Clinical documentation serves communication. Indeed, one of the commonest forms of communication emulates mailing of consultation letters. The parallel in clinical information systems happens when some document types are automatically sent to external systems via secure mail, messaging, facsimile, mail or systems interfaces.
There are two categories of clinical documentation:
Summative documentation gathers all information pertinent to an encounter, organizes observations, exposes meaning, and offers a plan. Examples include consultation notes, admission histories, discharge summaries, surgery reports, transfer notes and care paths.
Progress documentation highlights new or changed findings or otherwise indicates what is unique to a defined period within a larger encounter. Progress notes are transactional documents. They expose clinically important developments since the last summative note.
Summative documentation is suited to automatic sharing, while progress documentation is not, because it can "stand alone" without dependence on other parts of the health record. Summative documents are automatically shared with Alberta's electronic health record (EHR, Netcare). They may also be shared with community electronic medical records (EMR) enabled for eDelivery.
External System (Netcare, eDelivery) Sharing
Key summative Connect Care documents transfer to Netcare. The same summative documents may be automatically routed to primary care providers and authors who have EMRs capable of receiving such content via eDelivery.
Document Types Shared Externally
The following summative documents are configured for exchange to external systems:
Emergency Department Provider Note (summary of ED encounter; not copied to authors)
Admitting History and Physical
Labour and Delivery Report
Discharge Summary (including Discharge Summary, Deceased Summary and Inter-facility Summary templates)
Consult Letter (if sent with an appropriate Netcare letter communications template)
Procedure Report (if sent with an appropriate Netcare letter communications template)
Emergency and Inpatient Automatic and Manual Sharing
Emergency and Inpatient summative documents are automatically shared to the patient's primary care provider (PCP, if available). Signed ED provider notes are sent to the PCP only after a patient is admitted to hospital or discharged from the ED.
In addition, inpatient summative documents can be manually routed to any provider. A few document signing practices can minimize shared document management burdens for receiving providers:
Outpatient Communications and External Sharing
Outpatient summative documentation sharing does not happen automatically. The responsible prescriber needs to indicate if an outpatient communication should be externally shared and, if so, whether to the primary care provider and/or referring provider.
When prescribers see patients in outpatient settings (office, clinic, etc.), a "Communications" workflow letter typically is used to share findings with other prescribers. The same workflow can be used to copy the communication to external systems, including the Netcare EHR and compatible community EMRs configured for eDelivery.
If the communication is appropriate for sharing with external systems, the outpatient provider must use a letter template that includes "Netcare" in its name.
Communications assume that there is a recipient, usually a primary care provider and/or referring provider. However, there may be situations when a letter should route to Netcare when no primary care or referring provider is specified. Any of the following actions will work when default recipients are not available:
The patient may have been referred from an emergency encounter. The relevant emergency room prescriber can be entered as a "referring provider" before the communications activity is initiated. Communications can be routed to referring providers when there is no primary care provider.
Patient has no PCP
Connect Care allows "Patient has no PCP" to be entered as the primary care provider for a patient. "Patient has no PCP" can also be selected as a letter recipient even if not set as the patient's primary care provider. Use of a Netcare letter template will work but Connect Care will attempt a local print of the letter as well; avoidable by selecting "Print to PDF" and then not following through on the "save" part of the printing workflow.
Copy to self
Letters can still be routed to Netcare without primary care or referring providers identified. One can copy the letter to oneself. The letter will go to Netcare and be copied to the Connect Care prescriber's In Basket.
"Quick Click" for Outpatient External Sharing
Prescribers who document the content of an outpatient consultation in a progress note can instantly mark that note for inclusion in a letter that will route to the primary care provider and/or referring provider while also sending a copy to external systems. This is done with a checkbox at the top of the progress note. The external letter, with progress note included, will route at signing of the outpatient encounter through automatic selection of and inclusion within a Netcare-compatible letter template.
Outpatient sharing workflows are faster if personalized. Creation of a few communications speed buttons that include Netcare and non-Netcare template selections allow quick initiation of letters for sharing. Any SmartText (e.g., SmartPhrase) normally used to set up consult or procedure letters can be included in all types of outpatient communications.
External System Constraints
Connect Care users should be mindful of external sharing when preparing any of the above summative document types. There are limits to what Netcare (and EMRs) can handle. Currently, documents are rendered to "pdf" format for external sharing and may not be accepted if the file size is too large.
When viewed in an external system, the pdf document will not be part of the Connect Care record. Embedded links to Connect Care content will not work. Embedded links to Internet resources (hyperlinks) may not work in the receiving system.
Avoid embedding images or other media that could increase the file size of shared documents. Image(s) are essential to clinical communication (e.g., rash), try to keep the image size small and do not embed more than 2 images.
Corrections and re-Writes
When inpatient summative documents are revised (addended) and re-signed, the corrected document is automatically sent to Netcare (and compatible external EMRs) such that the revised document over-writes the old document. If removed, a letter remains visible in Netcare with a strikethrough to indicate that it is no longer intended to be part of the patient’s current documentation. The same functionality may not be available to EMR users, who must determine how to manage each re-delivered document.
Once and outpatient letter goes to external system, by contrast, it is not possible to edit and revise its contents. If necessary, the outpatient letter can be revoked (deleted) within the communications activity. This will send an appropriate message to Netcare. A new instance of the letter can then be created using an external systems template.
The Most Responsible Provider is ultimately accountable for accuracy and content of letters, even if support staff contribute, edit or help route the communication.
Author Copies to Community Electronic Medical Records
Connect Care prescribers may provide services where Connect Care is the record of care; and additionally provide follow-up services where a community EMR is the record of care. Physicians working in emergency departments, for example, may find themselves subject to "mixed-context" workflows. When these prescribers author summative documentation in Connect Care, copies are sent to their external EMR if it supports this type of "eDelivery".
Emergency Department Provider Notes are an exception. These are not copied to compatible external EMRs of authoring prescribers. Mixed context prescribers who use these reports as part of externally managed (non-Connect Care) billing workflows can adopt other workflows for tracking billable ED events:
Document Sharing with Patients
Most chart documents (e.g., progress notes, discharge summaries, consults) are not automatically shared with patients via MyAHS Connect. However, Clinicians are free to share any documentation items they author, preferably via MyAHS Connect as an approved and secure patient communications platform. Documents can be printed for patients who are not active on the patient portal.