How are Triplicate (Duplicate) Prescriptions handled in Connect Care?

Question: How should prescribers handle triplicate (or newer duplicate) prescriptions required for outpatient use of controlled substances?

Context: The Alberta Triplicate Prescription Program (now a duplicate program) monitors use of prescription drugs prone to abuse. It does this by ensuring that such prescriptions are handwritten to prescription pads with security features and copies. Unfortunately, the program has yet to take advantage of the additional security and surveillance made possible by digital health records. It is hoped that the advent of e-prescribing (PrescribeIT) will avoid paper. For now, physicians must follow CPSA requirements:

How, exactly, are Connect Care prescribers to keep a copy of a triplicate (duplicate) prescription?

Answer: Connect Care made application to the Alberta TPP program for workflow adaptations appropriate to a fully integrated clinical information system, like Connect Care. Some recommendations remain under consideration. However, a formal decision has been communicated (July 2019) to the effect that Connect Care prescribers do not need to scan a copy of the TPP paper form to the chart and can follow this workflow:

  • Order all prescriptions in Connect Care, including TPP Alberta specified Type 1 controlled substances.
  • Produce a manual (handwritten) paper 3-part or (newer) 2-part TPP prescription for specified Type 1 controlled substances.
  • Record the TPP prescription identification number (unique to each prescription) in Connect Care (ideally in the comments field of the actual order).
  • Provide the manual-paper TPP to the patient, or fax to the pharmacy (see guide).
  • Destroy any left-over paper copies or artefacts. 
The Connect Care order constitutes the official record. It is NOT necessary to scan or otherwise copy the paper TPP prescription to attach to the Connect Care digital record.

What does the "Accept Charges" Button do in Service Code Capture and can it be Ignored?

Question: What is the function of the "Accept Charges" button, which appears in the Service Code Capture (inpatient and outpatient), and can the button be suppressed or removed?

Context: The Service Code Capture (SCC) activity in Connect Care can be accessed as a tab within inpatient charts and as part of after-visit workflow or an independent activity in outpatient charts. Some prescribers have noticed an "Accept Charges" button towards the bottom of SCC, just above where claims (submitted billing codes) are listed.

Curiosity is increased when noting that failure to select this button does not stop billings from being recorded or processed. Understandably, the same prescribers wonder if clutter could be reduced by removing the button.

Answer: It is true that billings will be submitted and processed (in accordance with the prescriber's billing arrangement with Connect Care) if a charge is created in association with a clinical encounter, irrespective of whether the "Accept Charges" button is selected. The charges are processed when the user navigates away from the SCC (the charge status will change to "filed"). Erroneous charges can be deleted (during a grace period) even if filed.

Clicking on "Accept Charges" will immediately file the billing request while immediately performing any final validations (we do not have many of these). Given Connect Care's current configuration, there is not much to be gained by taking this extra step.

Users can suppress the "Accept Charges" button to make for a more streamlined SCC. Select the personalization button (wrench icon) near the top right of SCC and note that there is an option to "Use slim charge lists". Activating this will suppress the Accept Charges button for the current user.

How can a Scale or Score be Requested for use in Connect Care?

Question: How can addition of a clinical scale or score be requested for the Connect Care clinical information system?

Context: Clinical Scales Scores and Tools (CSST) offer valuable decision supports for estimating risks for and effects of health conditions.  Connect Care provides access to a wide range of common clinical measures, most in forms that allow trending observations over time.

The Connect Care Clinical System Design program ensures that deployed CSST are based on provincially validated instruments that are carefully evaluated for use in Alberta, avoid unhelpful duplication, and have use permissions secured from authors or owners.

Answer: First check to see if a desired CSST is already available in Connect Care as a calculator, advanced flowsheet or SmartForm (see relevant parts of the Manual).

