VA257-17-R-0506-021.docx

D. 20 Clinic Based Telehealth Operation Manual 11/3/2017

Table of Contents

CHAPTER 6: Credentialing and Privileging ………………………………………………………….. 25

CHAPTER 1: Purpose, Development Process and Audience Purpose The purpose of the Clinic Based Telehealth (CBT) Operations Manual is to provide standard operational guidance and resources to implement, operate and monitor quality Clinic Based Telehealth services that are safe and effective. The manual will describe the prerequisites and critical success factors for providing these services at VA Medical Centers (VAMCs) and Community Based Outpatient Clinics (CBOCs), other VA sites of care, or, where applicable, non-VA sites of care (federal and non-federal), within the framework of the National, VISN or VAMC Telehealth strategic plans for Telehealth. The content and tools therein are required to serve as a resource to improve and expand the delivery of care via Telehealth and ensure the efficiency, quality and sustainability of these services.

The Clinic Based Telehealth Operations Manual will assist VA staff to integrate practices and procedures used in VHA Telehealth programs for the benefit of patients and practitioners. This integration of processes and procedures applies to establishing a new Telehealth service and operational standards for an existing Telehealth service. The Clinic Based Telehealth Operations Manual includes links to numerous resource, support and training materials. Additional resources providing support material for this manual are identified at the end of each section.

The Operations Manual is meant to complement existing VHA clinical and administrative Directives and guidelines. It provides sufficient detail for the intended audience to gain an understanding of the complex components of developing and managing Telehealth programs. The Operations Manual also contains many links to additional training, tools and resources which, if fully reviewed and used/completed by the appropriate staff, supplement other requirements to ensure they are competent and able to successfully plan, deploy and manage Telehealth programs within the scope of their practice/authorization.

Development Process Telehealth leaders from the 21 Veteran Integrated Service Networks (VISNs) comprised the development committee for this Operations Manual with oversight and leadership from the Telehealth Training Centers, within the national VHA Telehealth Services. Content was developed with the underlying goal being to provide the greatest amount of relevant information in the least amount of time. Final reviews were completed by key staff within VHA Telehealth Services prior to approval and publication.

Audience Although much of the content of this Operations Manual may be pertinent to Telehealth operations outside of VHA, this document is a resource developed solely for internal VHA Telehealth programs, with the intended audience being VISN Telehealth leadership, Telehealth coordinators, Telehealth practitioners and VHA staff who provide management and/or support to Telehealth Programs.

CHAPTER 2: Clinic Based Telehealth - Introduction and History Introduction to Clinic Based Telehealth Operating the nation's largest healthcare system, the Department of Veterans Affairs’ (VAs’) Veterans Health Administration (VHA), uses a wide variety of communication and information technologies to ensure excellence in the health care it delivers to our nation's Veterans. New information technologies are revolutionizing health care and the VA has been recognized by the Institute of Medicine as a leader in using these technologies to improve the quality of its care delivery.

The primary focus of this Operations Manual is Clinic Based Telehealth activities, which typically occurs between two clinical settings. The term Clinic Based Telehealth (CBT) applies to the use of Clinical Video Telehealth (CVT) and Store-and-Forward Telehealth (SFT) modalities, and other technologies to provide clinical care and patient health education in circumstances where distance separates those receiving services and those providing services. Information is exchanged from one site to another, alleviating the constraints of time, distance and cost. Specifically, Clinic Based Telehealth involves a patient site (originating site) and a provider site (distant site). Clinic Based Telehealth is most commonly implemented between:

· Two VA Medical Centers (VAMCs).

· VAMC and a Community-Based Outpatient Clinic (CBOC) or Primary Care Telehealth Outreach Clinics (PCTOC).

· Two CBOCs.

· Telehealth activity between VA Centers of Specialized Care.

· Provider site into the Veteran’s home, Community Living Centers or contract nursing homes.

· Providers teleworking from their homes/Hub sites to VAMCs, CBOCs, VA Centers of Specialized Care, Veteran’s home, Community Living Centers, and contract nursing homes.

Any of the above can take place between VA sites of care within the same VISN or between VISNs. Telehealth programs also exist between VA sites of care and Non-VA sites of care, including Clinical Video Telehealth into Veterans’ homes and contract nursing homes.

The two types of Clinic Based Telehealth (CBT) services are: 1) Clinical Video Telehealth and, 2) Store-and-Forward Telehealth. The modalities are defined as follows:

· Clinical Video Telehealth (CVT) –the use of real-time interactive video conferencing, sometimes with supportive peripheral technologies, to assess, treat and provide care to a patient remotely. Typically, CVT links the patient(s) at a clinic to the provider(s) at another location. CVT can also provide video connectivity between a provider and a patient at home. CVT encompasses a wide variety of clinical applications, such as specialty and primary care.

