D.18 - Asynchronous Store and Forward Telehealth Manual.pdf

VA Telehealth Asynchronous Store and Forward Telehealth Manual (Updated May 2023)

1. Introduction to Asynchronous Store and Forward Telehealth Asynchronous Store and Forward Telehealth within the U.S. Department of Veterans Affairs (VA) is defined as the use of technologies to asynchronously acquire and store clinical information (e.g., data, images, sound, or video), which is then forwarded to or retrieved by a health care professional at another location for clinical evaluation. The Asynchronous Store and Forward Telehealth model of care in VA uses a recognized or nationally approved clinical pathway using VistA Imaging Capture or another approved, secure vendor data-collection or imaging interface. Nationally standardized Asynchronous Store and Forward Telehealth programs also incorporate program-specific requirements, which are identified in the specific Specialty Telehealth Operations Manuals.

This manual provides general guidance on Asynchronous Store and Forward Telehealth business, technical, and clinical processes, and comprehensive information can be found in the Connected Care Academy Communities for specialties. Additional resources can also be found on the Asynchronous Telehealth page on the Veterans Health Administration Telehealth Services intranet site. Program-specific requirements are found in the Specialty tab of the Telehealth Intranet Site (NOTE:This is an internal VA website that is not available to the public).

2. Obtaining Program Approval There are two levels of approval: one at the local level and one at the national level. Locally approved telehealth services may be conceived as local programs or may be working toward national approval.

Local approval, including notifying the Telehealth Advisory Board, is required for the use of Asynchronous Store and Forward Telehealth. An Asynchronous Store and Forward Telehealth program that has local approval assumes the responsibility and liability for the services and technology within that program.

Nationally approved telehealth programs have gone through the quality, implementation, and development process with the national telehealth teams, including, but not limited to the vetting of technology and equipment, the identification of pathways, and the creation of a specialty manual that will be published on the telehealth intranet site and the Connected Care Academy Communities.

National approval is a more complex process than local approval. See the Office of Connected Care Telehealth Manual for more information.

https://vaots.blackboard.com/bbcswebdav/xid-2770882_1 https://vaots.blackboard.com/bbcswebdav/xid-1496876_1 https://vaww.telehealth.va.gov/pgm/async/index.asp http://vaww.telehealth.va.gov/ https://vaots.blackboard.com/bbcswebdav/xid-1496876_1 https://vaots.blackboard.com/bbcswebdav/xid-1496876_1 https://vaots.blackboard.com/bbcswebdav/xid-510063_1

2.1. Local Approval

Once the Telehealth Needs Assessment/Business Plan for a proposed local Asynchronous Store and Forward Telehealth program has been completed, you will send the proposed local program to the facility and VISN telehealth levels for approval. This initial approval enables the program to begin development in local facilities and is considered local-level approval.

When the facility and the VISN have approved a program, the VISN Telehealth Program Manager will send an email notification to OCC National Asynchronous Telehealth Lead and National Telehealth Quality and Training. (NOTE:These are internal VA websites that are not available to the public). This email will constitute notification of the new initiative and will begin national team collaboration with local sites to gather and formalize information on the service. After a six-month pilot program, a summary review of the initiative will be presented to the Telehealth Advisory Board (NOTE:This is an internal VA website that is not available to the public) for its awareness, tracked for follow-up, and reviewed for progress, data, and quality evaluation.

The document used for email notification is the Asynchronous Store and Forward New Program Notification Email Form. The email notification will include:

• The program name.

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

• The Telehealth Business Plan/Needs Assessment (included as an attachment).

• The stop codes that are used for workload capture.

• The clinical pathway(s)-consult process in place (if possible).

• The equipment being used.

• How the data/image or video will be incorporated into the medical record.

• Use of the telereader app or another approved program.

• How the local site manages the retained camera images and data security.

• The metrics that are being used to measure success.

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

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

After the new asynchronous services have been in use for six months locally, the site will share the new initiative with the Telehealth Advisory Board and arrange a presentation through the Asynchronous Telehealth Lead. The program will also be reviewed to determine whether it is suitable and sustainable for national implementation and development or whether local implementation is a better fit.

https://vaots.blackboard.com/bbcswebdav/xid-694055_1 http://vaww.telehealth.va.gov/about/contact/index.asp#async http://vaww.telehealth.va.gov/about/contact/index.asp#async http://vaww.telehealth.va.gov/about/contact/index.asp#qt https://dvagov.sharepoint.com/sites/VHA-Telehealth/gb/Home.aspx https://vaots.blackboard.com/bbcswebdav/library/LibraryContent/Asynchronous/Asynchronous%20Store%20and%20Forward%20New%20Program%20Notification%20Email%20Form%20(sft-eml-ntf).pdf https://vaots.blackboard.com/bbcswebdav/library/LibraryContent/Asynchronous/Asynchronous%20Store%20and%20Forward%20New%20Program%20Notification%20Email%20Form%20(sft-eml-ntf).pdf