If a case is to be made for a new CSST, there is a process to follow. Complete and submit a CSST Clinical Requirements Form to provide background information about the tool, design details and clinical use cases. This is reviewed by an appropriate Connect Care Area Council. Priorities are established before build work can begin, including securing copyright or licensing arrangements. We ask that applicants do not directly contact copyright owners. AHS legal has developed a process for  that manages risks for AHS and clinicians alike. Any useful contacts can be specified in the requirements form.

How can Special Medication Approvals be Flagged in Patient Charts?

Question: How can patients with special approvals for medication access be flagged within Connect Care?

Context: Patient chart flags (FYIs) are short visual markers and notes associated with a patient record to signify considerations important to patient care. Some health care interventions, usually medications, are available for patient care only given special approvals. Examples include Compassionate Supply, Special Access Program (SAP), and Short Term Exceptional Drug Therapy (STEDT) programs. It can be useful to have a visual indicator on a patient’s chart to signify such approval status, facilitating more efficient pharmacy review of med orders.

Answer: A "Special Medication Approval Status" flag type is available to visually indicate patients accessing interventions under special approvals. Use of this can speed things like pharmacy order review and medication release.

What happens when Therapy Plan orders are changed during a visit?

Question: Physicians may wish to modify a specific order in a patient's therapy plan and need to know how this affects current and future visits.

Context: Therapy protocols help organize the delivery of tests and therapies across multiple encounters for a specific health condition. Therapy plans are patient-specific instances of therapy protocols, with elements selected to suit unique patient needs and constraints.

Answer: When a physician modifies an order in a therapy plan, (s)he will need to re-sign the plan in order for changes to propagate to subsequent encounters. There are some special considerations:

  • If the patient’s plan encounter is ‘today’ with a status of ‘arrived,’ signing a plan-related order will trigger a pop-up that notifies the provider that the patient is currently receiving a relevant intervention. 
  • If changes were intended for an intervention already underway, the provider must call the administering provider(s) to halt a potentially inappropriate medication administration. No call is needed if the ordering physician does not want changes reflected in the current therapy plan intervention.
  • Because changes to therapy plan orders do not change interventions underway, a warning reminds physicians that their work is reflected in future treatments.

How can patients be referred for Virtual Hospital services?

Question: How can patients be referred for possible admission to Virtual Hospital from emergency, inpatient and outpatient settings?

Context: The Edmonton Zone Virtual Hospital and Calgary Zone Complex Care Hub have enjoyed successful trials and are now expanding in their respective zones. They offer person-centered, technology-enabled, integrated “whole of system” modes of care for individuals living with chronic and complex health conditions. Patients admitted to "virtual beds" at home have access to more frequent tracking and monitoring of health functions, with surveillance by the multidisciplinary VH team.

Answer: Patients can be referred from outpatient clinics, emergency rooms and inpatient settings. Note that the label for the appropriate Connect Care order differs depending on context (but is still found with "virtual hospital" as the search term):

  • Inpatient Order = “Inpatient Consult to EZ Virtual Hospital”
  • Emergency Room Order = “Inpatient Consult to EZ Virtual Hospital” (if intent is for patient to be seen before leaving ER)
  • Emergency Room Order for outpatient followup = External Order Tab “Ambulatory Referral to Home Based Acute Care” (if intent is for patient to be reviewed after leaving the ER)
  • Outpatient Order = “Ambulatory Referral to Home Based Acute Care”

How is AHS Secure Email Accessed via a Web Interface?

Question: How can the new AHS secure email service be accessed via the Web and how does the offering differ from use of the full Outlook software application?

Context: Alberta Health Services is upgrading from Microsoft's 2007 Communications Server to infrastructure capable of supporting Office 365 (Outlook 365) and current versions of popular operating systems (Windows, Macintosh, iOS, Android). The change includes an improved user-interface for "webmail" where an internet browser (e.g., Safari, FireFox, Chrome, Edge, Explorer) is used to list, read and respond to email messages. 

