Remote Testing Devices

More Information about Remote Testing and Telehealth Services in the COVID-19 Pandemic

HHS.gov Telehealth Guidance
Medicare Coverage and Payment of Virtual Services

Remote Testing Overview

Examiners can administer the IVA-2, IVA-QS, IVA-AE2 or MeSA tests remotely. Remote test administration can be validly completed using the Chrome web browser or an iPad for the IVA tests and the MeSA tests requires the iPad. All remote testing requires that the testing be supervised using a separate audio-visual system such as Zoom, Web-Ex, doxy.me, Skype business, Doximity, or other similar services that are HIPAA compliant. Instructions and guidelines for remote testing are provided below. A test add-on called a Remote Testing License (RTL) is necessary in order to be able administer a remote test using the Chrome Browser on a PC or an Apple iOS device, such as an iPad.

Test usages can be used either on the RTD purchased (one web browser or one iPad per applicable license) or on the PC if you have a standard license.  Only one test can be run at a time on a Remote license.  For a Deluxe or Premium license (Unlimited Testing administration), you will be limited to assigning no more than 5 remote test codes at a time. If you generated 5 test codes and have not completed any of these tests, then you will have to complete at least one of those remote (or cancel that test code) in order to be able to generate more new test codes.

The Web Browser and iPad RTLs can be purchased by contacting BrainTrain Sales using the email:  contact@braintrain.com

Note that remote testing should only be administered under the clinical supervision of a qualified health care professional or technician. Remote test administration requires that the Examiner be able to validate that individuals completed the test in accordance with the specified test guidelines and performed to the best of their abilities. Testing can be administered either in-person or via interactive audio/video communication. The audio/video communication setup and functioning must enable the Examiner to view the individual being tested and their ongoing test responses during the entire test. For either in-person or remote testing it is the responsibility of the Examiner to determine if the test was administered in accordance with its guidelines and if an individual’s test compliance and effort was valid.

In general, it is the Examiner’s responsibility to determine if test results are valid or not. It is possible to use one of the Analysis options to view test responses in detail in order to review each individual test response and to check for any unusual patterns in test performance, including changes during the course of the test. If there are any concerns, BrainTrain will provide appropriate assistance and help.

The following links provide you with more detailed information:

• Web Testing Procedures using the Chrome Browser
• Essential Equipment/Procedures Necessary for Web testing
• Remote Testing using the iPad
• Generating a Remote Test Code

Web Testing Procedures Using the Chrome Browser

After you have the Test Code and Password you will need to copy and paste the web link provided into the Chrome Browser for the PC you are using to administer the test. Next, you will be prompted to enter the Test Code and Password in order to start the test. If you are running in trial mode you will have two free trials.

• The web browser based IVA tests require that a mouse be used as the input device. BrainTrain has determined that for Windows 10 or Mac OS that you can now use either a wired or wireless mouse and that the accuracy for the timing of individuals to test stimuli will be valid. However, you cannot use a laptop trackpad buttons to respond during the test, because the timing of test responses will not be valid.
• You will also need to plug in headphones or external speakers for testing. Testing is not permitted using a laptop’s built-in speakers because of their poor quality and delay in audio output.
• Some users have reported a Screen flicker or screen flashing issue during the test.  To resolve this, you will need to disable hardware acceleration in Chrome.  Follow the steps below:
  • 1. copy and paste the following address into the address bar:
    2. chrome://settings?search=hardware
    3. find the setting: “Use hardware acceleration when available”
    4. turn it off
    5. click the “Relaunch” button
• The Chrome browser window should be maximized such that it fills the entire screen.  You may also want to run the test in “Full Screen” mode which can be accomplished by pressing the “F11” key or clicking the following icon in your Chrome settings menu.
• If it is necessary to interrupt the test then is is accomplished by swiping a slightly visible swipe bar in the center of the upper edge of the screen. Swipe this bar with the mouse and you will be given an option to either start the test over again or to end the test and go back to the login screen. The test can never be resumed once it has been interrupted. The test use code is always available for use until you fully complete the test and, thus, can be re-entered at any time when necessary.