National data will be reviewed by Connected Care/Telehealth Services and the national office of Telehealth Services. In this process, Connected Care and national office staff may reach out to local programs to verify what the Asynchronous Store and Forward Telehealth credit stop codes are being used for, and request information on the local programs to evaluate whether the program is meeting the intent of new Asynchronous Store and Forward Telehealth and is in line with National Quality Measures and Conditions of Participation Guidelines (NOTE:This is an internal VA website that is not available to the public). Upon request, local programs will provide documentation of Standard Operating Procedures (SOPs) or policies for new Asynchronous Store and Forward Telehealth programs and will collaborate with the national-level process described below, if deemed appropriate.

2.2. Enterprise-Wide Designation and National Approval

The process for national approval of a new Asynchronous Store and Forward Telehealth program encompasses these steps:

1. Connected Care identifies a need for national standardized guidance, documentation, and training through any of the following means:

o Contact with the Quality and Training Email Group by VISNs or facilities with an Asynchronous Store and Forward Telehealth program plan.

o Contact with the National Asynchronous Telehealth Lead (NOTE:This is an internal VA website that is not available to the public).

o Information shared during VISN Leads calls.

o VHA Support Service Center data indicating the use of Asynchronous Store and

Forward Telehealth codes for new specialty clinics.

o Leadership- and specialty office-identified priorities or strategic planning.

o Conditions of Participation discussions and data.

2. Connected Care and the Quality and Training Division’s Knowledge Management team collaborate with representatives from VISNs, facilities, stakeholders, and other objective subject matter experts (SMEs) to modify or develop a Connected Care/Telehealth Services specialty supplements, with applicable implementation and operational guidance.

3. If the Telehealth Advisory Board’s Technology Committee (NOTE:This is an internal VA website that is not available to the public) has not already approved the technology, the Knowledge Management Team applies to the committee for technology approval (or to have the program “grandfathered” in) and to determine any need for future technology standardization.

o Future technology will be added to a Blanket Purchase Agreement if not already included in one.

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

4. The Knowledge Management Team collaborates with clinical telehealth health care professional and reader SMEs, Health Informatics Specialists, and Clinical Application http://vaww.telehealth.va.gov/quality/data/index.asp mailto:mailto:VHA12CCCONNECTCAREACADEMY@va.gov http://vaww.telehealth.va.gov/about/contact/index.asp#async https://dvagov.sharepoint.com/sites/VHA-Telehealth/gb/Technology%20Committee.aspx

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

5. After the program is vetted and shared through the Quality and Training Division and VISN Leads and is approved through the Telehealth Advisory Board, the Knowledge Management Team publishes the standardized supplement operations manual and announcements are made to the field through the Telehealth Intranet Site (NOTE:This is an internal VA website that is not available to the public), a VISN Leads call, forums, emails, and so on.

6. Training is drafted by the Quality and Training Division’s Training Team, with competencies defined by the Knowledge Management Team and finalized in collaboration with the Training and Quality Teams and clinical subject matter experts.

7. The National Training Team and specialized SMEs, in collaboration with Telehealth Program Leads and the Quality Team, develop an instructional strategy for how the training and role-based competencies will be facilitated.

8. The Knowledge Management Team in partnership with the Quality Team makes any needed additions to the Conditions of Participation standards, the review process, and the Virtual Care Scorecard to reflect the new program. This may include the addition of criteria and evidence to the Conditions of Participation standards and the addition of data elements to the Virtual Care Scorecard.

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

10. Asynchronous services are considered nationally approved when they are included in the specialty supplements on the Telehealth Intranet Site (NOTE:This is an internal VA website that is not available to the public).

o Note: Many services may not be included in the specialty operations manuals on the Telehealth intranet site but are in the process of being nationally approved.

Asynchronous Store and Forward Telehealth programs and Asynchronous Store and Forward Telehealth workload credit are for new and novel uses of technology and for instances where the telehealth service can replace face-to-face care. There are episodes of care that occur asynchronously but do not receive telehealth credit. These include services that may not be new or novel or may not be able to replace a face-to-face visit (e.g., radiology services, X-rays, and cardiac Holter monitors). The national program office over specific clinical areas and the Office of Connected Care collaboratively determine the approval of new services for telehealth workload credit, workflows, and appropriate staff for the telehealth function for new and proposed services.

