2. ESTADO DEL ARTE
2.1 Materiales compuestos de matriz polimérica
2.1.1 Fibras
As with any form of behavioral health service, it is necessary to have the requisite cultural awareness of the population one is serving. The same holds true for TMH. Of particular relevance for TMH is the patient’s prior experience with and comfort level with technology. This has relevance both in terms of cultural expectations about
appropriate uses of technology, and in terms of possible concerns about confidentiality or security related to the use of technology. Providers should consider the patient’s comfort level with technology and address any issues that may impact patient presentation. Asking about the patient’s expectations and history with technology may uncover some
26 concerns. The provider may also assess the patient’s comfort level by processing how they felt about using VTC at the end of the first encounter and/or later encounters. An additional resource offers a fuller discussion of the issue of TMH cultural competence.26 5.5 General Telemental Health Practice Guidelines
The American Telemedicine Association has published two resources for TMH practice. It is recommended that all staff participating in providing TMH services become familiar with these resources. They are the Practice Guidelines for Videoconferencing-Based Telemental Health 5 and Evidence-Based Practice for Telemental Health.6 In addition, the American Academy of Child and Adolescent Psychiatry published Practice Parameter for Telepsychiatry with Children and Adolescents.27 An additional ATA practice guideline for internet-based videoconferencing TMH using desktop computers is
expected soon. That guideline is expected to include additional information on handling emergencies.
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REFERENCES
1Health Resources and Services Administration Office of Telehealth, retrieved from
http://www.hrsa.gov/ruralhealth/about/telehealth/
2
U.S. Army Medical Command Tele-Behavioral Health Operations Manual, 1 May 2012. 3
DoD 6015.1-M, Glossary of Healthcare Terminology, January 1999 4
American Telemedicine Association, retrieved from
http://www.americantelemed.org/i4a/pages/index.cfm?pageid=3333
5
Yellowlees, P., Shore, J. & Roberts, L. (2010). Practice Guidelines for
Videoconferencing-Based Telemental Health – October 2009. Telemedicine and e- Health, 16(10) 1074-1089.
6
Grady, B., Myers, K. M., Nelson, E.-L., Belz, N., Bennett, L., Carnahan, L., …Voyles, D. (2011). Evidence-based practice for telemental health. Telemedicine and e-Health, 17(2), 131-148.
7
Richardson LK, Frueh BC, Grubaugh AL, Egede L, & Elhai JD. (2009) Current directions in videoconferencing tele-mental health research. Clinical Psychology (New York). 1;16-323-338.
8 Backhaus, A., Agha, Z., Maglione, M. L., Repp, A., Ross, B., Zuest, D., …Thorp, S. R. (2012). Videoconferencing psychotherapy: A systematic review. Psychological Services, 9(2), 111-131.
9
https://path.tamc.amedd.army.mil
10
Mahnke, C.B., Jordan, C.P., Bergvall, E., Person, D.A., Pinsker, J.E. (2011) The Pacific Asynchronous TeleHealth (PATH) system: review of 1,000 pediatric teleconsultations. Telemedicine and e-Health, 17(1), 35-39.
11
http://echo.unm.edu/
12
DoD 6025.18-R, DoD Health Information Privacy Regulation, 24 Jan 03 13
Department of Defense Health Information Security Regulation DoD 8580 02-R, 12 July 07
14
28 15
Health Insurance Portability and Accountability Act of 1996 (HIPAA). U.S. Department of Health and Human Services. Available at:
http://www.cms.hhs.gov/HIPAAGenInfo Accessed: August 22, 2011. 16
Hyler, S.E., and Gangure, D.P. (2004) Legal and ethical challenges in telepsychiatry. Journal of Psychiatric Practice, 10(4), 272-276.
17
Kramer, G. M., Mishkind, M.C., Luxton, D.L., & Shore, J.H. (2013) Managing risk and protecting privacy in telemental health: An overview of legal, regulatory, and risk
management issues. In Myers, K.M. & Turvey, C.L. (Eds.), Telemental Health: clinical, technical, and administrative foundations for evidence-based practice. (pp. 83-108). London: Elsevier.
18 TRICARE Policy Manual, 6010.54-M, Change 132, November 23, 2010 19
10 U.S.C. 1094 20
DoD 6025.13-R, Military Health System (MHS) Clinical Quality Assurance (CQA) Program Regulation, 11 Jun 04
21
10 U.S.C. 1094(d) (as amended by Section 713 of the National Defense Authorization Act for Fiscal Year 2012)
22
Waiver of Restrictive Licensure and Privileging Procedures to Facilitate the Expansion of Telemedicine Services in the Military Health System, signed by the Assistant
Secretary of Defense (Health Affairs), December 21, 2012. 23
Department of the Army OTSG/MEDCOM Policy Memo 13-009, 20 Feb 2013, Use of Telehealth in the United States Army Medical Command (MEDCOM)
24
42 CFR Part 482 and 485, Medicare and Medicaid Programs: Changes Affecting Hospital and Critical Access hospital Conditions of Participation: Telemedicine
Credentialing and Privileging, published May 5, 2011, Federal Register, Vol. 76, No. 87 25
Military Health System Coding Guidance: Professional Services and Specialty Coding Guidelines, Version 3.6, Unified Biostatistical Utility, 1 March 13
26
Brooks, E., Spargo, G., Yellowlees, P., O’Neil, P., & Shore, J.H. (2013) Integrating culturally appropriate care into telemental health practice. In Myers, K.M. & Turvey, C.L. (Eds.), Telemental Health: clinical, technical, and administrative foundations for evidence-based practice. (pp. 63-82). London: Elsevier.