Answer: Any of the links below can be used to log on to new AHS webmail using any Internet Browser. The web interface is simple to use and provides access to the same mail, calendar, contacts and tasks found in desktop versions of Outlook. However, some of the more advanced settings and features are not available via the web. 

For example, the Outlook application supports multiple mailbox accounts so that, for example, professional and AHS appointments can be combined in the same calendar view. Outlook webmail provides access to AHS mail, AHS calendars and AHS contacts only.

Most importantly, personal preferences for mail, event and task management (e.g., whether to reply or reply-all) need to be re-configured in webmail. One's settings from desktop or mobile Outlook are not inherited. It is prudent to go through all Outlook webmail settings to ensure that they fit the user's needs.

Who is a Supervising Provider?

Question: Which physician name should be selected by trainees when specifying their Supervising Provider?

Context: Trainees (medical students and residents) select a "Supervising Prescriber" when logging on to Connect Care, as previously posted. We've also posted about why this is important and what Connect Care activities are impacted in inpatient and outpatient settings.

While it is usually obvious to trainees who their Supervising Prescriber is, there are times when trainees cover multiple services or physicians and so see patients who have different attending physicians.

Answer: A supervising prescriber (physician) supervises another physician for some aspect of care provision. Trainees and some other clinicians (e.g., clinical assistants) are licensed to care for patients only while under the supervision of another fully licensed physician.

The supervising physician for a trainee is the physician accountable for the trainee's actions when orders are signed. During weekdays, this is usually the attending physician. However, after regular working hours, responsibility for patient care may be assigned to an on-call physician (also fully licensed and usually on the same specialty service).

To be sure, a resident should consider which staff physician (not a higher level trainee, but the fully qualified physician on service or call) the resident would call in the event of an emergency. That is who the trainee is acting on behalf of.

In a consultation context (inpatient or emergency consults), the same test applies. Consider who (staff physician) is called to discuss the case (or, who the senior resident or fellow would have to call). That consulting physician of the time is the supervising physician.

The supervising physician is NOT the resident training program director, a more senior trainee, or some other physician not directly accountable for the clinical care that the trainee is providing at the time an order is entered.

How do Connect Care physicians relate to the BrightSquid secure messaging solution?

Question: With Alberta Health announcing availability of another secure messaging service for patients and physicians, what does this mean for users of the Connect Care clinical information system?

Context: Alberta Health has contracted with Telus to make secure patient-physician messaging services more accessible during the COVID-19 pandemic; with BrightSquid the selected provider. An offering, branded as "MHR Secure Mail", is available at no cost to participating physicians until July 31, 2020. This will be promoted to Albertans. Patients may wonder whether or when they should use BrightSquid. Physicians may wonder when to use an existing AHS messaging system and when to use BrightSquid. The systems currently do not interoperate.

Answer: AHS strongly supports secure messaging solutions that meet regulatory requirements for messaging between patients and their physicians. This BrightSquid service promoted by Alberta Health until July 31, 2020, is one of many options. AHS supports physicians choosing a solution that best meets their practice requirements... and making sure that they have the required Privacy Impact Assessment addendum in place.

Physicians with independent clinics may elect to use the BrightSquid system alongside their existing electronic or paper records. Where AHS bears responsibility for the record of care (EMR or CIS), physicians should use AHS within-system secure patient communication tools or, failing that, AHS Secure Email.

How can Patient Consent to Virtual Care be Documented?

Question: How is patient consent to Virtual Care effectively documented?

Context: While written consent is not required when using telephone or teleconferencing technology to interact with patients patients should be informed about their options when switching from in-person to virtual care and their agreement to proceed should be recorded in the legal record of care.

Answer: The outcome of efforts to inform and the resulting decision(s) can be documented with a simple SmartPhrase.

How can Clinicians Manage Results Released through the Patient Portal?

Question: Can prescribers attach comments to results that may help patients appreciate the personal significance of information released through MyAHS Connect?