The Web RTD will automatically save the data once the test is completed as long as it has an internet connection. An internet connection is required to initially start the test as well. If the internet connection is not available after the test is completed then the test will save the data and upload it later once the RTD is reconnected to the internet. There is no identifying information saved on the RTD or on the internet pertaining to any client’s personal identifying information. In addition, all of the information on the internet and on the RTD that is saved is encrypted. Consequently, the RTD and the internet database do not contain any personal health information (PHI) that needs to be protected. All confidential PHI information and test data is stored only on the examiner’s PC station and this database is encrypted, as well.

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Remote Testing using the iPad

You can purchase a separate license to use either an Apple iOS such as an iPad Air, iPad Mini, iPad Pro or iPhone (running IOS 10.0 or higher) as a Remote Testing Device (RTD) which can be used to administer the IVA-2 and other tests remotely. The value of using an Apple device for remote testing is that the tests can be easily administered remotely and no mouse input device is required. The RTD cannot be used to perform any test analysis and the test results are transmitted to the Windows PC Station for interpretation and storage. No identifying Personal Health Information (PHI) is stored on the RTD or in the Cloud database used by this system. All data is encrypted and coded using a random identifier to provide the utmost in data security that meets HIPAA requirements. For all Apple devices the IVA-2 test takers respond using the touch screen by tapping a large green button with their index finger. Tapping the button will show a visual change in the button as if it was depressed and a clicking sound will also occur each time it is tapped. The test taker can rest his hand on the iPad screen positioning it slightly off to one side or placing their hand just below the button on the flat service of the table on which the device rests. A small wired speaker, ear buds or headphone must be connected to the Apple RTD in order to administer the test.

Please note that the RTD device’s built-in speakers, wireless Bluetooth speakers or Bluetooth headphones cannot be used due to timing delays and the IVA-2 will not run unless a wired speaker or headphone is connected to it. The user will be promoted to connect an external auditory output device, if one is not connected and an opportunity will be provided to adjust the volume level of the device used. In addition, a WIFI connection must be active before any tests will start. Otherwise, the test administration follows the same guidelines and procedures documented for the PC version. At the end the test data is automatically uploaded to the Cloud database and will then be automatically downloaded by starting the IVA-2 PC Station program.

After you have the Test Code and Password you will need to open the IVA Testing System app on your Apple device and enter the Test Code and Password in order to take the test. If you are running in trial mode the first two trials are free. The standard iPad or iPad Pro is generally recommended for testing purposes, because it is larger than the iPhone. You will first need to search for the IVA Testing System, MeSA-IE or MeSA-AE on the Apple App Store and download it. After you register the test on your PC Station and purchase the Apple Device RTD, you will be able to run tests back-to-back on your own iPad. You can also run tests remotely on a client’s Apple RTD device. Tests run remotely on a client’s Apple device can only be completed one per hour. Thus, you will have to schedule remote testing to allow one hour apart from the start of the last test administered. If there is a need to interrupt the test after it has begun, you will be able to restart it on that Apple device without any delay.

It is important that you set up your Apple iPad/iPhone Remote Testing Device correctly and disable features which could cause an interruption of the test.  More details can be found at: https://www.braintrainhelp.com/ipad-configuration-for-remote-testing/

To administer the IVA-2 on the RTD you will need to place the RTD flat on the table or you may choose to adjust it at a slight angle. You will also need to plug in headphones or external speakers. Testing is not permitted using the RTD’s built in speakers because of their poor quality.

To interrupt the test there is a slightly visible swipe bar at the upper edge of the screen. Swipe this bar and you will be given an option to either start the test over again or to end the test and go back to the login screen. The test can never be resumed once it has been interrupted. The test use code is always available for use until you fully complete the test and, thus, can be re-entered at a later time. It is also strongly recommended that you do not use overhead lights in the room where you are doing the testing because the test taker will very likely see a glare on the iPad screen.

