ata teleburn guidelines - telemedecine-360.com · by the health professional into medical image...

©AmericanTelemedicineAssociation

ACKNOWLEDGEMENTSTheAmericanTelemedicineAssociation(ATA)wishestoexpresssincereappreciationtotheATATeleburnCareGuidelinesWorkGroupandtheATAPracticeGuidelinesCommitteeforthedevelopmentoftheseguidelines.Theirhardwork,diligenceandperseverancearehighlyappreciated.

PRACTICEGUIDELINESWORKGROUPChair:LouTheurer,GrantAdministrator,BurnTelemedicineProgram,OperationsManager,DepartmentofTelemedicine,UniversityofUtahHealthSciencesCenter

•WorkGroupMembers•CindyLeenknecht,RN,BS,MS,TelemedicineProjectCoordinator,ClinicalInformaticsSpecialist,St.VincentHealthcareFoundationJackieBuschBSN,Nursing,ClinicalServicesDirector,InTouchHealthBeatrizCoccaroWord,RN,NP,WoundHealingNursePractitioner,MarshfieldClinicLibbaReedMcMillan,PhD,RN,AssistantProfessor,AuburnUniversityTomBrewer,BSBA,MS,IPC,VirtualHealthSolutionArchitect,Accenture

•SubjectMatterExpertReviewers•

JeffreyR.Saffle,MD,FACS,ProfessorofSurgery,Director,UniversityofUtahBurnCenterDanielCaruso,MD,FACS,Chief,BurnServices,ArizonaBurnCenterTamPham,MD,FACS,AssociateProfessorofSurgery,HarborviewBurnCenterNathanKemalyan,MD,FACS,OregonBurnCenter,LegacyHealthSystem

•ATAPracticeGuidelinesCommittee•Chair:ElizabethA.Krupinski,PhD,Professor&ViceChairforResearch,DepartmentofRadiology&ImagingSciences,EmoryUniversity


•CommitteeMembers•NinaAntoniotti,RN,MBA,PhD,ExecutiveDirectorofTelehealthandClinicalOutreach,SIUSchoolofMedicineDavidBrennan,MSBE,Director,TelehealthInitiatives,MedStarHealthAnneBurdick,MD,MPH,AssociateDeanforTelemedicineandClinicalOutreach,ProfessorofDermatology,Director,LeprosyProgram,UniversityofMiamiMillerSchoolofMedicineJerryCavallerano,PhD,OD,StaffOptometrist,AssistanttotheDirector,JoslinDiabetesCenter,BeethamEyeInstituteHelenK.Li,MD,AdjunctAssociateProfessor,UniversityofTexasHealthScienceCenterLouTheurer,GrantAdministrator,BurnTelemedicineProgram,UniversityofUtahHealthSciencesCenterJillM.Winters,PhD,RN,PresidentandDean,ColumbiaCollegeofNursing

•ContributingEditor•RashidBashshur,PhD,SeniorAdvisorforeHealth,UniversityofMichiganHealthSystem

•ATAStaff•JordanaBernard,MBA,ChiefProgramOfficerJonathanD.Linkous,CEO


PRACTICEGUIDELINESFORTELEBURNCARE

TABLEOFCONTENTS

PREAMBLE 1

SCOPE 2

DEFINITIONS 2

INTRODUCTION 2

PRACTICEGUIDELINES 3

AdministrativeGuidelines 3

ClinicalGuidelines 7

TechnicalGuidelines 11

APPENDIX 16References 16

©AmericanTelemedicineAssociation|Page1

PREAMBLETheAmericanTelemedicineAssociation(ATA)isamembership-basedorganizationcomposedofadiversesetofmembersincludinghealthcareproviders,academicians,researchers,programdevelopers,industryrepresentatives,andpolicymakers.ATAcollaboratesactivelywithrelatedhealthprofessionalorganizations,aswellasthepublicandprivatesectors,inpromotingthesafeandeffectiveuseoftelemedicinetoenhancethehealthandwellbeingofpeople.ATAhasembarkedonamissiontoestablishguidelinesinseveralareasoftelemedicinepracticetoassurepatientsafety,adherencetostandardprotocols,uniformityandqualityofservicesprovidedviatelemedicine.Theguidelinesweredevelopedbypanelsofexpertsintheirrespectivefields,andaredesignedtoassistprovidersofcareincomplyingwithethicalstandards,legalrequirementsandsoundbusinesspractices.Inaddition,theyserveasguidesforpatientsandtheircaregiversinassuringtheirrightsandprotectingtheirhealth.Thedevelopmentoftheseguidelinesentailedarigorousprocessofpeerreviewandanalysistoensuretheirappropriateness,relevancy,consistency,andcomprehensiveness.TheywereenactedafterfullreviewandapprovalbytheBoardofDirectors.Inviewofchanginglawsandregulations,researchevidence,circumstancesofpracticeandtechnologicaldevelopments,theseguidelinesarereviewedperiodicallyandupdatedasindicated.Compliancewiththeseguidelinesalonewillnotguaranteeaccuratediagnosesorsuccessfuloutcomesforpatients.Practitionersareurgedtorelyontheirbestprofessionalexperienceandexpertisewhenfacedwithuniquecases,unexpectedcircumstancesornewdevelopmentsintechnology.Whentheseconditionsexist,telemedicinepractitionersarestronglyadvisedtodocumentthisinformationandtherationalefortheactionstakeninthepatientrecord.Theframersoftheseguidelinesdonotpurporttoestablishstrictlegalstandardsfortelemedicineservices.Instead,theyfocusonthequality,safetyandeffectivenessoftelemedicineencounters.