· Store-and-Forward Telehealth (SFT) –the use of technologies to asynchronously acquire and store clinical information (e.g., data, image, sound and video) that is forwarded to or retrieved by a provider at another location for clinical evaluation. SFT in VA uses a clinical consult pathway and VistA Imaging in conjunction with a Telereader to provide screening, diagnosis and treatment services where time and distance separate the patient and provider.

Clinic Based Telehealth services are designed to achieve:

· Increased capacity.

· Improved access to primary and ambulatory care.

· Increased access to specialist consultations.

· Reduced waiting times.

· Decreased fee-based care costs.

· Decreased Veteran travel.

History of Clinic Based Telehealth VHA’s Telehealth Services, within the VHA Office of Patient Care Services, was established in July 2003 to support the development of new models of care in VA using leading edge health information technologies to address the pressing health needs of Veterans. Telehealth in VHA is defined as:

"The use of Telehealth technologies to provide clinical care in circumstances where distance separates those receiving services and those providing services. The value VA derives from Telehealth is not in implementing Telehealth technologies alone, but how VA uses health informatics, disease management, care/case management and Telehealth technologies to facilitate access to care and improve the health of Veterans with the intent to provide the right care, in the right place, and at the right time."

This intent is precisely VHA Telehealth Services’ mission. The vision is to improve quality, convenience and access for patients to receive care via the use of health informatics, Telehealth and disease management technologies that enhance and extend care, and case management.

VHA Telehealth Services is responsible for Telehealth implementation throughout VA. Telehealth Services addresses clinical, technical and business issues to ensure Telehealth programs are safe, cost-effective and sustainable to meet the needs of Veteran patients.

In developing Clinic Based Telehealth, VHA Telehealth Services has focused on the needs of patients as the central driver to prioritize areas of care. Consequently, the first standardized applications of CBT in VA were:

· TeleMental Health (Clinical Video Telehealth application, 2003)

· TeleRehabilitation, to include Polytrauma Telehealth (CVT application, 2005)

· TeleRetinal screening (Store-and-Forward Telehealth application, 2005)

· Primary Care Telehealth Outreach Clinics (PCTOC) (CBT applications, 2011) TeleMental health, the Polytrauma Telehealth Network, and TeleRetinal imaging are the most widespread Clinic Based Telehealth standardized applications in VA.

VHA’s National TeleMental Health Program TeleMental Health (TMH) was first documented in the United States in 1959 at the University of Nebraska*. By the 1960’s, the University of Nebraska was connected to Omaha, Lincoln and Grand Island VAMCs to deliver TeleMental Health services (Wittson & Benschoter, 1972). In 1968, the VA in Bedford was also connecting Veterans using TeleMental Health Services with clinicians at the Massachusetts General Hospital (Dwyer 1973). However, for large scale operations, the Clinical Video Telehealth technologies that supported TeleMental Health were too expensive and cumbersome until the computer age flourished in the 1990s.

Beginning in 1997, VHA implemented substantial start-up funding for TeleMental Health services nationally. The National TeleMental Health Center provides services in areas such as pain management, psychogenic non-epileptic seizure (NPES) care, as well as Compensation and Pension examinations to Veterans in the United States and abroad.

* Wittson, Affleck & Johnson, 1961 VHA’s TeleRehabilitation and National Polytrauma Telehealth Network (PTN) TeleRehabilitation is defined as providing a range of rehabilitation services at a distance using communication technologies. It is a relatively new in Telehealth, with most of the development in the last decade. Growth of TeleRehabilitation has been challenged by the “hands-on” approach to rehabilitation (i.e., many clinicians felt it was not possible to evaluate or treat patients without being able to touch them). However, these challenges are slowly being extinguished through the use of Telepresenters and new technologies. TeleRehabilitation is now seen as an exciting alternative model of care and can assist patients gain their ultimate functional outcome.

TeleRehabilitation is a collaborative effort between Rehabilitation and Prosthetic Services and Telehealth Services, and is part of the overall Connected Care Program. The mission of Telehealth Services is to provide the right care, at the right place, and at the right time through effective, cost- effective, and appropriate use of health information and telecommunications technologies. TeleRehabilitation, as part of Telehealth, strives to meet this mission by improving access to Rehabilitation specialty care services for Veterans, particularly patients in rural and highly rural areas.

Veterans with disabilities—especially in rural areas—can greatly benefit from the growth of TeleRehabilitation. Many live in areas void of Rehabilitation specialists. TeleRehabilitation can extend specialists from medical centers to Community Based Outpatient Clinics (CBOCs), thus providing increased access for these Veterans. For Veterans with disabilities in need of long-term follow up, such as stroke and Traumatic Brain Injury (TBI), TeleRehabilitation offers the option for clinicians to enhance services, resulting in increased functional gains and social reintegration.

