Wyoming Telehealth Consortium<= /p>

Video Conferencing

Provider Manual

May 2010

Introduction

The Wyoming legisla= ture appointed a consortium of health stakeholders and organizations to create Telehealth Policy and Procedure for applications in = Wyoming. Documents which should accompany t= his document include the Wyoming Telehealth Tech Policy and Procedure, the End = User Troubleshooting Guide, the Polycom Quick Guide, and more. Information can also be found on t= he Southeast Wyoming Telehealth Network website at www.sewtn.net

Room Considerations

Both the physician video conferencing room and the pat= ient video conferencing room should adhere to normal exam room requirements base= d on HIPAA requirements and policies for your clinic or hospital. Treat patient privacy to the same = level as if you were seeing the patient in person.

Recommended Room Color: Benjamin Moore paint numbers= 1627 or 829 This light blue-= grey contrasts well against skin tone.

Microphone placement should be close to the patient to receive appropriate patient intake in an Exam Room. Ceiling mount microphones should n= ot be mounted near in-ceiling speakers, PA announcement systems, HVAC vents, or ceiling mount fans; these items will create ambient noise which will be distracting for a video conference.

Lighting should be controlled room lighting and not na= tural lighting. Natural lighting fr= om windows will cast heavy shadows and other uncontrollable effects. Windows should be covered or blinds closed during a video conference. Video conferencing equipment should not be facing windows as this will cause patients to look like ‘silhouettes’. If overhead lighting is not adequate, provide ambient can-lighting fixtures ne= ar a wall. These fixtures sit on t= he floor and point upwards to provide additional ambient lighting and are very inexpensive. Lighting considerations are especially true when working in an Exam Room environment= .

Please see Appendix A for more detailed information in documentation created by Dr. Tom Richards during the Wyoming Telepsychiatry project, 2010.

Video Conferencing Considerations

Technical System Requirements for Telehealth Systems:

Video conferencing equipment for Telehealth use should follow the H.323 industry standards for video conferencing. Information regarding this require= ment is outlined for IT and other technical staff to assist in acquiring, configuring, and using video conferencing systems. The document provided for IT staff= is referenced as the Wyoming Telehealth Tech Policies. You may contact the State Consorti= um through the Wyoming Department of Health, WyHIO, or CRMC for the most curre= nt revision.

Minimum video conferencing requirements for room based systems:

- = H.323 Video Conferencing Codec

- = TV Monitor

- = Microphone

- = Handheld remote control

Minimum video conferencing requirements for desktop vi= deo conferencing systems:

- = H.323 web cam application (such as Polycom P= VX or Polycom CMA Desktop)*

- = Computer

- = Web cam

- = Head set with built in microphone

*non-H.323 web cam applications are not supported at this time. Examples not supported include: Sk= ype, LiveMeeting, in addition to many others. Please refer to the Tech Policies = and the Polycom PVX and Polycom CMA system requirement for CPU speed and RAM. Also take in to account the amount= of CPU speed and RAM other applications you may be using at the time such as electronic medical records or digital imaging systems. Some of these applications can be system-intensive.

In order for a provider to see patients, video confere= ncing will need to exist at both the provider and patient location.

To illustrate:

Scenario 1:

Scenario 2:

Scenario 3:

Scheduling Patients

Video conferencing is not meant to change the way medi= cal services are performed, rather, provide an additional avenue for patients or doctors who are separated geographically.&= nbsp; The following recommendations are not meant to replace current patie= nt scheduling, rather, provide an example on how the process may occur. Please see Appendix B for a sample checklist created by Dr. Tom Richards during the Wyoming Telepsychiatry project, 2010.

New Patients:

During scheduling, an intake should be performed with the patient and should consi= der:

- = Does the patient mind seeing the physician i= n a fully secured, private, video conferencing session?

- = The new patient will need to sign a video conferencing release to be placed in the patient file. Please see Appendix C for a sample consent form created by Dr. Tom Richards during the Wyoming Telepsychiatry project, 2010.

- = A video conferencing location conducive to t= he patient will need to be identified

- = A video conferencing location conducive to t= he patient will need to be approved and reserved for the patient. The IP address of that video conferencing room will also need to be given

- = A clinical assistant will need to be reserve= d at the patient location, to assist in the telehealth session

Existing Patients:

During scheduling, an intake should be performed with the patient and should consi= der:

- = Does the patient mind seeing the physician i= n a fully secured, private, video conferencing session?