Contact the National Asynchronous Telehealth Lead with any questions, and follow the notification processes above for new asynchronous services.

3. Credentialing and Privileging mailto:VHANationalClinicalTemplateWorkgroup@va.gov https://vaww.telehealth.va.gov/ https://vaww.telehealth.va.gov/

3.1. Memorandum of Understanding

Since the establishment of VHA Directive 1914: Telehealth Clinical Resource Sharing Between VA Facilities and Telehealth From Approved Alternative Worksites, memoranda of understanding are no longer required between facilities unless one of those facilities is a non- VA site.

See VHA Directive 1914 for more information on credentialing and privileging. For credentialing and privileging between VA facilities and non-VA sites, see the Telehealth Memorandum of Understanding Template.

3.2. Telehealth Service Agreement

Telehealth Service Agreements (TSA) define the clinical, technical, and business requirements for a clinical telehealth service to operate telehealth services effectively and safely between sites and are required for Asynchronous Store and Forward Telehealth. If the telehealth health care is being provided as an intrafacility effort, then an Intrafacility TSA is required. If the telehealth health care is being provided interfacility, then an Interfacility TSA is required. A Telehealth Service Agreement includes point-of-care guidance, contacts, and procedures for effectively communicating with the entire Asynchronous Store and Forward Telehealth virtual team for every visit. For instance, agreements provide contact information for the Clinical Application Coordinators and the Facility Telehealth Coordinators who are responsible for program administration. Telehealth Service Agreements also include specific clinic setup and stop codes.

For information on how the Telehealth Service Agreement process is managed and automated, see the Telehealth Management Platform Supplement.

3.3. Terms of Service

A Terms of Service (TOS) defines the clinical, technical, and business requirements for a telehealth clinical service delivered from a Nationally Designated Telehealth Hub (NDTH) along with the service's contingency plans and emergency handoff procedures. Comprehensive information regarding TOS and NDTHs can be found in VHA Directive 1915: Enterprise Clinical Resource Sharing through Telehealth from Nationally Designated Telehealth Hubs.

4. Clinic Setup Clinics serve as a mechanism for scheduling patients and connecting workload coding, charting, and other pertinent encounter information. Responsibility for clinic setup varies by facility. See the Telehealth Clinic Setup and Coding Guidance Reference Guide and Closing Same Site SFT https://www.va.gov/VHAPUBLICATIONS/ViewPublication.asp?pub_ID=8807 https://www.va.gov/VHAPUBLICATIONS/ViewPublication.asp?pub_ID=8807 https://www.va.gov/VHAPUBLICATIONS/ViewPublication.asp?pub_ID=8807 https://vaots.blackboard.com/bbcswebdav/library/LibraryContent/Telehealth%20Foundations-Business-Administration/Telehealth%20Memorandum%20Of%20Understanding%20between%20the%20VA%20and%20NON-VA%20Facilities%20%20for%20Credentialing%20and%20Privileging%20(cvt-cp-mou).pdf https://vaots.blackboard.com/bbcswebdav/library/LibraryContent/Telehealth%20Foundations-Business-Administration/Telehealth%20Memorandum%20Of%20Understanding%20between%20the%20VA%20and%20NON-VA%20Facilities%20%20for%20Credentialing%20and%20Privileging%20(cvt-cp-mou).pdf https://vaots.blackboard.com/bbcswebdav/xid-2633328_1 https://vaots.blackboard.com/bbcswebdav/xid-2601000_1 https://vaots.blackboard.com/bbcswebdav/xid-2332514_1 https://vaots.blackboard.com/bbcswebdav/library/LibraryContent/Telehealth%20Management%20Platform/Telehealth%20Management%20Platform-Supplement.pdf https://vaots.blackboard.com/bbcswebdav/xid-2132558_1 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=10116 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=10116 https://vaots.blackboard.com/bbcswebdav/library/LibraryContent/Telehealth%20Foundations-Business-Administration/Telehealth%20Clinic%20Set%20up%20and%20Coding%20Guidance.pdf https://vaots.blackboard.com/bbcswebdav/library/LibraryContent/Asynchronous/Asynchronous-Guidance%20on%20SFT%20Same%20Site%20Workload%20Capture%20(sft_sm_st).pdf

Encounters for more information and the most common Asynchronous Store and Forward Telehealth setup. For information by specialty and modality, see the relevant specialty supplements.