It is suggested that you have the person place their dominant hand either off to the side of the green “Tap Here” button or directly below it. Thus, it is permissible to have them position their finger directly over the “Tap Here” button while the rest of their hand would not touch the RTD screen or for the rest of the test taker’s hand to rest on the RTD screen. Choose whichever position would be most comfortable for the individual. As noted, it is perfectly alright for their hand to rest to the side on the RTD screen and for their other fingers to be touching the iPad screen.

When they do touch the “Tap Here” button they will hear a ‘tap’ sound (the “Tap Here” button will also visibly “depress” which makes it easier for the clinician to see a response has occurred). Test takers are not to be discouraged from playing and tapping on the test during the instruction, holding their finger down on the tap button or double clicking the button because these fidgety test behaviors count as significant fine motor hyperactive events. If the test taker does remove their finger from the screen, then they are to be instructed to place it back over top of the “Tap Here” button.

The RTD will automatically save the data once the test is completed as long as it has an internet connection. An internet connection is required to initially start the test as well. If the internet connection is not available after the test is completed then the test will save the data and upload it later once the RTD is reconnected to the internet. There is no identifying information saved on the RTD or on the internet pertaining to any client’s personal identifying information. In addition, all of the information on the internet and on the RTD that is saved is encrypted. Consequently, the RTD and the internet database do not contain any personal health information (PHI) that needs to be protected. All confidential PHI information and test data is stored only on the examiner’s PC station and this database is encrypted, as well.

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Essential Equipment/Procedures Necessary for Web Testing

1. 1. A wireless or wired USB mouse is necessary for accurate timing.  While wireless mice have now been determined to be accurate in timing for Windows 10 or Mac OS PCs, the wired USB is still the recommended input device in respect to its very high reliability and that it does not required the installation of any additional drivers or dongles. The current recommended model is available on Amazon:  Microsoft Basic Optical Mouse for Business – Black  It is important that you NOT use a  laptop touchpad as a test input device.

1. Wired headphones or external speakers will need to be used and plugged directly into the computer. Wired ear buds will work, as well. Please adjust and test the volume level to be acceptable for the test taker.  DO NOT use laptop speakers or any wireless speakers, including wireless Bluetooth headphones or earbuds.
2. Only the Chrome web browser can be used. It can be installed for free on either Windows or Mac PCs.
3. In addition, the Examiner will need to specifically view the finger on the left mouse button during remote testing. If the test taker lifts or removes their finger during testing, then they need to immediately be instructed to put their right index (or left index finger, if left-handed) back on the leftmost mouse button. Also, the right-most mouse button should not have any fingers resting on it in order to avoid it being held down during testing.
4. The Examiner will need to consider using video conferencing apps such as:

   FaceTime
   Zoom (Zoom HIPAA Docs)
   Skype
   Doxy.me
   Doximity

5. These audio/video apps enable Examiners to establish a separate connection to view the hand and finger used to click the mouse button during the test. Being able to view and communicate with the test taker will allow the Examiner to provide guidance and validate that the test was completed as per the test guidelines. The Examiner will also need to be clearly heard by the test taker and the video positioned so that the mouse is clearly in view. The audio-video interface needs to be tested before testing begins. An iPad or phone can be used, but the possibility of incoming calls needs to be blocked by putting the phone in airplane mode and enabling WiFi. The WiFi phone connection option will also need to be disabled. During the COVID-19 national emergency, the Department of Health and Human Services has issued additional guidance regarding the usage of Telehealth Remote Communications.  Please review HHS.gov for the current guidance.
6. It is important for examiners to establish an independent televideo connection with the client before beginning the test that enables them to view the client’s test responses using the mouse. This is necessary in order for the examiner to stop incorrect test responding (e.g., if the client removes their hand from the mouse). The video camera will need to enable the examiner to view the client’s hand on the mouse input device. It is important that the examiner reminds the client to only click the leftmost mouse button and also not accidentally hold down the rightmost mouse button. It is necessary that the examiner be able to view that the client’s hand during testing in order to make sure that the client does not remove their finger during testing or hold down the rightmost mouse button. Either of these incorrect test taking behaviors must be immediately corrected by the examiner during testing or the test results will be invalid. The televideo connection used should not be installed the same computer that is used for testing in order to avoid possibly impairing the computer’s test administration and/or timing. There is no advantage for the examiner to be able view the client’s computer screen during testing. Either the client’s phone or a second PC with televideo capabilities will need to be used.
7. If a minor is being tested, then it will be necessary to have a parent or guardian in the room that can enter the codes and access the test website. This parent needs to sit behind the child in case some type of guidance or intervention is needed. It is important that the parent be instructed by the Examiner not to say anything to the child during testing unless instructed. In addition, it is recommended that the parent be sent a copy of the test manual titled, “Do’s and Don’ts” and that the Examiner go over the rules privately with the parent or guardian during the test setup. The parent’s presence is primarily for the safety and compliance of the child in case the test needs to be stopped or restarted at the direction of the Examiner.
8. If the test taker speaks or asks a question, then the Examiner’s response is to acknowledge that person by saying, “Keep working, do your best.” Hyperactive or off-task behavior should not be corrected by the Examiner or parent, except specific behaviors such as the removal of the finger from the mouse button, the lifting of the mouse or any other test behavior that prevents the possibility of the test taker being able to respond to the test stimuli. There are manual sections that address “Do’s and Don’ts” and in addition there is a structured behavioral rating scale of observed hyperactive, inattentive and off-task test behavior that can be completed by the Examiner during the test. Its use is recommended and its data can be clinically incorporated within a comprehensive evaluation. In order to help establish test validity it is recommended that test takers be asked specific questions about their test experience and performance. There is a test questionnaire specifically for this purpose that can be used. The questions can be both shown and/or read to test takers at the end of the test. The Examiner will need to record and then manually enter the test taker’s responses into the test database. Two of the questions in this brief questionnaire specifically address aspects of test performance validity which are important in the clinical determination of the validity of the test results.
9. The computer screen saver will need to be temporarily disabled for the total testing time and then re-enabled once testing is completed.
10. It is also necessary to disable any scheduled virus scan that could activate during testing, but the security system should remain in place.
11. All programs other than the Chrome browser should be closed during testing.

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Generating a Remote Test Code

Follow the instructions below to begin using the Remote Testing Device:

1. Find the free IVA Testing System, download it, and install it on your iPad 2, iPad Mini, iPad Pro or iPhone (running IOS 10.0 or higher).
2. Add a person that you want to test in the IVA-2 program installed on your Windows PC.
3. Click on “Administer Test” and select that person. Complete the test administration form that then comes up on the screen and then click “Assign Remote Test Device Codes” toward bottom of the screen.
4. The next screen will ask you to select how you wish to administer the test:  iPad/iPhone (requires iOS 10 or higher) or on Chrome Web Browser (Windows PC or Mac PC only).  Each option requires a separate license.  Select the desired option and press OK.
5. You will then see the Test Login Info box pop up with both the Test Code and the Password for the person you just registered to test. You can email or print out this information for future use. This screen will also display either the link to the iOS app for installation or the web link to use for using the Chrome Browser for administration.  More detailed information about when to use “Print” and when to use “Email” can be found at Sending Remote Test Credentials to Remote User
   
6. NOTE:  If you have a Premium kit, you may only generate up to 20 Remote Test Licenses (per remote device) at any time. The Standard testing kit is only limited by the number of tests you have available.
7. Continue on to the appropriate section for administration procedures and guidelines for both the iPad/iPhone test and the Chrome Browser testing.
8. Once a remote test is complete, the test response data is stored online associated with the randomly generated “Test Code” and “Password” which maps that data back to the clinician’s PC and the client profile setup on that PC.  The test response data associated with that Test Code is encrypted on the server and it is stored inside a separately encrypted database. This online encrypted data is then downloaded to the clinician’s PC using a secure HTTPS connection through which the program submits a request for any test data completed by submitting the specific Test Code and password. The download of the data will occur automatically at the next start of the program (or they can perform a manual sync for any completed tests). The program checks that the test data was successfully downloaded and, once it is confirmed that a valid test record was received then the test download is marked as completed.  There is never any PHI data such as Date of Birth, Name, etc. stored online.

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