SCOPETheseguidelinescovertheprovisionofmedicalandrelatedhealthcareservicesusingtelecommunicationstechnologiesbetweenpatientsandtheirprovidersaswellasamongproviders(practitionersandspecialists)forthediagnosis,treatmentandfollow-upofpatientswithburninjuries.Healthcareprovidersincludeindividualpractitioners,singleandmulti-specialtypractices,hospitalsandhealthsystems,triageorcallcenters,andotherlicensedhealthcareprovidersdeliveringtelemedicineservices.Theseguidelinesdonotaddressothercommunicationsbetweenhealthcareprofessionalsandpatientsviashortmessageservice,emailcorrespondence,socialnetworksites,oronlinehealth“coaching”.

DEFINITIONS

Theguidelinesaddressthreeaspectsofservicedelivery:administration/management,clinicalpractice,andtechnicaldesignandarchitecture.Undereachaspect,theguidelinesarepresentedintheformofthreelevelsofexpectedadherence:“Shall”indicatesrequiredactionwheneverfeasibleand/orpractical.“Shallnot”indicatesaproscriptionoractionthatisstronglyadvisedagainst.“Should”indicatesrecommendedactionwithoutexcludingothers.“May”indicatesappropriateactionsthataredeemedappropriatebutnotmandatorytooptimizethetelemedicineencounterandthepatientexperience.Theseindicationsarepresentedinboldlettersthroughoutthedocumenttofacilitatetheirvisibility.ATAurgeshealthprofessionalsusingtelemedicineincaringforburnpatientsintheirpracticestofamiliarizethemselveswiththeseguidelines,aswellasotherclinicalguidelinesorbestpracticestandardsissuedbytheirprofessionalorganizationsorsocietiesandtoincorporatebothsetsintotheirtelemedicinepractice.TheseguidelinespertaintohealthcareservicesdeliveredviatelemedicinewhenbothpatientandproviderarewithintheUnitedStates(US).Otherjurisdictionsmayusetheseguidelinesattheirdiscretion.

INTRODUCTION

Severalaspectsofburninjuriesandtreatmentareideallysuitedforthepracticeoftelemedicine.1-5Burnsarecutaneousandtypicallyvisibleinjuries.Hence,inmostinstancestheycanbeevaluatedaccuratelyandquantifiedastobothextentanddepthbyvisualexamination.TheincidenceofseriousburnsintheUnitedStateshasdecreasedfromapproximately10.2per1,000annuallyinthe1960’sto4.2per1,000inthe1990’s.6Thedeclineinburninjurieshasledtoasignificantreductioninthenumberofburncentersaroundthecountry,7leavingsegmentsofthepopulationwithoutconvenientaccesstospecializedburncare.8In2015,theAmericanBurnAssociationestimatedthatabout486,000burnsrequiredtreatmentresultingin40,000hospitalizationsand3,240deaths.9Certainpopulationsareatincreasedriskofburninjuries,includingchildren,theelderly,andruralresidents.Hence,theysufferfromlimitedaccesstoappropriatecare.10Manyphysiciansreceivelittleornotraininginburnevaluationormanagement.Thiscanleadtoseriouserrorsinburnevaluation,11-12over-treatment,13over-


triage,and/orover-useofexpensiveandinconvenienttransportservices.13-16Thisisironicbecausetheimprovedlowerincidenceandimprovedsurvivalofburnpatientsinrecentdecadeshascreatedmoredemandforrehabilitationandlong-termfollow-upwhichareexpensiveandnotwidelyavailable.7,17-18Telemedicinepromisestofillthegapinmeetingtheneedforspecializedburncareatanaffordablepriceeveninlocationswhereitmaybelogisticallyimpossible.19-20Inmanyotherpartsoftheworldburninjuriesremainalltoocommonsourcesofdisabilityanddeath.Whenproperlyimplemented,telemedicinecanprovidereadyaccesstoqualifiedprovidersforoptimalburncare.21-48Thiscanbeachievedinrealtimewhentimeisoftheessenceorasynchronouslywhenseekingexpertopinion.Bothreal-time(synchronous)videoconferencingandasynchronous(store-and-forward)imagerycanbeimplemented,dependingontheconditionofthepatient.24-27SuccessfulburntelemedicineprogramshavebeendescribedintheUS,28-30otherindustrializednations,31-33austereenvironments,34developingnations35andininternationalcare.36-38Thetoolsoftelemedicineandmobileapplicationscanenhancepatientmanagement,whilesavingcostsandfacilitatingdocumentation.Mobileapplicationsaregainingpopularityinburntreatment,whicharguesfortheneedtodevelopanddisseminatepracticeguidelinesforteleburncare.39Telemedicinecanplayapivotalroleinresponsetodisasters,bothnaturalandman-made.Calamitouseventscanexhaustlocalresources,43andmayheavilytaxthenation’scapabilitiestoprovideatimelyresponse.44Telemedicinenetworkshavethepotentialtodealwithforsuchscenarios,whichtypicallyburninjuries.40-45Hence,itisimportantforprofessionalstobefamiliarwiththismodalityofpracticeifwearetodealwithsuchemergencieseffectively.Otherbenefitsoftelemedicinederivefromtheuseofdigitalimagesaspartofthemedicalrecordformonitoringundhealing,evaluatingtheeffectivenessoftreatment,anddocumentingrequestsforreimbursementpurposes46-48Standardizedtelemedicineprotocolsareneededtoensurequalitycareandpatientsafetyinthetreatmentofburninjuriesandinfacilitatingcommunicationsbetweenvariousprovidersrenderingcarewhomayhavedifferentlevelsofexpertiseandtraining.7

PRACTICEGUIDELINES

ADMINISTRATIVEGUIDELINES

TheAmericanTelemedicineAssociation’s“CoreOperationalGuidelinesforTelehealthServicesInvolvingProvider-PatientInteractions”addressesthegeneraladministrativeissuesintelemedicineconsultations.Theseguidelinesshallbeimplementedwherepertinent49However,thekeycoreguidelinesarerepeatedheretogetherwithadditionaladministrativeaspectsthatpertaintoteleburncare.

