Procedure # 2015.0109

Procedure Title: TeleHealth Technology Report Form

Effective Date: 06/01/2015

Supersedes: N/A

Approver:	Harald Lausen, DO, MA	Date

Chief Medical Officer, SIU HealthCare

Approver:	Nina M. Antoniotti, RN, MBA, PhD	Date Executive Director of TeleHealth and Clinical Outreach, SIU HealthCare

Document Owner:	Shantel M. Brown, RN	Date TeleHealth Clinical Coordinator, SIU HealthCare

Document Control Coordinator: Shantel M. Brown, RN

Authors: Nina M. Antoniotti, RN, MBA, PhD, Shantel M. Brown, RN

2015.0109	Page 1 of 4

TeleHealth Technology Report Form

Technology Report Form

1. SCOPE

System Wide: This procedure applies to all regional telepresenters working with SIU HealthCare providers and SIU HealthCare’s partner TeleHealth organizations providing care via TeleHealth.

PURPOSE

To outline the process for accessing the Technology Report Form, completing the TeleHealth Technology Report Form, the information that will be needed by the Telepresenter.

3. DEFINITIONS & EXPLANATIONS OF TERMS

3.1. Technology Report Form: the form is used to document visits with the patient and what, if any issues occurred during the visit.

3.2. MHN: indicates SIU Medical History Number.

3.3. Audio jitter: when sound being transmitted is of poor quality, echo is present, delay in mouth moving and sound being heard occurs, or sound being transmitted is heard intermittently.

3.4. Video jitter: when image being transmitted is of poor quality, delay in movement appearing on screen or appearing jerky, or image appearing intermittently.

3.5. Frozen picture: the picture does not change or move.

3.6. No Audio: there is a picture on screen but no sound being transmitted

3.7. No Video: there is sound but the screen is blue or black.

4. PROCEDURE BODY

All clinical staff responsible for presenting of patients to all SIU Specialties shall be proficient and appropriately trained in completing the TeleHealth Technology Report Form via TeleHealth technologies.

4.1. Accessing Technology Report Form:

a. To access the TeleHealth Technology Report Form, go to www.siumed.edu.

b. Once the SIU School of Medicine home page is on the desktop, click on Departments in the top right corner.

c. Select TeleHealth and Video Services Department.

4.2. Fill in the designated areas as indicated.

a. Date needs to be filled in using a two digit month, two digit day, and four digit year (i.e. mm/dd/yyyy).

b. All time fields throughout the form need to be expressed in military time (i.e.

2:00pm would be 1400).

c. Patient site: select the patient location.

d. Provider: free text the name of the provider seeing the patient.

e. Nurse: select the TeleHealth nurse from the drop down menu.

f. MHN: type in the SIU MHN.

g. Presenter start time is the time the TeleHealth nurse calls the patient back to prep for the consult.

h. Presenter time patient ready: is the time the TeleHealth nurse was finished prepping the patient for the TeleHealth consult.

i. Time Provider saw Patient: is the time the provider exam of the patient begins

j. Time Provider finished with patient: is the time the provider exam of the patient ends

k. Presenter stop time: is the time the consult ends.

4.3. Equipment Issues

a. Indicate what equipment was used by clicking next to the box in front of the equipment (i.e. stethoscope, otoscope, hand held video camera, digital camera).

b. If no equipment was used, do not check any of the listed items.

c. Technology problems; select “None" if no problems occurred. Otherwise, indicate the problems that occurred by clicking next the box in front of the problem. Multiple boxes may be checked.

d. Indicate if the problems were with the Provider site or Patient site or both.

e. Action Taken; check the box in front of what action was taken to resolve the problems. If no action taken, do not check any box.

f. Comments: any comments can be entered in the "Comments" box.

g. Click on the submit button located at the bottom of the page when finished.

h. If you have problems or questions regarding the form, please call the TeleHealth Help Line at (217)545-8600

5. ADDITIONAL RESOURCES

5.1. Additional Questions:

Dr. Nina M. Antoniotti, RN, MBA, PhD

(217)545-3830

Executive Director of TeleHealth and Clinical Outreach, SIU HealthCare

Shantel Brown, RN, BS

(217)545-3153

TeleHealth Clinical Coordinator, SIU HealthCare