The majority of TeleRehabilitation is through Clinical Video Telehealth (CVT), which is the use of real-time interactive video conferencing. CVT also includes peripheral technologies to assess, treat, and generally, provide care to a patient remotely. A typical CVT encounter links the patient(s) at a clinic (near site) to provider(s) at another location (far site). Examples of services provided through CVT TeleRehabilitation:

· TeleAudiology

· Blind Rehabilitation

· Kinesiotherapy (KT)

· Occupational Therapy (OT)

· Physical Therapy (PT)

· Recreation and Creative Arts Therapy

· Speech Language Pathology

· Specialty Clinics:

· Amputation

· Assistive Technology

· Be Active and MOVE!

· Durable Medical Equipment

· Polytrauma

· Traumatic Brain Injury (TBI)

· Wheelchair

TeleRehabilitation is also involved in Home Telehealth (HT), which applies the use of telecommunications technologies to provide clinical care and promote patient self-management as an adjunct to traditional face-to-face care. Health information is exchanged from the Veteran’s home or other location to the VA care setting, alleviating the constraints of time and distance. This is accomplished through the use of home devices, with Disease Management Protocols (DMPs) loaded into them. The DMPs provide a dialogue with the patient, whose responses are securely transferred from the Veteran’s home to the Veteran’s Telehealth Care Coordinator (e.g., a DMP for Traumatic Brain Injury has been developed and is a 28-day dialogue regarding managing the symptoms of the diagnosis).

Additionally, there have been developments in other types of technologies, such as mobile applications and the use of CVT into the Veteran’s home. An application, called “The Concussion Coach,” is available on iTunes for Smart Phones and will assist Veterans manage the symptoms of mild Traumatic Brain Injury. CVT into the Home connects VA providers to the Veteran directly into their homes; use of this modality in Rehabilitation is being explored.

The Polytrauma Network was created in 2005 to link, via videoconferencing, VA’s four national Polytrauma Rehabilitation Centers with the established Polytrauma Network Sites in VHA’s 17 other VISNs, to improve access and to bring Polytrauma care closer to home for combat-wounded Veterans. Technologically, the Polytrauma Network represented VA’s first clinical videoconferencing network, linking all 21 VISN’s with national network quality of service (QoS) standards to ensure video quality.

For the first time, clinical video traveling from VISN to VISN or coast to coast was identified and tagged as something distinct from all the other digital traffic traversing the national backbone of VA’s IT network. This distinction as clinical video afforded it a higher priority and quality of service if and when IT network traffic became congested.

What began as the 21-unit the Polytrauma Network has matured into a larger national Clinical Enterprise Video Network (CEVN) that currently connects over 1,900 Clinical Video Telehealth units in VA Medical Centers and CBOCs. Most recently, VA expanded CEVN even farther with additional Clinical Video Telehealth units in VA sites for Audiology and Spinal Cord Injury services, as well as connecting CEVN safely and securely to non-VA sites (e.g., university clinics, Indian Health Service {IHS} clinics, Department of Defense {DoD} treatment facilities and private residences) for bi-directional encrypted Clinical Video Telehealth.

VHA’s National TeleRetinal Imaging Program In 2006, VHA implemented a National TeleRetinal Imaging (TRI) program to screen for diabetic retinopathy. Diabetes is a major burden of disease that VHA provides care for since estimates suggest that over 20 percent of the VA patient population has diabetes mellitus. The prevalence of diabetes in the Veteran population makes the timely assessment of diabetic retinopathy a major VA health care need. TeleRetinal screening is an application whereby VHA accesses Veterans with diabetes and assesses for diabetic retinopathy. This is based on a clinical pathway developed as part of a cooperative effort with the Department of Defense, VHA and the Joslin Diabetes Center.

Since 2006, nearly 500,000 Veteran patients have been examined via more than 450 imaging systems, which are installed throughout all 21 VISNs nationwide. Since diabetes is one of the three leading causes of vision loss, the implementation of TeleRetinal imaging programs results in more rapid diagnosis and *timely and appropriate referrals for specialty care thus **significantly reducing the risk of vision loss.

* TeleRetinal Imaging to Screen for Diabetic Retinopathy in the Veterans Health Administration ** A Telemedicine Program for Diabetic Retinopathy in a Veterans Affairs Medical Center—the Joslin Vision Network Eye Health Care Model

Growth of Clinic Based Telehealth in VA There are more than 100 Clinic Based Telehealth applications in use nationally. Table 1 lists the top 20 Telehealth clinics in use during FY 2014. Although these applications are valid uses of Telehealth to provide care, where distance separates the patient and provider, VHA Telehealth Services has not completed formal reviews of all of these or developed standardized models for their expansion nationally.

