx

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Although much of the content of this Operations Manual may be pertinent to Telehealth operations outside of VHA, this document is a resource developed solely for internal VHA

Telehealth Programs, with the intended audience being VISN Telehealth Leadership, Facility

Telehealth Coordinators, Telehealth Clinical Technicians, telehealth practitioners and VHA staff who provide management and/or support to telehealth programs.

The Telehealth Manual is focused on the use of technology to deliver care to Veterans. The Home

Telehealth (HT) program is an example of that process. It is a specialty in and of itself and provides clinical care through care coordination. HT Care Coordinators and the HT programs use much of the processes noted in this Operational Manual. Further Guidance can be found in the

Home Telehealth Operational Manual.

3. Introduction to VA Telehealth

Telehealth is a group of care delivery modalities that use VHA sanctioned technology to meet security and privacy standards, and to deliver care to Veterans anytime, anywhere while supporting the telehealth vision within virtual care access. Telehealth can be conducted synchronously or asynchronously to accommodate Veteran preference, improve access and build capacity. To ensure safe, effective Veteran care, telehealth is built on an infrastructure that includes unique business, clinical, and technical processes. The telehealth processes are guided by data and need, while meeting quality standards with an emphasis on competent and caring staff.

This infrastructure creates a foundation to deliver care that includes the home, clinic and virtual environments.

Telehealth is commonly carried out between a providing facility and a receiving facility. A providing facility is the facility where the provider is physically located and/or assigned to provide patient care. A receiving facility is the facility where the patient is physically located and/or assigned to receive patient care.

Through telehealth, the VA seeks to:

• Increase capacity by better matching clinical supply and demand across the enterprise by redistributing provider services from densely populated, urban centers to rural or other underserved locations.

• Enhance accessibility by moving appointments closer to Veterans, including to their homes or home communities.

• Improve quality by facilitating the engagement between Veterans and the healthcare system in between office visits.

“Veteran Centered Care” is the principle in VHA that ensures Veterans are included in all discussions and decisions of their care. Veteran centered care is personalized, proactive, and

Veteran-driven health care. Veteran centered care focuses on discovering the Veteran’s goals for https://vaww.infoshare.va.gov/sites/telehealth/docs/HT-ops-manual.pdf?Web=1

Telehealth Manual – November 2018 Page 4 health and vision of living life fully. The healthcare team, including the Veteran and personal support persons, comes together as partners to create and implement the Veteran’s plan for health. The telehealth virtual healthcare team includes these principles and provides Veterans with a choice of where, when and how they are provided quality, safe care.

Access to care is important for all Veterans no matter their location. Telehealth technologies can facilitate connecting health care to Veterans anywhere. Veterans’ telehealth encounters can be conducted using technology from a variety of places for both the Veteran/patient and the clinician.

Environments can include both VA and non-VA locations, including the home, as well as institutional and non-institutional sites of care.

The three types of VHA telehealth care are Synchronous, Asynchronous, and remote monitoring

Home Telehealth.

3.1 Synchronous Telehealth

Synchronous telehealth encompasses real-time care delivered to Veterans through interactive video. Synchronous telehealth is available in VA facilities, non-VA facilities, in the Veteran’s home, and wherever the Veteran may be located. The “Anywhere-to-Anywhere” rule and code, as well as section 151 of 38 USC 1730C (the MISSION Act of 2018), explicitly authorize VA providers to care for their Veteran patients using telehealth, irrespective of the location of the provider or the

Veteran anywhere in the country, including States, Territories, and possessions of the United

States, the District of Columbia, and the Commonwealth of Puerto Rico. This rule and law is expected to expand synchronous care within the VA to underserved areas and improve access to primary and specialty care across the nation. For more information view the Anywhere to

Anywhere Intranet Page.