One important part of the clinic setup process is stop codes. Stop codes provide the standardization required to identify the workload for all outpatient encounters, inpatient appointments in outpatient clinics, and inpatient professional services. A current list of stop codes can be found in the Clinic Setup document.

Copay information can be found on the Copay Page on the Telehealth Intranet Site (NOTE:This is an internal VA website that is not available to the public). Copays can vary, depending on the stop code and the specific circumstances of the encounter. For instance:

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

• There is no copay for 718, TeleEye screening.

• As of October 1, 2020, there is no copay for Store and Forward Telehealth health care professional interpretations for any 695 or 696 credit stop codes.

• There is no copay for services paired with the credit stop code 189 for Asynchronous

Store and Forward Telehealth from home when no VA staff are involved.

• For Asynchronous Store and Forward Telehealth from home when VA resources (such as an imager) are used, follow the clinic-based pathways using 694 as a credit stop code on the patient side and clinic setup stop code 695/696 on the telehealth health care professional side.

• Discuss copay questions with your local business office staff or reach out to the National Asynchronous Telehealth Lead for more information if your questions are not answered locally.

5. Clinical Pathways The Asynchronous Store and Forward Telehealth clinical pathways provide guidance on the necessary steps to consider when developing Asynchronous Store and Forward Telehealth programs.

For guidance on the clinical pathways for specific services, see the Specialty Telehealth Operations Manuals and the documents in Connected Care Academy..

5.1. Type of Clinical Service

There are three types of clinical services that telehealth provides; Consultation, Management and Limited Scope Assessments.

https://vaots.blackboard.com/bbcswebdav/library/LibraryContent/Asynchronous/Asynchronous-Guidance%20on%20SFT%20Same%20Site%20Workload%20Capture%20(sft_sm_st).pdf https://vaots.blackboard.com/bbcswebdav/library/LibraryContent/Telehealth%20Foundations-Business-Administration/Telehealth%20Clinic%20Set%20up%20and%20Coding%20Guidance.pdf https://vaww.va.gov/COMMUNITYCARE/bizopsadmin/strategicmgmtpolicy/copayoptcare.asp https://vaots.blackboard.com/bbcswebdav/xid-2770882_1

5.1.1 Consultation

Consultation related to telehealth health care is defined as the provision of advice or recommendations to another health care professional who is responsible for managing the patient's care:

• When distance separates the participants.

• Where hands-on care is delivered at the patient site by a licensed independent health care professional.

5.1.2 Management

Management related to telehealth health care is defined as the provision of care to a patient.

This includes the distant telehealth health care professional writing orders and prescribing medications or treatments to a patient.

A crucial distinction between consultation and management is a consulting telehealth health care professional recommends diagnoses, treatments, and so on to the health care professional requesting the consult but does not write orders or assume the care of the patient.

If the consultant diagnoses, writes orders, or assumes care in any way, this constitutes “care” and requires privileges.

5.1.3 Limited Scope Assessments

Limited scope assessments are defined as when the visit is only meant to investigate and document an assessment and does not include consultation or management decisions (e.g., registry exams, disability medical assessments [compensation-pension exams], etc).

5.2. One-Consult Pathway

The one-consult pathway for Asynchronous Store and Forward Telehealth is as follows:

1. The technician meets with the patient to capture the requested image or data.

2. The technician initiates, updates, or forwards, the consult as appropriate and alerts the specialist telehealth health care professional to have them read and provide a diagnosis or recommendations to the referring health care professional. Note: This step will not work for interfacility consults.

3. The specialist telehealth health care professional enters their analysis and recommendations in the patient record.

4. The specialist telehealth health care professional closes the consult.

5. The referring health care professional is notified that the consult has been completed.

6. The referring health care professional receives the results and the referring health care professional or designee communicates the results with the patient.

Naming conventions for a one-consult process should indicate the consult is for the entire process, not just for imaging, data capture, or reading.

Figure 1: One-Consult Pathway Process https://vaots.blackboard.com/bbcswebdav/xid-685556_1

5.3. Two-Consult Pathway

The two-consult pathway for Asynchronous Store and Forward Telehealth is as follows:

1. An initial consult is generated by the referring health care professional and sent to the technician for the capture of data or images. In the TeleEye program, telehealth imagers may also initiate the consult on behalf of the responsible health care professional, as indicated by the TeleEye reminder and local policy.

2. The technician meets with the patient to gather information and prepare for image/data acquisition.

3. The technician closes the initial consult.

4. A second consult is generated by the technician, and images/data are acquired and sent to the specialist telehealth health care professional to have them read and to provide a diagnosis or recommendation to the referring health care professional.