Context: Most laboratory test results, diagnostic imaging reports and health intervention reports are released to MyAHS Connect, the Connect Care patient portal. Clinicians can use Hyperspace to detect whether a patient has MyAHS Connect enabled, is an active user, or has viewed specific results. It is also possible to attach comments to one or more test results or to manually withhold some results.

Answer: Connect Care offers some simple tools for recognizing when patients are active users of its patient portal and view results or reports. It is possible for physicians to comment on one or more results and to select specific results to withhold until further discussion has occurred.

How can I change Supervising Prescribers quickly?

Question: What are the fastest ways for busy trainees to change their supervising provider when working in outpatient or emergency settings where there are multiple attending physicians?

Context: We've previously described how to change supervising providers and where this is most important. Accurate patient-trainee-supervisor matching is essential for outpatient and ER consultation encounters, especially when orders are placed or documentation is saved or signed.

Some high-volume clinics for some specialties have trainees see many patients, possibly with different supervising consultants. Switching supervisors needs to be slick!

Answer: There are multiple ways to change supervisors from within a logged-in Connect Care session. Always available is an Epic menu command, "Change Context", which also appears in a drop-list just to the right of the Logoff button (top-right).

For multi-supervisor-challenged trainees, the fastest switch occurs when the Change Context command is saved as a favourite and then accessed via a keyboard shortcut.

When should Supervising Prescriber be changed for Inpatients?

Question: When is it most important for trainees to set/confirm their Supervising Prescriber in inpatient settings?

Context: Trainees (medical students and residents) select a "Supervising Prescriber" when logging on to Connect Care, as previously posted. Usually this is straightforward. There will be an attending or most responsible physician for the inpatient ward or the inpatient consultation service that the trainee is assigned to on a given day. However, there are also situations where a trainee is responsible for a particular inpatient ward and that ward has patients assigned to multiple attending physicians. It can be inconvenient to interrupt workflows to switch supervising providers when rounding on patients.

Answer: In can help to be aware of the intent and impact of a supervision relationship. While professional regulations require trainees to document and order under a licensed physician, in some cases this can be inferred and there is less functional impact to changing supervisors in Connect Care. However, in other cases it is essential to explicitly identify the supervising provider, as this determines how results and reports are delivered:
  • ER Consults: when a trainee is serving on an inpatient consultation service and helps with a consult in the emergency room, it is essential to select the correct Supervising Provider. Many providers may interact with a patient in ER. It is important to route late-reporting labs correctly because patients may be discharged from ER with the consulting service (and a specific consulting physician) responsible for followup.
  • Inpatient Ward: inpatients may be on a ward where there are patients admitted under different attending physicians. Inpatient laboratory results are not routed to In-Baskets unless the result is delayed until after the patient is discharged. Even then, they route to the inbox of the attending physician at the time of discharge. Critical results get called to the responsible provider, who will be the selected Supervising Provider. Accordingly, if a trainee elects to do ward rounds under a single Supervising Provider (e.g., the provider on call to cover that ward at night), know that the Supervising Provider will get called for critical results and be sure that is acceptable to the service that the trainee is working on. Of course, the best practice is to follow instructions for quickly changing Supervising Provider when moving to a patient with a different attending.

How can I switch Supervising Prescribers?

Question: How can trainees (students, residents and fellows) quickly change the supervising prescriber when working in Connect Care?

Context: As previously posted, and explained in the Connect Care Physician Manual, trainees identify a "Supervising Prescriber" when logging on to Connect Care. This ensures that any late-reporting results or reports get routed to the accountable physician; recognizing that the trainee may have moved to a different rotation.

Sometimes trainees serve in settings (e.g. multi-physician outpatient clinic) where the Supervising Prescriber can change multiple times in a single session. There is need to quickly change the supervising relationship without the hassle of logging off and back on again.

