D.19 - Synchronous Telehealth Manual.pdf

VA Telehealth Synchronous Telehealth Manual (Updated December 2022)

1. Introduction to Synchronous Telehealth Synchronous Video Telehealth is a real-time interactive videoconferencing modality through which providers to assess, treat, and provide care to patients remotely. Synchronous Video Telehealth video visits are conducted in hospitals, clinics, homes, or non-VA settings. The patient's location will determine the business, technical, and clinical processes for setting up and delivering care via Synchronous Video Telehealth.

This Synchronous Video Telehealth Manual provides administrative, technical, and clinical guidance when implementing a Synchronous Video Telehealth Clinic. In addition, resources for different telehealth specialties can be found in specialty-specific supplements available on the Connected Care Academy Landing Page and the Veterans Health Administration Telehealth Services Intranet Site.

VA telehealth health care professionals approved for telework must follow teleworking guidelines. Teleworking information can be found in the 2021 Guide to Telework and Remote Work in the Federal Government.

Note: Some of the links in this manual connect to internal VA sites unavailable to the public.

Therefore, if you are an external user you may not have access to all the links.

Clinical Resource Hubs (CRHs) offer a wide variety of clinical services to meet Veterans' needs.

Located in all 18 Veterans Integrated Services Networks (VISNs), CRHs provide primary care, mental health, and specialty care services primarily via telehealth modalities in underserved areas that are experiencing staffing gaps. The CRH mission is to enhance the Veteran experience and wellness through access to high-quality clinical care with a regional health care delivery model. If a Veteran requires telehealth services not available in your facility, the CRH is a great resource to assist you in connecting your Veteran to care across the VISN or nation.

The Clinical Resource Hub SharePoint contains information related to services offered by VISN through the associated CRH. If a patient site is unsure of how to request CRH services, it is recommended to reach out to the respective VISN Telehealth Program Manager/Lead.

2. Synchronous Video Telehealth Administrative Setup For new national telehealth programs using Synchronous Video Telehealth, there are two levels of approval: one at the local level (which includes both the facility and the VISN) and one at the national level.

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Local level approval is required for all uses of Synchronous Video Telehealth. A Synchronous Video Telehealth program with local level approval assumes responsibility and liability for all services and technology within that program.

Nationally approved telehealth programs go through quality, implementation, and development processes with the national telehealth teams. These processes include but are not limited to, vetting technology and equipment, identifying clinical pathways, and creating a specialty supplement that is published on the Connected Care Academy and the VHA Telehealth Intranet Site (Note: This is an internal VA site that is not available to the public). National level approval is a more complex process than local level approval.

Once the facility and the VISN have approved a Synchronous Video Telehealth program, the VISN Telehealth Lead will send an email notification to the Connected Care National Synchronous Telehealth Lead and the Connected Care and Telehealth Services Quality and Training Division. This email will qualify as a notification of the new initiative and will be presented for awareness to the Telehealth Advisory Board. The email should include the program name, purpose, stop codes used for workload capture, clinical pathways, consult pathways, equipment being used (technology and software), security protocols, and metrics used to measure success.

National staff may reach out to local programs to verify which Synchronous Video Telehealth credit stop codes are used by the local program. This assists in evaluating whether the program meets the intent for new Synchronous Video Telehealth programs, and whether it is in line with national quality measures and Conditions of Participation guidelines. Local programs will provide documentation of standard operating procedures or policies for new Synchronous Video Telehealth programs upon request and will utilize the following national level process if deemed appropriate.

A list of current telehealth specialty programs and supplements can be viewed in the Specialty tab on the VHA Telehealth Intranet Site and in the Communities tab on the Connected Care Academy. For specific details on a specialty, refer to the specialty's supplement. Specific individual and group visit information for programs can also be found in the VA Video Connect Community. The information below can be used to implement or expand a new Synchronous Video Telehealth program.

2.1. Idea/Concept Initiation

All ideas/concepts for new Synchronous Video Telehealth programs must first be taken to the Facility Telehealth Coordinator (FTC) (or equivalent) to identify if the program exists locally or if a VISN-wide or national program might fill the need.

2.1.1. Intrafacility Idea

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The FTC will work with the initiator to present and gain endorsement from the appropriate Service Line Chief (SLC). The initiator can then develop a Telehealth Service Needs Assessment/Business Plan after the SLC has tentatively approved.

2.1.2. Interfacility Idea

The FTCs at each facility will complete the approval process. The FTC will work with the initiator to present and gain endorsement from the appropriate Service Line Chief (SLC). In collaboration with the idea initiator and the SLC, the FTC or delegate will present and gain approval from the Chief of Staff. Presenting the Telehealth Service Needs Assessment/Business Plan before the facility medical board reviews is highly recommended. This review and decision can be documented in the facility medical board minutes. See the Terms of Service (TOS) and the Telehealth Service Agreement (TSA) Guidance.

