D.21 - Telehealth Business Operational Guidance.pdf

VA Telehealth

Telehealth Business Operational Guidance (Updated October 2022)

1. Purpose and Authority

The Office of Connected Care provides operational guidance on the business procedures required to implement VA Telehealth programs. This guidance sets forth mandatory business requirements for all Veterans Affairs (VA) medical facilities, telehealth health care professionals, and staff using synchronous and asynchronous telehealth to deliver care to Veterans. This guidance must be followed by all Facility Telehealth Coordinators (FTCs), VA Leadership, and all VA employees involved in establishing VA Telehealth programs. Business requirements for Remote Patient Monitoring-Home Telehealth are found in the Remote Patient Monitoring-Home Telehealth Operations Manual.

The VA is undergoing an Electronic Health Record (EHR) Modernization, transitioning from VistA to VA's new EHR system. This document contains guidance related to both the VA's new EHR and VistA/CPRS at the time of publishing. Additional guidance will be added to the Electronic Health Record Community as information and workflows are created. This information is authored by the Electronic Health Record Modernization Leadership and linked to the EHR Modernization SharePoint.

2. Definitions

a. Asynchronous Telehealth: 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.

Comprehensive information can be found in the Asynchronous Store and Forward Telehealth Manual

b. Clinical Application Coordinator (CAC): The Clinical Application Coordinator supports the daily interface between clinicians and the Veterans Health Information Systems and Technology Architecture (VistA) Electronic Health Record (EHR). (VistA User Manual).

c. Clinic Profile Manager: The Clinic Profile Manager coordinates clinical/provider profiles and scheduling grids, including clinic setup and maintenance in VistA. Clinic Profile Managers establish profiles to ensure the clinic structure allows for the scheduling of patients, direct workload capture, accurate access times, direct insurance, copay billing, and direct Managerial Cost Accounting (MCA) costing. In addition, it works with services to monitor grid validation and train other staff on how to request clinic setup, cancellation, and modifications through an electronic process using a clinic profile template.

d. Connected Care Academy: Connected Care Academy is the knowledge management platform of the VA Office of Connected Care and Telehealth Services' Quality, Training, and https://vaots.blackboard.com/webapps/login/?action=guest_login&new_loc=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_3041_1 https://vaots.blackboard.com/webapps/login/?action=guest_login&new_loc=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_3041_1 https://vaots.blackboard.com/bbcswebdav/xid-685564_1 https://vaots.blackboard.com/bbcswebdav/xid-685564_1 https://www.va.gov/vdl/documents/Clinical/VistaWeb/vistawebusermanual.pdf https://www.va.gov/vdl/documents/Clinical/VistaWeb/vistawebusermanual.pdf https://dvagov.sharepoint.com/sites/vhaovac/cpm/VHA%20Directive%20Resources/Forms/AllItems.aspx?id=%2Fsites%2Fvhaovac%2Fcpm%2FVHA%20Directive%20Resources%2FClinic%20Profile%20Management%20Guidebook%2Epdf&parent=%2Fsites%2Fvhaovac%2Fcpm%2FVHA%20Directive%20Resources https://dvagov.sharepoint.com/sites/vhaovac/cpm/VHA%20Directive%20Resources/Forms/AllItems.aspx?id=%2Fsites%2Fvhaovac%2Fcpm%2FVHA%20Directive%20Resources%2FClinic%20Profile%20Management%20Guidebook%2Epdf&parent=%2Fsites%2Fvhaovac%2Fcpm%2FVHA%20Directive%20Resources

Knowledge Management Division. This Platform is the ultimate source for the latest VA telehealth training and guidance resources. Connected Care Academy Quick Start Guide

e. Facility Telehealth Coordinator (FTC): The Facility Telehealth Coordinator ensures that the implementation of telehealth services at the VA medical facilities adheres to National Telehealth Quality Conditions of Participation Standards and follows VHA policies and guidelines. The FTC ensures that only approved telehealth technologies are acquired and used for telehealth appointments. The FTC manages and monitors the day-to-day business aspects of a Telehealth program. (Synchronous Telehealth Manual)

f. Facility Scheduling Business Owner: The Facility Scheduling Business Owner minimizes and monitors access to the Scheduling Options for scheduling appointments, menu options, and recall entries to ensure staff competency in performing these duties. The scheduling business owner also completes timely appointment cancellation requests. (Appointment Management Business Rules)

g. Health Information Management System (HIMS) Department: The Health Information Management System Department maintains, collects, and manages health records. HIMS ensures timely and accurate delivery of data to health care providers. In return, the health care providers rely on the information that HIMS provides to deliver quality health care. The HIMS Department also provides record analysis, transcription support, coding, and compliance reviews. (Clinic Profile Management Guidebook)

h. Inpatient Consultation: Impatient Consultation is a request for consultative services expected to be completed during an inpatient admission in VistA/CPRS. Some outpatient consults may be ordered on patients admitted to acute or long-term inpatient units such as a Community Living Center. (VHA Directive 1232 Consult and Processes and Procedures) In the VA's new EHR system, a "Consult" is for an inpatient Veteran, and "Referral is for an outpatient Veteran

i. Interfacility Telehealth: Interfacility telehealth is telehealth care provided to a different parent facility or associated Community Based Outpatient Clinic (CBOC). Example: two locations with separate physical addresses and patient station identification numbers.(Synchronous Telehealth Manual)

j. Interfacility Consultation (IFC): Interfacility Consultation is a request for service between different parent facilities in VistA/CPRS. The IFC must either be an outpatient clinical consultation or clinical communications. The results must be returned to the requesting site through the interfacility consult request and completed when the result is available. (VHA Directive 1232 Consult and Processes and Procedures)