- = Verify that there is a video conferencing release present in the patient file. Please see Appendix C for a sample consent form created by Dr. Tom Richards during the Wyoming Telepsychiatry project, 2010.

- = A video conferencing location conducive to t= he patient will need to be identified

- = A video conferencing location conducive to t= he patient will need to be approved and reserved for the patient The IP addres= s of that video conferencing room will also need to be given

- = A clinical assistant will need to be reserve= d at the patient location, to assist in the telehealth session

Cancelling a Telehealth Session:

If a cancellation occurs be sure to inform the physici= an, clinical assistant, IT or tech assistants, bridging source, or others invol= ved in your telehealth experience.

Telehealth Session

Provider Location

The following recommendations are not meant to replace current office protocol, rather, provide an example on how the process may occur. Adapt any recommendati= ons to enhance office capability to perform telehealth. Telehealth sessions are encrypted,= per HIPAA requirement. Encryption= is set up by technical staff when a video conferencing unit is installed or a bridged call is scheduled. Information regarding this requirement is outlined for IT and other technical staff to assist in acquiring, configuring, and using video conferencing systems. The doc= ument provided for IT staff is referenced as the Wyoming Telehealth Tech Policies. You may contact the= State Consortium through the Wyoming Department of Health, WyHIO, or CRMC for the most current revision.

1. = 10 minutes prior to the telehealth session turn on the video conferencing equipment, and dial the location hosting the patient

2. = Leave the provider microphone muted until the provider is ready to begin

3. = Position, Pan, or Zoom the provider’s Camera so that the patient can feel comfortable; it should be realistic as if they are seeing the provider in person

4. = Turn on any Picture-In-Picture feature so the provider can also see what they are transmitting

5. = Bring necessary documents and patient records

6. = If specific applications need to be started, such as electronic medical record= s, x-rays, or prescription records, provide those documents prior to the start= of the provider telehealth session

7. = Assist in unmuting the provider microphone or beginning the telehealth session once the patient has arrived and the provider is ready to begin

8. = Confirm the identity of the patient and continue with telehealth session

9. = Mute the microphone once the provider is finished and end the video conferencing call to ensure transmission is no longer occurring

Patient Location

The following recommendations are not meant to replace= current office protocol, rather, provide an example on how the process may occur. Adapt any recommendations to enhan= ce office capability to perform telehealth.

1. = 10 minutes prior to the telehealth session turn on the video conferencing equipment; the video call should occur automatically from the provider

2. = Leave the patient microphone muted until the provider is ready to begin

3. = Position, Pan, or Zoom the provider’s Camera so that the patient can feel comfortable; it should be realistic as if they are seeing the provider in person

4. = Turn on any Picture-In-Picture feature so the patient can also see what they are transmitting

5. = Bring necessary documents and patient records. Assist in unmuting the patient microphone or beginning the telehealth session once the provider is ready to begin

6. = Provide a patient intake/ evaluation to include vitals for the provider. Turn the session over to the provi= der, but remain in the room to assist with any evaluation or patient assistance<= /p>

7. = Mute the microphone once the provider is finished and end the video conferencing call to ensure transmission is no longer occurring

Appendix A

Tel= ehealth Sample Room Guidelines=

Provided by Tom Richards MD/MS, Apollo Telemedicine

Environmental Factors

For both the provider and t= he patient it is important that privacy be assured and that the acoustics and lighting are adequate for the telepsychiatric interview. We recommend the following:

&= nbsp; A quiet room where voices from t= he outside are not regularly overheard and privacy can be assured.

Overhead lighting is best for videoconferencing.= If indirect light is used in a videoconference, the participants tend to appear silhouetted. It is important to make sure that window coverings are closed,= so indirect light from outdoors does not cause silhouetting.

If the room has large windows it = is best to not place the patient in front of the windows (as sometimes even wi= th the window shades closed the person will appear like a silhouette). Y= ou could place the video unit near the windows and the natural light from the window would work well on the patient.

Full-spectrum fluorescent light bulbs = are recommended as opposed to standard fluorescent light bulbs. Full-spectrum light bulbs provide the most natural lighting; allowing you, and the camera, to see true colors and making skin tones appear healthy and realistic.

Solid colors are best for backgrounds, tables, and the participants

If you choose to have a table or desk= in the room then stay away from extremely dark or light colored tabletops. A neutral color, such as a blue-gray tone or a medium oak, works best. The ca= mera cannot adjust correctly if it is aimed at a tabletop made out of a reflecti= ve material such as chrome or glass. Bright white or dark wood tabletops create dramatic contrast, which appear as glowing areas or completely black areas = on camera.

