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 (cmio@ahs.ca) 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.

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.