k. Intrafacility Telehealth: Intrafacility telehealth is telehealth care provided within a facility, health care system, same parent station, or two locations with separate physical addresses in the same parent station i.e.telehealth services between a main facility and its outpatient clinics https://vaots.blackboard.com/bbcswebdav/xid-1128988_1 https://vaots.blackboard.com/bbcswebdav/xid-774214_1 https://dvagov.sharepoint.com/:b:/r/sites/vhaovac/cpm/VHA%20Directive%20Resources/Appointment%20Management%20Business%20Rules_11-15-2022.pdf?csf=1&web=1&e=QwuTz9 https://dvagov.sharepoint.com/:b:/r/sites/vhaovac/cpm/VHA%20Directive%20Resources/Appointment%20Management%20Business%20Rules_11-15-2022.pdf?csf=1&web=1&e=QwuTz9 https://dvagov.sharepoint.com/sites/vhaovac/cpm/VHA%20Directive%20Resources/Forms/AllItems.aspx?id=%2Fsites%2Fvhaovac%2Fcpm%2FVHA%20Directive%20Resources%2FClinic%20Profile%20Management%20Guidebook%2Epdf&parent=%2Fsites%2Fvhaovac%2Fcpm%2FVHA%20Directive%20Resources https://www.bing.com/ck/a?!&&p=d791b280ab51b4446fc094a18eb040c0520629b33ddfb8ac0ee2a78a70181445JmltdHM9MTY1MjcxMTA2OSZpZ3VpZD0xMTQxMTY4Ni0xOWYzLTQwMGItYjU0NS1iZmE5ZTJmZDZkNTEmaW5zaWQ9NTE2MA&ptn=3&fclid=e59ee200-d523-11ec-904c-a13150df37f9&u=a1aHR0cHM6Ly93d3cudmEuZ292L3ZoYXB1YmxpY2F0aW9ucy9WaWV3UHVibGljYXRpb24uYXNwP3B1Yl9JRD0zMjMw&ntb=1 https://vaots.blackboard.com/bbcswebdav/xid-774214_1 https://vaots.blackboard.com/bbcswebdav/xid-774214_1 https://www.bing.com/ck/a?!&&p=d791b280ab51b4446fc094a18eb040c0520629b33ddfb8ac0ee2a78a70181445JmltdHM9MTY1MjcxMTA2OSZpZ3VpZD0xMTQxMTY4Ni0xOWYzLTQwMGItYjU0NS1iZmE5ZTJmZDZkNTEmaW5zaWQ9NTE2MA&ptn=3&fclid=e59ee200-d523-11ec-904c-a13150df37f9&u=a1aHR0cHM6Ly93d3cudmEuZ292L3ZoYXB1YmxpY2F0aW9ucy9WaWV3UHVibGljYXRpb24uYXNwP3B1Yl9JRD0zMjMw&ntb=1 https://www.bing.com/ck/a?!&&p=d791b280ab51b4446fc094a18eb040c0520629b33ddfb8ac0ee2a78a70181445JmltdHM9MTY1MjcxMTA2OSZpZ3VpZD0xMTQxMTY4Ni0xOWYzLTQwMGItYjU0NS1iZmE5ZTJmZDZkNTEmaW5zaWQ9NTE2MA&ptn=3&fclid=e59ee200-d523-11ec-904c-a13150df37f9&u=a1aHR0cHM6Ly93d3cudmEuZ292L3ZoYXB1YmxpY2F0aW9ucy9WaWV3UHVibGljYXRpb24uYXNwP3B1Yl9JRD0zMjMw&ntb=1 at different locations but hosted under the same station identifier code (e.g., Medical Center A Station 111 to Community-Based Outpatient Clinic A Station 111) and in compliance with Directive 1914. Example: The telehealth health care professional is in the medical center providing services to one of its associated Community-Based Outpatient Clinics (CBOCs). NOTE: Intrafacility TSAs are also used for the provision of telehealth services when a patient and provider are at two different locations on the same VAMC campus. (Synchronous Telehealth Manual)

l. Managerial Cost Accounting Office (MCAO) Staff: Managerial Cost Accounting Office Staff reviews labor mapping of active and inactivated clinics, making appropriate changes following MCAO guidelines. In addition, MCAO assigns stop codes to newly established or modified clinics and conducts an annual review of all active clinic profiles, ensuring the accuracy of MCAO codes and making labor mapping adjustments as needed. The Business Process for Stop Codes further defines the Managerial Cost Accounting Staff

m. Nationally Designated Telehealth Hubs (NDTH): 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

n. Outpatient Consultation is a request for clinical evaluation where the sending provider and receiving provider are in the same parent facility using VistA and the receiving provider is treating the patient in an outpatient setting in VistA/CPRS. NOTE: outpatient consults include virtual care and can be ordered while patients are admitted to an inpatient unit or emergency department. Oracle Cerner uses Consults when patients are in inpatient status. (VHA Directive 1232 Consult and Processes and Procedures)

o. Referrals are entered using a Care Pathway to ensure that necessary information to determine clinical appropriateness is available, and prerequisites are completed in advance of scheduling in Oracle Cerner. (VA and Cerner Lexicon)

p. Synchronous Telehealth is a real-time interactive videoconferencing modality through which telehealth health care professionals remotely assess, treat, and provide care to a beneficiary.

