How are COVID-19-related Conditions added to Problem Lists?

Question: How are COVID-related conditions codified for addition to problem lists, chief complaints, admitting or discharge diagnoses?

Context: The novel coronavirus SARS-CoV-2 is associated with coronavirus disease syndromes collectively referred to as COVID-19. These are new to medicine. The International Classification of Diseases (ICD-10) has newly codified COVID-19 health states. These have been available in Connect Care real-time but are now complemented by physician-friendly synonyms that make it easier to look up and select a best fit problem, complaint or diagnosis. Use of the correct code is important for reporting and clinical decision supports.

Answer: Whenever seeking a clinical condition name in Connect Care (e.g., problem lists, professional billing, discharge diagnosis, etc.), simply enter "COVID" as a search term. A number of matching conditions will appear to choose from, each appropriately coded.


What COVID-19 Admission Order Sets are Available?

Question: What Connect Care order sets are available to support the admission of patients with COVID-19 presentations?

Context: Connect Care clinical system design (CSD) stakeholders (Area Councils, Support Units, Knowledge Leads, Informatics Leads, Strategic Clinical Networks and provincial programs) mobilized with exceptional efficiency to consider best available evidence, produce clinical guidance summaries and then start to design decision supports to help express that guidance for clinicians to use at the point of care. The first products of this work can help clinicians admitting patients (to wards and to critical care) with COVID-19 syndromes.

Answer: Connect Care order sets for adult and paediatric admissions are now live in the clinical information system. Equivalent order sets are also rendered to the SCM legacy clinical information  system. Paper "transforms" summarize the same orders and actions for those still in paper-based flows. For those using the Connect Care CIS, use "COVID" as a keyword when seeking orders in an inpatient context. The four admission sets will appear (look to the "Facility List" tab if these do not show on the "Preference List" tab in the order navigator).


These order sets are based on current best guidance for care in Alberta. They will change based on feedback, emerging evidence and any change in available therapies.

Each order set also serves as a quick source of current management advice. Sections include clinical decision supports, investigations, monitoring, fluid management, medications, consults, isolation requirements and alert triggers. All contain ample links to supporting evidence.

Resources:

When is explicit consent required for digital communications?

Question: Given expanded options for interacting with patients remotely, when should physicians secure explicit patient authorization to use of digital communications during virtual care?

Context: It is always important to carefully confirm patient identity before initiating any remote interaction.

Under increased pressure to provide a broader range of virtual care services, including email, texting, videoconferencing, remote monitoring, image and video file transfers, etc., physicians may wonder when explicit agreement needs to be solicited and formally documented. The CPSA, AMA and CMPA have all commented on this question:
Answer: The bottom line is that virtual care encounters, however facilitated, must confirm patient identity and willingness to participate in the proposed medium of interaction (i.e., verbal authorization). As long as the telecommunications tool(s) in use are regulated and secure, explicit (non-verbal) assent does not have to be documented:
  • Telephony - As long as the telephone interaction is not recorded, patient willingness to converse is implied and there is NO need to request or document formally. 
  • Email - Explicit authorization is NOT required if AHS secure email is used. However, email messages should include a disclaimer in the footer (e.g., "Please note that, although this communication is encrypted, confidentiality of information transmitted through e-mail is inherently difficult to protect. Please be aware of this limitation when contacting us using e-mail").
  • Connect Care Messaging - Explicit authorization is NOT required when communicating with patients using embedded patient messaging tools (In-Basket and MyAHS Connect portal). 
  • Connect Care Virtual Visits - Explicit authorization is NOT required when using virtual visit (or virtual hospital and consultation) tools embedded within Connect Care (coming soon).
  • Non-Connect Care Virtual Visits - Explicit authorization is NOT required if AHS videoconferencing or telehealth tools (AHS Skype for Business, AHS RealPresence, AHS Zoom) are used. AHS clinical videoconferences should not be recorded. If this is done, explicit consent should be obtained and documented. Use of the same technologies outside of AHS enterprise licenses (e.g., personal account or university account) is not recommended, would require explicit consent, and can be considered only if no other option is available (see CPSA COVID-19 guidance).
In sum, physicians should be respectful of communication stresses experienced by patients when switching to virtual care. They should discuss the risks and benefits of any new communication tools and the physician should ensure their clinical documentation reflects this discussion.  
 