5. The specialist telehealth health care professional enters their analysis and recommendations in the patient record.

6. The specialist telehealth health care professionals closes the second consult.

7. The referring (or responsible) health care professional is notified that the second consult has been completed.

8. The referring health care professional receives the results, and the referring provider or designee communicates the results with the patient.

Naming conventions must be considered in naming a two-consult process. For direction on these naming conventions, see the appropriate specialty operations manual. The names should make logical sense, indicating the first consult is for capturing and uploading the image/data and the second consult is for the reading or interpreting the image/data.

Figure 2: Two Consult Pathway Process https://vaots.blackboard.com/bbcswebdav/xid-685557_1

5.4. Asynchronous Store and Forward Telehealth into the Home

Mobile apps have been developed for Asynchronous Store and Forward Telehealth. The My VA Images app is an example of a patient-facing app for Asynchronous Store and Forward Telehealth into the Home that is in production today.

The Asynchronous Store and Forward Telehealth into the Home clinical pathway below uses a web-based app for the patient to collect images or data. However, if Asynchronous Store and Forward Telehealth into the Home uses VA resources, such as an imager, it should follow the Two-Consult Pathway.

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

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

For more information on My VA Images, please visit the My VA Images Community on Connected Care Academy.

6. Asynchronous Store and Forward Telehealth Visit The VHA and Telehealth Services are committed to providing a health care environment that supports respect for patients and protects patients’ right to autonomous, informed participation in health care decisions. The essential elements of high-quality health care are noted below. They establish a process for informing patients about telehealth options and obtaining their consent before treatment.

Some key features of high-quality telehealth care are as follows:

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

• The patient has the right to refuse telehealth services.

• Each clinical service obtains oral consent from the patient before the initial telehealth appointment.

• If a telehealth session is part of a research study, written consent must also be obtained following VHA research guidelines. For more information on this requirement, refer to the VA Office of Research.

6.1. Telepresenting

Telepresenting refers to assistance provided to a remote clinician through telehealth technology for a patient’s assessment. Telepresenters also collect data and orient patients to the technology. They collect images and other data during the exam for storing and forwarding to specialists. Depending on the skills and scope of practice needed for the telehealth https://vaots.blackboard.com/bbcswebdav/xid-685557_1 https://vaots.blackboard.com/webapps/login/?action=guest_login&new_loc=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_2480_1 encounter, telepresenting may be completed by a licensed independent provider, a registered nurse, a licensed practical nurse, a Telehealth Clinical Technician, or a specialty-certified technician such as an ophthalmic technician, sleep technician or an audiology technician.

See the Connected Care Academy Telehealth Presenters Community for more information.

6.2. Imaging

Imaging is the act of obtaining telehealth images, videos, or test results as part of an Asynchronous Store and Forward Telehealth program. Examples include but are not limited to operating digital retinal and hand-held imaging systems to acquire a series of images based on a standard protocol related to the Asynchronous Telehealth Specialty. Like telepresenting, imaging may be completed by a wide range of clinicians and technicians, depending on the needs of the Asynchronous Store and Forward Telehealth service.

For more information on dermatology and eye imaging specialties, see the Dermatology Imagers Community and the Eye Care Program Community respectively, on the Connected Care Academy. See the Asynchronous Store and Forward Telehealth Community for a complete list of relative communities.

6.3. Staff Competencies

Both the referring provider and the technician must be constantly aware that they are responsible for the only intervention that takes place directly with the patient. While telespecialties have specific competencies, all Asynchronous Store and Forward Telehealth programs require the following technician and imager competencies:

• Capturing clinical images or data of sufficient quality, according to the appropriate protocol, so that the specialist reader can make an accurate diagnosis and recommendation.

• Following appropriate infection control policies and procedures. VHA Directive 1116(2):

Sterile Processing Services (SPS), provides procedures for decontamination, high-level disinfection, and sterilization of critical and semicritical reusable medical instruments and equipment and for storage of items reprocessed in VA facilities. VHA Directive 1131(5): Management of Infectious Diseases and Infection Prevention and Control Programs, establishes requirements in VA facilities for infectious disease and infection prevention and control programs. For more information, refer to Appendix B: Policies on Quality, in the Telehealth Manual, as well as any relevant local policies.

• Showing images or data to the patient. This should be done immediately after the imaging session, if possible and appropriate for the telespecialty.