Answer: Switching Supervising Prescribers is fast and easy. It can be done without logging off. Before opening the chart of a patient with a new Supervising Provider, use the "Change Context" function (part of the logoff button drop-list) and then select a different physician. The following demo illustrates this (~1 min):

Virtual Care Professional Billing Codes - COVID Considerations

We've previously posted about new Virtual Care Professional Billing codes. Questions arise related to e-consults and e-visits within and without health care facilities, with Dr Adrian Wagg providing these clarifications:

  • The pandemic code 03.08CV can be billed from anywhere and can be used for inpatient virtual consults as much as any other virtual consultation.  The AMA suggests that being in the same facility should be no barrier to the use of this code.
  • The code 03.03FV is for outpatient follow up only as indicated in its name description, so please use this accordingly.
  • The code 03.03CV is for unreferred limited assessment, but there's nothing in the rules preventing the use of 03.03CV to bill virtual inpatient encounters.
  • Note: at a minimum a physician must complete a limited assessment of a patient's condition requiring a history related to the presenting problems, appropriate records, and advice to the patient. The assessment must last a minimum of 10 minutes. An assessment that does not meet the minimum requirements or is less than 10 minutes must be claimed using 03.01AD
  • Existing codes deal with telephone consultations with nursing, pharmacy and allied health staff - this is unchanged from usual practice.
All codes are fully configured and operational within Connect Care.

How can Prescribers Check-In Virtual Visits?

Question: How can prescribers check-in and manage virtual visits without support staff assistance?

Context: Prescribers (physicians and outpatient healthcare providers) may participate in “virtual” Connect Care encounters that were originally scheduled as in-person encounters. The switch to remote interaction – by telephone, teleconference or e-visit – may be last-minute or otherwise needing check-in without support staff or “rooming” workflows.

Answer: Ideally, support staff will pre-register and check-in patients (even remotely) either the day prior to or the morning of the planned clinic. This allows staff to collect or update demographic information and attach relevant documents.

Situations may arise where no support staff are available to facilitate patient identification or check-in activities. The prescriber can take care of this independently.

How can Patient Consent to Virtual Care be Facilitated?

Question: How is patient consent to Virtual Care (VC) facilitated?

Context: While written consent is not required when using telephone or teleconferencing technology to interact with patients (see our posting about patient acceptance of digital communications), patients should be informed about their options when switching from in-person to virtual care.

Answer: Patients have the right to consider the pros and cons of VC and to request an alternate method of conducting their healthcare interaction within the limits set by circumstance and resources. A simple script illustrates (see Crib-Sheet) exemplifies how this can be done efficiently at the time of booking an appointment and starting a visit.

How can Prescribing Workflows work with Virtual Care?

Question: How can physicians providing virtual care, or otherwise working remotely, support requests for new or changed prescriptions?

Context: The COVID-19 pandemic has shifted many patient interactions to "virtual" modes. These include physicians managing prescription refills from remote locations without access to clinic devices (printer, scanner, facsimile) or support staff. The prescriber needs to order medications in the record of care (Connect Care) while getting prescription information to the intended pharmacy.

Answer: Working remotely can be frustrating. It is unlikely that Alberta Health Services (AHS) help desk staff are able to support devices that are not AHS-provisioned. The CMIO portfolio will continue to learn about and support remote workflows for physicians. So, the important "answer" is to ask physicians to share problems with us ( so we can share-back here.

Alberta has yet to implement e-prescription protocols. Accordingly, outpatient prescriptions get from prescriber to pharmacy by three possible pathways:
  1. Printed and (manually) signed prescription handed to patient who takes it to a pharmacy of choice;
  2. Printed and signed prescription faxed from the physician to the intended pharmacy; or
  3. Documented prescription telephoned by the physician to the intended pharmacist.
The first option does not work with virtual care.  The third option is a fall-back that can be used in any context. The second option can be adapted to virtual Connect Care workflows:
We will post again with suggested workflows when support staff are (remotely) available to help. 

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.