Operational Teleconsultation Best Practices

Prepare - Plan and Train

Operational TC begins with the PREP mnemonic: Prepare through Planning and Training; recognize when to “make the call,” execute the consultation, and problem solve challenges. Ultimately, the safety and quality of care is the responsibility of the local caregiver and therefore telemedical support in the area of engagement (AOE) requires preparation and a PACE (Primary, Alternate, Contingency, and Emergency) plan to be successful. If a local caregiver intends to have consultation available but is unable to reach a remote consultant through one communications method, alternate methods should already have been established and tested. Thus, PACE planning takes two forms, one about when to utilize telemedicine and one for how to use telemedicine. See example in Table 1. A detailed example is in Appendix A.

Once a plan exists for when and how to perform TC, medical teams must train in realistic scenarios that require TC use to ensure this capability is available and easily utilized when needed. Given a variety of constraints in time, Class VIII (medical material equipment, consumables, blood), funding, and personnel, most medical training focuses on managing common casualties in typical operating contexts. These scenarios rarely require LCs to engage in TC because the scenarios do not outstrip their level of training or resource availability. TC, in its current form, is an ALTERNATE care plan for prolonged casualty care (PCC) or unusual cases that exceed PRIMARY plans. Therefore, training must include unexpected scenarios that require KSAs that are unavailable to the trainees and cannot be reasonably obtained by them prior to a deployment or within their scope of practice, and thus require them to call for help from a RE. Examples include:

- Medics/corpsmen managing a burn patient over time, especially if needs include an escharotomy and advanced airway management.
- Role 1 providers managing severe community acquired pneumonia that requires mechanical ventilation or a patient with an extremity injury that requires fasciotomy.
- Role 2 surgical team managing a casualty with a head injury that requires neurosurgical input and a decompressive craniectomy or a septic patient that develops the acute respiratory distress syndrome.
- Role 3 team managing a local national with an infection caused by a highly drug resistant organism, or a patient with acute kidney injury that requires renal replacement therapy, or a burn patient with severe inhalation injury.

Recognize

Culturally, the U.S. Military trains medical providers to succeed on their own merits; we validate individuals, not their ability to perform tasks or manage casualties as teams. Consequently, one of the hardest aspects of TC is for LCs to recognize when they should call for help. When a healthcare provider is uncertain about a casualty’s diagnosis or the best management plan, s/he should consider calling for help. Because there is no single-entry point for TC within the OVH system, LCs must first determine the urgency of the consultation and then conduct TC using the appropriate technology. The OVH system is divided into routine TC and urgent/emergent TC, and direct patient care. Table 2 on the next page highlights these TC pathways and when LCs should use one or the other.

Table 2. The operational virtual health system according to teleconsultation acuity and direct-to-patient telemedicine.

Global Teleconsultation Portal (GTP) is a Defense Health Agency (DHA) supported low-bandwidth web-based, secure, HIPAA-compliant, asynchronous platform used for non-urgent provider-to-provider teleconsultation, patient movement, and case management. Operational providers and consultants can access GTP and request a new account at: https://gtp.health.mil/

Lifesaving direct patient care takes priority over calling for help! Never leave the casualty to get help if the casualty’s condition may worsen while you are absent. Consider having a teammate “make the call “while the primary medical provider is delivering patient care.

Execute

The hardest and most dangerous part of TC is for the RE to efficiently provide an accurate consultation when unable to assess a casualty themselves – inaccurate information can lead to bad recommendations and, in the worst case, bad patient outcomes, or, more commonly, confusion. Consequently, the hardest part of TC for the LC is conveying an accurate description of a patient to a RE.

LCs must possess excellent assessment skills and the ability to convey their assessment to a RE efficiently. Inaccurate and/or incomplete assessments poorly communicated to a RE makes TC inefficient because the RE will inevitably pose probing questions of the LC to better understand a casualty’s condition, problems, and treatments.

To date, no adverse outcomes associated with military TC have been reported. More commonly, poorly communicated data or incomplete assessment leads to frustration, lengthy consultations, dissatisfaction with recommendations, and ultimately delayed casualty care.