As long as communications tool(s) are AHS approved and use is accepted by the patient, a formal documentation of approval from the patient is not required.  

Virtual Care Professional Billing Claims - UPDATE

We've previously posted about the re-introduction of billing code 03.03AD to support physicians providing COVID-19 related advice to patients via telephone, teleconference or other virtual care support technologies. Unfortunately, physicians struggling with the need for more pandemic-appropriate remote care find the 03.03AD option a poor fit to things like remote chronic disease management and legacy telemedicine billing codes have an AHS facility requirement incompatible with social distancing.

New Virtual Care Codes
Alberta Health has released information about three new virtual care billing codes:
These codes will become available in Connect Care service code navigator within 24 hours and can be used retrospectively from March 17, 2020.

Restrictions
The new Virtual Care codes are intended for health services that cannot or should not be provided in-person during a pandemic. Physicians must meet all the usual standards applicable to the provision and documentation of clinical care, including:
  • Appropriate request to initiate (e.g. referral, patient request) the health service(s)
  • Appropriate clinical documentation in the legal record of care
  • Time assessments should be limited to the duration of actual patient interaction
  • Usual limits on number of assessments for the same patient (in-person or virtual) in the same day
  • Premium (time, complexity, etc.) modifiers cannot be used
  • 03.03AD should be used for virtual care services 10 minutes or less in duration
Choice of Virtual Care technology is important. The telephone can be used when this fully meets the clinical interaction need. Otherwise, AHS enterprise video conferencing (Skype for Business, AHS Zoom) has requisite privacy protections and should be used.

Are AHS Zoom Video Conferences Secure?

Question: Does use of the AHS Zoom video conferencing tool satisfy privacy and security requirements when used for physician-to-physician collaboration or physician-to-patient care?

Context: AHS Zoom is one of a number of video conferencing and virtual care tools supported by Alberta Health Services Unified Communications and Virtual Health. It is available inside and outside of Connect Care contexts and is well suited to situations where communication must bridge AHS networks to reach providers or patients using external or personal networks and devices.

Answer: Zoom is freely available to anyone via free and paid accounts. These may not satisfy Alberta's requirements for privacy protection. However, if AHS Zoom is used within the Connect Care clinical information system, or outside Connect Care via the AHS Zoom gateway, then privacy protections are legislation and standards-compliant. This is because the AHS enterprise instance of Zoom ensures full encryption and avoidance of any data transfers outside Canadian network contexts.  This applies to both basic and advanced accounts provided via AHS. The health instance of Zoom is HIPPA, PIPEDA and DPA compliant.

Technically...

Zoom is Canada Personal Information Protection and Electronic Documents Act (PIPEDA), Canada Personal Health Information Protection Act (PHIPA), and Health Insurance Portability and Accountability Act (HIPAA) compliant with complete end-to-end encryption.  Personal Health Information (PHI) is protected and there is no persistent storage of information transmitted. The AHS Zoom instance enables the following best practices:
  • Submit privacy practices to independent assessment and certification with TrustArc
  • Undergoing an annual SSAE-16 SOC 2 audit by a qualified independent third-party
  • Performing regular vulnerability scans and penetration tests to evaluate our security posture and identify new threats  

How can COVID Virtual Visits be Billed? - UPDATED

Question: How can COVID-19 Virtual Visits be managed and billed in Connect Care?

Context: As the COVID-19 pandemic unfolds, physicians need to shift as much patient interaction as possible to "virtual care". This can allow isolated physicians to continue to participate in care. Additionally, avoiding patient visits to clinics and emergency rooms may blunt virus spread among patients and staff. Physicians are asked to convert as many follow up outpatient visits as possible to telephone consultations in order to maximize social distancing. Some of those encounters may require use of Virtual Care supports made available to AHS physicians. These telephone and televideo encounters have new provisions for professional billing claims.

Answer: A previously used code, HSC 03.01AD (with health condition code ICD 079.82 or 079.8) is reactivated for immediate use to support COVID-19 related patient interactions. The claim can be used provided that the patient interaction (via telephone, teleconferencing, virtual health) is:
  • Providing care related to COVID-19
  • Providing care for any condition when the physician or patient is in isolation.
  • Limited to one claim per patient-physician combination per day.
  • Can include advice, prescription management.
  • Documentation of the encounter is required.
  • Communication must be with the patient or patient's agent.
  • Must relate to actual care and symptoms, not providing general COVID-19 information that can be gleaned from publicly available sources.
  • Not to be used for Health Link communications or services.
Unfortunately, this 03.01AD code is calibrated for short interactions and, if used, precludes use of other virtual care codes. HSC 03.05JR (physician to patient telephone advice), HSC 03.01R (physician to physician secure communication), 03.01S (physician to patient secure electronic communication) remain available. HSC 03.01T (physician to patient secure video conference) is under discussion to open its availability for the virtual care technologies appropriate to the current pandemic.

