NARBHA Checklist for Provider Orientation
on Use of Video Equipment for Telemedicine

Provider name: ______

Network Provider: ______

Orientation conducted by:

____ Review of NARBHA DVD AND PACKET (or)

____Sara Gibson, MD, NARBHA Telemedicine Medical Director in person

Telemedicine care provider, please sign and date when orientation is completed and:

1. Ensure that this documentation is placed in your personnel record.

2. Fax a copy (this page only) to NARBHA, attn. Telemed Staff (928) 774-5665

Provider signatureDate

______

Handouts

  1. NARBHA’s Provider Policy 10.10, “Clinical Telemedicine Services”
  2. NARBHA ProviderPolicy 3.11, “General and Informed Consent to Treatment.”
  3. Informed Consent to Participate in Telemedicine Services, PM Form 3.11.2
  4. Informed Consent to Record Participation in Telemedicine Services,PM Form 3.11.3

3. Telemedicine Allowable Codes

4. Informed Consent for Psychiatric Medication Treatment, modified for telemedicine use PM 3.15.1

A.Privileging/Scope of Practice

  1. Credentialing information from another JCAHO-accredited facility may be used in considering utilization of a telemedicine health care provider if the privileging decision is made at the network provider.
  1. Privileges/scope of practice are specific to the services that the health care provider can deliver via telemedicine.
  1. Orientation/training and competence in the use of videoconferencing equipment are documented in the health care provider’s personnel file.
  1. The provider must be appropriately licensed to provide services in the state and network provider in which the member resides.

B.Orientation of Members

  1. Members are given the option to refuse telemedicine services. They may choose to transfer care to another network provider.
  1. Member must consent and sign the “Informed Consent to Participate in Telemedicine Services” 3.11.1 before their initial telemedicine session. This form becomes part of the Member’s medical record. See NARBHA Provider Policy 3.11, “General and Informed Consent to Treatment.”
  1. Don’t apologize! Point out the benefits to the Member of seeing their doctor over video (less driving for the Member, don’t have to take an entire day off work, better physician continuity). If you present this in a positive, “this is how it works best” light, others will pick up on your acceptance.
  1. Explain where you are located (e.g., Flagstaff at an administrative office that oversees the Member’s clinic). Show your room and reassure that no other people are present.
  1. Show the Member the use of the camera (e.g., move the camera to show the Member the entire conference room in order to give them perspective and reassure the Member that no one is hiding and watching. You can also describe what you see so younger members understand that you really CAN see them!).
  1. Explain the monitor, microphone (emphasize that there is no need to yell because the microphone is very sensitive; for kids, say “don’t touch it or you will hurt my ears!”), and remote control or touchpad (again, “don’t touch!”).
  1. Members are often nervous initially. A staff member at the remote facility should be with the Member for the initial session, and ideally every session. The Member’s therapist, case manager, or nurse encourages a team treatment model, increases security and maintains confidentiality.
  2. Patients on conditional release from the ArizonaStateHospital are seen by the psychiatrist with another mental health professional (e.g., case manager, or nurse) present with the patient. This helps ensure that clinical issues not apparent to the psychiatrist using this modality (e.g., alcohol on breathe, etc.) are transmitted to the psychiatrist by the mental health professional present with the patient.
  1. Explain in non-technical terms that the two video locations are confidential, e.g. “as secure as a land-line phone call so that no one else can listen in on the session.”
  1. Explain the videotaping policy or reassure that videotaping will not occur without prior notice. Generally, videotaping is not recommended except for unusual clinical needs. If the session is going to be videotaped, make sure the Member has consented and signs “Informed Consent to Participate in Telemedicine Services and Videotape.” Provider Manual 3.11.2. This form becomes part of the Member’s medical record.

C.Technology

  1. Camera Placement
  1. Maintain good eye contact with the Member. (The camera is placed on top of the monitor, so that when the physician or health care provider looks into the monitor, it gives a normal appearance of looking into the Member’s eyes.)
  1. To ensure that video images are as natural as possible, keep the image of yourself as life-size as possible (head and shoulders in the monitor). Ensure the image is in focus. Minimize distractions behind the image (a solid blue background maximizes clarity).
  1. To facilitate eye contact, the camera at each site should be placed on top of the TV monitor.
  1. Leave your picture-in-picture window open to see what the Member is seeing.
  1. Ensure that the Member’s picture-in-picture window is closed, because seeing themselves makes most people acutely self-conscious and aware of the technical system.

2.Sound: Microphone can be moved and volume adjusted so that Provider and Member hear each other clearly.