29 27
American Academy of Child and Adolescent Psychiatry, Practice Parameter for Telepsychiatry with Children and Adolescents, (December 2008), available at
30
Appendix A – T2 Telemental Health VTC - Basic Equipment Troubleshooting Checklist
Check
POWER DISTANT SITE ORIGINATING SITE
Is the VTC system power turned on? Is the power strip turned on?
Is the power cord plugged into the electrical outlet? Is the power cord plugged securely in the VTC system? Are the batteries in the remote control good?
AUDIO DISTANT SITE ORIGINATING SITE
Is the mute button on?
Is the volume setting high enough to be heard? Is the microphone connection secured properly?
If there are external speakers, is the speaker volume turned on?
Are the audio connectors (red and white cables) connected to their respective inputs?
VIDEO DISTANT SITE ORIGINATING SITE
Is the monitor input correctly connected (the ‘video in’ cable should be connected to the video input)?
Is the monitor output cable(s) connected? (follow the monitor cord to the VTC system and ensure that it is plugged into the correct port)
Is the correct camera source selected? Is the correct display setting selected?
NETWORK DISTANT SITE ORIGINATING SITE
Is the network cable plugged into the VTC system correctly? Is the network cable plugged into the wall jack correctly? Is the network cable broken on either end?
Is the IP information correct?
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Appendix B – Preliminary Needs Assessment Questions General Overview
1) What do you see as the greatest healthcare access challenges facing your beneficiaries?
a. In general medical care? b. In specialty medical care?
c. In mental/behavioral health care?
d. In patient education and prevention efforts?
2) Where (locations & types of services) would you most like to see telehealth services started or expanded? Who are the providers who will be willing to help with the expansion of telehealth care?
3) Where will patients receive care and from where are providers delivering care? 4) When do you want to begin? Become fully operational?
5) When during the day can telehealth care be provided?
6) What investments (time, personnel, technology, space, supporting services) are you prepared to make in order to expand access to care through telehealth?
7) How are you planning to maintain the services? What help is needed in this regard? Clinical Services
1) What services are you currently offering? What do you want to offer? 2) Do you have any existing SOPs? If so, please send with these questions. Business Processes
1) Are you familiar with/establishing processes for Credentialing and Privileging and Workload Accounting and Coding?
Policy and Guidelines
1) What guidelines have you followed to develop plans and procedures? Assessments
1) Have you determined whether providers and patients will utilize telehealth? IT Requirements
1) What equipment do you currently have available for telehealth? What are you expecting to acquire?
2) What is the current bandwidth and number of connections into proposed telehealth sites?
3) How much bandwidth is likely to be allocated for telehealth care? 4) Are you working off an IP or ISDN network?
2 Future Implementation
1) What do you think are the most critical issues to address that might hinder or enhance more widespread telehealth implementation? (e.g., structural/administrative changes to providing care, patient education, provider acceptance, provider training and education, technology costs and integration, etc.)
2) How do you view leadership support for telehealth and what information or data might impact their level of support?
3) Where do you see the biggest need/optimal insertion points of telehealth for the future?
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Appendix E – Clinical TMH Checklist
Preparing Your Equipment Prior to a Session
Technical Setup
Laptop on and logged in Test the connection Remove Lens Cap Find IP address
Make/Model of equipment Launch Software
Install headphones
Have Tech Service contact information readily available Update Address Book
Introducing Patient To Telehealth Consent
Why telehealth? Recorded or not?
Reassure that they are receiving quality of care Emphasize confidentiality and privacy
Review the TBH consent form with the SM and answer any questions that remain Options for face-to-face meetings if available
Go over patient concerns
Screening Assess patient for sign of instability - communicate any concerns for providing TH session to provider Patient Education
Inform patient about procedures if technical difficulties occur Operational Security
Emergency procedures Identify Emergency contact list
Conducting a Clinical Session Image/Sound Configuration
Place Call/Receive Call Adjust the Volume
Adjust the Video Settings - Brightness, Hue, Contrast Adjust Camera - Zoom, PIP, Set to correct level Pan around the room
Begin Session
Introduce everyone in the room at the start of the encounter Inform patient that the connection is on a secure network Operational Security
Go over emergency procedures Identify Emergency contact list
At each session assess the patient’s comfort with TBH. Answer any questions or concerns Rapport Bldg
Eye contact
Avoid distracting behavior -excessive movement, facial expressions, hand gestures, phone noise Use PiP
If Lost Connection Occurs Re-establish the connection by placing the call again If that fails then reboot the computer
Environmental Considerations Lighting How is the lighting in your room and patient's room? Shadows?
Can you clearly see faces (prov/pat.)
Background How do you optimize the background behind yourself? Distractions (clutter, background objects and color)
Clothing How does your clothing affect the image? What are optimal colors and patterns? Can you adjust your uniform or wear a lab coat?