A.OrganizationsandOtherProviderEntities

1. Organizationsandotherproviderentitiesprovidingteleburnservices(hereafterorganizations)shallensurecompliancewithallrelevantlocal,stateandfederal(or


internationalifappropriate)lawsandregulations,withrespecttomedicalandotherhealthcareservicesprovided,includingbutnotlimitedtoinformedpatientconsent,protectionofpatientidentifiableinformationuseofhumansubjectsinresearch,andallprevailingregulatoryrestrictionsrequiredbythestatemedicalboardinthestatewherethepatientislocated,includingrelevantprescriptionpracticeandsubstance(s).

2. Organizationsshallobserveandfollowthepoliciesandstandardoperatingprocedures

ofthegoverninginstitution.Ifthetelemedicineprogramisanindependententityorpartofasolopractice,theentityorsolopracticeshallestablishpoliciesandprocedurestogovernalladministrativefunctionsincludingthefollowingprovisions:

a. Theorganizationshallensurethatallprovidersengagedintelemedicinehavethe

propertraining,arecredentialedtoprovideburnservices,andhaveaclinicaloversightandevidence-basedcontinuousqualitymanagementprogram.

b. Theorganizationshallensurethatprivacyandsecurityofprotectedhealthinformation(PHI),records,documentation,transmissionandstorageisincompliancewithallrelevantlocal,stateandfederalregulations.

c. OrganizationsthatemployotherpartiestohandletheirpatientrecordsshallhaveinplaceaBusinessAssociateAgreementwiththesepartiesthatbindsthemtoHIPAAobligations.

d. OrganizationsshallreviewrelevantFederal,state,local,andotherregulatoryandethicalrequirementsshalltodeterminetheirimplicationsforprovidingburncareviatelemedicinewhenthepatientandproviderarenotinthesamelocationand/orwhenthepatientislocatedathomewithoutatele-presenterorfacilitator.

e. Ownershipofpatientdataand/orrecordsshallbedefinedwithattentionto OBRA(OmnibusBudgetReconciliationAct)andCOBRA(ConsolidatedOmnibusBudgetReconciliationAct)requirementsfordocumentationsharingwithreferringprovidersandcareteammembers.

f. Patientandclinicianrightsandresponsibilitiesshallincludetheconsultingprovider,tele-presenterorfacilitatorandpatient.

g. Referencematerialsontheuseofequipment,devicesandtechnologyincludingperipheraldevices,networkhardwareandassociatedsoftware,andelectronichealthrecordsshallbeavailabletoallpartiesparticipatingintheteleburnencounter.

h. Fiscalmanagementoftheteleburnprogramshouldbeconsideredevenwhenfinancialconsiderationsarenottheprimeobjectiveofaprogram.Abusinesscase(suchasreturnoninvestmentROI)forinitialdevelopmentandongoingmaintenanceandsupportshouldbedeveloped,periodicallyreviewedandupdatedasindicated.

3. Organizationsshallhaveinplaceanexplicitcontinuousqualitymanagementprogram

andperformancemonitoringthatcomplieswithallorganizational,regulatory,andaccreditingrequirementsforoutcomesmanagement.Thisprocessshallbereviewedperiodicallyandupdatedasappropriate.

a. Clinicalconsultationsshallbereviewedaccordingtopracticestandardsforcliniciansconductingburncarethesameasin-personcare.


b. Patientvisitsshallbereviewedregularlytoascertainnetworktechnicalperformanceandtheabilityofproviderstocompleteallcomponentsoftheencounterswithpatients.

c. Communicationofqualityperformanceresultsshallbecommunicatedtotheparticipatingpatientsiteswhileobservingpatientconfidentiality.

4. Organizationsshallhaveanestablishedprocesstoassuretheimplementationofstandardoperatingprocedures,includingpatientinformedconsent,andpatientrightsandresponsibilitieswithrespecttotheuseoftelemedicineintheircare.Thisappliesregardlessofwhetherthepatientisatahealthcareinstitutionorathome,schoolorwork.Thisalsoincludesaprocessforcommunicatingcomplaints.

a. Theinformationshallbeprovidedinsimplelanguagethatcanbeeasilyunderstoodbythepatient,whichisparticularlyimportantwhendiscussingtechnicalissueslikeencryptionorthepotentialfortechnicalfailure.