To avoid this, LCs must be prepared for TC. Unfortunately, many caregivers may find conducting a TC to be anxiety provoking because they may be unsure of their assessment, uncertain about what information to provide an RE, and are worried the RE will judge them. Probing RE questions to gain further confidence in data shared may feel uncomfortable for LCs, especially if/when data is missing due to incomplete assessment. THIS IS COMMON: every caregiver has a different way of prioritizing information and not all information will be available at the time of consultation. Real world consultations take an average of three (3) synchronous TC encounters to complete, often with several asynchronous communications between synchronous touch points. Missing data may be filled in over-time and recommendations may be refined or even changed as information is updated.

The following best practice recommendations have been identified to maximize TC efficiency, information transfer, and quality of recommendations while minimizing frustration and risk of missing information necessary for best consultation in context:

1. If calling the ADVISOR line:

- When the agent answers the phone, tell the agent if the call is real-world and deployed or in garrison or for training.
- Indicate the specialty needed or, if unknown, ask for the emergency department.
- Provide a good call-back number.

2. Use a script familiar to the both the local caregiver and remote consultant (see Appendix B for an example with an instruction on use).

3. Send background information using asynchronous technology ahead of synchronous TC encounters (see below).

4. Use closed loop communication that includes intentional pauses in communication for read-back and clarification.

5. Have the RE document the telemedicine encounter and send that documentation with a summary of recommendations to the LC using an agreed upon asynchronous solution.

Images and Asynchronous File Transfer - Best Practices

Sending information, documentation, files, and particularly images (sometime of other files) related to casualty care before synchronous TC is a best practice because it allows the RE to consider the context of the consultation and to begin organizing thoughts ahead of the TC.

1. Ideally, send images of patients and care context to REs before starting a TC. This helps the remote expert to provide “consultation in context” and avoids recommendations that are discordant with local capabilities. Useful images include:

- Flowsheet and other documentation like the TC script
- Patient wounds
- Imaging – pictures or video of collected imaging studies (ultrasound, x-ray, etc.)
- Whole patient
- Special equipment
- Facility or aid station

2. Image quality is important (Figure 1). Photographs that are less than 500KB are often of insufficient quality to convey information to a remote consultant.

3. Be mindful of patient privacy and operational security (OPSEC):

- Images should be compliant with HIPAA. Do not include personally identifiable information in the image like full face images and unique tattoos unless they are essential for communicating injury or disease state to the remote expert in which case the image must be encrypted before sending. Best practice is to use the GTP to send these images.
- Similarly, do not include images of the environment that could cause a safety issue for the local care team by exposing their location or affiliation or other information that could be used against them (consider, for example, media implications of the image).

4. Note that digital photos may also contain “geotags” which can provide an exact location where it was taken. This feature can be disabled if there are security concerns. The easiest way to do so is to disable location services on your device before taking pictures.

Security - Cyber, OPSEC

- DO NOT DELAY teleconsultation due to an unsecure connection unless operational requirements dictate otherwise.
- Traditional teleconsultation is UNCLASSIFIED; the local caregiver should maintain normal rules of operational security when utilizing unclassified networks. Most RE consultants DO NOT have access to SECRET communications, but this may be established in special circumstances after UNCLASSIFIED communication is established first.
- Maintaining patient privacy should be a priority, and many available tools for communication meet patient privacy requirements.
- When sending patient information or images by open communication methods, limit patient identification to sex and age. Location can be generic by addressing temperature (hot/warm/cold), surroundings (urban/rural), or environments (desert/tropical).
- Location to the level of continent or region can be useful for the consultant/expert to better identify diseases specific to certain areas (e.g., hemorrhagic fevers, malaria, etc.).

The provided examples in the above figure are examples of call scripts sent ahead of the teleconsultation (TC) with a remote expert (RE). Panel A (size 2.17MB) is larger, takes more time to send, but is of sufficient quality to be read. Panel B (size 36.4kb), transmits easily, but is uninterpretable and of no utility. A reasonable file size that balances transmissibility and legibility is 500-1000kb (0.5-1MB). Panel C is a great example of legible and functional transmission of a vital sign flow sheet with the interventions sent to the RE prior to the initiation of TC.

Problem Solve

A general understanding of the capabilities and limitations of the various TM and TC technologies available is important. Intentionally using different technologies during training, especially switching between them, and limiting network resources during an encounter, helps LCs and REs become flexible in their use of technology and its limitations for delivering casualty care with TC support. Not all questions can be answered with TC; sometimes the best recommendation is simply to evacuate the casualty or experience the consequences. Still, TC may help mitigate risks if/when evacuation is no possible or available quickly.