Cameras prefer a blue background. The back= ground color should not be too light or too dark. Robin's-egg blue is the ideal color for background color in video. This can be achieved through paint, wallpaper, or a curtain. If you decide to use paint, make sure it is a flat paint that will not be reflective. The key to a good background is to provi= de adequate contrast on camera to the participants' skin tones and clothing. <= o:p>

Clothing: What to Wear

It is best to wear solid colors without patterns while you are on camera. You = do not want to cause a visual distraction; instead, you want the remote participants to concentrate on what you're saying, not what you're wearing. Wild patterns can cause the camera to keep refocusing. Avoid bright whites = and reds, as these will appear to blur or flash on camera. Do not wear a color that mat= ches your skin color; this will cause you to look washed out. Multiple colors or busy patterns c= an cause the cameras to continuously adjust for focus, contrast, and light control.

Camera and Microphone Placement

= &nb= sp; The videoconferencing equipment should= be positioned to allow for a comfortable interaction between the provider and = the patient. The camera should be placed at eye level with patient and provider approximately six feet away f= rom the person the camera is focused on. The microphone should be placed a foot or two in front of the patien= t. The screen view of the consultant = should be of the head and shoulders. The screen view of the patient may show more of the patient’s body depend= ing on the preference of the consultant. = The system should be tested using staff interaction or a mock patient before attempting a telepsychiatric consultation so that any technical issu= es can be addressed.

&= nbsp; We recommend introducing everyone at the beginning of the consultation just as would typically happen at the consultant’s office and having the consultant pan around the office to assure the patient that no one else exc= ept the consultant is present during the interview.

3D"Polycom_VSX_3000_49aa5c3406e0c.jpg" <= ![endif]>

3D"39-Telehealth1_jpg

Promote a video conferencing set up which allows the provider and patient to be “face-to-face” for a more personal experience.

Keep necessary peripherals attached to the machine to reduce troubleshooting and provide appropriate tools for the provider.

Avoid the use of conference rooms or large areas for regular telehealth sessions. The larger rooms provide a less personal feel for the patient.

Polycom, Inc.

Saskatook Health Regi= on

Polycom, Inc.

Appendix B

Telehealth Exam Sample Checklist

Provided by Tom Richards MD/MS, Apollo Telemedicine

PROVIDER:____= ________________ = &nb= sp; PATIENT:____________________=

Phone ____________________<= span style=3D'mso-spacerun:yes'> &n= bsp; = ; &n= bsp; = ; Date of Birth:___/___/_____

Fax ______________________

&= nbsp; &nbs= p; =

PURPOS= E: To assure the needs of the patient and provider are met by supplying the necessary patient information and a secure environment for the patient is m= ade available.

&nbs= p;

SUPPORTING DATA: Each specialist’s practice pattern is unique to their specialty and office practice. In order to a= chieve positive outcomes during the telemedicine examination, the practice pattern= is incorporated into the telemedicine experience as much as possible.

&nbs= p;

EQUIPMENT REQUIRED:

`= 33; Video Conferencing Unit

`= 33; Computer with MMPI availability and/or other resources as required by consultant

APPROPRIATE PATIENT: Any provider referred patient, new= or established, for whom a psychiatric and or behavioral health consultation is indicated and agreed to by the provider.

SCHEDULING PROCESS:

`= 33; May use form: Patient information sheet/scheduling.

`= 33; Contact is made between the two involved sites (specialist’s office and spoke site where patient will be or is being seen). Call Hub Site if assistance is nee= ded.

`= 33; Determine which site will make the call for the videoconference or if the call will be connected automatically through the bridge system. It is generally expected to connec= t ten minutes prior to actual consult time to allow for trouble shooting if neede= d.

`= 33; Upon agreement between the two sites regarding date/time of telemedicine consultation, the Hub Site is notified of scheduled time at (307)__________= _.

`= 33; Requesting party will assure that patient is aware of date and time of consultation, t= ime and location to arrive for registration, and that there may be an “Originating Site Fee.”

`= 33; Will presenter need to be present? If so, who? RN, LPN, MD, other?<= /p>

CONSULTATION = PROCESS - SPECIALIST SITE:

Prior to date/time of Consu= ltation

`= 33; Determine if clinically appropriate to evaluate/consult via telepsychiatry.