Table 1. Top 20 Clinic Based Telehealth Clinic Stops and Names during FY13

The following figures provide the growth of Clinic Based Telehealth within VA since 2004.

Figure 1. CVT Patient Numbers, FY 2004-2013 and Projected through FY 2014

Figure 2. SFT Patient Numbers, FY 2004-2013 and Projected through FY 2014

CHAPTER 3: Organization and Infrastructure of the VISN Telehealth Network Organization and Infrastructure The importance of organization and infrastructure, at both VISN and VAMC (Station) levels, in the development and operation of Telehealth programming cannot be over-emphasized. Because Telehealth involves such a large number and variety of organizational entities within these different levels of the organization, high degrees of coordination, communication and oversight are necessary.

Telehealth must be seen as a continuum, including clinic-based, home-based and mobile patient settings, as well as synchronous (Clinical Video Telehealth) and asynchronous (Store-and-Forward Telehealth) modalities of clinical service delivery. In order to effectively plan, deploy and operate Telehealth programs, basic infrastructure and oversight should be in place at the VISN and VAMC levels. The oversight is recommened to be a committee of diverse stakeholders committed to the development and expansion of quality telehealth programs. Important elements of this infrastructure which relate to Clinic Based Telehealth are listed in Table 2.

Table 2. Telehealth Categories Clinic Based Telehealth

Home Telehealth

· Digital Camera

· Image Capture

· Peripherals

· Video teleconferencing

· Telehealth Clinical Cart

· Peripherals

· Messaging Device

· Interactive Voice Response (IVR)

· Peripherals

· Broadband Video (MOVI)

· Videophone

· Peripherals

· Imager

· Reader

· Care Coordinator

· Dermatology

· Wound Care

· Pathology

· Cardiology

· Gynecology

· Mental Health

· PM&R

· Audiology

· Patient Health Education

· Endocrinology

· Gynecology

· Women’s Health

· Pharmacy

· Non-institutional care

· Management of chronic conditions

· Health Promotion/ Disease Prevention

· Acute Care/Case Management

· HBPC

· Mental Health

· Medication

· Management

· PM&R

· Home Evaluations

· Care Coordination

* Although using a SFT pathway, Home Telehealth (HT) programs have dedicated stop codes and clinic locations distinctly different and separate from those used for SFT. Clinical Video Telehealth (CVT) stop codes and clinic locations for care provided into the home setting are identical, whether provided by an HT program or a CVT program.

Oversight This manual will describe the underlying processes to: 1) plan, 2) implement, and, 3) manage the day-to-day operations for maintaining and expanding safe and effective Clinic Based Telehealth programs.

A VISN Telehealth program and infrastructure consists of Clinic Based Telehealth and Home Telehealth services programs, and are designed to achieve:

· Increased workload capacity.

· Increased access to health care, including primary care, specialty consultations and patient education.

· Improved continuity and coordination of care across the continuum of care.

· Reduced waiting times for access and treatment.

· Provide alternatives to long-term institutional care.

The general strategy for implementing Telehealth in a VISN takes place in five (5) stages:

1. Develop, standardize and maintain the organizational, clinical, technical and business infrastructure at VISN, VAMC and program levels, as a foundation to all Telehealth development and operations.

2. Identify the health care needs of patients Telehealth can address appropriately, safely and cost-effectively, ensuring a thorough analysis of cost/benefit/sustainability.

3. Determine suitable Telehealth clinical, business and business/management processes to meet identified health care needs.

4. Design, implement and manage Telehealth programs to meet identified health care needs.

5. Practice continuous quality improvement processes to optimize Telehealth operations at all levels of the organization with oversight from a diverse body of stakeholders who meet regularly to evaluate and make recommendations.

An aspect of a VISN Telehealth Program is to provide timely, efficient access to health care, improve clinical outcomes, improve patient satisfaction and reduce health care costs. The VISN Telehealth Program is also charged to promote and advance the use of Telehealth modalities for clinical care, consultations, health promotion and disease prevention, and coordination of care, where such use is deemed appropriate.

The organizational structure of the VISN Telehealth Program is designed to ensure local control, with proper VISN oversight for planning, deployment and operational functions. Integration with existing programs and processes, as well as functional communication with VISN and station systems, is a critical factor for success. Also, there are technology infrastructure components to support the VISN, which include the VHA Clinical Enterprise Videoconferencing Network (CEVN) and Telereader/ VISTA applications.