b. Priortoinitiationofateleburnencounter,theproviderordesigneeshallinformthepatient(eitherinwritingorverbally)abouttheuniquenatureoftelemedicineservices,itsbenefitsandlimitationscomparedtoin-personcare,includingbutnotlimitedto:

i. Privacy,securityandconfidentialitywhenrelyingonelectroniccommunication

ii. Potentialfortechnicalfailureandalternateproceduresforcompletingtheencounter

iii. Emergencyplans(particularlyforpatientsinsettingswithoutclinicalstaffimmediatelyavailable)

iv. Conditionsunderwhichcareservicesmaybeterminatedandareferralforin-personcare

v. Timingofservices(e.g.,frequency,appointmenttimes)vi. Recordkeepingandmandatoryreportingvii. Schedulingarrangementsviii. Credentialsofthedistantsiteproviderix. Billingarrangementsx. Proceduresforcoordinationofcarewithotherprofessionalsxi. Protocolforcontactbetweensessionsxii. Informationspecifictothenatureoftheinteraction(e.g.,store-forward

transmissionofdata/images,videoconferencing)

5. Organizationsshallestablishamechanismforinforminghealthcareprovidersatboththeoriginatingandremoteoftheirrightsandresponsibilitieswithrespecttousingtelemedicineintheirpractice,includingtheprocessforcommunicatingandaddressingcomplaints,whereappropriate.

6. Organizationsshallapplyintegratethemintoexistingoperationalproceduresforobtainingconsentfortreatmentfrompatients.Additionalinformedconsentforprovidingservicesviatelemedicineisnotrequiredunlessmandatedbylocal,state,federalorotherregulations.


7. Organizationsshallhaveanestablishedprocesstoassuretheimplementationofstandardoperatingprocedures,includingpatientinformedconsent,andpatientrightsandresponsibilitieswithrespecttotheuseoftelemedicineintheircare.Thisappliesregardlessofwhetherthepatientisatahealthcareinstitutionorathome,schoolorwork.Thisalsoincludesaprocessforcommunicatingcomplaints.

a. TelemedicineAgreementthatincludescredentialingrequirementsandconditionsofparticipationforcriticalaccesshospitalsandotherhospitals

b. Individualclinicalserviceagreement–denotingexpectationsandbusinessarrangements

c. HIT(HealthInformationTechnology)agreementsforsharingelectronichealthinformation,includingBusinessAssociateAgreements;

d. Alloftheabovecanbeincorporatedintoasingledocument.

B.HealthcareProfessionals

1. Healthcareprofessionalsprovidingteleburnservices(hereafterprofessionals)shallobservethejurisdictionalregulatory/licensinglawspertainingtotheirprofessionalpracticeintheirownjurisdictionwheretheypracticeaswellasthejurisdictionwherethepatientislocatedatthetimeofcare.Theseinclude:

a. TelemedicineAgreementthatincludescredentialingrequirementsandconditionsofparticipationforcriticalaccesshospitalsandotherhospitals

b. Individualclinicalserviceagreement–denotingexpectationsandbusinessarrangements

c. HIT(HealthInformationTechnology)agreementsforsharingelectronichealthinformation,includingBusinessAssociateAgreements;

d. Alloftheabovecanbeincorporatedintoasingledocument.

2. Professionalsshallbeinformedconcerningcredentialing/privilegingrequirementsatthesitewherethepatientislocatedProfessionalsshallmeetMedicare’sConditionsofParticipation(COP)orsimilarlocalregulatoryrequirementsforauthenticationandvalidationofprovider’scredentialspriortostartingservices.

3. Professionalsshallbeawareoftheiraccountabilityandany/allrequirements,includingthoseforliabilityinsurance,thatapplywhenpracticingtelemedicineinanyjurisdiction,includingbutnotlimitedto:

a. Consultingwithcurrentmalpracticecarrierforanyconcernsorrestrictionsin

coverageb. Addingariderorotheradditionalcoverageasneededc. Reviewingstate-basedlawsforcoverageofaccidentalinjuriesandrequirements

forpatientcompensationorotherliabilitycoveragerequirements,suchaslimitsonpayments.


4. Professionalsshallbecognizantoftheconditionsnecessaryforestablishingaprovider-patientrelationshipinthecontextofatelemedicineencounter,whetherreal-time(live),store-and-forwardorothermodeofcommunication/interactionisused,andshallobserveevidence-based,bestpossiblestandardofcare.

5. HealthProfessionalsshallhavethenecessaryeducation,training/certification,andongoingcontinuingeducation/professionaldevelopment,inordertoensurethesafeprovisionofqualityhealthservicestotheirpatients.

6. Professionalsshallbeculturallycompetenttodeliverservicestothepopulationsthattheyserve.Examplesincludeawarenessoftheclient’slanguage,ethnicity,race,age,gender,sexualorientation,geographicallocation,socioeconomic,andsensitivitytoculturalorreligiouspractices.

7. Professionalsmayuseonlineresourcestolearnaboutthecultural,ethnic,andreligiousaffiliationofthepatientandthecommunityinwhichthepatientresides.

CLINICALGUIDELINES

Healthcareprofessionalsprovidingteleburnservices(hereafterprofessionals)shallobservethejurisdictionalregulatory/licensinglawspertainingtotheirprofessionalpracticeintheirownjurisdictionwheretheypracticeaswellasthejurisdictionwherethepatientislocatedatthetimeofcare.Theseinclude:

1. Professionalsshalldeterminetheappropriatenessoftelemedicineonacase-bycasebasis,whetherornotatelemedicinevisitforburncareisindicated,andwhatportionoftheexaminationshallbeperformedclinicallyanddocumentedinconformancewithappropriatestandardsinevaluatingthepatient.Whereverpossible,diagnosticinterventionsshallbesupportedbyhighqualityevidence.1-4,24-39,44-48,50-62Whereevidenceislacking,providersshallexercisetheirprofessionaljudgment,experienceandexpertiseinmakingsuchdecisions.Clinicalguidelinespertainingtotelemedicinearelikelytochangeasindicatedbynewevidencefromresearchandtechnologicaldevelopment.

