Showing posts with label COVID. Show all posts
Showing posts with label COVID. Show all posts

How can I report an adverse effect following immunization?

Question: How can prescribers satisfy requirements for reporting an adverse event following immunization (AEFI)?

Context: In a separate post, we describe how to report a patient safety event and how to report serious adverse drug reactions. There is another process for reporting an adverse event following immunization (AEFI), defined as an unfavourable health occurrence experienced by a patient that:

  • follows immunization
  • cannot be attributed to a pre-existing condition
  • is determined by a health practitioner to be one or more of the following:
    • a life-threatening health occurrence requiring hospitalization or urgent medical attention
    • an unusual or unexpected health occurrence not previously identified, or previously identified but of increasing frequency
    • a health occurrence that cannot be explained by the patient's medical history, recent disease, illness or use of a medication
All AEFIs must be reported to the AHS Provincial AEFI team. By completing the AEFI form within Connect Care, the team is automatically notified; no further notification to the team is required.

Answer [updated January 2025]: AEFI reports can be completed entirely within Connect Care. From within an opened patient chart, seek the "Serious Adverse Drug Reaction Form" (SADR Form) activity by using Chart Search with "serious" or "reaction" as a keyword. Note the "AEFI Criteria" tab at the top of the SADR Form activity. Select (click on) the “Complete an AEFI report form in Connect Care” link; a “Flowsheet Pop-Up” form will appear. Fill in the form, ensuring the “Patient Aware of Notification” questions are both answered. Add a brief note in the “Notes” sidebar activity.

Once completed and signed, the report is automatically directed to the Provincial AEFI team for review and reporting.

For screenshots, see the tip sheet.

Related postings:

How is COVID-19 Testing Ordered? - UPDATED

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

Answer: Ordering of rapid COVID-19 PCR occurs using the "Respiratory Infection (incl. COVID-19) NAT" order. Connect Care prescribers can enter "COVID" when searching for an order in ER, outpatient or inpatient contexts. Any physician can order the test. If the "Respiratory Infection (incl. 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. This order is also used to order rapid influenza/RSV PCR and the respiratory pathogen panel (RPP); rapid COVID-19 testing will be automatically selected by default.

Be sure to indicate the reason for testing (symptomatic, infection control screen or pre-transplant testing) and then patient location/disposition (not required for outpatient orders). As resources for rapid on-site testing are limited, answering accurately whether the patient is admitted or is likely to be admitted is very important to ensure the sustainability of the rapid COVID-19 testing program.

For more information, see the tip sheet and lab bulletin.

How is discontinuation of isolation ordered for patients on COVID-19 precautions?

Question: Are there special considerations when discontinuing isolation for patients with COVID-19 risks, exposures or disease?

Context: Inpatient and emergency patients can be placed on contact and/or droplet and/or airborne precautions by means of an "Initiate Isolation" order. A different order is required to remove isolation precautions already in place. 

“Discontinue Isolation” orders must be mindful of evolving COVID-19 protocols. The order composer reflects this by providing within-order links to current guidance and policy while also providing pop-up summaries of relevant clinical data from the patient's chart.  

Answer: The discontinue isolation order is unchanged for most exposures. There are special requirements for discontinuation of COVID-19 precautions. Ordering prescribers are asked to affirm that the order complies with those requirements. Links to both relevant guidance and data are provided within the order to facilitate efficient workflows.

How can an inpatient's provider service be changed by ward clerks?

Question: How can the clinical service for an inpatient be corrected by a ward clerk?

Context: Inpatients are associated with a location (e.g., emergency department, ward, facility), a clinical service (e.g., family medicine, general internal medicine) and one or more inpatient or consultant provider teams.

The clinical service assignment is important. It affects the integrity of lists and reports. Patients are assigned to an appropriate clinical service (e.g., general surgery) as part of admitting and bed allocation workflows. 

The clinical service can change during an admission if a patient is transferred to a new service (e.g.,  cardiology, critical care) or when patients are moved within a facility to manage things like outbreaks. Bed management and service census reports depend upon accurate service attachments. 