How is COVID-19 Testing Ordered? - UPDATED

Question: How can a prescriber order COVID-19 laboratory testing in Connect Care?

Answer: Connect Care prescribers can enter "COVID" when searching for an order i n ER, outpatient or inpatient contexts. Any physician can order the test. If the "COVID-19 NAT" test does not immediately appear in one's department preference list, be sure to click on the "Facility List" tab to find the order.


Be sure to complete the questions that appear when requesting COVID (NAT) testing. These include prompts for details about travel or other exposures. This information helps the microbiology lab to quickly route relevant swabs for appropriate testing with appropriate priority.


Can Patients get COVID-19 Test Results through MyAHS Connect?

Question: Are COVID-19 test results (initial and confirmation) made available to patients through the patient portal (MyAHS Connect) and is result release delayed?

Answer:  The results of COVID-19 NAT testing (and later confirmation testing) are made available through MyAHS Connect with no delay. Encourage all patients to sign up for the portal, as this method of results release can take pressure off of call centres. Physicians have the ability to manually override results release or to comment on results, just as with other test results.

Where are COVID-19 test results found?

Question: Where are COVID-19 NAT and confirmation results displayed within the Connect Care medical record?

Answer: COVID-19 test results are co-located with other respiratory pathogen test results in a "Microbiology" folder in the "Lab" tab of outpatient "Chart Review":


If in doubt, use the "Search" box with the keyword "COVID", as the NAT test classification has changed and some results may still appear under an "Other" category. For inpatients, respiratory viral studies, including COVID, do not appear in the Micro tab of chart "Summary". Instead, use Results Review or look in the "Lab" tab of chart "Summary" activity.

COVID-19 results also appear in Netcare outlines in the "Microbiology" folder. Netcare is the preferred resource for encounters that do not involve Connect Care. Netcare is a supplemental resource for Connect Care users and continues to be launchable from within Connect Care.

Which test results are delivered to MyAHS Connect after a delay?

Question: While most test results and reports are routed to MyAHS Connect (patient portal), some are subjected to a 5 working day delay. Which test results are delayed?

Context: After wide consultation, and consideration of Alberta Health policies, the Connect Care patient portal is configured to receive almost all test results and reports for patient access. A very small number are not released by default. These exceptionally sensitive results can be released to the portal by manual physician override. A modest number of test results are released after a 5 day delay, allowing clinicians time to annotate the results, otherwise inform the patient, or manually hold back the results until the time of a visit. The majority of results are released as soon as they are posted to the clinical information system. Results in the manual-share and delayed-share categories were carefully reviewed by clinical oversight groups, and closely match past practice with the eCLINICIAN patient portal.

Answer: A list of delayed delivery test results is available for skimming and searching, in categories of histology/pathology, genetics, microbiology and other:

How can patient messages be restricted to provider-patient?

Question: How can a clinician send a message to a patient via the patient portal and also ensure the the patient's response is returned directly to the clinician without copying others?

Context: Patients who have activated MyAHS Connect (Patient Portal) are able to securely communicate with healthcare providers via Connect Care. However, outpatient clinics are configured by default to send incoming patient messages to a clinic pool for monitoring, screening and forwarding. This can help shield physicians from excess In-Basket messages, or delays in answering messages when physicians are busy. However, sometimes physicians will want to both send and receive a patient message without anyone else being part of the communication loop.

Answer: When composing messages to patients (e.g., using the "Send Patient Message" activity in chart review, accessible via the global search box by typing the keyword "message"), look for and be sure to check the "Send patient reply to me" option. From February 2020, this option is selected by default, but can be unselected. Checking this option will avoid sensitive information unintentionally being copied to a clinic incoming message pool.

The physician should have an understanding with the patient about reasonable response times, as no support staff will be monitoring responses. Also remember that if one's In-Basket is signed out to a delegate or covering group (e.g., in case of vacation), then the patient message will be seen by the delegate.