2. Healthcareprofessionalsshallbeguidedbyprofessionaldisciplineandnationalexistingclinicalpracticeguidelines50-56whenpracticingviatelemedicine,andanymodificationstoexistingclinicalpractice,thestandardsfortelemedicinepracticeshallbeconsistentwithstandardclinicalrequirements.

3. Meansforverificationofproviderandpatientidentityshallbeimplemented,asinstandardpractice.

a. VerificationofbothprofessionalandpatientidentificationmayoccuratthetimeoftheconsultthroughpictureID,throughappropriatemethods,includingpatientfullnameandbirthdate.ProfessionalsmayaskpatientstoverifytheiridentitymoreformallybyprovidingagovernmentissuedphotoID.


b. Whenprovidingprofessionalservicestoapatientinasettingwithoutthepresenceofahealthprofessional(e.g.,patient’shome),thetelemedicineprovidershallprovidethepatient(orlegalrepresentative)withhisorhername,birthdate,andverbalapprovaloflegalrepresentative,andpatientlocation.

4. Providerandpatientlocationshallbedocumented,especiallyincaseswheresuchinformationrequiredforreimbursement.Thisinformationisneededincaseofanemergency,whichrequirestheimplementationofamanagementprotocol.However,itisnotnecessaryforthehealthprovidertorevealtheirexactaddresstothepatient(i.e.,cityandstateisadequate).

5. Contactinformationforprofessionalandpatientshallbeverified,includingtelephonenumber,emailaddressforthepatientifpatientconsents,andregularmailaddress.

6. Theon-sitehealthcareprovidershallobservetheprinciplesofinitialevaluationofburnpatientsasdescribedbytheAmericanCollegeofSurgeons63andAmericanBurnAssociation,64includingcriteriaforpatientreferraltoregionalburncenters.Inparticular,theon-sitepractitionershallensurethatpotentialongoinginjuryisaddressed(e.g.,burningprocessstopped,resuscitationprovidedasneeded,fluidsadministered).Practitionersshoulddiscusstheperformanceoftheseprocedureswiththeburncenterorexpertconsultingprovider.

7. Theprofessionalshouldbefamiliarwiththeavailabilityoflocalin-personresourcesandshouldexerciseclinicaljudgmentin.makingareferralforadditionalhealthservicesasappropriate.

8. Whenaprofessionalseesaburnpatientviatelemedicineinaformalhealthcaresetting(e.g.,localclinic,community-basedoutpatientclinic)orothersettingwherededicatedstaffmaybepresent(e.g.,school,seniorcenter)theprofessionalshouldconfirmthattheorganizationhasaplanforaccessingacutelevelburncareon-site,especiallywhenthepatient’sconditionmaybedeterioratingrapidly.Ifthesettingdoesnothavetherequisiteskillorplansinplaceforaccessinghigherlevelsofcare,theprofessionalshouldworkwiththeorganizationtodevelopsuchaplanThebasicproceduresmayinclude:

a. Establishingarecordofcontactinformationforlocalemergencyresourcesthe

cityandthecountyb. Becomingfamiliarwithlocationofnearesthospitalemergencyroomcapableof

managingburninjuriesc. Havingpatient’sfamily/supportcontactinformationd. Learningthechosenemergencyresponsesystem'sresponsetime(e.g.,30

minutesvs.5hours)

9. Wheninitiationoftreatmentisnecessaryinasettingwithoutclinicalstaff,theprofessionalshouldrequestthecontactinformationofafamilyorcommunitymemberwhocouldbecalleduponforsupportinthecaseofanemergency.Inthecaseofanemergency,theprofessionalmaycontactthispersontorequestassistanceinevaluatingthenatureoftheemergencyand/orinitiating9-1-1fromthepatient’shomeormobile


telephone.

10. Incaseofmedicationsideeffects,elevationinsymptoms,and/orissuesrelatedtomedicationnon-adherence,theprofessionalshouldbefamiliarwiththepatient’sprescriptionandmedicationdispensationoptions.Moreover,whenprescribing,theclinicianshouldbeawareoftheavailabilityofspecificmedicationsinthegeographiclocationofthepatient.Theprofessionalshouldbefamiliarwithavailableresourcestorendermedicalservicesforpatients.

11. Patientswithseriousacuteinjuriesrequireinitialevaluationandstabilizationpriortothetelemedicineconsultationwithprovider.Dependingonthenatureoftheinjuryandpatientstatus,theonsitepractitionermayrequestemergentvideo(orphoneifdeemedappropriate)consultationwhileinitialevaluationisinprogress,providedthatsuchcommunicationcanbearranged.Otherwise,consultationcanbeperformedfollowinginitialevaluation.Forsmallwounds,digitalphotographsmaybetransmittedtotheconsultantasstore-and-forwardimages.Sincevisualassessmentofburnwoundsisakeycomponentofevaluation,consultationshouldbeperformedfollowinginitialevaluationanddebridementofwounds(byappropriatelytrainedindividuals),andbeforedressingsareapplied.Thissequenceisespeciallyimportantiftheconsultationisdonetodeterminetheneedforemergenttransport,orforadviceregardingappropriatewoundcare.