Synchronous telehealth visits are conducted in the hospital, the clinic, the home, or another non-VA setting and sometimes use supportive peripheral technologies. Comprehensive information can be found in the Synchronous Telehealth Manual

q. Telehealth health care professional is a VA health care professional who is credentialed and assigned privileges, a scope of practice or a functional statement, as appropriate for their occupation. Examples include, but are not limited to physicians, social workers, and dieticians. VHA Directive 1914, Telehealth Clinical Resource Sharing Between VA Facilities and Telehealth from Approved Alternative Worksites https://vaots.blackboard.com/bbcswebdav/xid-774214_1 https://vaots.blackboard.com/bbcswebdav/xid-774214_1 http://vaww.dss.med.va.gov/DSS%20Documents/DSS%20Identifiers-Stopcodes/Business%20Process%20for%20Stop%20Codes.docx https://www.bing.com/ck/a?!&&p=d791b280ab51b4446fc094a18eb040c0520629b33ddfb8ac0ee2a78a70181445JmltdHM9MTY1MjcxMTA2OSZpZ3VpZD0xMTQxMTY4Ni0xOWYzLTQwMGItYjU0NS1iZmE5ZTJmZDZkNTEmaW5zaWQ9NTE2MA&ptn=3&fclid=e59ee200-d523-11ec-904c-a13150df37f9&u=a1aHR0cHM6Ly93d3cudmEuZ292L3ZoYXB1YmxpY2F0aW9ucy9WaWV3UHVibGljYXRpb24uYXNwP3B1Yl9JRD0zMjMw&ntb=1 https://www.bing.com/ck/a?!&&p=d791b280ab51b4446fc094a18eb040c0520629b33ddfb8ac0ee2a78a70181445JmltdHM9MTY1MjcxMTA2OSZpZ3VpZD0xMTQxMTY4Ni0xOWYzLTQwMGItYjU0NS1iZmE5ZTJmZDZkNTEmaW5zaWQ9NTE2MA&ptn=3&fclid=e59ee200-d523-11ec-904c-a13150df37f9&u=a1aHR0cHM6Ly93d3cudmEuZ292L3ZoYXB1YmxpY2F0aW9ucy9WaWV3UHVibGljYXRpb24uYXNwP3B1Yl9JRD0zMjMw&ntb=1 https://dvagov.sharepoint.com/sites/oehrm_cerner/Lex https://vaots.blackboard.com/bbcswebdav/xid-774214_1 https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fvaww.telehealth.va.gov%2Fresources%2F1914%2Findex.asp&data=05%7C01%7C%7C104962a2088649d37c4308dabe9c3a57%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638031875438238801%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=juce6B7r%2ByAK0yihllhwGMCV9A4txW9zvGq0WyBaljs%3D&reserved=0 https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fvaww.telehealth.va.gov%2Fresources%2F1914%2Findex.asp&data=05%7C01%7C%7C104962a2088649d37c4308dabe9c3a57%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638031875438238801%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=juce6B7r%2ByAK0yihllhwGMCV9A4txW9zvGq0WyBaljs%3D&reserved=0

r. User Role Assignment Coordinator supports the coordination of the assignment of end-user roles within the Electronic Health Record Modernization (EHRM) at their local facility, including respective community-based outpatient clinics (CBOCs), and works directly with the Change Leadership Team (CLT). (VA and Cerner Lexicon)

3. Agreements and Authorization to Provide Care

All VA health care professionals must be authorized to provide care through credentialing and privileging, following VHA Directive 1100.20, Credentialing of Health Care Providers. Additionally, prior to initiating care through telehealth to patients, VHA Directive 1914, Telehealth Clinical Resource Sharing Between VA Facilities and Telehealth from Approved Alternative Worksites and VHA Directive 1915, Enterprise Clinical Resource Sharing Through Telehealth from a Nationally Designated Telehealth Hub (NDTH) require that an approved Telehealth Service Agreement (TSA) is in place or care is requested through an approved Terms of Service (TOS). These directives specify the unique credentialing process related to health care professionals providing care via telehealth. Fee-basis and without compensation health care professionals are appointed and credentialed as VA employees and must adhere to all standards and applicable policies for providing health care within VA. VA-contracted telehealth health care professionals are not covered by VHA Directive 1914 and 1915 and will need legal guidance to review each use case.

In an individual urgent patient care situation where a VA health care professional can provide or support care to a patient located at another VA Medical Center (VAMC) through telehealth but there is no approved TSA or TOS in place, the process for requesting waivers to VHA policies is outlined in VHA Directive 1023, Waivers to VHA National Policy. Guidance on the process for waivers is provided in documentation on the Waivers to VHA Policy SharePoint site.

During a national, regional, or local emergency or disaster, VA facilities will follow VHA Directive 1100.21(1), Privileging, sections 6.h. "Temporary Privileges for Important Patient Care Needs," 6.i. "Disaster Privileges", and 6.k. "Privileging by Proxy," which informs the minimum standards for continuity of care and would also be applicable for telehealth-based care. Privileging by Proxy is only allowable for provision of telemedicine services and Disaster Privileges can only be granted when such a process is described in a VA facility's Medical Staff Bylaws and emergency management plan.

3.1. Telehealth Service Agreement (TSA):

TSAs are required for all synchronous and asynchronous telehealth programs except those that are offered by an NDTH under a TOS. TSAs are used to define the clinical, technical, and business requirements, including scheduling, closing encounters, emergency handoff https://dvagov.sharepoint.com/sites/oehrm_cerner/Lex https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9444x https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9444x 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://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=10116 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=10116 http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=11711 https://dvagov.sharepoint.com/sites/VACOVHACBI/VHAPolicyWaivers/SitePages/FAQs.aspx http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=10179 http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=10179 procedures, and contingency plans for a clinical telehealth service to operate services effectively and safely between sites. There are two types of TSAs - Interfacility and Intrafacility.