As depicted in the graphic below, synchronous telehealth may occur in nearly any private location that the Veteran desires. This includes non-VA locations such as Veterans Service Organizations

(i.e., Veterans of Foreign Wars, American Legion Posts), Federally Qualified Health Centers, community clinics, libraries and churches to name a few. Telehealth care may also occur in VA

Medical Centers (VAMCs), Community Based Outpatient Clinics (CBOCs), Primary Care Telehealth

Outreach Clinics (PTOCs), VA Centers of Excellence, VA outpatient and inpatient sites of care, Community Living Centers and contract nursing homes. Any of the above can take place between sites of care within the same facility (Intrafacility) or between facilities (Interfacility).

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3.2 Asynchronous Telehealth

Asynchronous or Store-and-Forward Telehealth within VA is defined as the use of Telehealth

Advisory Board approved technologies and processes to acquire and store clinical information

(e.g., data, image, sound and video) that is then forwarded to or retrieved by a provider at a different time for clinical evaluation. Store-and-Forward Telehealth can take place between VA sites of care within the same VISN or between VISNs using a variety of technologies and applications. Telehealth programs also exist between VA sites of care and Non-VA sites of care, including Store-and-Forward Telehealth into Veterans’ homes and contract nursing homes.

The Store-and-Forward Telehealth asynchronous model of care in VA uses a recognized or nationally approved clinical pathway utilizing Veterans Information Systems and Technology

Architecture (VistA) Imaging or other approved vendor data collection or imaging interface.

Nationally standardized Store-and-Forward Telehealth Programs also involve program specific requirements that are identified in the TeleSpecialty Supplements. For more information view the

Standardization of Store-and-Forward Telehealth Guidance: Program Recognition document.

Another resource is the Standardization of Store-and-Forward Telehealth Guidance, which assists telehealth field staff in the implementation of safe, standardized Store-and-Forward Telehealth programs with national guidance and training. Additionally, the Standardization of Telehealth

Competency Assessment Guidance provides recommendations on improving the operations and standardization of Store-and-Forward Telehealth imaging and/or Telehealth Clinical Technician competency assessments.

3.3 Remote Monitoring Home Telehealth

“Home Telehealth” applies to the use of telecommunication technologies to provide clinic care and promote patient self-management as an adjunct to traditional face-to-face health care. Health https://vaww.infoshare.va.gov/sites/telehealth/docs/sft-rcgn-gde.docx https://vaww.infoshare.va.gov/sites/telehealth/docs/sft-csnlt-gde.docx https://vaww.infoshare.va.gov/sites/telehealth/docs/sft-cmpt-assm.docx https://vaww.infoshare.va.gov/sites/telehealth/docs/sft-cmpt-assm.docx

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Information is exchanged from the Veteran’s home or other location to the VA care setting, thus alleviating the constraints of time and distance.

Home Telehealth provides non-urgent/non-emergent care and case management that also includes tracking and trending vital signs and other biometric data and symptoms.

The essence of Home Telehealth as implemented in VHA involves the ongoing assessment, monitoring, patient education and case management of Veterans in their place of residence and provides the appropriate information to Patient-Aligned Care Teams and the healthcare system to enable timely care.

In the VA, Veterans may be enrolled in Home Telehealth, a specialty program that applies care and case management principles to coordinate care. Home Telehealth uses health informatics, disease management, and technologies such as in-home and mobile monitoring, messaging and/or video technologies to manage care. The goal of Home Telehealth is to improve clinical outcomes and access to care while reducing complications, hospitalizations, and clinic or emergency room visits for Veterans in post-acute care settings. Home Telehealth enrolls high-risk Veterans with chronic disease or who are at risk for institutional long-term care. Veterans are also enrolled to benefit from additional health promotion and prevention activities such as weight management and/or tobacco cessation.

Home Telehealth works collaboratively with Patient-Aligned Care Teams and specialty programs such as Mental Health to ensure timely and appropriate care. The use of Home Telehealth has demonstrated the potential to reduce clinical complications and maximize the use of health care resources that health complications may consume, as well as provide proactive and preventative care.