12. Thefollowingpatientscenariosmayrequiredifferentapproachesforinitialcareandsubsequentinvolvementoftheteleburnconsultants:

a. AcuteBurns–MajorSystemswithaHighBurnPercentage

i. Inacuteburnsituations,theon-siteprofessionalshalladheretothe

principlesofinitialevaluationofthetraumapatientasoutlinedbytheAmericanCollegeofSurgeons63andAmericanBurnAssociation,64includingthecriteriaforreferralofburnpatientstoregionalburncenters.

ii. On-sitepractitionersshouldobtainandtransmitbasicmedicalhistoryofthepatientandon-siteenvironmentalassessment,including:

1. patientidentification,age,gender2. circumstancesofinjury(i.e.,etiologicagent,durationof

exposure,evidenceofothertrauma,possibleexposuretohazardoussubstancesandsmoke)

3. significantpastmedicalhistoryincludingillnesses,medications,surgeries,currentmedications

4. allergies5. treatmentprovideduptothetimeofconsultation,including

volumeandtypeofresuscitation,fluid,analgesics,andothermedicationsadministered

6. evaluationofburnextentanddepth7. vitalsignsandpatientstatus


8. anylaboratoryvalueswhichhavebeenobtained9. anyradiographsthathavebeenobtained

b. AcuteBurns–SmallSingleBurnwithLowPercentageCoverage

i. Forburnsthatarenotlife-threateninganddonotrequiretransfertoa

burncenter,consultationcanbeperformedfollowingtheinitialevaluationorasafollow-up.

1. On-sitepractitionersshouldobtainandtransmitthesamebasicinformationtotheburnconsultantaboutthepatient.

2. Formanysmallwounds,digitalphotographsmaybetransmittedinastore-and-forwardmode.Sincevisualassessmentofburnwoundsisakeycomponentofevaluation,consultationshouldbeperformedfollowinginitialevaluationanddebridementofwoundsandbeforedressingsareapplied.Thissequenceisespeciallyimportantiftheconsultationisaimedatdeterminingtheneedforemergenttransport,orforadviceregardingappropriatewoundcare.

c. Follow-upVisits

i. On-sitehealthcarepractitionersshouldobtainandtransmitbasicinformationaboutthepatientasnotedabove.

ii. Patientsitesshallensurethatenoughtimeisallocatedpriortoandaftertheactualtelemedicinevisittoundress,clean,andredresswounds.

iii. Forfollow-upvisits,thepatientsiteshallbepreparedtofacilitateallaspectsofcaredeliveryasanextensionofthehealthprofessionalsiteincluding:

1. Ensureadequatesuppliesforburndressingsincludingthepreferredtypeofdressingusedbytheburncenterorhealthprofessional

2. Havingprofessionalstrainedinmoderatesharpsdebridement(burnorwoundtherapistorRNtele-presentertrainedbythehealthprofessional)ataminimumandpossiblydeeperdebridementifavailable(typicallyatrainedsurgeon)

3. Physicaltherapyservicesasorderedbythehealthprofessional(on-siteoravailableasareferralservice)

4. Abilitytotransmitimagesoftheburnifrequestedbythehealthprofessionalandagreeduponasapartofthetelehealthagreement

5. Abilitytoreferthepatienttocommunityservicesasneeded


13. Theburnconsultationshouldproceedinanorderlyfashionandinsequentialstepsasfollows.However,thesestepscanbealteredasindicatedbyworkflow,patientneedandconsultantpreference.

a. Completesetofvitalsignsonthepatientandtransmissiontoconsultantb. Preparationofthepatientfortheexamination,includingphysicalpositioning

andgowning.Dressingremovalandphotographsofthedressingtoshowthedressingduringtheliveconsult

c. Pictureswithmeasuringtapeshowingthedimensionsoftheburnpriortocleaningtoshowduringtheconsult

d. Picturesoftheburnfollowingcleansingofthewound.e. Debridementmayoccurduringthetele-consultationunderthesupervisionof

thetele-consultantattherequestordirectionoftheconsultingservicef. Aftertheclinicalconsultisended,thepatient’swoundisredressedandthe

patientdischarged.g. Consultingprovidersmaywanttoobservetheburndressing

14. Thepatientsiteshouldensurethatenoughtimehasbeenallocatedforthetele-

presenterorpatient/familysupporttoassistwithremovingdressings,cleaningwounds,andredressingwounds,inadditiontothetimetheproviderneedstomeetwiththepatient,takeamedicalhistory,discusstheplanofcare,andrespondtoanypatientconcerns.

TECHNICALGUIDELINES

A.CommunicationModes&Applications

Alleffortsshallbetakentousesecurecommunicationmodesandapplicationsthathaveappropriateidentityverification,privacyandsecurityprotectionsincompliancewithrelevantfederal,stateandlocallawsandregulations.Telecommunicationsplatformsshallhavesufficientbandwidthtoallowforaccuratevisualization,assessmentanddiagnosisoftheburn.Whenfeasibleandappropriate,existingimagingguidelineshouldbeused(e.g.,AmericanTelemedicineAssociation’sTeledermatologyGuidelines65-66).Patientsseenfromhomemaytransmitdigitalimagesthatcanthenbeimportedinacommonformat(e.g.,ADICOMwrapper)bythehealthprofessionalintomedicalimagestoragesystemsandstoredonthepatientelectronicrecordoranotherplace.

B.Devices&Equipment

1. Boththeprofessionalandpatientsiteshouldusehighqualitydigitalcameras(minimum3megapixel),audio,andrelateddatacaptureandtransmissionequipmentnowwidelyavailableforpersonalcomputersforbothreal-time(live)andasynchronousstore-and-forwardencounters.Imageresolutionshouldbesufficienttoallowforanaccurateassessmentanddiagnosisofthepatient’scondition.