• Demonstrating minimum required competencies for patient education which are (1) Educating the patient on the telehealth process and (2) Explaining how the recommendations and results will be communicated to the patient.

https://vaots.blackboard.com/webapps/login/?action=guest_login&new_loc=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_2489_1 https://vaots.blackboard.com/webapps/login/?action=guest_login&new_loc=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_2487_1 https://vaots.blackboard.com/webapps/login/?action=guest_login&new_loc=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_2487_1 https://vaots.blackboard.com/webapps/login/?action=guest_login&new_loc=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_2438_1 https://vaots.blackboard.com/webapps/login/?action=guest_login&new_loc=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_2439_1 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3186 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3186 https://www.va.gov/VHAPUBLICAtIONs/ViewPublication.asp?pub_ID=5616 https://www.va.gov/VHAPUBLICAtIONs/ViewPublication.asp?pub_ID=5616 https://www.va.gov/VHAPUBLICAtIONs/ViewPublication.asp?pub_ID=5616

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

• Following the appropriate steps in the clinical pathway related to the Asynchronous

Telehealth specialty to ensure referrals are received, documentation is appropriately captured and the clinical data and/or images are available for the reader.

• Taking appropriate quality assurance measures while the patient is in the examination room including but not limited to patient identification, ensuring the ordering provider receives the results and recommendations from the reader, verifying all necessary images are viewable in VistA Imaging Display, and ensuring patient images and information do not reside anywhere outside of the medical record or approved technology platforms after the visit.

• Maintaining equipment properly.

To help the patient access Asynchronous Store and Forward Telehealth services, the technician may find or identify patients who meet screening, testing, or clinical reminder requirements (e.g., they may review incoming patients who are due for an at-risk eye Screening). The patient may also be referred by the primary care provider after review (e.g., the primary care provider may refer a patient to TeleDermatology for a teleconsultation). For telemedicine, a specialist may refer a patient for data, images, or other information acquisition where the results come back to the same ordering provider for interpretation and follow-up care (e.g., a specialist may refer a patient for an Asynchronous Store and Forward Telehealth sleep study).

Asynchronous Store and Forward Telehealth staff trainings are available through VHA Telehealth Services from the Office of Connected Care Quality and Training Division. VHA Telehealth Services provides training on business and technology as well as guidance on starting a telehealth program. All the training is modular and has been developed for busy telehealth staff and telehealth health care professionals.

To locate training for your telehealth role or specialty, go to the Asynchronous Store and Forward Telehealth Training Plans by Role.

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

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

3. Select Begin the Training. This will bring you to your training plan, which outlines which training applies to you.

A majority of telehealth training is located on the Talent Management System (TMS). To find a training on this system, open TMS and copy or key in the course ID number into the search box.

This will bring you to your training. Some facilities or telehealth programs will assign training to your TMS My Learning Assignments. Clinicians and other staff should also consult the specialty operational manuals to determine their required training. Some Asynchronous Store and Forward Telehealth specialties will require, for certain roles, skills-based training provided by a telehealth preceptor.

6.4. Scheduling for Clinic-Based Asynchronous Store and

Forward Telehealth

Asynchronous Store and Forward Telehealth encounters require some resources that traditional in-person/face-to-face encounters do not. Among these additional resources at the patient site are:

• VistA Imaging and display.

• Approved technology to capture specific images.

• A telepresenter or imager.

Note: Data and images are read asynchronously. The telehealth health care professional side reading (interpreting), is never scheduled, and the telehealth health care professional side clinic setup does not require a grid to be entered. Instead, the telehealth health care professional enters a note and encounter in the proper telehealth health care professional clinic to do their documentation. This entry includes selecting the day and time of that reading or interpretation (sometimes referred to as an add/edit).

7. VA Telereader Software The Telereader app (or the Cerner Telereader service for sites that have transitioned to Cerner) provides a worklist for local or remote imaging studies that are waiting to be read and interpreted. Asynchronous Store and Forward Telehealth that involves the reading of asynchronous images should use Telereader. For more information on Telereader, see the Telereader user guide. The Cerner manual will be added when available.

8. Documentation It is essential to create encounter forms, progress notes, and consult templates for Asynchronous Store and Forward Telehealth clinic visits. Some guidelines for creating such documentation are as follows:

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

• Include the location title on encounter forms for all visits (e.g., TeleDermatology, TeleEye Care, TeleCardiology) and include the appropriate telehealth encounter codes and modifiers.

• Close routine visits that are not consult-specific visits with a progress note (e.g., Surgical Telehealth Progress Note, Primary Care Telehealth Progress Note).

https://vaots.blackboard.com/bbcswebdav/library/zzarchivefiles/Asynchronous/Asynchronous%20TeleReader%20Configurator%20User%20Guide%20-%20July%202013%20version%202%20(trdr-confg-ug).pdf

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

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

Additional information can be found in the TeleEye Care Supplement.

