Mount Rogers Community Services Board

  1. Title: Protocol for provision of services via Telehealth
  1. Purpose: To establish a protocol for the provision of services via telehealth.
  1. Definitions:

Interactive Televideo (ITV) Communications- The interaction of two or more individuals, in real time, to share information through electronic media.

Substitute Decision Maker (SDM)-Apersonwhomakesdecisionsonbehalfoftheindividualreceiving services if that individual is incapable of making those decisions independently. An SDMmaybeappointedbytheindividualorappointedbythecourt.Withinthispolicy,"individual" shallrefertoeithertheindividualortheSDM,asapplicable.

Telehealth Services -The use of interactive audio, video, or other electronic media used for the purpose of diagnosis, consultation, or treatment pertaining to the delivery of health care services. Telehealth services do not include audio-only telephone, electronic mail message, orfacsimiletransmission(CodeofVirginia,§38.2-3418.16)

Telepsychiatry-TheuseofITVcommunication fortheprovisionofclinicalpsychiatriccarethat is usually delivered in person. Telepsychiatry does not includetelephone conversation, electronic mail message, or facsimile transmission between a health carepractitioner and an individual/substitute decision maker, or a consultation between two health care practitioners, although these activities may support telepsychiatry services. Telepsychiatry services may include (but are not limited to) diagnosis and assessment; medication management; and individual and group therapy.

Telepsychiatrist-A licensed medical professional providing thediagnosticassessment,evaluation, prescribing of psychiatric medication, and monitoring. Credentials include psychiatrist or nursepractitioner.

Telecommunication Technology-Technological methods or protocols used toestablishan ITV connection.

  1. Protocol:

Mount Rogers Community Services Board clinical staffareencouragedtodiscussTelehealth withtheindividualwhentheclinical staffbelieveitmaybebeneficialfortheindividualtoreceivesuchservices.Thedecisionshallbe based on the best interests of the individual, at the individual’s request, and whether the individual’s clinical condition is suited for visualandaudiopresentationviaTelehealth.

If Telehealthis deemed to be appropriate, the individual shall be provided education and an explanation of the process to assist the individual in making an informed decision. The individual must then provide consent to receive Telehealthbefore the process is initiated by signing informed consent form (see Section A below). If an individual determines that he/she does not want to utilize Telehealth, alternative services with Mount Rogers Community Services Board may be unavailable, and as such, the individual would be referred to other providers.

A.Informed Consent

An Informed Consent for Mount Rogers Community Services Board (MRCSB) form shall be completed, signed, and maintained in the individual’s MRCSB’s electronic health record. Appropriate informed consent shall, at minimum, include the following:

  • Identification of the individual;
  • Qualifications for Telehealthprovider;
  • Definition ofthepotentialrisksofTelehealth,relatedtoallofthefollowing:
  • Technical failure (including power outages, breaks in connectivity, etc.) that may disrupt service provision;
  • Transmission of information electronically; and
  • Typical risks associated with receiving any outpatient service;
  • TypesofactivitiespermittedthroughTelehealth(e.g., prescriptionrefills, appointment scheduling, andindividual education);
  • The individual’sagreementthat MRCSB staffandtheTelehealth providershalldetermine whether the condition being diagnosed and/or treated is appropriate for a Telehealth encounter;
  • Details on security measures taken with the use of Telehealth(e.g., encrypting data, password protected screen savers and data files, or utilizing other reliable authenticationtechniques),aswellaspotentialriskstoprivacynotwithstandingsuch measures;
  • The individual’s agreementforMRCSB stafftobepresentinthesession,asclinically indicated andappropriate;
  • Requirement for express individual consent to forward individual’s identifiable information to a third party for the purpose of treatment, payment, and healthcareoperations;
  • Permission of the individual for teleprovider’s access to the MRCSB’s electronic health record;
  • Protocol for contact between sessions;
  • NoticethattheindividualmaydiscontinueTelehealthservicesatanypointwithout impact totheindividual's abilitytoapplyforotherMRCSB’s services;and
  • Dated signature of the individual or their guardian or SDM.

B.Individual Health Record

The MRCSB individual health record established during the use of Telehealth must be documented following established MRCSB documentation policies and procedures. As such, the record shall include, as appropriate, any and all informed consent forms, copies of all individual-related electronic communications, including communication between the provider and the individual; prescriptions; laboratory and test results; evaluations and consultations; records of past care; and instructions obtained or produced in connection with the utilization of Telehealth.

C.Privacy and Security of Individual Records and Exchange of Information

1.All MRCSB policies and procedures related to documentation, record access, transmission and storage, as well as all HIPAA and confidentiality policies and procedures concerning privacy and security apply to this service, as well as all providers, MRCSB staff and contractors working in conjunction with this service.

2.The Program Directors shall be responsible for ensuring that all providers and staff are trained on all MRCSB policies and procedures related to HIPAA, confidentiality and Virginia DBHDS Human Rights.

3.MRCSB shall ensure that all equipment and software utilized meet required guidelines. MRCSB staff are responsible for ensuring that rooms utilized for Telehealth meet established guidelines (See section G below).

4.The contract signed with the provider or entity shall include a Business Associate Agreement. In addition, the MRCSBProgram Directors and provider shall attest that the location where the provider provides services meets MRCBS guidelines.

D.Clinical Guidelines

1.The standard of care delivered via Telehealth shall be equivalent to any other type of care delivered to MRCSB individuals in person.

2.All persons present at each Telehealth site shall be identified to all participants at the start of the session.

3.During the first Telehealth session (and as circumstances warrant in the judgment of the provider), it is essential that the identity (names and credentials) of those participating in the Telehealth session are identified.