2. WhentheInternetisused,healthprofessionalsandpatientsshallhaveup-to-dateantivirussoftwareandafirewallwiththelatestsecuritypatchesandupdatesappliedtotheoperatingsystemandthirdpartyconnections.

3. Intheeventofatechnologybreakdowntheprofessionalshallhaveabackupplaninplace,whichmustbecommunicatedtothepatientorreferringproviderbeforethestartofconsultortreatment.Thisinformationshouldbeincorporatedintothegeneralemergencymanagementprotocol,reviewedandupdatedasnecessaryonaperiodicbasis.

4. Allequipmentsufficienttosupportdiagnosticneedsandthepatientvisitshallbeavailableandfunctioningproperlyatthetimeofclinicalencounters;andorganizationalprocessesshallbeinplacetoensureoperationalreadinessofequipmentthroughon-goingmaintenanceandtesting,conductedatleastannually.

5. Infectioncontrolpoliciesandproceduresshallbeinplacefortheuseoftelemedicineequipmentandpatientperipheralsincompliancewithorganizational,legal,andregulatoryrequirements.

C.ImageAcquisition

Imagequalityisessentialteleburnconsultation,includingaccuratediagnosisandtreatmentrecommendations.1-2,24-39,47,57-62Theprofessionalshouldthefollowingprocessesinimageacquisitionanddisplay:Thefollowingguidelinesrelatedtoimageresolution,storage,transferandviewingarebasedoncurrentindustrystandards.Thesearelikelytobechangedandupdatedcommensuratewithadvancesintechnology.Hence,thesestandardsmustbereviewedonanannualbasistodeterminetheircompatibilitywithnewerandmoreadvancedsystemsthatofferimprovedimageresolutionandimagecapture/transferthataremoreclinicallyandeconomicallyappropriate.

1. Real-timevideoconferencing

a. Aminimumof640X360resolutionat30framespersecondshallbeusedregardlessoftechnology(e.g.,Internet,mobilephone)

b. Audiocompressionratessufficienttoallowforuninterruptedtwo-wayaudioduringlivevideoconsultationsshallbeusedsupportgoodcommunicationbetweenthehealthprofessional,thepatient,andthetele-presenter

c. Examroomlightingshouldbeaminimum(?)750-1500lumensforgoodvisualizationoftheskin.Additionalindoorlightingusingfluorescentdaylightorfullspectrumbulbsmaybeneededtoaugmentillumination.Toomuchunfilteredlightingcanblanchskincolororwhitentheentireimage.

i. Whenthepatientisinthehome,askthepatienttomoveintodirectdaylightifpossible.

ii. Roomlightingshouldbesufficienttolighttheparticipants’facesduringconversations.Lightshouldnotbedirectlyoverthem.Shadowsshouldbeconsideredwhenpositioningthepatientasshadowswillhideimportantclinicalindicationsontheburn.Additionalroomlightingcan


beaccomplishedbyturningonanexaminationlightoradditionallightingsourcesintheroompositionedinfrontofthepatientandawayfromthevideocameralens,butavoidblindingthepatient.

d. Thetele-presentershouldholdthecameraatadistanceinitiallytoshowthegeneraldistributionoftheburninjurybeforeobtainingclose-upimages.Whenmovingthecameratoshowthegeneraldistributionoftheinjury,thetele-presentershouldinquirewhetherthespeedofcameramovementimpedesimagequality.

i. Capturingandstoringimagespriortothevisitcanbeamoreefficientwayofprovidingimages.

e. Ifthecameradoesnotcontainanimageviewer,thetele-presenterwillneedtobeabletoseetheimageviaPIP(PictureinPicture)orSENDimageonthevideoconferencescreenandshouldpositiononeselftoensurethequalityofimagesforanassessmentoftheburnintermsoflocation,size,color,depth,etc.

f. Asthetele-presentermovesthecameraovertheburnarea,he/sheshouldcontinuouslyverbalizethepartofthebodythatisbeingcaptured,notingimportantcharacteristicssuchassize,color,appearanceoftissuesandfluids.Thiswillorienttheburnspecialisttothelocationoftheinjuries.

g. Forcapturingclose-upimages,positionthecamera8-10’fromtheburnsurfaceandallowthecameratofocusinandoutforcloserviews.

i. Autofocuscamerasarethebestoptionforpatienthand-heldcameras.h. Mostvideo-formatgeneralexaminationcamerasareequippedwitha

freeze-framefeaturetoproducestillimagesthatareveryusefulfordiagnosis,allowingtheburnspecialisttoappreciatedetailedfeaturesofinjuries.Freeze-framecaptureshouldbeusedwhenconnectionspeedislow,asslowconnectionscanresultindegradationofimagequality.

i. Viewingdevicesshouldbecolorcalibrated.Althoughthereisnoacceptedcalibrationstandardforcolormedicaldisplays,itisimportanttoselectonethatcanreadilybeimplementedandmaintainedonthedisplayofchoice.67

j. Removedistractingjewelryandclothingfrominjurysite.k. Usemeasurementtoolstoascertainsizeofburnasappropriate.l. Usesolidneutralcolorforbackground.