The use of technology is a core component of the Home Telehealth model, which also includes active care and case management. Case management paired with technology increases patient satisfaction, improves outcomes, and enhances management of chronic disease through collaboration between the Veteran, the Home Telehealth clinician (Care Coordinator), and the

Veteran’s healthcare team using an interdisciplinary approach.

Home Telehealth is not intended to replace or duplicate other care management or case management activities. Rather, the use of disease management and health informatics technologies in Home Telehealth enhances and extends current VA care management and case management activities into non-VA settings and Veterans’ homes to expand access to case management services.

Refer to the Home Telehealth Operations Manual for information and guidance on the implementation of Home Telehealth.

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3.3.1 Low Acuity/Low Intensity Telehealth

Low Acuity/Low Intensity or “L2” Telehealth is an extension of the existing VHA Home Telehealth program. L2 Telehealth offers services to Veteran patients who have stable health conditions (low acuity) and who do not require frequent interventions (low intensity). The L2 Telehealth program complements but does not replace VHA’s current Home Telehealth programs. The L2 Telehealth program was developed to expand the size and scope of technology-assisted care, disease and patient self-management services that can support Veterans with chronic conditions. The intention behind L2 Telehealth is that the accepted model(s) of care act as an extension of services beyond that which is currently provided by VHA’s Home Telehealth programs. L2 Telehealth programs are designed to utilize platform-independent technologies for Veterans who would benefit from patient education, patient self-management and appropriate input from health professionals. The expected result is an increased ability to manage symptoms, behaviors and lack of knowledge about Veterans’ chronic conditions, which in turn leads to avoidable deteriorations, improves Veterans’ health, and reduces outpatient visits.

The use of browser technology and utilization of My HealtheVet are core components of the

L2 Telehealth model. Other core components include patient monitoring, educational support, and close collaboration with the Patient Aligned Care Teams to provide the comprehensive self-care management necessary to support a holistic, medical home model of care. Self-care management paired with technology increases patient satisfaction, improves outcomes and enhances management of chronic disease through collaboration between the Veteran, the Home Telehealth clinician (called a Care Coordinator), and the Patient Aligned Care Team using an interdisciplinary approach.

Refer to the Home Telehealth Operational Manual for more information.

3.4 Other VA Office of Connected Care Solutions

Administratively, Telehealth Services and Connected Health comprise VHA’s Office of Connected

Care. Other virtual care solutions of note in VA’s Connected Health portfolio include Annie, My

HealtheVet, and Web and Mobile Apps. Information about these technologies are available through VHA’s Connected Care Digital Health Solutions document.

3.4.1 Annie

Annie is a free text-messaging service that helps providers support Veterans as they engage in self care. Providers can assign specific protocols for self-management of conditions to their Veterans.

The Veterans can enter specific Veteran-generated data such as vital signs, into Annie which may be viewable by providers. Annie provides reminders and education to Veterans as well.

Separate versions of the Annie app are provided for Veterans and Clinicians.

https://vaww.infoshare.va.gov/sites/telehealth/docs/HT-ops-manual.pdf?Web=1 http://vaww.prevention.va.gov/PREVENTION/docs/NPOPatientDocuments/DigitalHealthSolutions.docx https://mobile.va.gov/app/annie-app-veterans https://mobile.va.gov/app/annie-app-clinicians

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3.4.2 My HealtheVet

My HealtheVet enhances Veteran access to VA physicians and medical records. Through My

HealtheVet, Veterans can communicate with their providers using secure messaging.

Communications include requesting and receiving refills for prescriptions. Veterans are also able to download their personal medical records through the Blue Button functionality of My

HealtheVet.

More information is available at the My HealtheVet Intranet Site. There is also a separate Veteran-facing My HealtheVet internet site for Veterans.