2.2. Telehealth Service Needs Assessment/Business Plan

The Telehealth Service Needs Assessment/Business Plan identifies the program's purpose, resources, and activities needed to achieve the plan. It is also a tool that can be utilized as a systematic method for identifying unmet needs. The Telehealth Service Needs Assessment/Business Plan will contain the program description, coding information, population information, staffing requirements, technology/environmental assessment, program sustainability, and other considerations. The Telehealth Service Needs Assessment/Business Plan may be completed by the FTC or delegate in collaboration with the initiator, the SLC, and leadership over telehealth staff (if the FTC does not have this responsibility).

Note: In some facilities, the Chief of Staff and/or facility leadership may require this step to be completed before approval of the program ides.

2.3. Memorandum of Understanding (MOU)

With the establishment of the VHA Directive 1914: Telehealth Clinical Resource Sharing between VA Facilities and Telehealth from Approved Alternative Worksites, MOUs are no longer required when the telehealth partnership is between VA facilities. When a partnership is being established between a VA facility and a non=VA facility, a Telehealth Memorandum of Understanding between VA and Non-VA Facilities for Credentialing and Privileging is required. A telehealth MOU is an umbrella agreement that authorizes the sharing of clinic services through telehealth between a non-VA site and a VA facility. The telehealth MOU defines the requirements and expectations of sharing credentialing information and authorizes privileging of VA health care professionals using privileging-by-proxy. MOUs set forth the requirement that telehealth providers must have clinical appointments at the providing facility and must be credentialed and privileged in accordance with The Joint Commission and VHA regulatory standards.

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Note: For the purposes of this particular MOU guidance, a non-VA facility does not include Accessing Telehealth Through Local Area Stations (ATLAS). Information specific to the ATLAS program Memorandum of Agreements (MOAs) can be found on the ATLAS intranet site.

2.4. Telehealth Service Agreement (TSA)

A Telehealth Service Agreement is required if the telehealth program does not qualify as a Nationally Designated Telehealth Hub (NDT). A TSA is required for interfacility and intrafacility telehealth. A TSA defines the clinical service, technical and business requirements of the telehealth program, and provides guidance for point of care, emergency handoff procedures, contingency plans, and emergency plans to mitigate risk. A TSA can be an overarching agreement that lists all specialty services telehealth provides or can be an agreement for individual telehealth services. It is recommended to review the communities on the Connected Care Academy to develop the TSA. Any unique local requirements need to be included in the TSA. Each site's FTC must sign the TSA for acknowledgement. The FTC's signature confirms that all required resources are/will be secured and available before the first visit.

2.5. Terms of Service (TOS)

When the VHA Directive 1915: Enterprise Clinical Resource Sharing through Telehealth from Nationally Designated Telehealth Hubs (NDTHs) is released, sites classified as NDTHs no longer must complete a TSA. Instead, the NDTH needs to establish an overarching or individual specialty Terms of Service (TOS) that will apply to the NDTH host VA medical facility and the originating site. The directive enables NDTH health care professionals to deliver health care services through telehealth to patients at any originating sites without recredentialing or re-privileging. Once the NDTH establishes the TOS, it will apply to all facilities choosing to receive telehealth services from the NDTH.

2.6. Technology

Technology meeds may vary depending on the location and type of telehealth visit. The technology should suit the purpose of the visit. The approved technology list can be found on the Telehealth Equipment and Technologies SharePoint. For equipment that has not been nationally approved, local sites assume full responsibility and liability for any issues with the equipment's use during a telehealth visit. For information on installing and configuring technology, refer to the VA Video Connect Fundamentals Intranet Page, the Telehealth Equipment and Technologies SharePoint, or your local Office of Information and Technology staff.

2.7. Gaining Access to Interfacility Electronic Health Records https://vaots.blackboard.com/bbcswebdav/xid-726584_1 https://vaots.blackboard.com/webapps/portal/execute/tabs/tabAction?tab_tab_group_id=_3_1 https://vaots.blackboard.com/webapps/portal/execute/tabs/tabAction?tab_tab_group_id=_3_1 https://vaots.blackboard.com/bbcswebdav/xid-2132558_1 https://dvagov.sharepoint.com/sites/VHA-Telehealth/Lists/equipment/Datasheet.aspx https://vaww.telehealth.va.gov/pgm/vvc/index.asp#fundamentals https://dvagov.sharepoint.com/sites/VHA-Telehealth/Lists/equipment/Datasheet.aspx https://dvagov.sharepoint.com/sites/VHA-Telehealth/Lists/equipment/Datasheet.aspx

When providing telehealth health care across different facilities, there is a need for telehealth health care professionals to have access to multiple Electronic Health Records (EHRs). The VA will continue to maintain VistA, including the Computerized Patient Record System (CPRS) until all VA facilities have implemented the new Electronic Health Record (EHR). Users will leverage the Joint Legacy Viewer (JLV) to communicate record updates made at VA facilities that have already transitioned, to those not yet converted to Cerner.