2. Store-forward

a. Digitalcamerasshouldbeusedforimagecapture(avoidPDAs;highquality

imagecellphonecamerascanbeusedifthisistheonlyoptionavailable).Minimumresolutionshouldbe2000x1500pixelsor3megapixels.

b. Macromodecapabilityisideal(“flower”image).c. Usesolid,neutralcolorforbackground.d. Usediffuse,indirectlight,avoidshadows.Forindoorsfluorescentday-lightor

fullspectrumbulbsarebest(avoidincandescent).Foroutdoors,usewell-litbutevenlyshadedareaifitissunny.

e. Flashmaybeusedasnecessarytohelpeliminateshadows.Testtoseeifneeded.Itshouldbelocatedabout18to24inches(45to60cm)awaytoavoidblanchingorwhiteout.


f. JPEGorothercompressionalgorithmscommonlyusedinmedicalimagingmaybeusedatlevelsnottoexceed20:1(e.g.,mediumorlowsettings).

g. Cameraangleshouldbeperpendiculartotheskinlesions.h. Autofocusshouldbeusedwithareaofinterestincenterofframe.i. Imageviewsshouldshowlocationandarrangementoflesions.Takeseveral

views:

i. Far-largersegmentofthebodytoshowtheexactregionii. Medium-areainvolvedcentralinimagebutincludeclose-by

anatomicallandmarksuchasthenavelorhandiii. Close-Up-usemacrocapacityortheopticalzoom(i.e.,“flower”image)

toacquireimageslessthan18inches(45cm)fromtheskin.Usestraightandobliqueviewsforclose-ups

iv. Removedistractingjewelryandclothingfromtheburnsitev. Forfaceshots,eyesshouldbeopenifpossiblevi. Usemeasurementtoolsasappropriatetoindicatelesionsize,indicate

whetherinchorcentimeter.vii. Reviewimagesforclarity,resolutionandcoveragebeforesendingviii. Donotalterimagesinanywayaftertakenix. Labelimages,transmittedtextandconsultantresponsetobecomepart

ofasecure,retrievablemedicalrecord.

a. Displayscreenresolutionshouldbe1280x1024pixelstoallowadequateviewingof3megapixelimagesandmagnificationwithoutnoticeablelossinimagequality.Viewingdevicesshouldbecolorcalibrated(see1jabove)

D.Connectivity

1. Adequatevideobandwidth(minimumof512kbps)shallbeusedtoenabletheremotecliniciantomakeanaccuratediagnosisandtointeractwiththepatientandthepresentingprovideratthebedsideorsceneofinjury.Lowerbandwidthmaynotbesufficient,abandwidthof512kbpsshallbeusedwhenfeasible.

2. Wherepractical,providersmayrecommendpreferredvideoconferencingsoftwareand/orvideoandaudiodevicestothepatient.

3. Theproviderand/orpatientmayuselinktesttools(e.g.,bandwidthtest)toverifybandwidthconnectivitybeforethestartthesessiontoensuresufficientqualityofservice.

4. Wiredconnectionsshouldbeusedwhenavailable(e.g.,Ethernet).

5. Thevideoconferencesoftwareshouldbeabletoadapttochangingbandwidthenvironmentswithoutlosingtheconnection.

6. Organizationsshallhaveappropriateredundant(appropriatebackup)systemsinplacethatensureavailabilityofthedatatransmissioninfrastructureforcriticalconnectivity.


E.Privacy

1. Allmodesofcommunication,dataacquisition,storageandretrievalinvolvingshallcomplywithfederal,state,andlocallawsandregulationsforassuringsecurityandconfidentialityofpersonalhealthinformation.

2. Organizationsshouldbefamiliarwithchangesincomputingandmobilecommunicationdevicesandtheirpotentialforassistingpatientsandimprovingtheirperformance.

3. Organizationsshouldimplementastandardpolicyforsecurepatientandproviderauthentication,includingtheuseofpasswordsandfirewallstoprotecttheirelectronicsystems.

a. Two-layerauthenticationshouldbeused.

4. Computersandotherdevicesshouldbedesignedtohavea“sleep”functionwhennotusedformorethanaspecifiedtimeframe,withre-authenticationtoresumeaccess.

5. OrganizationsshouldhaveremoteaccesscapabilitytodisableelectronicdeviceswhenlostorstolenandtowipeoutstoredPHIorPII.

6. Organizationsshallhaveasecuredataback-upandrecoveryplan.Thisincludesdatawarehouseorcloudstoragethatcomplywithlocal,state,andfederalregulations.

7. PHIandotherconfidentialdatashallbebackeduporstoredonsecuredatastoragelocations.

a. IfPHIisstoredonamobiledevicesuchasalaptoporcellphone,thedatashallbesecuredaccordingtolocal,state,andfederalrequirementsforthestorageofPHI.Examplesofsecuritymeasuresincludewholediskencryption(FIPS140-2,knownastheFederalInformationProcessingStandard,andencryptionsuchasAES(AdvancedEncryptionStandard)

8. Informedconsentshallbesecuredfromthepatientbeforevideorecordingconsultationsessionsorpartsofsessionsforeducationalorresearchpurposes.Whentherecordingisintendedaspartofthepatientrecord,thepatientshallbeinformedofthefactandhowtherecordingwillbesecured.

a. Accesstorecordingsshallonlybegrantedtoauthorizedusersandshouldbesharedinamannerthatprotectsthedatafromaccidentalorunauthorizedfilesharingand/ortransfer.

b. Recordingasessionorpartofasessionforpurposesofrenderingcareshallcomplywithrelevantprivacyandsecurityrequirements.


APPENDIX

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