• Interfacility: An Interfacility Telehealth Service Agreement (TSA) is used by facilities and Telehealth Hubs (i.e., Clinical Resource Hubs and National Telehealth Centers and Programs) to provide telehealth services between locations when the providing and receiving sites are not hosted under the same station identifier code (e.g., Medical Center A Station 111 to Medical Center B Station 222) and in compliance with VHA Directive 1914, Telehealth Clinical Resource Sharing Between VA Facilities and telehealth from Approved Alternative Worksites.

• Intrafacility: An Intrafacility Telehealth Service Agreement (TSA) is used by individual facilities to provide telehealth services between a main facility and its outpatient clinics at different locations but hosted under the same station identifier code (e.g. Medical Center A Station 111 to Community-Based Outpatient Clinic A Station 111) and in compliance with VHA Directive 1914. NOTE: Intrafacility TSAs are also used for the provision of telehealth services when a patient and provider are at two different locations on the same VAMC campus.

A TSA is required for both synchronous and asynchronous telehealth, whether providing interfacility VA care or care to a non-VA partnership site. An interfacility TSA is required if telehealth care is provided to a patient in their home when that patient is enrolled at a different site than the health care professional's site. An exception to this guidance would be intrafacility VA Video Connect (VVC) which does not require a TSA.

When creating a new TSA, the list of all specialty services that are approved to be provided between the two sites should be included in the body of the TSA. Each specialty must have a corresponding appendix, ordered alphabetically for ease of review, which describes the service to be provided and any requirements specific to that service. Appendices listed should only be those that are agreed upon between sites of care.

The TSA template includes links to the required National Telehealth Emergency Handoff Standard Operating Procedures (SOPs). If the facility has service-specific Telehealth Emergency Handoff Procedures in addition to the national SOPs, these additional facility-level SOPs must be included in the appendices. The Telehealth Technology Contingency Plans must also be described and/or linked in the TSA. NOTE: There is not a requirement to have service-specific Telehealth Emergency Handoff Procedures if the national procedures are sufficient for the program.

For appropriate scheduling and workload capture, the clinic information needs to be linked or listed in the TSA for review and approval so that appropriate clinics are created in the EHR before providing telehealth services. NOTE: Guidance for sites using VA's new EHR can be found on Connected Care Academy in the VA's new EHR Community.

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A TSA contains an overarching informational section regarding standard site names, clinical services, and service-specific appendices. Any unique, local requirement needs to be included in the TSA. Reviewing the Telehealth Foundational Resources Home Page and the VHA Directive 1914 Community to develop the TSA is recommended.

Per VHA Directive 1914, TSAs may reference the location of information instead of embedding this information within the body of the TSA, particularly in cases where the information is subject to change. While this referenced, shared location is optional for TSAs, it is highly encouraged as a strong practice for easy storage and editing purposes. The referenced, shared location, for example, a SharePoint or intranet site, must be accessible by all VHA staff so that all individuals involved in remote/virtual care can access the information as needed. Some examples of information that would be appropriate to reverence within the TSA as being stored in a shared location include the list of health care professionals who are providing remote/virtual care, the list of service specific contacts and local Technology Contingency or other Standard Operating Procedures (SOPs). For guidance on setting up a SharePoint site, see section 3.3 SharePoint Creation below.

Telehealth between VA and a non-VA site, including synchronous and asynchronous telehealth, requires both a TSA and a Memorandum of Understanding (MOU). NOTE: See Section 3.4 Memorandum of Understanding below.

Based on VHA Directive 1232(5) Consult Processes and Procedures , TSAs follow the Care Coordination Agreement guidelines and must be reviewed or updated as changes are needed, at a minimum annually. At the time that a TSA is due for annual review, it must be updated using the newest versions of the TSA templates. Facility Telehealth Coordinators (FTCs) must review the new TSA templates and compare with any current TSAs to ensure that if any critical item in the new templates is missing from current signed TSAs, that this new requirement is addressed in an addendum to the TSA.

If at any time it is determined that a major change is required for a TSA, a new TSA must be initiated and routed for approval. If minor changes are required, then the changes can be made during the annual review process without initiating a new TSA and routing for approval.

Definitions of major and minor changes, and those changes that are up-to-facility discretion are listed below:

3.1.1. Major Changes to the TSA include modifications to the

information in the following fields:

• Originating Site

• Distant Site

• Clinical Services to be delivered

• Scheduling information - the site responsible for scheduling

• Telehealth modalities to be used https://vaots.blackboard.com/webapps/login/?action=guest_login&new_loc=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_2376_1 https://vaots.blackboard.com/webapps/login/?action=guest_login&new_loc=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_3222_1 https://vaots.blackboard.com/webapps/login/?action=guest_login&new_loc=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_3222_1 https://vaots.blackboard.com/bbcswebdav/xid-2521265_1#33-SharePoint-Creation https://vaots.blackboard.com/bbcswebdav/xid-2521265_1#34-Memorandum-of-understanding https://vaots.blackboard.com/bbcswebdav/xid-2521265_1#34-Memorandum-of-understanding http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=3230

• Intended care settings

• Intended care locations

• Clinical Service type - consultation, management, limited scope assessments

• Use of health professional trainees

• Specialty telehealth operations manuals

• Admission, discharge, and exclusion criteria

• Ordering provider for clinical studies, images, and/or laboratory tests before the first telehealth appointment