2.7.1. VistA Access

National Telehealth Program Directors and Telehealth Hub Directors with signed Telehealth Service Agreements (TSAs) and/or Terms of Service in place with VA Medical Facility Directors authorizing remote access to an interfacility Electronic Health Record (EHR) may request a WebVRAM business unit setup by VHA Telehealth Services. WebVRAM enables virtual VA telehealth health care team members authorized by the Program or Hub Director to access remote EHR accounts from all over the country through a single web portal. WebVRAM is helpful for virtual telehealth health care team members who need access to a remote EHR (1) where they do not have a local account on the remote EHR, or (2) where they wish to use the same menu options and keys in their home user profile. Note: Telehealth Program Directors and Telehealth Hub Directors may approve and/or disapprove user account setup requests to use WebVRAM and are responsible for determining which remote EHR stations a user will be granted access. For more guidance, refer to the WebVRAM Management Intranet Page.

2.7.2. Cerner Access

To get access to Cerner, a remote user needs to be provisioned for the site with which they will be working. See the Electronic Health Record Modernization (EHRM) Provider (User Role Assignment) URA and Training Request for a step-by-step guide on the provisioning process and the EHRM contacts needed for assistance. Users at a go-live site would not have to follow this procedure. The EHRM Integration Office Sustainment Resource Center can be accessed to find more information containing the EHRM transition.

2.8. Credentialing and Privileging

Credentialing and Privileging is the responsibility of the Facility Credentialing and Privileging Office which manages all records and communication. This office must be engaged throughout the process and as needs arise. VHA Directive 1914: Telehealth Clinical Resource Sharing between VA Facilities and Telehealth from Approved Alterative Worksites establishes a policy and efficient procedures for sharing telehealth clinical resources between VA medical facilities and clinics. VHA Directive 1915: Enterprise Clinical Resource Sharing through Telehealth from Nationally Designated Telehealth Hubs enables Nationally Disignated Telehealth Hubs (NDTHs) to deliver health care services through telehealth to Veterans at any originating sites without re-credentialing or re-privileging the NDTH telehealth health care professionals at the originating site by establishing "privileging by proxy".

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2.9. Business Processes

All business process guidance (clinic setup, clinic profiles [including stop code guidance], consults, scheduling, documentation, workload coding, and encounter management) can be found in the Telehealth Business Operational Guidance.

2.10. Telehealth Hub

A Telehealth Hub is a clinical and administrative organization at a national, consortia, regional, VISN, or VA medical facility level that facilitates and supports the sharing of telehealth services across VA medical facilities by health care professionals from one or more host VA medical facilities. Examples include Clinical Resource Hubs, TeleCritical Care Hubs, and VISN level Clinical Contact Centers. Each Hub has specific policies and guidelines to follow regarding telehealth clinic implementation.

2.11. Nationally Designated Telehealth Hubs

Nationally Designated Telehealth Hubs (NDTHs) are telehealth Hubs that have been designated by the Assistant Under Secretary for Health for Operations to manage the provision of cross-VA medical facility telehealth services, delivered by NDTH telehealth health care professionals, from one or more host VA medical facilities to any VA medical facility in the enterprise. NDTHs must follow requirements in VHA Directive 1915: Enterprise Clinical Sharing through Nationally Designated Telehealth Hubs.

3. Synchronous Video Telehealth Clinical Guidance

3.1. Before the Visit

Preparation is a critical factor in a successful telehealth visit. Pre-visit preparations for Synchronous Video Telehealth visits may vary by specialty. Please see specific national community guidance by accessing the Connected Care Academy Community Guest Links and following any local facility guidance that is available.

Clinical Preferences - The provider's clinical preferences (e.g., pre-visit labs, x-rays) should be defined in the TSA, TOS, or Intrafacility Service Line approval form.

3.2. During the Visit

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Although a Synchronous Video Telehealth visit can in most instances provide the same service as an in-person visit, there are some factors specific to telehealth visits that must be highlighted. For information on a particular specialty, see the specific Connected Care Academy Community. Details on joining VA Video Connect (VVC) sessions can be found on the VA Video Connect Fundamentals Intranet Page (Note: This is an internal VA site that is not available to the public), the VA Video Connect Web 2 User Guide (for Veterans), and the Veteran Instructions for Tablet Single Use Mode.