How can patient receipt of appointment reminders be checked?

Question: How can prescribers check to see if a patient has received a reminder notification of upcoming appointment(s)?

Context: An automated telephone appointment reminder system was integrated with Connect Care and implemented at the end of January 2020. This calls patients at a preferred number to remind 2-5 days (weekend dependent) before the appointment. It also provides for interaction so that patients can confirm, cancel or request a reschedule. Should a clinic no-show happen, prescribers may want to check the status of any telephone reminders. Patients who have opted-out or who preferentially use MyAHS Connect (patient portal) may not receive telephone reminders.

Answer: There are at least two ways for physicians to check what's happened with telephone reminders.

1. Appointment Desk

Easiest is to open the "Appointment Desk" activity within hyperspace, lookup the patient and appointment of interest, then check for notification details:


  • This can be done within a chart or before a chart is opened.
  • Use global search with the term "Appts" (case sensitive) or find the item in the master Epic menu. 
  • Click on the "Jump" link that appears for "Appts", select (or search for) the patient of interest, and so open the "Appt Desk" activity within the patient's chart.
  • Use the tabbed list that appears in the bottom half of the screen to select either "Future" or "Past" appointments.
  • Select and open the appointment of interest by double-clicking on it.
  • Scan the right column of information in the "Appointment Information" section of the pop-up information screen and look for "Auto confirm status" (appears just below "Referral status". The status will indicate what happened in response to the automated telephone reminder (i.e., "Confirmed", "Answer Machine", "Cancelled", etc.).
  • If there is no "Auto confirm status", then an automated telephone reminder was not sent.

2. Department Appointment Report

If the need is to see the reminder status for a many patients and appointments, then the Department Appointments Report (DAR) Works best. One can save a personalized copy of the DAR, editing the display columns to include one or more appointment status-related columns (e.g., "Patient Communication Preference", "Patient MyChart Status", "Confirmed Appointment", "Appointment Reminder Sent", "ES Phone Reminder Status"). Instructions for doing this are included in the tip linked below.


    How can a referral be directed to a specific colleague?

    Question: How can a referral for specialty services be directed to a specific individual?

    Answer: If the referral is "internal" to a clinic, service or consultant using Connect Care as the record of care for the requested service, then use the "To Provider" field (usually left blank) to request a specific individual.

    If the referral is "outgoing" to a service operating outside the Connect Care record of care, then it is essential to use the "To Provider" field. The look-up for this will filter for the requested specialty and will allow selection specific to a provider at a particular location.

    If the provider and location of interest cannot be found in the "To Provider" lookup, then the field can be left blank. The referral order process is still valuable and a standardized referral letter can still be generated. You can address the letter to the missing provider and mail or fax with information you possess. It is important to submit a help desk request to have the missing provider added to the Connect Care provider registry.

    How can a prescriber know whether to choose an "internal" or "outgoing" Referral?

    Question: How can a prescriber know if an "outgoing" referral "class" should be used?

    Context: The top of Referral order requests asks for the classification of a referral order as “Internal” or “Outgoing”. Think of the province being divided into health care settings where Connect Care is or will become the record of care and settings where Connect Care is not and will not be the record of care. Referrals that start and end within the Connect Care “sector” are “Internal”, even if the destination clinic has not yet launched the CIS. Referrals that are fulfilled outside the Connect Care sector are “Outgoing” and rely upon delivery and fulfillment steps that occur in other information systems.

    Answer: The most practical answer to this question is that "you will know". Connect Care physicians will have a limited number of ambulatory referrals used for commonly requested specialty services. Once one of these referral pathways is figured out, the associated referral order properties can be saved as a personal preference. This includes whether an internal or outgoing order class works best.

    If in doubt, start an unfamiliar referral order with the class set to "internal". Try finding the refer-to department of interest. If nothing can be found (with various keyword attempts), then it is likely that the required specialty services is not yet active in Connect Care. The "outgoing" class can be selected and an order placed that involves the referral letter being mailed or faxed to the clinic of interest.

    If you believe that there is an error in the list of available internal referral destinations, please send this observation, with specific clinic name(s) to ClinicalOperations-Patient.Access@ahs.ca.

    During the early weeks to months post-launch, some clinics may not be fully referral-ready. It is always possible to generate the "internal" referral order and benefit from the standardized referral letter it generates. This can additionally be faxed (from within Connect Care) to the clinic as a fail-safe until referral notifications confirm that closed-loop referral capacity is fully established.