• Results reporting for asynchronous telehealth

• Service-specific telehealth emergency handoff procedures

• Service-specific training requirements

• Service-specific scheduling requirements

• Patient site space requirements

• Ancillary/other service requirements

• Veteran personal technology requirements

• Clinical documentation and communication requirements

• Staffing requirements (patient site)

• Controlled substance prescribing

• Clinic set up and stop codes

• Additional requirements for technology and software

• Other information and requirements (service-specific workflows, processes, or SOPs)

• Other service-specific requirements not addressed elsewhere

3.1.2. Minor Changes to the TSA include modifications to the

information contained within the following fields:

• Contact information - distant and originating site personnel

• List of participating telehealth health care professionals

• Service-specific points of contact

• Space requirements (distant site)

3.1.3. Modifications that may fall into either major or minor categories based on their impact for services provided:

Some modifications to the TSA may fall into either the major or minor category based on their impact on the services provided. These changes are left to the discretion of the collaborating sites to identify whether modifications to the information contained within the following fields should be considered major or minor:

• Standard technology contingency plan facility processes

• Scheduling platform

• Patient registration process

• Quality oversight report

• Other general workflows, processes, or SOPs

• Service descriptors - short-term, long-term

• Service-specific technology contingency plans

• Hours of operation

• Appointment duration

• Equipment/technology requirements (patient site)

• Equipment/technology requirements (distant site)

• Service test session

The Originating Site and the Distant Site FTCs (or delegates) are to confirm that the TSA is complete before moving forward for review and approval and that the appropriate required training is complete. The FTC's signature does not approve the agreement. If the local facility decides to skip the FTC review portion, they must document this decision in the signature section. If the FTC does not sign the TSA, the onus of responsibility to ensure the TSA is complete and accurate will fall to the next higher level of signature. Local facilities can delegate the FTC review portion at their discretion. Options for delegation could be the Deputy FTC, Lead Telehealth Clinical Technician (TACT), or a position of the same stature and responsibilities or higher.

For approval, a TSA must be signed by both the patient site Chief of Staff and provider site Chief of Staff and/or Clinical Resource Hub (CRH) Director. The Chief of Staff and/or CRH Director signatures cannot be delegated to other individuals. The signatures can be completed by an individual that is in an acting role for the Chief of Staff or CRH Director.

A TSA may be cancelled by the providing or the receiving site of care at any time and for any reason with the approval of the appropriate facility and/or VISN leadership. A TSA can be canceled by contacting the appropriate Chief of Staff and/or Telehealth Hub Director listed in the approval section of the agreement. Notably and per policy, in the event there is an interruption to a telehealth service, both participating facilities are responsible for ensuring patients continue to receive needed care and services in a manner consistent with VHA patient safety and health care standards.

Per the January 2020 VHA Records Control Schedule 10-1, both intrafacility and interfacility TSAs must be closed at the end of the agreement terms and destroyed after four (4) years from the end of service.

3.2. Terms of Service (TOS):

With the implementation of VHA Directive 1915, Enterprise Clinical Resource Sharing Through Telehealth from a Nationally Designated Telehealth Hub (NDTH), sites classified as NDTHs are no longer required to complete a Telehealth Service Agreement (TSA).8 Instead, the NDTH is required to establish a Terms of Service (TOS) that will apply to the NDTH Host VA Medical https://vaots.blackboard.com/bbcswebdav/xid-2929023_1

Facility and all facilities that receive telehealth care services from the NDTH for each specialty provided. The process to request designation as an NDTH and guidance on TOS completion are listed in the VHA Directive 1915 Resources Home Page in Connected Care Academy. The TOS defines the clinical, technical, and business requirements for a clinical telehealth service delivered from an NDTH, along with the service's emergency handoff procedures and contingency plans. It contains the information needed to operate telehealth services effectively and safely between host and originating sites.

TOS requires the Host VISN Director's approval and other VISN Directors if services cross into other VISNs. If the NDTH is operated from multiple host sites in more than one VISN, the VISN director(s) for the additional Host VISN(s) must also approve. Additional staff may be added for signature at the discretion of the VISN Director(s) or NDTH Director.

3.3. SharePoint Creation

VHA Directive 1915, Enterprise Clinical Resource Sharing Through Telehealth from a Nationally Designated Telehealth Hubs Appendix B indicates that information may be included within the TOS or within a shared or online location referenced in the TOS. Each medical center must create a location, such as a shared drive or SharePoint site, to house their important telehealth documentation and points of contact for the TSA/TOS to be accessed securely by staff and stakeholders. Shared drive links or SharePoint links to additional documents, once created, can be added into the TSA or TOS Template. For Example, links can be added for the following:

• Facility Contact Information

• Training requirements

• Lists of participating health care professionals

3.4. 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 only required when the telehealth partnership is with a non-VA facility. A Telehealth MOU is an umbrella agreement that authorizes sharing resources (including telehealth health care professionals), privileging and credentialing through telehealth between a VA and non-VA location. In addition, MOUs ensure that VA and non-VA health care professionals are credentialed and privileged following The Joint Commission and VHA regulatory standards.

Accessing Telehealth Locations through Local Area Stations (ATLAS) uses Memorandums of Agreement (MoA), which set forth a structure in which both the VA and ATLAS location will work in a mutually beneficial manner to advance and improve the quality of care for our nation's Veterans.

https://vaots.blackboard.com/webapps/login/?action=guest_login&new_loc=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_3079_1 http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=10116 http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=10116 http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=8807

MOUs follow the same standard per the January 2020 VHA Records Control Schedule 10-1, which states that MOUs and MoAs must be closed at the end of the agreement terms and destroyed after four (4) years from the end of the service.