Intra-facility transfer workflows are largely facilitated by non-prescribers, who can double-check and correct inpatient service assignments. The current service attachment is easy to see. Look to the StoryBoard (leftmost column) and the "ADMITTED" section. Hover to reveal admission details, with the "Service" identified:

Answer: Service assignments can be updated during intra-facility transitions. The following steps are available to ward clerks (inpatient unit clerk role), with similar workflows available to nursing and inpatient unit managers.

  1. With Hyperspace opened to an appropriate role and department (e.g., specific ward), select the "Unit Manager" workspace, which lists patients in the location for the login department.


  2. Select a patient by clicking within the appropriate row of the unit list.
  3. Select the "Update" button from among the command buttons at the top of the Unit Manager workspace.



    If the Update button is not present, be sure to check the personalization tool (wrench icon at far right of button row at the top of the Unit Manager workspace) for rarely used buttons that can be dragged back to the Unit Manager button bar.

  4. The selected patient chart will open with an "Update Admission" activity displayed by default. Look to the "Service" field, where a new inpatient service can be selected (be sure to document the reason in the field provided by selecting "Patient Status/Service Changed"). The "Finish" (bottom-right) button must be used to save the change.

How can patients view and print immunizations in MyChart?

Question: How can patients view and use Connect Care immunization records, including COVID-19 vaccinations, using the MyChart patient portal?

Context: Pandemic public health directives have increased the importance of ready access to immunization information for Albertans. 

The Netcare provincial electronic health record contains a good representation of COVID-19 vaccinations administered in Alberta (although some pharmacy and other locations can be missed). Patients can download and print a PDF summary via a dedicated website (www.albertavaccinerecord.ca). Their Netcare information can also be viewed and printed from MyHealth Alberta.

The Connect Care clinical information system also contains an immunization record, which receives information from Netcare and other clinical information systems. It also contains information added by clinicians to fill gaps where immunizations were performed in other jurisdictions or countries. In short, the Connect Care immunization record is part of the patient's digital chart, supporting where Connect Care is the record of care. Patients may ask if and how they can access and print immunization information using the Connect Care patient portal, MyChart

Answer: Once logged in to the web version of MyChart, patients can enter "imm" in the top search box of the portal "Your Menu" tool, then select the "Health Summary - Immunizations" option that appears.

At the "Health Summary" screen, be sure to select the "Immunizations" tab, then select "View details" for COVID-19 vaccinations (grouped in one box).

With the COVID-19 vaccinations display opened, use the print icon appearing at the top right to generate a PDF file that can be saved or printed.

While immunizations can be viewed through the MyChart mobile app, the app does not support rendering to a PDF file for printing or saving. The app is useful for reminders about the types and dates of immunizations.

Why is COVID-19 vaccination information missing in Connect Care?

Question: Why does an important immunization (e.g., first dose COVID-19 vaccine) not appear in the Connect Care immunization history?

Context: A blog posting clarifies where in Connect Care a patient's immunization history can be found, and a Manual section explains how to add vaccination information to that history. The Connect Care record of care should have a complete listing of the most recent instance of all vaccination types, just like it should have a complete listing of a patient's medications, problems and surgical history.

Many prescribers are not accustomed to checking immunization histories. However, this has become increasingly important to pandemic care. Accordingly, more is being done to automatically pull recent immunizations into things like summative documentation (e.g., discharge summaries), health maintenance reminders and even order sets.

Most patients will have some information in their Connect Care immunization record. This may have come from system interfaces with Netcare or pre-Connect Care legacy clinical information systems (e.g., eCLINICIAN). However, there are many reasons why the immunization record may be incomplete:

  • System interfaces are recent and may not include relevant immunizations (e.g., pneumovax) from many years ago.
  • Some immunizations (e.g., some private travel vaccination clinics) may not share information with provincial systems.
  • Immunizations may have been received outside the reach of provincial immunization management systems.
  • Some immunization information shared with Connect Care from external systems is added at set intervals (e.g., end of month), and so may appear in Connect Care days to weeks after administration.
It is important for prescribers to know how to add important missing information when patients present with a valid immunization record from external sources.

Answer: When a patient reports having had COVID-19 vaccination but there is no corresponding record in the Connect Care immunization history, consider whether this might simply result from a delayed interface information feed. If the patient has the immunization record provided at the time of vaccination, a clinician can enter this information to the Connect Care record.