    How can prescribers complete an outgoing (external) referral without support staff assistance?

    Question: How can a prescriber complete an outgoing (external) referral order (and letter) without medical office support staff assistance?

    Context: Physicians working in contexts that have medical office assistant support can place outgoing referral orders (ie., to non-Connect Care specialists) and trust that the support staff will take care of tweaks to the referral letter when ensuring that it routes (fax or mail) appropriately. There are other contexts (e.g., placing an outpatient referral order from within an inpatient context) where such support is not available. And some physicians simply prefer to do things themselves!

    Answer: A short (7 min) demonstration walks through all of the steps that a prescriber can independently complete and control when ordering an outgoing referral.

    How can Referrals be tracked within a Patient Chart?

    Question: How can the state of a referral order be tracked for a particular patient using that patient's Connect Care chart?

    Context: Prescribers participating in referral intake and management will do most of their work through In-Basket workflows. Referring physicians can also use In-Basket for referral tracking, as that is where they receive notices about the status of the referrals they have ordered. In addition, referring physicians may wish to quickly check the the status of one or more referrals that pertain to a particular patient.

    Answer: The "Chart Review" section of any opened patient chart has a tab labelled "Referrals". Opening this gives access to a list of all active referrals for the current patient. These can be selected to dig deeper, check referral progress and facilitate communications.

    How do Physicians triage incoming Referrals via In-Basket?

    Question: How does the Connect Care In-Basket help prescribers who facilitate triage and acceptance/rejection/deferral of incoming outpatient referral requests?

    Context: Prescribers working as part of a specialty service may take turns triaging incoming referral requests. This step of closed-loop referral management usually requires a decision about the relative priority of a referral, a target schedule-by date and any needed actions for the patient to be ready for the clinic visit.

    Answer: A short (6 min) demonstration walks through all of the functions and actions that a triage prescriber can manage through In-Basket alone.

    Do Connect Care Referral Workflows address CPSA expectations?

    Question: The College of Physicians and Surgeons of Alberta (CPSA) has recently updated standards that physicians must meet respecting the receipt, acceptance, notification and fulfillment of referral requests in outpatient settings. There are metrics and milestones. Would adoption of Connect Care closed-loop referral workflows comply with these standards?

    Answer: Prescribers and support staff who use Connect Care referral management tools (both to place and to receive referrals) will use information flows that include all data elements required by the CPSA. Tracking of CPSA events occurs automatically. Required notifications to referring physicians are automatically prompted. For a quick review of CPSA expectations and Connect Care matching functions:

    How can an Outpatient Referral be ordered in an Inpatient Context?

    Question: Physicians ordering referrals for outpatient specialty assessment cannot find the needed orders when using the Order activity in inpatient encounters. How can follow-up consultations be arranged?

    Considerations: Whereas inpatient consultation requests can only be placed from inpatient or emergency contexts, outpatient referrals are available to outpatient, inpatient, emergency, critical care or continuing care contexts. Unfortunately, inpatient and outpatient order catalogues are different. Users may be frustrated when trying to find outpatient referral orders from within an inpatient order navigator.

    Answer: Outpatient referrals can be ordered during Inpatient encounters, but there are a few tricks to be aware of. Emergency physicians need to pay attention to where ("After visit procedures") the referral order may appear. Inpatient physicians need to use either the Discharge Navigator or an External Orders tool to make the outpatient referral arrangements; all explained in:

    How are Referring Prescribers notified of a Referral's progress?

    Question: How are referring physicians notified of the receipt and processing of their request?

    Context: Connect Care has a standardized approach to communicating about the progress of outpatient referrals and appointments.  The Referrals workflow has been designed to transform the referral experience for both clinicians (sender and receivers of referrals) and patients. It meets expectations of CPSA Standards for Referral Consultation, Path to Care and the AHS Wait Time Policy.

    Answer: Once a referral has been accepted and processed, an “accepted and waitlisted” letter will be automatically sent to the referring provider according to the communication preferences they have indicated in the system.  Typically, these communications will route via InBasket. If the provider does not use Connect Care, the letter will be generated for print and mail or RightFax.

    A number of automated notifications are sent to the referring prescriber as Connect Care referrals pass milestones in close-loop referral management.