1. Camera Etiquette

Practicing good camera etiquette helps the patient's experience in Synchronous Video Telehealth visits mirror their experience in an in-person visit. Patient and provider side camera etiquette includes avoiding any audio or visual distractions such as side conversations or note passing, maximizing the clarity of video and audio transmission by adjusting lighting, camera angle, and seat height to optimize appearance in the self-view feature; maintaining eye contact with the patient and communicating why you need to look away; and using camera features such as presentation mode, pan, tilt, and zoom (when applicable). If a TelePresenter is involved, they should ensure optimal views for both the provider and the patient by ensuring their views are unobstructed using the pan, tilt, and zoom features, and keeping the camera focused on the speaker or material being presented.

2. Space Requirements

It is essential for the patient to feel like the virtual environment is private, confidential, and professional - a safe space. An effective and efficient clinical environment for telehealth visits can positively impact the patient's perception of telehealth and their likelihood of choosing telehealth in the future. Note: The background in the frame should not indicate the provider's location.

3. Privacy

This environment should ensure both audio and video privacy. Headsets, white noise technology, and the strategic positioning of video equipment will increase the privacy of conversations and images. In addition, ensure there are no other non-clinical persons in the vicinity to ensure patient privacy.

4. Background and Personal Appearance

The telehealth health care provider's appearance needs to reinforce professionalism and a sense of privacy for the patient. Consider artwork, clitter, open doors, and any personally identifying information in your background. Ensure the telehealth health care provider has dressed appropriately avoiding patterned clothing or anything with a logo, brand name, or messaging. All personal devices should be turned off during the appointment (cell phones, Alexa, Google Home, etal.).

5. Technology Failures/Disruptions https://vaots.blackboard.com/ https://vaots.blackboard.com/ https://vaww.telehealth.va.gov/pgm/vvc/index.asp#fundamentals https://vaww.telehealth.va.gov/pgm/vvc/index.asp#fundamentals https://vaots.blackboard.com/bbcswebdav/xid-797113_1 https://vaots.blackboard.com/bbcswebdav/xid-604982_1 https://vaots.blackboard.com/bbcswebdav/xid-604982_1

In case of a technology failure and/or disruption, contact the clinic POS/Veteran using the obtained contact information at the start of the visit through the CAPS Lock procedure. The visit will then be completed using the phone or alternate technology.

• VA Video Connect Troubleshooting Tips (geared toward Veterans) provide patients and telehealth health care professionals information on a list of common technology issues and how to troubleshoot them.

• The Telehealth-Health Information Management's Provider Coding and Reference Guide provides guidance on how to document cases when an alternative technology is used to complete the call due to unexpected technical problems. If the provider can assess the patient before the video interruption and completion via audio only, the service will be documented in the progress note as such, and the encounter completed as telehealth with appropriate face-to-face visit codes and modifier 95. If the video capability is not available for the provider assessment of the patient, then the encounter would need to be captured as a telephone encounter.

• After the visit is complete it is encouraged to seek technical support from the Office of Connected Care Help Desk (OCCHD). The OCCHD can be reached at 866-651-3180 or 703-234-4483, 24 hours a day, seven days a week. The OCCHD portal is also available for submitting and tracking tickets. Registration is required to utilize the portal https://status.occhdsupport.ironbow.com/. Click the New User Register Here button if you have not already registered.

• Details on joining VA Video Connect sessions can be found on the VA Video Connect Fundamentals Intranet Page. For information on a particular specialty, see the VHA Telehealth Services Intranet Page or the specific Connected Care Academy Community.

3.3. After the Visit

Much of what happens after the visit is the same as an in-person appointment. Providers must document information concerning the Synchronous Video Telehealth patient visit. For more information on documentation requirements, see the Telehealth Business Operational Guidance and specialty-specific information from the Specialty Communities in the Connected Care Academy. Following a visit, notes are written, the encounter is completed, and the patient receives test results and pertinent education. Ensure the correct Return to Clinic (RTC) orders or follow-up orders are listed in the patient's EHR. Steps on appropriate documentation, closing the encounter, and workload validation are listed in the administrative aspect of this guidance.

4. Synchronous Video Telehealth Groups Group appointments can be conducted through VA Video Connect in the home and the clinic.

On a group's initial call, the provider should have the patients introduce themselves. This will help provide identification and build rapport. The patients participating in the group session may also assist in building rapport with each other. Patients might not all be physically in the https://www.youtube.com/watch?v=edQ8XuU87D0 https://vaots.blackboard.com/bbcswebdav/xid-719219_1 https://vaots.blackboard.com/bbcswebdav/xid-719219_1 https://status.occhdsupport.ironbow.com/ https://vaww.telehealth.va.gov/pgm/vvc/index.asp#fundamentals https://vaww.telehealth.va.gov/pgm/vvc/index.asp#fundamentals https://vaww.telehealth.va.gov/ https://vaww.telehealth.va.gov/ https://vaots.blackboard.com/bbcswebdav/xid-1496876_1 https://vaots.blackboard.com/bbcswebdav/xid-2521265_1 https://vaots.blackboard.com/bbcswebdav/xid-2521265_1 https://vaots.blackboard.com/bbcswebdav/xid-1496876_1 same location and allowing for patient interaction can help improve group cohesion. Here are some resources that provide more detailed information and tools for groups:

• Group Notes documentation

• Group Telehealth Agreement (terms of engagement)

• Telehealth Management Platform: Scheduling VVC Group Appointments

• Telehealth-Health Information Management's Provider Coding and Reference Sheet

• Virtual Care Manager Scheduling Quick Guide

• VA Video Connect Veteran Toolkit

Telehealth staff are responsible for ensuring the following for group visits:

• Appropriate lighting and seating to maintain good video quality.

