Showing posts with label Virtual Health Services. Show all posts
Showing posts with label Virtual Health Services. Show all posts

Which Encounter Type should be used for Specialty Outreach Services?

Question: Which ad hoc (unscheduled) outpatient encounter type best fits the needs of patient visits (virtual or in-person) that are part of a specialty outreach service?

Context: Specialty health services may be based in an organization using Connect Care as the record of care, yet provide consultative services to community or facility locations elsewhere. Services might include telephone consultative support to clinicians at other (usually rural) facilities, telehealth virtual visits, or drop-in in-person visits to assist with the care of selected patients; all as part of outreach from the central service requiring service documentation in Connect Care.

Outreach appointments may be scheduled or otherwise organized by the remote location (e.g., primary care network) and so not involve Connect Care support staff for appointment management. In such cases, ad hoc (unscheduled) outpatient visits are needed and clinicians may wonder which visit type to select when creating a new encounter in their specialty department.

Answer: If Connect Care is the record of care for part, but not all, of an integrated health service program, it may be appropriate to use Connect Care integrative charting tools (e.g., therapy plans, care paths, disease management documentation, SmartSets) to manage and document related care. A "Documentation" visit can be created if the outreach support need is limited to generating and sharing a consultation letter. More commonly, the "Telemedicine" visit type works best for outreach services because it benefits from specialty-specific visit, order and documentation tools in Connect Care.

How can non-Connect Care patient messaging tools be used when needed?

Question: When and how can non-Connect Care patient messaging tools be used?

Context: While AHS provides a variety of healthcare-appropriate communication tools, there remain situations where no secure or approved technology is available... but asynchronous communication is essential to care. The COVID-19 pandemic poses extraordinary challenges when patients and families must be supported at a distance. Clinicians may need to use non-approved technologies that are immediately available to both provider and patient when approved tools are not.

Examples of situations where secure tools may not be usable within a clinically reasonable time frame include:

  • Patient portal (MyChart) activation challenges:
    Patient activation of MyChart is not instantaneous, as patients do not get access to the portal until they have completed registration for an Alberta.ca Account. This can involve delays of a week or more, and some patients find the process difficult. While Connect Care secure patient messaging is always preferred, it is not always available.
  • Patient email:
    Email communications to patients and families can be secure if sent from an AHS email account when "!Private" is inserted in the subject line. However, the email services commonly available to patients are unlikely to support equivalently secure return emails.

Answer: MyChart clinical secure messaging should be used when available. Temporary use of un-regulated technologies may be necessary when they are the only available solution for a pressing clinical need. Patients should be aware of the risks, provide verbal consent to proceed, and have that documented in Connect Care. 

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 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 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.

As of July 25, 2023, AHS and AHS partner facilities using the Connect Care clinical information system can send prescriptions directly to community pharmacies via an electronic fax process ("eFax"), without the need for a printed prescription or handwritten signature. Accordingly, outpatient prescriptions get from prescriber to pharmacy by four possible pathways:
  1. Sent directly from Connect Care to the patient’s preferred pharmacy (as set in their profile) via electronic fax.
    • There are two steps for this pathway: confirm/enter the patient's preferred pharmacy (or pharmacies); and change the order class to "Fax" (the default is "Print") and select the destination pharmacy (or pharmacies). As the screens where these steps occur depend on the context (ambulatory, ED, or outpatient), see the tip sheet for further details.
    • Please note the Connect Care eFax workflow cannot be used for prescriptions for drugs classified as Type 1 under the Tracked Prescription Program (TPP); these prescriptions still require the use of a paper TPP secure prescription form.
  2. Printed and (manually) signed prescription handed to patient who takes it to a pharmacy of choice.
  3. Printed and signed prescription faxed from the physician to the intended pharmacy.
  4. Documented prescription telephoned by the physician to the intended pharmacist.
If the first option (direct electronic fax) is not possible, the key is to be able to “print” the prescription locally so that it can be managed at the remote location where the prescriber is working; the second option therefore does not work with virtual care. The third option can be adapted to virtual Connect Care workflows, and the last option is a fall-back that can be used in any context.
We will post again with suggested workflows when support staff are (remotely) available to help. 

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.