CHAPTER 4: Planning and Deploying Integrated Telehealth Services Planning for Clinic Based Telehealth Services Planning is essential, and developing a strategy to implement Clinic Based Telehealth involves numerous steps. A methodical approach is recommended to ensure critical elements are not overlooked, which could seriously impact overall program success. Successful Telehealth applications integrate technology with clinical program needs. The primary components of planning for integrated Telehealth services are:

· A thorough needs assessment, which includes basic infrastructure such as staffing, equipment and space.

· A strong business case, which includes an analysis of the Return on Investment (ROI) and plan for sustainability; an essential element for Telehealth program development.

· A well-developed budget, which will identify the resources and provide a foundation to track, report and sustain the program financially, and provides additional evidence the program is feasible and sustainable.

· Gain approval and initiate Telehealth Service Agreement, which include service chief and Chief Medical Officer (CMO) approvals, along with clinical, business and technology requirements for deployment, organization, accountability and management.

Needs Assessment There may be situations where a healthcare service may want to formally establish a new Telehealth program and/or expand an established Telehealth program. In either instance, the program needs to demonstrate solid evidence the Telehealth program provides cost-effective and equal or greater benefits for patients over traditional care. One may want to consider soliciting the assistance of staff who have expertise in this area (i.e., health systems specialist, health services researcher, etc.) to conduct a formal needs assessment.

The needs assessment provides a structure to guide one in the development of a program business plan. The needs assessment identifies the goals and objectives of the project, as well as resources and activities needed to achieve the plan. The needs assessment is used to provide information such as the targeted population, business perspectives and metrics for performance evaluation. A needs assessment is also a systematic method of identifying unmet needs of the population and making changes to a population that will benefit from an intervention. Criteria in the needs assessment appraisal must include the following:

· Access to the targeted population: What specialty population(s) will one serve with Telehealth?

· Expected outcomes from both the clinical and business perspectives: What does one hope to accomplish using Telehealth?

· Performance measures: What performance measures will Telehealth affect?

· Space and resources available: Is there appropriate space to conduct a Telehealth visit?

· Staffing needs: Is there a specialty provider willing and able to use Telehealth? Are there other clinical staff who can assist in the Telehealth visit? What training may be needed to support/provide Telehealth? Are there specific staffing requirements for special populations (e.g., female Telepresenters for women Veterans, and chaperones for gender-specific examinations)?

· Capacity and workload: How many specialty clinics could utilize this technology based on the resources available?

· Technical considerations: What types of Telehealth equipment will best serve a specialty population? Is there adequate bandwidth to support new clinics and/or new equipment?

· Equipment inventory: What equipment currently exists to support Telehealth? Will it meet the patient needs, as well as information and privacy security, and quality standards of practice?

The Telehealth service planner needs to determine the patient population as well as the specific fields of relevance for analyses. Useful data includes:

· Patient data/metrics.

· Documented problems in meeting the needs of a group of patients (such as distance and travel barriers, no-shows, particular medical problems, weather problems, etc.).

· Available resources.

· Workload and clinic capacity.

· Special needs populations.

· Provider data.

Information received from the needs assessment will help support a productive clinical strategic plan to deploy Telehealth.

Business Case Development A business case is made to ensure the program will provide quality care, a return on the financial investment and have potential for sustainability. The needs assessment is also a major component of the business case and constructed from: 1) the number of patients who have health needs that can be treated via Telehealth, and, 2) the costs of providing care via Telehealth compared to other methods of providing care. Given the current demand for primary and specialty care services in VHA and the mandate to improve access to services, especially at geographically remote sites, it is likely the need for Telehealth will continue.

Factors to consider when developing the business case for Telehealth:

· Costs associated with equipment, labor and facilities.

· Capital investment, expenses and overhead.

· Start-up and ongoing sustainability for both the patient and provider sites.

· Complex issues surrounding workload and reimbursement.

· Lifespan of technology.

It is important to develop specific strategies and targets to guide the Clinic Based Telehealth program development. The next step in developing the plan is execution and deployment. Information obtained from the needs assessment should guide the plan. The following are key elements that should be included when developing the strategic plan:

· Focus on the “Who, What, Where, When and How” of both clinical and business aspects of the Telehealth program.

· Roles and responsibilities of the team should be well-defined for successful implementation.

· Action items and deadlines should be clear.

· Legacy review.

Budget Development Due to the National VA initiatives for Telehealth, there has been a recent infusion of funding to VISNs for expansion of Telehealth, related to needs for additional patient panel capacity, timely access, and increased outreach to Veterans in rural areas. For the majority of Telehealth programs, these resources are allocated from the VISN to VAMCs, or additional funding is provided at the VAMC level. In either scenario, there is a need to assess and plan for funding requests to support Telehealth.

Things to consider when putting together the budget proposal:

· Perform a needs assessment of Telehealth services at VISN and/or facility level.