• Reduction of noise in the group environment.

• Review of terms of engagement at the beginning of the visit.

4.1. Telehealth Into the Home Groups

Synchronous into the Home group appointments can be conducted with patients across many locations. Patients should be screened for social and behavioral health appropriateness before group participation. Patients should also be screened for Synchronous Video Telehealth into the Home readiness and feasibility. Detailed information and resources regarding VVC group visits can be found on the VA Video Connect Groups Website and in the VVC Groups Workflow document.

4.2. Pre-Group Visits

Pre-group visits are recommended to obtain the needed information for a visit and prepare for the future group; this may be done in person, by phone, or via VVC. Before a group visit begins, patients must agree to the terms of the Group Telehealth Agreement (NOTE: This is an internal VA site that is not available to the public).

4.2. Scheduling Group Visits

In the clinic, recurring group visits may be scheduled efficiently via a multi-book request in VSE GUI. Comprehensive information can be found in the VSE Schedulers Training and the Scheduling Groups Intranet Webpage.

4.3. Group Notes

Group notes are a companion to CPRS's Notes tab and assist the provider in documenting group sessions. Some local guidance does not allow for the use of the Group Notes feature; please https://www.va.gov/vdl/application.asp?appid=142 https://vaots.blackboard.com/bbcswebdav/xid-1044499_1 https://vaots.blackboard.com/bbcswebdav/xid-1170153_1 https://vaots.blackboard.com/bbcswebdav/xid-719219_1 https://vaots.blackboard.com/bbcswebdav/xid-512166_1 https://vaots.blackboard.com/bbcswebdav/xid-1179134_1 https://vaww.telehealth.va.gov/pgm/vvc/groups/index.asp https://vaots.blackboard.com/bbcswebdav/xid-1429961_1 https://vaots.blackboard.com/bbcswebdav/xid-1429961_1 https://vaots.blackboard.com/bbcswebdav/xid-1044499_1 https://dvagov.sharepoint.com/:p:/r/sites/VHASchedulingTrainer/Shared%20Documents/Training%20Materials/Official%20SCHEDULER%20Training%20Courses/VSE%20Schedulers%20Training%2008.26.21-508.pptx?d=w521a9369bc50485b9153fbcf7473b45d&csf=1&web=1&e=4ANJSE&nav=eyJzSWQiOjU3NywiY0lkIjo1NjEwODU0MTZ9 http://vaww.telehealth.va.gov/pgm/vvc/groups/scheduling.asp check local facility guidance to determine if this is approved for use. Additional guidance can be found in VHA Directive 1907.01, VHA Health Information Management and Health Records, and the Group Notes/Encounter Collection User Manual.

If a mixed-modality group (mixed audio/video/in-person), please note that the correct clinic and CPT code should be entered for each modality. The Group Note Application may not be the best solution for a mixed-modality group situation. For group visits where multiple providers are serving as facilitators, providers must document in the clinic of the primary provider and add other providers to the encounter form.

5. Tracking Telehealth Encounters Workload

5.1. Reports

Telehealth Services has many data sources. Please see the link to the Telehealth Reports Guide below. Also, note that your facility and VISN may have other reports that capture your telehealth workload.

Telehealth Reports Guide provides valuable links to various reports that Telehealth frequently uses. Helpful reports in this database are Telehealth Scorecard, Home Telehealth Cube, and CVT SFT Telehealth workload Pyramid. Data definitions in each report reveal the purpose, target audience, data description, and instructions on how to run each report.

6. Office of Connected Care Quality Management Team https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9235 https://www.va.gov/vdl/application.asp?appid=142 https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fTeleHealth%2fTelehealthGuide&%25rs%3aCommand=Render

The Office of Connected Care/Telehealth Services Quality program is an evolving effort based on a continuous quality improvement model. This model includes implementing telehealth programs, evaluating and monitoring performance data and outcomes, critically reviewing program operations, and identifying and encouraging the implementation of strong or leading practices nationwide. The Quality program strongly focuses on achieving and sustaining clinical, business, and technology outcomes through Quality Management initiatives. Further information about the Quality Management Program can be found in the Telehealth Manual and Quality University.