4.A qualified MRCSB staff shall be present with the individual to take appropriate vital signs and/or other medical information requested by the teleprovider (if applicable).

5.Designated MRCSB staff shall remain present during the session, unless the Program Director (or designee) has endorsed otherwise.

E.Licensure

The teleproviderfallsunderthejurisdictionof his or her licensing board and must abide by the laws, regulations, and policies, including the relevant licensing laws, of the Commonwealth of Virginia. Out-of-state psychiatristsprovidingtelepsychiatryservicestoVirginiaresidentsareconsideredtobe practicing intheCommonwealthofVirginiaandmustabidebyVirginialaws,regulations,and policies, including the relevant licensing laws, as well as the laws of the state in which they practice.

F.Relationship between Practitioner and Individual

All teleproviders must adhere to Virginia law defining relationship between practitioner and individual, Virginia Code(§ 54.1-3303) and all regulatory requirements.

G.Physical Environment

1.Both the teleprovider's and the individual’s environment shall aim to provide comparable professional specifications of a standard services room. Efforts shall be made to ensure privacy such that clinical discussion cannot be overheard by others outside of the rooms in which the service is provided. If other people are in either the individual's or the professional's room, both the professional and individual shall be made aware of the other person and agree to their presence. If the individual does not agree and consent to the presence of another party, appropriate accommodations will be made with the consent of all parties.

2.Both the teleprovider and the individual should maximize clarity and visibility of the person at the other end of the ITV.

3.To the extent possible, cameras will be securely placed on a stable platform to avoid movement during the session. To the extent possible, cameras shall be placed at the same elevation as the eyes, with the face clearly visible to the other person.

  1. Crisis/Emergencies-Medical (e.g., cardiac arrest)

Mental/behavioraland/or medicalemergenciesoccurringduringaclinicalencounter shallbemanagedaccordingtoexisting MRCSB policiesand guidelines.Mandatory reporting and related ethical requirements, such as duty to notify, must be fulfilled in accordance withCommonwealth of Virginia rules and regulations.

I.Community and Cultural Competency

Teleproviders shall be culturally competent to deliver services to the populations they serve. Examples of factors to consider include awareness of the individual’srace, color, religion, sex, age, national origin, disability, sexual orientation, gender identity or expression, marital status, veteran status, or any other category protected under applicable law. Teleproviders shall be oriented to the Mount Rogers Community Services Board policies and procedures.

J.Documentation and billing

Documentation and billing for services provided via Telehealth shall be completed in the same manner as face-to-face services, with the following exceptions:

1.The provider shall obtain informed consent by the initial visit.

2.The appropriate code shall be used when entering services into the EHR.

3.Progress notes for the session must document the following:

a.The names and role of all persons present during the session.

b.Confirmation of the location(s) where the patient will receive telehealth services. In addition, the location of the provider shall be documented. However, it is not necessary for the teleprovider to reveal their specific location to the individual, especially if the provider is located at home at the time of the service.

c.Documentation shall meet all standards for Licensure, Department of Medical Assistance, HIPAA, and industry standard practices.

d.Any issues that arose during the session or that prevented the service from being provided or completed (e.g., equipment issues).

K.Prescriptions

1.The indication, appropriateness, and safety considerations for each prescription provided via telepsychiatry must be evaluated by the physician in accordance with applicable law and current standards of practice and consequently carry the same professional accountability as prescriptions delivered during an in-person session.

2.Prescriptions for Schedule III – V medications may be phoned or faxed to the pharmacy. Schedule II medications unable to be electronically prescribed must be generated on paper and mailed to the MRCSBclinic location.

L.AdministrativeGuidelines

1.The Program Directormust ensure that allMRCSB staff involved in the delivery of Telehealthservices have received necessary training and are aware of all procedures which must be followed.

2.Credentialing must be obtained prior to establishing Telehealth services (according to MRCSB policy).

3.Appointments, cancellations, and reschedules must follow current MRCSB procedures.

4.Rooms at the MRCSBsitesused for Telehealth must have been set up with ITV equipment prior to the Telehealth session.

M.Technical Specifications/Room Requirements

1.Videoconferencing Applications

a.MRCSB must use video conferencing applications that have the appropriate verification, confidentiality, and security parameters necessary to be properly utilized for this purpose.

b.Video software platforms must not be used if they include social media functions that notify users when anyone on a contact list logs on. If a software platform is utilized that has this as a setting, it must be disabled. These platforms also must not include the capability to create a video chat "Room" that allows others to enter at will. This type of functionality must also be disabled.

2.Device Characteristics

Teleprovider must ensure the computers and devices they use have up-to-date antivirus software and have firewalls installed or utilize appropriate security protocols for dedicated end-point devices.

Connectivity

Telehealth must be provided through equipment that uses videoconferencing software programs that provide such services at a bandwidth of at least 384 Kbps or higher in each of the downlink and uplink directions. Such services must provide a minimum of 640 X 360 resolutions at 30 frames per second. Because different technologies provide different video quality results at the same bandwidth, each end point shall use bandwidth sufficient to achieve at least the minimum quality shown above during normal operation.

3.Contingency Plan

In the event of a technology breakdown, causing a disruption of the session, the servicebackupplanincludescalling MRCSB’s Data and Technology Resources department and/ortheMRCSB provider onsiteand troubleshooting the issue together; or providing the individual with access to other behavioral healthcare as appropriate. If the technical issue cannot be resolved promptly,the qualified MRCSBstaffwillconsultwiththe teleprovider to determine how to proceed. This may include rescheduling with theteleprovider.Ifunabletoreachtheteleprovider,consultwiththeMRCSB Program Director (or designee)todeterminehowtoproceed.