Assures that the following information is available prior to consultation:

`= 33; Signed “Telepsychiatry Informed Consent” (request fax copy if necessary)= . Place on office medical record.

`= 33; Patient information to include patient name, date of birth, social security number, billing and insurance data, and chief complaint.

`= 33; Relevant Medical History and Test Results

Date/time of Consultation:<= /p>

`= 33; Prepare room for Telepsychiatric Consult

`= 33; Turn Video Conferencing system on and establish picture-in-a-picture view.

`= 33; Place microphone in appropriate place and test audio level.

`= 33; Assure relevant paperwork is present.

&nbs= p; During Consult

`= 33; Assure the patient’s privacy is protected at all times. Close the door to the clinical room before the consultation begins.

`= 33; Assure introduction of all participants.

Post Consultation:

`= 33; Complete the “Provider Satisfaction” Form and send/fax to Wyoming Telepsychiatry Pilot Project at (307)_________.

`= 33; Send written summary of consultation to originating site/referring provider with notation consult was completed via telepsychiatry.

`= 33; Log telemedicine encounter on log sheet.

CONSULTATION = PROCESS - Originating SITE (Patient Site):

Prior to date/time of Consu= ltation:

Obtains and faxes the foll= owing to specialist’s office:

`= 33; Completed “Information Sheet” to include billing and insurance data

`= 33; Completed Intake Form

`= 33; Relevant Medical History and Test Results

`= 33; Signed Consent form.

Date/time of Consultation:<= /p>

Prepare room for Telepsych= iatric Consult – refer to ‘How to prepare for a telepsychiatric consultation’.

`= 33; Turn Video Conferencing system on and establish picture-in-a-picture view.

`= 33; Place microphone in appropriate place and test audio level.

`= 33; Assure relevant paperwork is present.

&nbs= p; During Consult

`= 33; Assure the patient’s privacy is protected at all times. Close the door to the clinical room before the consultation begins.

`= 33; Assure introduction of all participants.

Post Consultation:

`= 33; Assure written/faxed report received and placed on chart.

`= 33; Record telemedicine encounter in log.

`= 33; Patient to fill out Patient Satisfaction Survey

`= 33; Fax surveys to Wyoming Telepsychiatric Pilot Program at 307-_______.

Appendix C

Telehealth Sample Patient Consent Form

Provided by Great Plains Telehealth Resouce Center

Telemedicine Consent Form

I understand that my health care provider = &nb= sp; = (provider’s name) wishe= s me to have a

= telemedicine consultation with = &nb= sp; = = (consultant’s name). This means that I and/or my

healthcare provider or designee will, through interactive video connection, be able to consult with the above named consultant about my condition.

My healthcare provider has explained to me how the telemedicine technology will be used to do such a consultation.

I understand there are potential risks with this techn= ology:

1. &n= bsp; The video connection may not work of that it may stop working during the consultation.

2. &n= bsp; The video picture or information transmitted may not be clear enough to be usef= ul for the consultation.

3. &= nbsp; I may be required to go to the location of the consulting physician if it is = felt that the information obtained via telemedicine was not sufficient to make a diagnosis.

&nbs= p;

The benef= its of a telemedicine consultation are:

1. &= nbsp; You may not need to travel to the consult location.

2. &= nbsp; You have had access to a specialist through this consultation.

3. &= nbsp; Other:

&nbs= p;

I give my consent to be interviewed by the consulting = health care provider. I also underst= and other individuals

may be present to operate the video equipment and that= they will take reasonable steps to maintain confidentiality of the information obtained.

I understand that a limited physical examination will = take place during the videoconference and that I have the right to ask my health= care provider to discontinue the conference at any time. I understand that some parts of th= e exam may be conducted by individuals at my location at the direction of the consulting healthcare provider.

I authorize the release of any relevant medical inform= ation about me to the consulting healthcare provider, any staff the consulting healthcare supervises, third party payers and other healthcare providers who may need this information for continuing care purposes.

I hereby release = &nb= sp; = &nb= sp; (local facility name) its per= sonnel and any other person participating in my care from any and all liability wh= ich may arise from the taking and authorized use of such videotapes, digital recording films and photographs.

I have read this document and understand the risk and benefits of the telemedicine consultation and have had my questions regardi= ng the procedure explained and I hereby consent to participate in a telemedici= ne visit under the conditions in this document.

= &nb= sp; =

Patient/legal representative signature Relationship = &nb= sp; = Date/time

Witness = &nb= sp; = = Date/time