3.4.3 Mobile Apps

VA Mobile provides technologies that expand VA clinical care beyond the traditional office visit. It pursues the development of mobile applications for both Veterans and VA care teams that offer secure access to VA patient data and provides more opportunities for Veterans to be active participants in their health care.

The VA App Store now features more than two dozen apps for Veterans and more than a dozen apps for VA healthcare professionals. In addition to being a library for accessing VA’s apps, the website is also a resource center. Veterans and VA employees can visit each app’s dedicated page and find these educational materials:

• Downloadable Guides – Many app pages include training guides which can be downloaded or printed for easy reference. Look for the Quick Start Guide and/or User Manual buttons under the app name.

• Training Materials – Some apps have this additional information tab, which offers additional images and instructions, and may even include video tutorials.

• Frequently Asked Questions – Many apps also have a Frequently Asked Questions tab.

Here, you will find answers to the common questions users have.

More information:

• VA App Store

• VA Mobile Discussion Series

• VA App Store video

• My HealtheVet Community – VA Mobile Apps page

4. Telehealth Organization

Telehealth organization at the National, Veteran Integrated Service Networks (VISN) and the

Veterans Affairs Medical Center (VAMC) levels is of utmost importance. The development, coordination, and communication regarding telehealth programming is essential to providing

Veterans with quality care. Telehealth implements business practices that improve capacity, http://vaww.va.gov/MYHEALTHEVET/index.asp https://www.myhealth.va.gov/mhv-portal-web/home https://mobile.va.gov/ https://mobile.va.gov/appstore https://mobile.va.gov/appstore https://mobile.va.gov/discussion-series https://www.youtube.com/watch?v=grKceEkD760 https://www.myhealth.va.gov/mhv-portal-web/mobile-apps

Telehealth Manual – November 2018 Page 9 accessibility, quality of care, and Veteran satisfaction using state of the art telehealth technologies.

Directives, policies and procedures define the structure of the telehealth services and provide standardization of processes for safe, high quality delivery of care.

4.1 Office of Health Informatics (OHI)

The Office of Health Informatics is aligned under the Principal Deputy Under Secretary for Health

(10A) and the Undersecretary for Health (10). Connected Care (10A7D) is one of four divisions within the Office of Health Informatics. The other divisions include Health Informatics (10A7A), Health Information Governance (10A7B) and Strategic Investment Management (10A7C).

4.1.1 Mission

The Office of Health Informatics supports Veteran-centered care by facilitating the deployment of innovative, secure health data systems and collecting, analyzing and disseminating the highest quality health information for Veterans, caregivers, clinicians and administrative staff for decision-making.

4.1.2 Vision

The vision of the Office of Health Informatics is to act as an integral partner to Veterans, caregivers, clinicians, managers and leaders by providing timely, relevant, accurate and secure information that improves Veterans’ health and their experience.

4.2 Connected Care

The Office of Health Informatics, Connected Care/Telehealth improves care convenience for

Veterans by providing access to medical services from their homes or local clinics. Connected Care helps facilitate ease of Veterans’ care by increasing capacity in clinics and providing the option of

VA Mobile Telehealth Apps to make accessing VA records easier for both Veterans and health care professionals. To improve care, the VHA Innovation Program, run by Connected Care, hosts annual events that allow healthcare ideas to emerge from the field, leading to new solutions for improving

Veterans’ overall telehealth experience.

4.3 Telehealth Staffing

Telehealth implements business practices that improve capacity, accessibility, quality of care, and

Veteran satisfaction using state of the art telehealth technologies. The value VA derives from telehealth is not in implementing telehealth technologies alone, but in how VA uses health informatics, disease management, care/case management and telehealth technologies to facilitate access to care and improve the health of Veterans with the intent to provide the right care in the right place at the right time. VA is recognized as a world leader in the development of telehealth services which are now mission critical to the future direction of VA care to Veterans.

For more information view the VHA Telehealth Intranet Site.