7. Laws, Regulations, and VHA Policies All care delivered through telehealth must adhere to federal laws, regulations, and national VHA policy. Links to Telehealth law, regulation, and policy information can be found in the Telehealth Foundations – Business Administration Library and the VHA Telehealth Services Website.

8. Synchronous Video Telehealth in the Hospital Synchronous Video Telehealth into the Hospital involves remote providers delivering care to patients in an inpatient hospital setting due to the need for consultation with specialists at other VA hospitals. Each Telehealth into the Hospital program has built separate guidance regarding establishing, consulting, providing care, and documenting workload. Examples of Synchronous Video Telehealth into the Hospital programs are TeleCritical Care, TeleStroke, and Telehealth to a Community Living Center (CLC).

8.1. Synchronous Video Telehealth into the Hospital

Administrative Guidance

1. Staffing Resources

Staffing resources for Synchronous Video Telehealth into the Hospital will vary by specialty and level of needs determined in the Telehealth Service Agreement and/or the Terms of Service.

The Office of Connected Care recommends that video-to-home clinics be staffed with clinical and administrative support to emulate in person encounters.

2. Consults

Inpatient Consultation is a request for consultative services expected to be completed during an inpatient admission, which must be completed, canceled, or forwarded to the outpatient provider before the patient's discharge. Some outpatient consults may be ordered on patients admitted to acute or long-term inpatient units such as a CLC. All consults must follow VHA Directive 1232 Consult Processes and Procedures.

https://vaots.blackboard.com/bbcswebdav/xid-510063_1 https://vaots.blackboard.com/bbcswebdav/xid-510063_1 https://vaots.blackboard.com/webapps/login/?action=guest_login&new_loc=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_2430_1 https://vaots.blackboard.com/bbcswebdav/xid-692973_1 https://vaww.telehealth.va.gov/index.asp https://vaww.telehealth.va.gov/index.asp https://vaots.blackboard.com/webapps/login/?action=guest_login&new_loc=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_2552_1 https://vaots.blackboard.com/webapps/login/?action=guest_login&new_loc=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_2552_1 https://vaots.blackboard.com/webapps/login/?action=guest_login&new_loc=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_2531_1 https://vaots.blackboard.com/webapps/login/?action=guest_login&new_loc=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_3092_1 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3230 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3230

3. Documentation

For Synchronous Video Telehealth into the Hospital, comprehensive guidance related to documentation is found in the respective specialty supplements. Most appointments will be interfacility and only require the telehealth health care professional to document the patient side of the encounter.

8.2. Synchronous Video Telehealth into the Hospital Clinical

Guidance

1. During the Visit

Each specialty may require a specific set of skills or level of licensure to be present on the patient side of the encounter. The TeleCritical Care, TeleStroke, and Telehealth to a Community Living Center (CLC) communities and associated guidance documents will provide recommendations and requirements for performing Synchronous Video Telehealth into the Hospital appointments. Although a Synchronous Video Telehealth visit can, in most instances, provide the same service as an in-person visit, there are some factors specific to telehealth visits that must be highlighted. A staff member from the patient side team may be needed to re-position the patient or technology as directed by the provider so the provider may adequately assess the patient. At the start of any synchronous video telehealth visit, the telehealth health care professional must verify emergency information through the CAPS-Lock process. The CAPS-Lock process must be documented in a telehealth disclosure in the electronic health record note.

2. CAPS-Lock

It is required that the CAPS-Lock process, described below, be used during every telehealth visit.VA Video Connect Troubleshooting Tips (geared toward Veterans) provide patients and telehealth health care professionals information on a list of common technology issues and how to troubleshoot them.

C – Consent

Obtain or confirm that verbal consent for virtual care has been documented. This is a one-time requirement for the service. The patient must be fully informed of the risks and benefits of virtual care services and procedures. The patient has the right to refuse virtual care services and must be given this option. Informed consent is obtained in accordance with VHA Handbook 1004.01(4), Informed Consent for Clinical Treatments and Procedures. In special situations such as a medical emergency, the patient's consent is implied by law. The practitioner may provide necessary medical care in emergencies without the patient's or surrogate's express consent when the following conditions are met in VHA Handbook 1004.01(4), Informed Consent for Clinical Treatments and Procedures Section 15- Consent in Special Situations.

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A – Address

Verify the location of the patient site to ensure readiness to direct emergency responders to the patient, if necessary. Verify the patient's location within the VA facility (e.g., building number and room number). For Synchronous Video into the Hospital, this verification takes place with a patient-side staff member.

P – Phone Numbers

Verify the primary and alternate phone numbers for the patient site for use in emergency and contingency plans if the visit is disconnected.

S – Survey

Survey the environment and identify all participants in your and the patient's rooms. Confirm camera and audio equipment are in the correct position.