· Identify necessary resources (i.e., Telehealth equipment, staffing, furniture, etc.).

· Estimate the cost of resources and establish the budget request.

· Develop a proposal that describes the needs, goals, strategies, investment, evaluation and expected outcomes.

· Document the Telehealth program investment payback period.

· Refine and specify estimated items as the project is implemented.

· Gather any supporting data reflective of the needs (e.g., wait time, travel cost, etc.). Assistance from VISN strategic planners may be required to obtain this data. Establish targets for all utilization, expenses and benefits (indirect and direct).

· Use of legacy resources, space, staff, and equipment.

Feasibility and Sustainability Feasibility is defined as the ability for a program to meet a clinical need and achieve specific outcomes. Sustainability is a program developed in such a manner it will be able to continue functioning long into the future, achieve financial and clinical stability, while meeting clinical outcomes and providing quality care. Long-term sustainability of any Telehealth program requires methodical planning and evaluation. It is important to train providers and give providers feedback (e.g., data on number of visits per provider, service, patient satisfaction, etc.).

Funds may be available to pilot a program. However, evidence must be provided, in terms of quality and performance outcomes, in order to continue and/or expand a newly established program beyond the pilot phase. Clinical, technical and business elements need to be assessed and analyzed using data collection, as well as the design of business operations to ensure processes are in place to enable effective, efficient and sustainable Telehealth programs. This information is vetted through a panel of Subject Matter Experts (SMEs) and included in TeleSpecialty Supplemental Operations Manuals.

Funding to initiate a Telehealth program and maintain it for the first one to three years is usually determined in the original business plan. Funding can come from a variety of sources (e.g., Rural Health Initiative, VISN, etc.) Veterans Equitable Resource Allocation (VERA) is the typical funding route for sustaining VHA healthcare systems, and is effective in the Telehealth model, too. A Veteran who receives care at more than one location is described as having shared care. This is of particular importance when the patient and provider sites are located in different facilities (Interfacility). The “Pro-Rated Patient” (PRP) reimbursement is prorated based on the cost of care at each facility. Although distributed between the facilities and VISN, the PRP VERA allocation is equal to and never exceeds one (1).

The following contacts may be helpful to provide guidance regarding feasibility and sustainability of a program:

· National Telehealth Training Centers

· National Telehealth Clinical Video Telehealth Leads

· VISN Telehealth Leads/Program Managers

· The Telehealth Services Intranet website Specialty “hub” and “spoke” programs in VHA (e.g., Endocrinology Televisits between Medical Centers and affiliated CBOCs, Spinal Cord Injury specialty consults between SCI hub site and support clinics) Satellite Broadcasts for Telehealth (available on VA Knowledge Network {VAKN} and re-broadcast on the Content Distribution Network {CDN}). Provides current updates and changes in the field, and allows for interaction between the field and Subject Matter Experts (SMEs).

Gaining Approval and Agreements Clinic Based Telehealth development and implementation activities must involve those individuals who have ultimate responsibility for governance, administrative and fiscal authority, and oversight of the programs. Examples of the individuals with approval authority include the Chief Medical Officers (CMOs), Directors, Chiefs of Staff (COS) and clinical service chiefs for each location involved in the planned Telehealth service. Potential programs should be thoroughly vetted and have approval obtained from the governing individuals noted at the VISN and facility levels, depending on the type of program. This approval process should go through appropriate channels.

Included in the approval process is the completion of the Telehealth Service Agreement (TSA) and Memorandum of Understanding (MOU) agreements. The Telehealth Service Agreement specifies and governs the clinical, business, and technical details of operations of the Telehealth services between providing and receiving facilities, and defines the responsibilities and procedures involved in establishing and operating a Telehealth clinic between involved medical facilities. A Memorandum of Understanding serves as an agreement between participating facilities, and defines expectations of the providing facility and the receiving facility with regard to credentialing and privileging of providers in the provision of Telehealth service delivery. Credentialing and Privileging also has required levels of administrative and clinical approval. The resources will guide you through the steps of the agreements and their purpose. VHA Telehealth Services, in cooperation with VISN Telehealth Managers, has developed the resources to support the development and implementation phases for Clinic Based Telehealth programs.

Deployment and Management of Clinic Based Telehealth Services The key elements to success are knowledge of the integral components of Clinic Based Telehealth (CBT), to include clinical applications, business plan and partners, Veteran populations to be served, and promotion and outreach strategies. The core of the Clinic Based Telehealth business plan is to implement business practices that support the goal to improve capacity, access, quality of care and Veteran satisfaction using state of the art Telehealth technologies, and the supporting Information Technology infrastructure that facilitates provision of care to Veterans.

The key to success is to implement the business plan simultaneously with the clinical plan. No matter how robust the technical infrastructure, a Telehealth program cannot be successful without appropriate business infrastructure.