How can an inpatient's provider service be changed by prescribers?

Question: How can the clinical service for an inpatient be corrected by a prescriber?

Context: Inpatients are associated with a location (e.g., emergency department, ward, facility), a clinical service (e.g., family medicine, general internal medicine) and one or more inpatient or consultant provider teams.

The clinical service assignment is important. This patient characteristic affects lists and reports. Patient admission orders demand selection of an appropriate clinical service (e.g., general surgery) and the value is checked by bed planners. 

The clinical service can change during an admission if a patient is transferred to a new service (e.g.,  critical care), and the transfer order usually takes care of this. Sometimes providers do not attend to the service change during intra-facility transfers, with the consequence that the patient can be attributed to the wrong service and turns up in the wrong place in census reports.

The clinical service affiliation is easy to check. Look to the StoryBoard (leftmost column) and the "ADMITTED" section. Hover to reveal admission details, with the "Service" identified:

Answer: It is easy to correct a service assignment missed during an intra-facility transfer. 

  1. With the patient chart open to the current inpatient encounter, go to the "Orders" activity.
  2. Enter "Patient Status" as a search term and select the "Update Patient Status" order.
  3. Use the first property in the order composer to select the new inpatient clinical service, then accept and sign the order. No other values need to be changed.

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". The International Classification of Diseases (ICD-10) has newly codified COVID-19 health states. These are available in Connect Care and are complemented by prescriber-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: When documenting a COVID-19–related condition in Connect Care (i.e., problem lists, professional billing, admitting diagnosis, chief complaint, discharge diagnosis, etc.), simply enter "COVID-19" as a search term. A number of matching conditions will appear to choose from, each appropriately coded.


With a little more effort, one can quickly land on best-matches for commonly sought diagnostic codes. Some useful keywords for quicker searching include:
  • "COVID-19 suspected" → "Suspected COVID-19 virus infection"
  • "COVID-19 confirmed" → "Laboratory confirmed diagnosis of COVID-19"
  • "COVID-19 disease" → "2019 novel coronavirus disease"
  • "COVID-19 pneumonia" → "Pneumonia due to COVID-19 virus"
  • "COVID-19 cardiac" → "Acute cardiac injury due to COVID-19"
  • "COVID-19 enceph" → "Encephalopathy due to COVID-19 virus"
  • "COVID-19 infl" → "Multisystem inflammatory syndrome associated with COVID-19"
  • "COVID-19 gast"  → "Gastroenteritis due to COVID-19 virus"

How is "COVID-19-related MIS" added to Problem Lists?

Question:  How is “COVID-19–related multisystem inflammatory syndrome” 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. The International Statistical Classification of Diseases and Related Health Problems Tenth Revision, Canada (ICD-10-CA) has recently added a newly codified COVID-19 health state for “COVID-19–related multisystem inflammatory syndrome.” This is available in Connect Care and is complemented by physician-friendly synonyms. Use of the correct code is important for reporting and clinical decision supports.

Answer:  A previous posting addresses general COVID-19 diagnoses. When seeking the “COVID-19-related multisystem inflammatory syndrome” in pick-lists, enter “COVID” as a search term. A number of matching clinical terms will be displayed for selection, with each appropriately coded. The relevant options for “COVID-19-related multisystem inflammatory syndrome” are:

  • MIS-C associated with COVID-19
  • multisystem inflammatory syndrome associated with 2019 novel coronavirus in pediatric patient
  • MIS-A associated with COVID-19
  • multisystem inflammatory syndrome associated with COVID-19 in adult
  • multisystem inflammatory syndrome associated with 2019-nCoV in pediatric patient
  • multisystem inflammatory syndrome associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in adult
  • multisystem inflammatory syndrome associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pediatric patient
  • multisystem inflammatory syndrome associated with COVID-19 in pediatric patient

For questions, comments or feedback, contact: clinicalterminologies@ahs.ca.

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.

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 MyChart 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.

Can patients get COVID-19 test results through MyChart?

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

Answer:  The results of COVID-19 NAT testing (and later confirmation testing) are made available through MyChart with no delay. Encourage all patients to activate their patient portal account, 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.