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

Note: The coding for Asynchronous Store and Forward Telehealth is typically different from the coding for face-to-face care. See the appropriate specialty operations manual that contain specific diagnosis codes and Current Procedural Terminology (CPT) codes. For more information, speak to local coding Health Information Management Service (HIMS) departments.

8.1. Interfacility Documentation

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

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

Another option that meets the requirements for telehealth documentation is the creation of “pointer notes.” In this case, there will be a completed note on the patient side that includes the clinical reminders, orders, and so on, with a corresponding pointer note on the telehealth health care professional side. Pointer notes may be referred to as follow-up notes in TeleEye screening to satisfy clinic reminder requirements in interfacility TeleEye screening.

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

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

8.2. Closing the Patient-Side Encounter

https://vaots.blackboard.com/bbcswebdav/library/LibraryContent/Eye%20Care/Eye%20Care-Specialty%20Supplement.pdf

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

1. Under the visit, select the proper Imager clinic for the service and answer the Service- Connected Condition and any other pertinent or required questions. Selecting the primary care clinic will result in orphans.

2. Select the appropriate Diagnosis Code for the service. See the specialty operations manual for the service for more information.

3. Select the appropriate CPT Code for the action. See the specialty operations manual for specifics.

4. Enter the Imager for the patient-side encounter as the primary provider if this information is not autopopulated.

5. Digitally sign the form.

8.3. Closing the Provider-Side Encounter

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

To close an encounter on the telehealth health care professional side, follow these steps:

1. If the diagnosis codes are not prepopulated, select the appropriate Diagnosis Codes from the form or search function.

2. Enter the Procedure Code. Confirm with local HIMS if the CPT code guidance is not in each specialty supplement. Note: CPT codes for Asynchronous Store and Forward Telehealth are not always the same as the face-to-face CPT codes.

3. In the Visit Related To section, answer the Service-Connected Condition and any other pertinent or required questions.

4. Digitally sign the form.

8.4 Results Reporting

Asynchronous Store and Forward Telehealth involves a pathway in which a consult is answered for clinic-based care and a view alert is sent to the referring provider to alert them of the completed consult. In a consultation model, the referring provider is responsible for following up on recommendations from the consultant and communicating the outcome to the patient, as well as taking any needed next steps for the care plan. In other models, which the consultant assumes responsibility for the care of the patient (such as in a management model), that consultant is the one responsible for communicating results, ordering medications, acting on the recommended care plan, and follow-up care.

With the release of VHA Directive 1915: Enterprise Clinical Resource Sharing through Telehealth from Nationally Designated Telehealth Hubs (NDTHs), the approved NDTHs will begin the https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=10116 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=10116 transition from individual TSAs to a TOS. The TSA will remain essential for all other intrafacility and interfacility telehealth partnerships. The TSA and TOS should clearly outline the responsibilities of the referring and consulting health care professionals for communicating results to patients and acting upon recommendations.

Telehealth staff, including interpreting telereading telehealth health care professionals, should ensure they are aware of the facility results reporting policy outlined in Directive 1088:

Communicating Test Results to Providers and Patients.

In accordance with Directive 1088, diagnostic providers are responsible for:

• Identifying and communicating all critical life-threatening test results and urgent non-life-threatening abnormal test results to the ordering/referring provider or their designee (as determined by each facility’s policies or procedures). See the FAQs on the Communication of Test Results Toolkit SharePoint Site (NOTE: This is an internal VA website that is not available to the public).

• Documenting in the medical record the time and means of communication of critical life-threatening results and the name of the ordering/referring provider or designee informed of these results.

• Ensuring test results reports are available in the patient’s Electronic Health Record as soon as the reports are verified.

Emergency consults should not be placed within Asynchronous Store and Forward Telehealth.

However, if there is any critical, life-threatening result or a suspected critical, life-threatening result, the consultant following Directive 1088 must document in the medical record the time and means of communication of the critical, life-threatening results and the name of the ordering/referring provider or designee informed of the results.

For urgent non-life-threatening abnormal results, the recommended guidelines in telehealth include adding the referring provider as an additional signer or documenting oral or electronic communication to the referring provider in the example situations including but not limited to the below at the consultants determination (this is above and beyond the completed consult and the view alert back to the referring provider):

• Recommended biopsy or action needed within two weeks.

• Serious injury.

• Time-sensitive findings.