Lock

Lock the virtual medical room once all expected participants have arrived.

3. Managing Emergencies in the Hospital

Emergent and urgent situations require a team effort to ensure provider and patient sites work together to respond to patient needs. Leadership at the Veteran site is responsible for having a facility emergency plan. Leadership at both sites ensures that the staff understands the emergency plan's purpose and content. This includes ensuring that telehealth health care professionals know whom to contact at the patient site and where to find the information to activate the patient site emergency plans.

9. Synchronous Video Telehealth into the Clinic Telehealth technologies can help medical professionals in different locations connect to discuss patients' health care and develop a care plan. Telehealth providers can diagnose, manage care, and perform exams virtually for patients in a clinic, while the provider is at a different location from the patient. The telehealth health care professional can be located at a VA facility or teleworking. If the provider is teleworking, they will often utilize VA Video Connect technology to connect to the Telehealth appointment virtually if they do not have desktop video conferencing equipment available to them. Examples of Synchronous Video Telehealth into the Clinic are TeleAudiology, TeleNutrition, and TeleMental Health. The Office of Connected Care recommends that video-to-home clinics be staffed with clinical and administrative support to emulate in person encounters.

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9.1. Synchronous Video Telehealth into the Clinic

Administrative Set Up

1. Outpatient consultation can be a one-consult process even though it allows for two-way communication between providers. For Synchronous Video Telehealth into the Clinic, an outpatient consultation can be used to request clinical evaluation where the sending provider and receiving provider are under the same parent facility (intrafacility).

2. Interfacility Consultation (IFC) is a request for service between different parent facilities.

The requested results must be returned to the requesting site through the inter-facility consult request and completed when the result is available.

9.2. Synchronous Video Telehealth into the Clinic Clinical

Guidance

1. During the Visit

Although a Synchronous Video Telehealth visit can, in most instances, provide the same service as an in-person visit, there are some factors specific to telehealth visits that must be highlighted.

2. CAPS-Lock

It is required that the CAPS-Lock process, described below, be used during every telehealth visit. The CAPS-Lock process must be documented in a telehealth disclosure in the electronic health record note.

C – Consent

Obtain or confirm that verbal consent for virtual care has been documented. This is a one-time requirement for service. The patient must be fully informed of the risks and benefits of virtual care services and procedures. The patient has the right to refuse virtual care services and must be given this option. Informed consent is obtained in accordance with VHA Handbook 1004.01(4), Informed Consent for Clinical Treatments and Procedures.

A – Address

Verify the location of the patient site to ensure readiness to direct emergency responders to the patient, if necessary. Verify the patient's location (building number/name and room number).

P – Phone Numbers

Verify the primary and alternate phone numbers for the patient clinic site for use in emergent situations.

S – Survey

Survey the environment and identify all participants in your room and the patient's room.

Confirm camera and audio equipment are in the correct position. During a telehealth appointment in the clinic, if a TCT or telepresenter will not be in the room during the visit, ensure that the patient and any other participant in the room or home know how to alert clinic staff in case of an emergency.

Lock

Lock the virtual medical room once all expected participants have arrived. When conducting a telehealth appointment in the clinic, minimize noise outside the clinic room by ensuring the room's door is closed and a sign is posted on the door indicating a telehealth visit is in session.

3. Managing Emergencies in the Clinic

In respect to patient emergencies, telehealth at a Community Based Outpatient Clinic (CBOC) location may differ from in-person care because the treating health care professional may be located remotely and not physically at the patient's location to respond to an emergency (e.g., perform CPR) or activate a local/patient site emergency response (e.g., run out of the room and call for help). Therefore, the remote health care professional needs a process to notify personnel who are physically at the patient's location (onsite personnel) that an emergency is occurring so the onsite personnel can respond and provide the needed emergency care. In the event of a medical, mental, or behavioral health emergency, the Standard Telehealth Emergency Handoff Procedures for Patient Emergencies During Synchronous Video Telehealth Visits into a VA Clinic ensures that telehealth health care professionals know the patient's location and have the phone numbers and/or access to alternate communication tools to contact onsite personnel at the patient's location. VISN Leads and FTCs are responsible for working with local facility Quality and Patient Safety Officers to develop the facility contact information list in Virtual Care Manager (VCM) and add other critical facility contact information. Detailed instructions can be found in the VCM Facility Contact Information Configuration Guide and the VCM Facility Contact Provider Guide.

The Synchronous Video Telehealth Emergency Procedure Scenario Guide details how a remote health care professional activates emergency resources at the patient's location in a medical or behavioral health emergency. Emergency resources may include facility staff at the patient's location or a 911 emergency activation at the patient's site.