Synchronous video helps make TC more efficient because REs can see what is happening in real time, but it is rarely required if TC does not involve tele-mentoring a procedure. Preliminary data from a small study presented in abstract10 demonstrates that key aspects of procedural quality may suffer when voice only TC is utilized for procedural tele-mentoring compared to video. When not performing a procedure, sending image asynchronously and/or providing detailed description by text or during synchronous audio TC can convey the same information as real-time video with significantly less network consumption. Indeed, some procedures can be completed with frequent asynchronous “chats” that include images (often with the RE sharing annotations on the image).

Because the telemedicine capability is a function of network resources matched to the number of casualties or encounters (Figure 2), understanding this relationship is important for mission planning.

Always use the most appropriate technology to optimize the consultation. Do not waste time establishing a network heavy video TC if lesser or more available technology (i.e. a radio or phone call) is sufficient. Also, it may be possible to increase the technology (i.e. go from an asynchronous consultation to a video consultation) if resources (hardware, software, and network) are available and the TC would benefit.

Understand the limitations of your technology and how to maximize its utility. It is difficult to complete a physical exam or part of a physical exam virtually without the correct digital equipment (e.g., stethoscope, ophthalmoscope, otoscope, etc.). Similarly, if bandwidth is limited, but video is needed by the RE for understanding, consider turning off the RE’s video (thus decreasing bandwidth needs by approximately half).

If utilizing TC for casualty care, always have a back-up means of communication – a second radio/frequency, a second phone-line/cellphone (on both ends of the encounter – LC and RE), an alternate computer – whatever your pace plan states. At the beginning of an encounter, always ensure that call back numbers and second options are discussed at the beginning of the consultation (this is included in the example call scripts in Appendix B). Train to use back-up options.

While network resources may be robust and able to support multiple continuous remote monitoring encounters, they may rapidly diminish when supporting a real-time, high quality video teleconference to facilitate a procedure. Similarly, asynchronous modes of communication (texting, email) require little bandwidth making it possible for many local caregivers to consult remote experts simultaneously, but it will take longer to receive responses. Increasingly synchronous and higher quality modes of communication require increased amounts of bandwidth but deliver shorter latent periods and increased capabilities to support local caregiver needs. Increasing network resources increased capability or encounter volume or both.

DOCUMENTATION

Documentation of the TC encounter is important for process improvement and lessons learned as teleconsultation continues to develop and inform future CPG development.

Documentation of casualty care is ultimately the responsibility of the LC providing direct care. All theater and local command documentation requirements should be completed by the LC. Best practice, however, is for REs to also document their consultation and recommendations and to send them to the LC as soon as possible. For routine consultations, this is automatic within the GTP. For TC not utilizing the GTP (urgent/emergent consultation), asynchronous communication between LCs and REs is on an ad hoc basis (using HIPAA compliant messaging applications or using encrypted email).

Additionally, REs document all OVH encounters using the Operational Virtual Health Report (OVHR) available at: https://info.health.mil/army/VMC/Lists/OperationalVirtualHealthReport/Item/newifs.aspx?source=/army/VMC/Pages/VMC/ADVISOR.aspx (must have CAC enabled computer/mobile device).

If a TC is for a casualty who is a Military Health System beneficiary, and at least two of the following patient identifiers are available and can be provided by the LC managing the casualty, REs should document the encounter in MHS Genesis or other electronic medical record:

- Patient name
- Social Security Number
- DoD Identification Number
- Date of Birth

Best practice is to copy information from the OVHR into the appropriate note in the EMR.

TC encounters for patients who are NOT MHS beneficiaries or for whom identifiers are not available/cannot be provided cannot have documentation in the EMR. REs will complete OVHRs and send recommendations to LCs as described above.

LCs utilizing ADVISOR for TC are also asked to complete an Operational Virtual Health Evaluation (OVHE) available at: https://info.health.mil/army/VMC/Lists/OperationalVirtualHealthEvaluation/Item/newifs.aspx?source=/army/VMC/Pages/VMC/ADVISOR.aspx .

When deployed LCs need to follow up with the appropriate medical theatre POCs on where they should document the patient encounter.