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4.3.1 Telehealth Executive Director

Responsible for:

• Providing leadership and oversight that endorses, supports, and promotes telehealth for delivery of comprehensive, coordinated, patient-centered care to all Veterans in VHA.

• Ongoing strategic planning for the development and sustainment of telehealth care in VHA.

• Ensuring adequate resources (staffing, technology, equipment, space, and training) within the Office of Health Informatics-Connected Care/Telehealth section.

• Facilitating and leading inter-service collaboration at the national level to enhance and expand Telehealth with such entities as: Office of Information and Technology (OIT), BioMed, Home Telehealth, contracting and Veteran Services.

4.3.2 Telehealth Deputy Director

Responsible for:

• Providing leadership and support of the mission and vision of the national program office that endorses and promotes Telehealth for delivery of comprehensive, coordinated, patient-centered care to all Veterans in VHA.

• Ongoing strategic planning support for the development and sustainment of telehealth care in VHA.

• Supporting inter-service collaboration at the national level to enhance and expand

Telehealth with such entities as: Office of Information and Technology (OIT), Office of

Veterans Access to Care (OVAC), BioMed, Veterans’ Experience Office, Home Telehealth, contracting and Veteran Services.

4.3.3 Synchronous Lead

Responsible for:

• Assisting staff in aligning work of Telehealth Services with defined national strategies and in making necessary adaptations to accommodate VISN/locality needs when this is required to support their individualized priorities in relation to meeting national strategies.

• Planning work for the area under their oversight to ensure work meets defined patient care needs and aligns with strategic direction of both VA and VHA.

• Providing national guidance and direction to VISN Leads in the area of synchronous video telehealth to support and/or implement nationally agreed-to strategies.

• Supporting strategies to promote the use of synchronous telehealth to Veterans.

• Collaborating with external agencies and organizations, including the Department of

Defense, Indian Health Services, Health and Human Services, Veteran Service

Organizations, and private entities to expand and enhance the availability of VA health care through telehealth at non-VA locations.

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• Assisting the Executive Director and Deputy Director in providing consultations to VISNs and other headquarters’ elements on telehealth technologies and services.

• Leading the synchronous video telehealth subcommittee of the National Telehealth

Governance Board to align the strategic direction of synchronous video telehealth modalities in VHA with the necessary information and telecommunication technology assets.

• Overseeing the Telehealth Emergency Management Program.

• Coordinating with the Executive Director and Deputy Director on National Reporting.

• Collaborating with the Office of Academic Affiliations (OAA) to incorporate synchronous video telehealth and other programs involving trainees into the training curriculum for existing residencies.

• Managing budget.

4.3.4 Asynchronous Lead

Responsible for:

• Defining and executing enterprise strategy for maintaining and expanding services to

Veterans through asynchronous telehealth in collaboration with Connected Care’s

Executive Director for Telehealth Services and Telehealth Deputy Director.

• Overseeing and managing asynchronous telehealth services and their clinical integration, implementation, related product support and maintenance, clinical quality management and training, and any other areas as designated by the Executive Director or Deputy

Director for Telehealth Services.

• Working with Office of Information & Technology (OIT), Health Care Technology

Management, Office of Health Informatics (OHI) and other offices to develop and maintain a consistent and reliable enterprise-level infrastructure and the necessary resources for the portfolio of asynchronous telehealth programs nationwide.

• Collaborating with identified VA and VHA Program Offices and/or other staff in the development and implementation of telehealth programs/projects and pilots.

• Preparing horizon scan for future capabilities and requirements.

• Directing colleagues on work and administrative matters pertaining to Asynchronous

Telehealth.

• Assisting the Executive Director and Deputy Director in managing the budget to support all

Connected Care activities including new asynchronous telehealth products from ideation through development and delivery, measurement and quality review, and all administrative aspects for the asynchronous telehealth program.

