## 3 Method
### Setup  
Videoconferencing infrastructure: Prior to launching SCAN-ECHO, the videoconferencing network had already been deployed at the Greater Los Angeles VA Medical Center and the affiliated CBOCs. Initially, this system was being used for selected provider to remote patient care encounters (e.g., infectious disease care and elemental health sessions). As the SCAN-ECHO implementation advanced, additional videoconferencing consoles were deployed throughout this region. This system can be used in one-on-one or (for SCAN-ECHO) multipoint mode, wherein all videoconference participants are present on a designated portion of the screen; hence, all attendees can see and hear each other (Figure 1). The presenter can choose to broadcast an image of him/herself via the camera in the presentation image area (Figure 1) or, at the touch of a button, the presenter can switch to broadcasting the full-screen image of a computer connected to the telehealth unit. Our presenters regularly prepared PowerPoint presentations for the didactics and each clinical case. These sessions involve strategically alternating between camera and computer screen (PowerPoint) view. The basis of our (initial) system configuration involved the use of a dedicated high-speed digital audiovisual communication network, proprietary hardware (dedicated digital communication lines, terminals and a multipoint control unit (MCU) that serves as the videoconference system interface) and corresponding technical support staff (see the paragraph on technical staffing). Alternatively, a secured web-based videoconferencing system may be considered as a more economical alternative, requiring only that participants have access to a standard computer equipped with a high-speed Internet connection (\(\geq\)3 mbps) and a webcam with a built-in microphone (around $30-$60), obviating the need for the acquisition, deployment, maintenance and staffing costs associated with a proprietary videoconferencing network. Figure 1: Screen layout for multipoint videoconference. Regardless of the communication technology utilized, all participants are expected to adhere to appropriate confidentiality protocols when referring to specific patients (e.g., [PERSON]'s 2 nd patient, Patient #101, _etc._). Additionally, if images or health records are included in case presentations, all identifying information should be removed or graphically obscured per Health Insurance Portability and Accountability Act (HIPAA) protocols. Specialty consult submission: The SCAN-ECHO process begins with the primary care provider obtaining informed consent from the patient to engage in this consultation; the patient has the right to know that his/her case will be discussed with other healthcare providers and that his/her medical records will likely be reviewed and discussed. Part of this informed consent process involves explaining to the patient that care may be better managed by the patient's local provider, based on the recommendations rendered by the SCAN-ECHO consult. Alternatively, the patient has the right to refuse the SCAN-ECHO consult with no consequence and to have an (in-person) appointment with the specialist at the (distant) VA Medical Center. Finally, the patient is told that even if he/she consents to the SCAN-ECHO consultation, this does not preclude future in-person visits to the specialist at the VA Medical Center should such appointments be clinically warranted. Patients typically embrace the convenience of the SCAN-ECHO option and willingly give consent to the process. Next, the primary care provider submits a SCAN-ECHO specialty consult request via the Computerized Patient Record System (CPRS), which is routed to the lead physician on the specialty team.