Directives, policies and procedures define the structure of the Telehealth service and provide standardization of processes for safe, high quality delivery of care. Elements that must be covered by policies and procedures are:

· Staffing: Roles and responsibilities of staff involved.

· Credentialing and privileging.

· Clinical Service Guidelines.

· CBT visit and clinical environment, to include patient privacy, safety, and confidentiality.

· Scheduling.

· CBT documentation.

· Informed consent.

· Workload capture and data management.

· Telehealth technology.

· Staff competency and training.

· Quality and Risk Management.

· Conditions of Participation.

· Emergency procedures.

· Infection control.

Details and resources for these critical components, as well as promotion of Telehealth services through information outreach are included in subsequent chapters.

Links to Related ResourcesClinic Based Telehealth Service Deployment Checklist This is a comprehensive 65 item checklist which should be used each time a new clinic based Telehealth program is contemplated.

Telehealth Needs Assessment Template The Needs Assessment is a fundamental component to any Telehealth development.

Telehealth Service Approval Process Reference chart to ensure that all approvals are completed Chief of Service Line Approval Form Template for approval of Service Line Chief Chief of Staff Approval Form Template for Chief of Staff approval Telehealth Service Agreement Essential document for each Telehealth application to identify Telehealth variables. To be used in conjunction with the Credentialing and Privileging MOU Telehealth Clinical Service Guidance Development Tool Tool and process to identify variables between Telehealth and traditional face-to-face healthcare.

CHAPTER 5: Human Resources: Virtual Team Members Human factors involved in a Telehealth visit are crucial to a successful service and must be considered when creating Telehealth clinics. A major challenge in the implementation and sustainability of programs is working with a large number of individuals, various procedures and guidelines, different work styles, development of position descriptions and functional statements, biases and human factors. Human factors include the ability to build relationships, communicate effectively and provide quality customer service. The human factors matter most in the Veteran’s experience during a Telehealth visit. Arguably, the people involved contribute as much toward a successful encounter or service as specialized Telehealth equipment or adequate video connections.

One of the critical predictors of a successful and sustainable Telehealth program is adequate and competent staff. Telehealth Clinical Technicians (TCTs) provide technical support and a Facility Telehealth Coordinator (FTC) ensures business and infrastructure processes are in place. The same professional and support staff must be available as in a traditional clinic setting.

Suggested staffing requirements for a mature patient population or patient panel include the following:

1. One Telehealth Clinical Technician per 5,000 patients

1. One Registered Nurse: Telepresenter per 1,200 Primary Care patients

1. One Registered Nurse: Telepresenter per 5000 specialty care patient encounters

The Virtual Team Staffing is one of the challenges of Clinic Based Telehealth and Store-and-Forward Telehealth implementation. The best practice staffing model for Telehealth is inclusive of several positions and levels designed to facilitate the operation of Clinic Based Telehealth and Store-and-Forward Telehealth services. Once the basic administrative and clinical operational systems are agreed upon and established, the heart of the successful patient visit is dependent upon the patient, provider and support staff preparation. The roles and responsibilities of the Teleprovider, site clinical coordinator, Telepresenter, Telehealth Clinical Technician (TCT), clerk and patient must be clear to each person involved to provide a smooth and efficient Telehealth visit.

Particular to this service is all staff involved need to be synchronized in the delivery of care. The location where the patient is receiving the Clinic Based Telehealth services is known as the patient site (Originating Site or OS). Generally, the patient site is at a CBOC or other outpatient clinic (OPC). The Teleprovider location, also known as the facility site or Distant Site (DS), is where the Primary Care, specialty or consulting provider is located. This section will provide examples of staff position descriptions, roles, duties, recommended competencies, training and orientation for those involved in Clinic Based Telehealth. There are the Joint Commission (JC) requirements for Telehealth programs to have:

· Position descriptions for each staff member.

· Training plan for orientation, initial competency and regular competency performance review.

· Troubleshooting procedures.

VISN Telehealth Manager and Analyst The VISN Telehealth Manager is responsible for the development, deployment, management and quality of all Telehealth programs throughout the VISN. Due to the size and scope of these responsibilities, the structure may also include a VISN Manager assigned to CBT and another to Home Telehealth (HT) services. With assistance of the VISN Analyst, the Telehealth manager is responsible for the execution and operation of Telehealth programs within the VISN. It is recommended these positions be aligned under the VISN Chief Medical Officer (CMO).

Facility Telehealth Coordinator (FTC) The Facility (VAMC-level) Telehealth Coordinator (FTC) is responsible for the execution and operation of Telehealth programs within the facility and other divisions (i.e., CBOCs), and for the overall planning, coordination, implementation and evaluation of clinical applications of Telehealth and video conferencing technology based on facility needs. The Facility Telehealth Coordinator works collaboratively with the VISN-level Telehealth Program Manager. It is recommended this position be aligned under the facility Chief of Staff.