4.3.5 Remote Monitoring Home Telehealth Lead

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• Providing expert clinical technical knowledge about Home Telehealth equipment and informatics to assist staff in delivering Home Telehealth to Veterans and their families in keeping with the mission of Connected Care/Telehealth Services.

• Providing leadership and substantial involvement in developing a quality and performance improvement program for Home Telehealth programs related to technologies purchased by VA for the care of Veterans.

• Triaging and prioritizing technology related issues raised by Home Telehealth clinicians nationally, and through analysis, making complex recommendations for integrating program policy and clinical and technical requirements into quality improvements.

• Collaborating with multiple sites across a continuum of care and taking a collaborative and leadership role in working with all levels of staff in developing and implementing Home

Telehealth programs for Veterans.

4.3.6 National Technology Manager

Responsible for:

• Planning, budget preparation, coordination and implementation of National Program

Technical Initiatives.

• Implementing, managing and evaluating all telehealth technologies/applications, in support of Connected Care and Telehealth.

• Ensuring technology purchased and used is VA approved. To view the approval form, visit the Purchasing/Set-Up Guide in SharePoint.

• Managing budget.

• Coordinating with the National Telehealth Technology Help Desk.

4.3.7 Quality and Training Director

Responsible for:

• Providing oversight, coordination, and leadership in developing and managing the National

Telehealth Quality Management/Performance Improvement program.

• Assuring excellence, coherency and consistency with system wide goals and strategic objectives, including VHA’s strategic framework for quality.

• Monitoring and evaluating quality of telehealth-based care VHA-wide.

• Implementing national review and periodic revision of VA’s internal accreditation process for telehealth programs, called the “Conditions of Participation”.

• Facilitating the national reduction of variance in telehealth care, facilitating the integration of quality management into both the VISN and the Telehealth Program Office’s day-to-day operations and culture, ensuring that Conditions of Participation and telehealth training products/offerings are well-aligned.

https://vaww.infoshare.va.gov/sites/telehealth/docs/bpa-119-15a-0131_Purchasing_Guide.docx

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• Implementing Telehealth Education and Training for VA employees, including identifying training needs for different staff populations, training development/design and assessment of training quality/outcomes as they link to Conditions of Participation.

• Overseeing internal review of National Telehealth infrastructure components, such as the

National Telehealth Training Center, National Telemental Health Center and other program operations.

• Managing budget and overseeing contracts.

• Directing oversight of Joint Accreditation.

4.4 VISN Roles and Responsibilities

The organizational structure of the VISN Telehealth Program is designed to ensure local control, with proper national and VISN oversight for planning, deployment and operational functions. The following VISN roles and responsibilities are necessary to strategically and adequately support telehealth processes and programs.

Based on need and strategic alignment, VISN Leadership ensures quality of care, improved access, increased capacity and integration of telehealth into routine Veteran care through programmatic oversight of all telehealth clinicians and the assessment and tracking of facility telehealth staff competency. The VISN also acts as a liaison for telehealth programming between Connected Care/

Telehealth and the VAMC telehealth staff.

4.4.1 VISN Director

Responsible for:

• Ensuring implementation of this Manual at all sites of care in the VISN where Veterans receive care via telehealth.

• Providing leadership and oversight that endorses, supports, and promotes telehealth for delivery of comprehensive, coordinated, patient-centered care to Veterans.

• Ongoing strategic planning for the development and sustainment of telehealth care.

• Ensuring adequate resources (e.g., staffing, technology, equipment, space and training).

• Facilitating and supporting inter-service collaboration to enhance and expand telehealth with Office of Information and Technology (OIT), BioMed, Home Telehealth, contracting and Veteran services.

4.4.2 VISN Chief Medical Officer (CMO)

Responsible for:

• Ensuring operations of telehealth throughout the VISN are coordinated with operations of other services aligned with VISN and national VHA initiatives and priorities.

• Designating and providing oversight to a VISN Telehealth Program Manager and establishing responsibilities consistent with telehealth priorities and goals.