D.Confidentiality/Privacy

To ensure confidentiality/privacy of the telemedicine session, policies require that clinical telemedicine sessions be held in a room that maintains the member’s privacy and includes the following:

  1. Keep the telemedicine room door closed at all times while a Member is on the screen or can be heard talking.
  1. Make sure the sign stating that a clinical session is in progress is posted on the telemedicine room door to ensure Member privacy.
  1. Members must consent to the presence of all teleconference participants. Presence of a therapist, case manager, or nurse with the Member is recommended.
  1. Windows to the Member and Provider rooms should be covered or the monitor in the Provider room placed so that no one looking in can see the Member on the screen.
  1. Volume should not be turned up so loud that the conversation can be heard outside the room at either location. Some locations may require soundproofing or white noise machines outside telemedicine rooms.
  1. All videoconferencing equipment in rooms used for telemedicine or member services must have the camera lens covered and the microphone muted or must be turned off whenever the equipment is not in use and a member is in the room.
  1. The following security measures are the responsibility of NARBHA Telemedicine staff and the MIS staff at the provider’s location.
  • All videoconferencing equipment is set to automatically mute its microphone(s) when answering any incoming calls.
  • All videoconferencing equipment is set NOT to automatically answer multipoint calls.
  • All videoconferencing equipment with Internet access that is used for telemedicine has an administrative password.
  1. Clinical Records
  1. All Member information is confidential and is treated as such at all times.
  1. The clinical record generated during the telemedicine session is the property of the network provider where the Member is enrolled, and NARBHA/DBHS record-keeping requirements are met.
  1. All clinical records of Members who are seen via telemedicine clearly document that the service was provided via telemedicine.
  2. All psychiatric notes and other documents that are documenting a service provided via telemedicine contain “Telemedicine” in the document title. Examples include: “Psychiatric Evaluation – Telemedicine”; “Psychiatric Follow-up –Telemedicine”; “Progress Note – Telemedicine.”
  3. The clinical record includes the signed “Informed Consent to Participate in Telemedicine Services” form.
  1. A written clinical record generated during the telemedicine session is mailed, faxed, or sent Federal Express securely for inclusion in the Member’s medical record, or printed off the electronic medical record or maintained electronically.
  1. If clinically indicated, the Provider utilizing the NARBHA site copies the clinical record for inclusion in a duplicate chart located in a locked, confidentialfile cabinet at the NARBHA site. This is considered property of the Provider’s Responsible Agency.
  1. It is the responsibility of the Provider to determine appropriate records for inclusion in a duplicate record located at NARBHA.
  1. Designated NARBHA support staff may be available to assist with filing, copying, faxing, and mailing, and will have access to the key to the filing cabinet where clinical records are stored.
  1. Medical Prescriptions
  1. The physician provides Members with timely and accurate prescriptions via mail, phone, fax, or electronic prescriptions.
  1. When a prescription is written that cannot be called in (e.g., Federal Schedule 2), it is mailed to the pharmacy in an envelope marked “confidential, attention pharmacist,” or it is securely mailed to the network provider, which is then responsible for delivery to the Member or guardian for whom it is written.
  1. Prescriptions are called or faxed in to the pharmacist in compliance with HIPAA policies and procedures or mailed to the network provider for distribution to Members when clinically indicated.
  1. All policies and procedures on disclosure of confidential health information are strictly adhered to.
  2. Informed Consent for Psychotropic Medication Treatment via Telemedicine (TIPS)
  • Use PM Form 3.15.1 (Informed Consent for Psychotropic Medication Treatment) “Suggested Format for Telemedicine Providers”. DBHS/ADHS approved this form and the following procedure in April 2006.
  • The Behavioral Health Medical Practitioner’s (BHMP) name(s) can be pre-printed on the blank form.
  • Have blank copies of Informed Consent form available AT THE PATIENT SITE.
  • As a medication is initiated, patient (or clinician sitting in with patient) can fill out the form with medication, target symptom, date. PERSON/GUARDIAN MUST INITIAL/SIGN and date where indicated. This then goes into the patient chart, complete.
  • The BHMP/prescriber does not need to sign or fax the form. It is designed so that the informed consent process is documented in that day’s signed psychiatric note: “Informed consent form signed by patient.” A check box on a prepared psychiatric note facilitates this.
  • The BHMP will need assistance to audit the chart for the signed form if the chart is not immediately available at the telemed (remote provider) site.
  • When outside agencies audit charts for informed consent for psychotropic medication treatment, they typically audit both the informed consent form AND the practitioner note for evidence that informed consent was done. (rev 09/09)
  1. Coding and Appropriate Telemedicine Services
  1. Provider SALS must include the "GT" indicator for all telemedicine services provided.
  1. Network providers must input “GT” services into their service recognition system as telemedicine services.
  1. Attention is given to appropriate service codes because not all are allowed as “telemedicine services” by ADHS/DBHS or Medicare. See ADHS/DBHS Covered Behavioral Health Services Guide Appendix B-2 (a link on the website).
  2. Services such as telephone calls and chart-only codes (review or report preparation) are not allowable telemedicine services.
  3. Medicare is more restrictive in the telemedicine services it will reimburse than Medicaid (AHCCCS) is.

H. Review Provider Policies (see handouts).

I:\Telemed\PR, reports, orientations\Sara's provider Orientations\provider orientation checklist.doc (NR 6/21/06)

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