Teleprovider The Teleprovider is a practitioner who strongly supports the implementation of one or more Clinic Based Telehealth applications into the system of care and is interested in promoting Clinic Based Telehealth among peer providers. It is important for the provider to have a good understanding of the benefits Telehealth can provide to Veterans, the VA and themselves.

The following elements describe this role:

· Expert on Clinic Based Telehealth within specialty clinics.

· Clear the path for Clinic Based Telehealth deployment.

· Collaborates with specialty care provider(s) and CBOC staff.

· Familiar with all aspects of the Telehealth equipment and the clinical environment.

· Telereader in Store-and-Forward Telehealth (SFT) modality.

· Directs care for Telehealth patients.

Telepresenter The Telepresenter can be any person assisting the provider in the presentation of the patient using Telehealth technology. The Telepresenter is the hands, eyes, ears, and nose for the provider. Depending on the skills needed for the encounter, Telepresenter can be licensed independent providers, Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Telehealth Clinical Technicians (TCTs).

The following elements describe the role of the Telepresenter:

· Cover Telehealth clinics scheduled for the day.

· Manage required screenings and complete clinical reminders and documentation within scope of practice.

· Assist Teleprovider with the patient physical exam as needed.

· Patient education and documentation within scope of practice.

· Workload capture.

· Regular contact with the Facility Telehealth Coordinator to work out any process issues, equipment needs/problems, data collection and any other logistical issues.

· Provide customer service to all Veterans.

· Schedules initial and follow up appointments.

· Provide chaperone for female patients when required (refer to VHA Handbook 1330.01 “Health Care Services for Women Veterans” for services that require female chaperones).

· Operate and troubleshoot technology used in the patient encounter.

Telehealth Clinical Technician (TCT) The Telehealth Clinical Technician is a staffing asset that supports the clinical, business and technical areas needed to deploy, implement and manage Telehealth clinics.

The following elements describe the role of the TCT:

· May serve as CVT Telepresenter and/or SFT Imager.

· May provide clerical support.

· Expert in deployment, operation, and troubleshooting of Telehealth technology.

· Collaborates with Facility Telehealth Coordinator (FTC).

· Schedules initial and follow up appointments.

· Educates staff on Telehealth technology.

· Educates patient on Telehealth technology.

· Supports Home Telehealth and CVT into the Home.

· Coordinates with supporting services such as IRMs, Biomed or OIT.

SFT Imager The imager is essential for the clinical aspects of the intervention, should be part of the clinic team and available for all Clinic Based Telehealth visits. Telepresenter and Telehealth Clinical Technicians can also be trained to perform the duties of a Store-and-Forward Telehealth Imager, or this can be a dedicated position, such as in the TeleRetinal screening clinics. The duties of the Imager include:

· Function as a patient care coordinator and familiar with computer use, CPRS, the scheduling package and Veterans Health Information Systems and Technology Architecture (VistA).

· Obtaining digital Store-and-Forward Telehealth images according to validated guidelines.

· Specifically for TeleRetinal screenings, providing post-imaging patient education sessions, which include a brief anatomical explanation of important appropriate structures and an overview of the pertinent condition.

· Specifically to TeleRetinal screenings, reporting and communicating findings of the image evaluations to appropriate providers and clients, and being responsible for maintaining a patient database.

· Identifying patients requiring immediate image evaluation once images are obtained, and assisting in scheduling and appointing patients for referral and comprehensive specialty care examination.

· Proficient in navigating CPRS, VistA and proprietary image acquisition software required to operate the digital imaging systems.

· Proficient in operating digital retinal and hand-held imaging systems to acquire non-simultaneous stereoscopic images for retinal screening, and appropriate skin/lesion images for Dermatology.

· May want to consider a female Telehealth Clinical Technician who can also serve as required chaperone for Women’s Health gender-specific examinations, when required.

Clerical Support Responsible for the administrative tasks involved in every visit and is typically an existing position at the clinic. This individual will be used to support Clinic Based Telehealth and may provide the following services:

· Reminder phone calls.

· Reminder letters.

· Veteran check in through VistA into two clinics; provider site (Distant Site) and patient site (Originating Site).

· Veteran check out of VistA once the Clinic Based Telehealth clinic appointment is completed.

· Schedule Veterans for follow up appointments if ordered by the Teleprovider.

· Distribute patient satisfaction surveys for return to the National Telehealth Training Center.

Technical Support Information Resources Management (IRM), Office of Information and Technology (OIT) and Biomedical Engineering…