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• Establishing a standard process for the identification, implementation and sustainment of telehealth, including business, clinical, training, and technical standard processes.

• Ensuring the VISN Telehealth Council/Committee is established and chartered for:

o Developing strategies and processes for development, deployment and management of telehealth initiates throughout the VISN.

o Serving as a primary vehicle for communications and dissemination of information regarding local, network and Office of Telehealth Services initiatives and news to all appropriate contacts within the network.

o Defining processes and standards for VISN telehealth services and their operations.

4.4.3 VISN Telehealth Program Manager

Responsible for:

• Developing, deploying and managing quality of all telehealth programs throughout the

VISN.

• Ensuring the national program office’s standardized competency assessment program is deployed and tracked appropriately at each facility within their VISN to meet internal and external accreditation requirements.

• Ensuring the national program office’s standardized preceptor program is deployed and tracked appropriately at each facility.

• Integrating Conditions of Participation standards into the routine practice of telehealth throughout the VISN.

• Working closely with the VISN Quality Manager to monitor data and performance improvement activities to ensure quality care.

The full scope and training for these responsibilities can be found on the Telehealth VISN

Leads intranet page. Due to the size and scope of these responsibilities, VISN level managers for synchronous telehealth, asynchronous telehealth, and Home Telehealth may be necessary.

4.4.4 VISN Quality Manager

Responsible for:

• Maintaining oversight of quality performance data of all telehealth programs.

• Ensuring that telehealth is integrated into the routine managerial practices at the VISN level.

• Working closely with telehealth staff to ensure Conditions of Participation standards and data are continually monitored and performance improvement activities address deficiencies.

• Ensuring Joint Commission standards and expectations are applied to telehealth as with all other modalities and services.

http://vaww.telehealth.va.gov/roles/leads/index.asp http://vaww.telehealth.va.gov/roles/leads/index.asp

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4.4.5 VISN Telehealth Analyst

• Implementing data acquisition, oversight and analysis to ensure that VISN and facility leadership is informed regarding telehealth specific data.

• Ensuring actions from this data are coordinated with local and VISN outcomes and Quality

Management groups as well as the leadership and Telehealth Oversight Committee.

4.4.6 VISN Telehealth Technology Manager

The position reports directly to the VISN Telehealth Manager and works closely with VHA

Connected Care, National, Regional, VISN, and facility leaders and staff to incorporate new technology, concepts and programs into new and existing systems.

Responsible for:

• Planning, budget preparation, coordination and implementation of National Program

Technical Initiatives.

• Implementing, managing, and evaluating all telehealth technologies/applications, in support of Connected Care and Telehealth within the network.

• Ensuring technology purchased and used is VA approved. To view the approval form visit the Purchasing/Set-Up Guide in SharePoint.

• Serving as the VISN telehealth technology Subject Matter Expert (SME) for all Connected

Care Telehealth Technologies.

4.5 Facility Organization

The organizational structure of the Facility Telehealth Program supports the development of

Telehealth programs, documentation of workload, measurement of performance, and attention to clinical indicators to ensure safe and effective Veteran care. Based on need and strategic alignment, the facility telehealth leadership is responsible for clinical integration of telehealth to improve access and expand capacity for quality Veteran care. Facility administrative structures are developed locally. Therefore, telehealth must integrate into the organizational structure and report to clinical executive leadership. These individuals provide governance and delineate responsibility for the telehealth process.

4.5.1 Facility Director

Responsible for:

• Ensuring implementation of this Manual at all sites in the Facility where Veterans receive care via telehealth.

• Ongoing strategic planning for the development and sustainment of telehealth care.

• Ensuring adequate resources (e.g., staffing, technology, equipment, space, and training).

• Ensuring a competent staff.

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• Facilitating and supporting multi-disciplinary service collaboration to enhance and expand telehealth with Office of Information and Technology (OIT), BioMed, Home

Telehealth, contracting and Veteran services.