3.5. Telework Agreements:

Telehealth creates the opportunity for telehealth health care professionals to deliver interactive health care services from non-traditional clinical spaces, such as administrative offices or home or remote offices.

Creating the infrastructure to support the provision of clinical video telehealth services from approved alternative worksites by VA telehealth health care professionals operating under Telework Agreements enhances VHA's ability to expand and maintain clinical services, including in situations where health care professional space has traditionally been a limiting constraint and during emergencies when clinical space may be compromised. Telehealth additionally provides unique opportunities for the recruitment and retention of health care professionals (e.g., health care professionals recruited to telework from home to provide care via telehealth to areas of health care professionals scarcity) as well as the development of unique Veteran-centric care opportunities (e.g., ability for health care professionals to staff after-hour clinics from their homes via telehealth).

In addition to all Telework Agreement requirements outlined in VA Handbook 5011, Hours of Duty and Leave, Part II, Chapter 4, dated October 12, 2016, VA staff that provide telehealth services from an approved alternative worksite have specific requirements related to the provision of clinical video telehealth care and related services, documentation of these services, and the use of telehealth technologies to provide these services. VHA Directive 1914, Telehealth Clinical Resource Sharing Between VA Facilities and Telehealth From Approved Alternative Worksites and VA Handbook 5011 identified above outlines these requirements to ensure the safety and security of beneficiaries, teleworking telehealth health care professionals, and the security of the information that is being exchanged remotely. These references also state the requirements that ensure clinical, technical, and business standards are identified and met.

Additional information regarding Telework Agreements is available in VA Handbook 5011 mentioned above.

4. Business Procedures

1. Clinic Setup Overview:

Clinic profiles provide the vehicle to capture outpatient and related workload for Veterans Equitable Resource Allocation (VERA), MCA, and Financial Revenue Management to schedule patients and monitor clinic performance. The first step is to ensure all telehealth clinics meet https://dvagov.sharepoint.com/sites/OCHCO/Shared%20Documents/5011.pdf https://dvagov.sharepoint.com/sites/OCHCO/Shared%20Documents/5011.pdf http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=8807 the appropriate VHA Policies, such as VHA Directive 1231 Outpatient Clinic Practice Management and VHA Directive 1230 Outpatient Scheduling Management. The Clinic Profile Management Guidebook and National Telehealth Quality Conditions of Participation Standards outline requirements that must be in place before establishing a clinic and clinic maintenance requirements. The requestor should know the appropriate stop-codes, one-sided or two-sided clinic requirements, whether the clinic will be intrafacility or interfacility, group and/or individual, and the attached naming convention to complete the clinic setup request.

Local clinic setup points of contact and/or process may vary by facility. VHA Health Information Management and Health Records Handbook outlines the Health Information Management programs.

The clinic profile manager / User Role Assignment Coordinator will set up the clinic and assign all associated providers. Clinic setup requires the initiator to understand and provide the following information to the Clinic Profile Manager / User Role Assignment Coordinator:

• Clinic Name[A1] [A2]

• Clinic Stop Codes

• Clinic Grids

a. Clinic Naming: It is essential to use standardized naming conventions when naming clinics.

Most clinics require a patient-side clinic and provider-side clinic setup. See the corresponding Connected Care Academy Community for specialty-specific clinic naming information. NOTE: Connected Care Academy Communities contain specialty-specific resources organized by specialty, role, program, and technology, including the operations manual. Approved naming conventions must be followed for accurate clinic setup; examples of naming conventions are listed below. Refer to the Clinic Profile Management Guidebook for guidance on the clinic setup and naming conventions; examples of naming conventions are listed below.

1. Provider Side Naming Convention:

• Use up to three letters for the geographic location (Fort Meade=FTM)

• Enter the modality (i.e., CVT)

• Enter the specialty/service (i.e., PACT)

• Enter a generic team or generic provider (i.e., Gold Pro A)

• Example Provider Side Clinic Name: FTM CVT PACT GOLD PRO A

2. Patient Side Naming Conventions:

• Use up to three letters for the geographic location (Fort Meade=FTM)

• Enter the modality (i.e., CVT)

• Enter the specialty/service (i.e., PACT)

• Enter a generic team or generic provider (i.e., Gold Pro A)

• Example Provider Side Clinic Name: FTM CVT PACT GOLD PAT A https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=8727 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=8727 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=9810 https://dvagov.sharepoint.com/:b:/r/sites/vhaovac/cpm/VHA%20Directive%20Resources/Clinic%20Profile%20Management%20Guidebook.pdf?csf=1&web=1&e=eBXsYP https://dvagov.sharepoint.com/:b:/r/sites/vhaovac/cpm/VHA%20Directive%20Resources/Clinic%20Profile%20Management%20Guidebook.pdf?csf=1&web=1&e=eBXsYP https://vaots.blackboard.com/bbcswebdav/xid-1425334_1 https://vaots.blackboard.com/bbcswebdav/xid-1425334_1 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9235 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9235 https://vaots.blackboard.com/bbcswebdav/library/LibraryContent/Telehealth%20Foundations-Business-Administration/Telehealth%20Business%20Operational%20Guidance/Telehealth%20Business%20Operational%20Guidance/Telehealth%20Business%20Operational%20Guidance.html#_msocom_1 https://vaots.blackboard.com/bbcswebdav/library/LibraryContent/Telehealth%20Foundations-Business-Administration/Telehealth%20Business%20Operational%20Guidance/Telehealth%20Business%20Operational%20Guidance/Telehealth%20Business%20Operational%20Guidance.html#_msocom_2 https://vaots.blackboard.com/webapps/portal/execute/tabs/tabAction?tab_tab_group_id=_3_1 https://dvagov.sharepoint.com/:b:/r/sites/vhaovac/cpm/VHA%20Directive%20Resources/Clinic%20Profile%20Management%20Guidebook.pdf?csf=1&web=1&e=eBXsYP

3. Patient Friendly Clinic Naming Convention: The patient will see this on appointment check-in, appointment reminders, My HealtheVet, and VA Online Scheduling (VAOS) communication.