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10. Synchronous Video Telehealth into the Home Synchronous Video Telehealth into the Home enhances the accessibility of care. It enables the patients and providers to connect through the VA Video Connect (VVC) app as an alternative to in-person care. With special consideration for safety and privacy, providers can make a diagnosis, perform follow-ups, and see the patient at their chosen location. The Office of Connected Care recommends that video-to-home clinics be staffed with clinical and administrative support to emulate in person encounters. The VA Video Connect Website provides an in-depth overview of VA Video Connect processes, Virtual Care Manager, and VA Video Connect Now. Examples of Synchronous Video Telehealth into the Home are TeleChaplain, TeleMental Health, and TeleGenomics.

10.1. Synchronous Video Telehealth into the Home

Administrative Set Up

Technology needs vary from patient to patient. There are two categories of technology utilized during a Synchronous Video Telehealth into the Home visit:

10.1.1. Patient Owned Technology

Patients can utilize personally owned devices that are video capable and have internet connectivity (e.g., smartphone, personal computer, etc.). The VVC Veteran Tool Kit provides in-depth information to assist patients in connecting to a VVC appointment.

10.1.2. Patient Loaned Technology

To help patients cross the digital divide, the Office of Connected Care has made loaned devices available to patients through the Digital Divide Consult. To qualify for a VA loaned device, the patient cannot have their own video-capable device and/or connectivity and must meet one or more of the clinical criteria on the Digital Divide Consult. The provider who intends to see the Veteran via VA Video Connect may place a Digital Divide consult to initiate the process.

The Digital Divide Consult SOP has in-depth information containing the history and initiation of the consult.

10.2. Synchronous Video Telehealth into the Home Clinical

Guidance

1. Before the Visit https://vaww.telehealth.va.gov/pgm/vvc/index.asp https://vaww.telehealth.va.gov/pgm/vvc/index.asp https://vaots.blackboard.com/webapps/login/?action=guest_login&new_loc=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_2491_1 https://vaots.blackboard.com/webapps/login/?action=guest_login&new_loc=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_2508_1 https://vaots.blackboard.com/webapps/login/?action=guest_login&new_loc=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_2503_1 https://vaots.blackboard.com/bbcswebdav/xid-1179134_1 https://vaots.blackboard.com/bbcswebdav/xid-714516_1

In preparing for a Synchronous Video Telehealth into the Home visit, follow specific Guidance, as well as local facility guidance. The VA Video Connect Fundamentals Website lists critical items to consider and processes to follow when preparing, starting, and completing the VA Video Connect Visit.

a. Test calls for VA Video Connect can be conducted in four ways:

• Patients contact the clinic

• Patients contact Help Desk: Contact the Office of Connected Care Help Desk (OCCHD) to conduct a test call with a help desk technician. Use the Help Desk Portal or call 866-651-3180

• Patients with VA Loaned Devices utilize the Connected Device Support Program

• Once logged into the Help Desk Portal, the patient uses Chatbot to guide them

b. Joining the Visit. A step-by-step guide for providers and clinicians can be found in the VVC Web Provider Guide. There are two options for joining a Synchronous Video Telehealth into the Home appointment: the VCM application and the VVC scheduling email notification. When connected to the VVC platform, you may be asked to configure your settings (including identifying how your name will be displayed to the patient) and approve the use of a microphone and camera

2. During the Visit

Although a Synchronous Video Telehealth visit can, in most instances, provide the same service as an in-person visit, there are some factors specific to telehealth visits that must be highlighted.

3. CAPS-Lock

It is required that the CAPS-Lock process, described below, be used during every telehealth visit. The CAPS-Lock process must be documented in a telehealth disclosure in the electronic health record note.

C – Consent

Obtain or confirm that verbal consent for virtual care has been documented. This is a one-time requirement for your service. The patient must be fully informed of the risks and benefits of virtual care services and procedures. The patient has the right to refuse virtual care services and must be given this option. Informed consent is obtained in accordance with VHA Handbook 1004.01(4), Informed Consent for Clinical Treatments and Procedures.

A – Address

Obtain or confirm the patient's present location and address. Ensure the location is private and safe.

P – Phone Numbers https://vaww.telehealth.va.gov/pgm/vvc/index.asp#fundamentals https://occhdsupport.ironbow.com/dva https://occhdsupport.ironbow.com/dva tel:1-866-651-3180 https://vaww.telehealth.va.gov/technology/devices/cds.asp https://occhdsupport.ironbow.com/dva https://vaots.blackboard.com/bbcswebdav/xid-711099_1 https://vaots.blackboard.com/bbcswebdav/xid-711099_1

Obtain and confirm the patient's phone number that can be used in case of technological disruption (e.g., losing connectivity) that requires the visit to be completed via the telephone. The provider will share the facility phone number with the patient which can be used in case of a provider emergency. If others are present, it is recommended to obtain their name(s) and phone number(s).

S – Survey

Survey the patient's environment and address the findings that contribute to a patient…