• Providing leadership that endorses, supports, and promotes telehealth function for delivery of comprehensive, coordinated, Veteran-centered care.

• Collaborating with Facility Service Chiefs, Facility Leadership, and the Quality

Management Officer to develop and implement systematic methods for soliciting and analyzing patient input regarding telehealth functions.

• Ensuring overall quality of care and performance improvement for telehealth.

4.5.2 Facility Chief of Staff

Responsible for:

• Complying with all applicable laws, regulations and Information Technology (IT) security mandates.

• Providing leadership and oversight that authorizes and requires telehealth to deliver comprehensive, coordinated, patient-centered care to Veterans.

• Ensuring all requirements are met for deployment, organization, accountability and management of telehealth clinics and patient encounters through the Medical

Executives Committee and service lines.

• Ensuring operations of telehealth throughout the facility are coordinated with operations of other services, aligned with facility initiatives and priorities.

• Establishing a standard process for the identification, implementation and sustainment of telehealth programs, which includes business, clinical and technical standardized processes.

• Ensuring the implementation of process for Privileging and Renewal of Privileges for synchronous telehealth and asynchronous telehealth.

• Ensuring the Facility Telehealth Council/Committee is established and chartered for:

o Developing strategies and processes for development, deployment and management of telehealth initiatives throughout the facility.

o Using the committee as a primary vehicle for communications and dissemination of information regarding local, network and Office of Telehealth Services initiatives and news to all appropriate contacts within the network.

o Defining processes and standards for facility telehealth services and their operations.

o Approving Telehealth Service Agreements.

4.5.3 Facility Quality Manager

Responsible For:

• Ensuring the Receiving Facility and the Providing Facility are meeting Credentialing and

Privileging requirements set forth in current policies, regulations, and standards.

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• Ensuring telehealth performance indicators/monitors, process deficiencies and improvement plans, and aggregate information related to incidents/complications/deaths will be integrated into the facility’s current Quality

Management structures and processes.

• Exchanging Focused Professional Practice Evaluation and Ongoing Professional Practice

Evaluation related data in locations where telehealth services are performed. The specific data, reporting entities and frequency of reporting are specified in the

Telehealth Service Agreement.

• Integrating bidirectional data for telehealth providers into accepted practice evaluation methods.

• Monitoring Telehealth Service Agreements in the Telehealth Management Platform to verify provider Credentialing and Privileging.

• Confirming the integration of telehealth in the usual oversight activities of the Quality

Management department.

4.5.4 Facility Telehealth Coordinator (FTC)

Responsible for:

• Overseeing execution and operation of telehealth within the facility and other divisions

(e.g., CBOCs).

• Planning, coordinating, implementing and evaluating clinical applications of telehealth modalities (e.g., Clinical Video Telehealth, Store-and-Forward Telehealth and Home

Telehealth).

• Deploying and overseeing, as designated, the national program office’s decentralized competency and preceptor programs.

4.5.5 Facility Telehealth Technology Manager

The position reports directly to the VISN Telehealth Manager and works closely with VHA

Connected Care, National, Regional, VISN, and facility leaders and staff to incorporate new technology, concepts and programs into new and existing systems.

Responsible for:

• Planning, budget preparation, coordination and implementation of National Program

Technical Initiatives.

• Implementing, managing and evaluating all telehealth technologies/applications, in support of Connected Care and Telehealth within the facility.

• Ensuring technology purchased and used is VA approved. To view the approval form, visit the Purchasing/Set-Up Guide in SharePoint.

• Serving as the facility telehealth technology Subject Matter Expert (SME) for all Connected

Care Telehealth Technologies.

http://vaww.telehealth.va.gov/quality/tmp/index.asp

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4.5.6 Supervisory Telehealth Clinical Technician (TCT)

The Supervisory Telehealth Clinical Technician functions as the direct…