• Use up to three letters for the geographic location (Fort Meade=FTM)

• Enter the modality (i.e., CVT would be entered as Clinical Video Telehealth)

• Enter the specialty (i.e., Patient Aligned Care Teams are entered as PACT)

• Enter the provider's name (i.e., Davies)

• Example Patient Friendly Clinic Name: FTM Clinical Video Telehealth PACT Davies

b. Stop Code Guidance: Stop Codes identify workload for all outpatient encounters, inpatient appointments in outpatient clinics, and inpatient professional services. Therefore, it is crucial not to deviate from nationally directed stop code standards. In addition, stop codes indicate the workgroup responsible for providing the specific set of clinic services and what modality was used and also serve as a standard identification method that can be used to compare costs.

Therefore, VHA facilities must ensure that all encounters are identified, coded, and completed correctly for appropriate workload capture, and reimbursement follows VHA Coding Guidelines[A3] for accurate information. A complete set of current active stop codes is available through the Managerial Cost Accounting Office. For comprehensive information about stop codes, please see Stop Codes- Instructional Guide and Business Process for Stop Codes.

Oracle Cerner: Stop codes will be assigned to the individual charges. Charges are roughly aligned to the individual CPT codes and ICD codes documented as work done. Each charge will contain information such as the Provider Specialty and Activity Type to aid with stop code assignment. Oracle Cerner only maintains primary stop codes (removes secondary stop codes).

Each specialty has training available in the EHRM Training Library.

VistA: Attached to the clinic are stop codes used to track the amount, type, and workload cost for both the provider and patient sides.

1. Primary Stop Code: The primary stop code is the first set of three digits that designate the main clinical group responsible for the care and will differ based on service.

2. Secondary Stop Code: The secondary (credit) stop code varies based on the modality and the patient's location. The last three digits of the stop code serve as a credit stop code, further defining the primary workgroup. Stop codes must be determined to complete the clinic setup step and ensure the appropriate workload is mapped appropriately and captured correctly. The credit stop code (secondary stop code) varies based on the modality and the patient's location.

3. Telehealth specialty-specific stop codes may be used when appropriate (e.g., Tele-Post Deployment Integrated Care Patient Site coding XXX/136).

4. Synchronous Telehealth in the Clinic stop codes: These stop codes are used most frequently when the patient is in a VA space at the appointment time. A complete set of current active stop codes is available through the Managerial Cost Accounting Office.

5. Synchronous Telehealth in the Home stop codes: These stop codes are used when the patient is not in a VA space. The patient could be at their home, location of their https://vaots.blackboard.com/bbcswebdav/xid-719219_1 https://vaots.blackboard.com/bbcswebdav/xid-719219_1 https://vaots.blackboard.com/bbcswebdav/library/LibraryContent/Telehealth%20Foundations-Business-Administration/Telehealth%20Business%20Operational%20Guidance/Telehealth%20Business%20Operational%20Guidance/Telehealth%20Business%20Operational%20Guidance.html#_msocom_3 http://vaww.dss.med.va.gov/programdocs/pd_oident.asp http://vaww.dss.med.va.gov/DSS%20Documents/DSS%20Identifiers-Stopcodes/Stop%20Codes-%20Instructional%20Guide.docx http://vaww.dss.med.va.gov/DSS%20Documents/DSS%20Identifiers-Stopcodes/Business%20Process%20for%20Stop%20Codes.docx https://dvagov.sharepoint.com/sites/EHRMTraining680/Shared%20Documents/Forms/AllItems.aspx http://vaww.dss.med.va.gov/programdocs/pd_oident.asp choosing, or an Accessing Telehealth through Local Area Stations (ATLAS) site. NOTE: Telehealth in the Home is not to be confused with Remote Patient Monitoring – Home Telehealth (RPM-HT). RPM-HT information can be found in the Remote Patient Monitoring- Home Telehealth Manual.

Location of Care Primary Stop Code Secondary Stop Code

Intrafacility Synchronous Video Telehealth in Home/ATLAS

Patient Side: No clinic required

Provider Side: Specialty Specific

Patient Side: No clinic required

Provider Side:179

Interfacility Synchronous Video Telehealth in the Home/ATLAS

Patient Side: 674

Provider Side: Specialty Specific

Patient Side: Specialty Specific

Provider Side: 179

Intracility Synchronous Video Telehealth in the Clinic

Patient Side: Specialty Specific

Provider Side: Specialty Specific

Patient Side:690

Provider Side: 692

Interfacility Synchronous Video Telehealth in the Clinic

Patient Side: Specialty Specific

Provider Side: Specialty Specific

Patient Side:690

Provider Side: 693

Intrafacility Asynchronous Telehealth in the Clinic

Patient Side: Specialty Specific

Provider Side: Specialty Specific

Patient Side: 694

Provider Side: 695

Interfacility Asynchronous Telehealth in the Clinic

Patient Side: Specialty Specific

Provider Side: Specialty Specific

Patient Side: 694

Provider Side: 696

Intrafacility Asynchronous Telehealth in the Home

Patient Side: No clinic required

Provider Side: Specialty Specific

Patient Side: No clinic required

Provider Side: 189

Interfacility Asynchronous Telehealth in the Home

Patient Side: 674 *patient side clinic is only to be used if the Asynchronous visit has a component in the home (e.g., sleep studies) and uses patient side resources (e.g., Patient Side: Specialty Specific

Provider Side: 189 https://vaots.blackboard.com/bbcswebdav/xid-1467697_1

VA staff involvement or equipment assigned to the patient and returned for data upload).