For interfacility care, where a consultant cannot add the referring provider as an additional signer, documented oral or electronic communication with the referring provider should be placed in the medical record for the above findings. WebVRAM (Web VistA Remote Access Management) is an option for documenting in the patient’s home medical record and adding the referring provider as an additional signer in an additional note. The Significant Findings option on consults is another option that can be leveraged with closed loop communication.

https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=10366 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=10366 https://dvagov.sharepoint.com/sites/VHAOPCOps/Policy/CTR/SitePages/Home.aspx

Best practices include having an identified staff person at the patient-aligned care team level or location to ensure all consultation recommendations and findings are communicated to the patient and needed actions are taken for the recommended care plan in a teleconsultation model.

It is essential to include a local quality review in auditing actions and oversight to ensure that recommended follow-up and communication to the patient on results received through telehealth are monitored and audited in line with local facility procedures.

9. Workload Validation and Identification of Orphans As telehealth continues to expand, it is imperative to monitor, manage, and track proper coding to ensure the full workload is received for patient visits. Workload validation is essential to maintaining telehealth clinics and should be monitored regularly. All Asynchronous Store and Forward Telehealth visits consist of a patient-site and a telehealth health care professional site encounter match. Visits must have identical primary stop codes and a secondary stop code that reflect the use of telehealth technology. If there is only one encounter that does not follow the Asynchronous Store and Forward Telehealth business rules, this encounter will be labeled an “orphan.” Common causes of Asynchronous Store and Forward Telehealth orphans include:

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

• Documentation was created in a non-telehealth clinic.

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

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

• The Asynchronous Store and Forward Telehealth patient visit documentation was completed after the telehealth health care professional visit documentation.

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

• A telehealth clinic was erroneously used for a non-telehealth visit.

• Multiple encounters or notes were completed for one visit.

• A visit was erroneously marked as historical.

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

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

For information about Asynchronous Store and Forward Telehealth orphans, go to the Telehealth Scorecard in the VSSC Capital Assets Databases. (NOTE:This is an internal VA website that is not available to the public).

https://vssc.med.va.gov/VSSCMainApp/Defaultrsg.aspx https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fTelehealth%2fTelehealthScoreCard&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fTelehealth%2fTelehealthScoreCard&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fTelehealth%2fTelehealthScoreCard&rs:Command=Render

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

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

For non-USB-connected devices:

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

• Ensure latent drives do not contain images.

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

• It is recommended that sites develop a local SOP to set forth expectations if images do not successfully transfer.

For USB-connected devices:

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

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

• It is recommended that sites develop a local SOP to set forth expectations if images cannot be uploaded on the same day and remain on the camera, SD card, or computer workstation.

For other devices that leverage software, follow the instructions provided in the modality-specific training or user manuals.

11. Risk Management Risk management can be defined as a process centered on the identification, analysis, treatment, and evaluation of real and potential hazards. Some matters must be considered to guard against and prepare for patient safety risks. These matters include but are not limited to:

• The safe and effective management of any medical, mental health or behavioral health emergency that might occur during an Asynchronous Store and Forward Telehealth encounter.

https://vaots.blackboard.com/bbcswebdav/library/LibraryContent/Telehealth%20Foundations-Business-Administration/Telehealth%20Workload%20Troubleshooting%20and%20Resolution%20Quick%20Guide%20(orp-trb-rsl).pdf

• Addressing telehealth equipment failures that might prevent the patient and telehealth health care professional encounter from occurring.

• Safe and effective care of patients who are severely immunocompromised and high risk, including the use of standard precautions.

• Notification of critical diagnostic test results.

• Documentation for continuity of care.

There may be a case in which the imager finds an urgent issue to bring to the reader’s or the primary care health professional's attention. If the technician needs to notify a reader or the ordering provider about an issue, they should follow local emergency protocols and the TSA.

Clear and concise documentation is critical to the continuity of care. The technician should always document accurately, following local policy and scope of licensure.

11.1 Emergency Procedures

All patient safety risks and incident must be reported to the local facility Quality, Safety and Value Office following local policies for these events. The local facilities must ensure that telehealth is addressed in the local facility emergency plan. The Office of Connected Care, Telehealth Services has collaborated with the VHA National Center for Patient Safety (NCPS) to enhance the capture of patient safety events reported in the Joint Patient Safety Reporting (JPSR) System that are telehealth specific. The JPSR is an incident reporting system that allows for tracking, trending, and monitoring of self-reported events. The Connected Care Academy Quality University Community contains information related to NCPS and JPSR. For any emergency that occurs during an Asynchronous Store and Forward Telehealth appointment, staff in the appointment are to follow local facility emergency procedures.

For Asynchronous Store and Forward Telehealth into the clinic routinely…