Provider Side: Specialty Specific

Asynchronous Telehealth- Remote Temperature Monitoring

Patient Side: No clinic required

Provider Side: Specialty Specific

Patient Side: No clinic required

Provider Side: 698

Synchronous Video Telehealth to Non-VA Location (e.g., State Veterans Home)

Patient Side: No clinic required

Provider Side: Specialty Specific

Patient Side: No clinic required

Provider Side: 648

b. Cost and Workload Mapping: Mapping of cost and workload varies depending on which of the scenarios covers the locations of the patient and the provider. It is recommended that the facility FTC work closely with the MCA office to ensure clinic products and labor mapping are set up accurately. Resources to assist with workload and cost structure specific to telehealth can be found on the MCA National Programs and Implementation Guide website, under Telehealth. Instructions for Labor Mapping to Asynchronous Workload Account Level Budgeter Cost Centers (ALBCCs) provides directions for mapping provider time for care associated with specific Asynchronous Store and Forward Telehealth Clinics and Remote Patient Monitoring outside of the RPM-HT program. Remote Monitoring and Asynchronous Clinical Care- Recommendations of Bookable Hours Exceptions provides guidance to support adjustments to bookable time expectations for providers using remote technology or asynchronous care. This guidance is needed to account for unscheduled remote monitoring clinical workload.

2. Clinic Profile (Clinic Grids)

When creating the clinic grids (also called scheduling template grids in Oracle Cerner), please refer to the Clinic Profile Management Guidebook in the Directives, Standard Operating Procedures (SOPs) & Guidebooks SharePoint , VHA Directive 1232, Outpatient Clinic Profile Management and VHA Directive 1230, Outpatient Scheduling Processes and Procedures. The clinic set up point of contact may vary by the facility; there will be a limited number of staff per facility that has access. The VHA Coding Guidelines Telehealth Section [A1] details coding and documentation requirements for Synchronous Video Telehealth, Asynchronous Video Telehealth, Remote Patient Monitoring- Home Telehealth, and Telephone care.

• Each visit modality requires a separate clinic grid (i.e., one grid for telephone visits, one for in-person visits, one for telehealth in the clinic visits, and one for telehealth in the home visits).

http://vaww.dss.med.va.gov/programdocs/pd_clinictop.asp https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fmcareports.va.gov%2Fmcadatadef%2FNLMT%2FInstructions%2520for%2520Labor%2520Mapping%2520to%2520Asynchronous%2520Workload%2520Suffix.docx&data=05%7C01%7C%7C03fd1c1b98d849281c6b08dac8c17ade%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638043030552958495%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=4JQ%2BDna8uhDHPMIDP%2BndK3VUuqEshdPFkpISV2Zf%2FW0%3D&reserved=0 https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fmcareports.va.gov%2Fmcadatadef%2FNLMT%2FInstructions%2520for%2520Labor%2520Mapping%2520to%2520Asynchronous%2520Workload%2520Suffix.docx&data=05%7C01%7C%7C03fd1c1b98d849281c6b08dac8c17ade%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638043030552958495%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=4JQ%2BDna8uhDHPMIDP%2BndK3VUuqEshdPFkpISV2Zf%2FW0%3D&reserved=0 https://vaots.blackboard.com/bbcswebdav/xid-2589691_1 https://vaots.blackboard.com/bbcswebdav/xid-2589691_1 https://dvagov.sharepoint.com/sites/vhaovac/cpm/SitePages/AccessPolicyResources.aspx#standard-operating-procedures-%28sop%29-and-guidebooks-on-vha-policies https://dvagov.sharepoint.com/sites/vhaovac/cpm/SitePages/AccessPolicyResources.aspx#standard-operating-procedures-%28sop%29-and-guidebooks-on-vha-policies http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=8727 http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=8727 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=9810 https://vaots.blackboard.com/bbcswebdav/xid-719219_1 https://vaots.blackboard.com/bbcswebdav/library/LibraryContent/Telehealth%20Foundations-Business-Administration/Telehealth%20Business%20Operational%20Guidance/Telehealth%20Business%20Operational%20Guidance/Telehealth%20Business%20Operational%20Guidance.html#_msocom_1

• The clinic profile may allow patients to view, cancel, and/or directly schedule an appointment using a variety of Veteran self-scheduling applications. However, the profile must disallow direct scheduling in provider clinics that offer "virtual appointments." For example, VistA uses VA Online Scheduling (VAOS), and Oracle Cerner uses my VA Portal.

• Asynchronous provider-side clinics should not have a scheduling grid, as provider-side asynchronous reads are never scheduled.

• The Administrative Contact clinic in CPRS should be used for the following patient contact:

o Leaving messages on answering machines o Documentation of patient contact by administrative staff o Scheduling/Billing/Administrative issues o Ordering consults o Communication of non-clinical information o Providing test results without any medical decision making o Any workload which does not meet the definition of an encounter

a. Four Character National Codes (CHAR4 Codes) are assigned to clinics by MCA site teams in VistA/CPRS.