Meaningful Use Norm - Patient Communication and Education
What is it?
Connect Care provides a number of tools that can help provide, collate and communicate patient support information before and at the time of discharge:
After Visit Summary (AVS) is printed at the end of emergency, outpatient and inpatient encounters. It is presented directly to the patient and/or designated decision-maker, with details about the encounter purpose, interventions, medication changes, diet and activity instructions, links to a post-encounter satisfaction survey and other clinically important details.
Educational handouts about conditions, interventions or medications can be incorporated into the AVS if selected (and optionally edited) by a provider.
Green Sleeve plastic pocket containing advance care planning documents printed at discharge and presented together with the AVS.
MyAHS Connect patient portal provides enduring access to discharge documents, educational materials, visit scheduling, communications and a wide range of other patient-centred information services.
Attention to these tools, promoting MyAHS Connect sign-up, and provision of resources to patients at the end of emergency, outpatient or inpatient encounters, is among the Connect Care Meaningful Use Norms, with compliance feedback provided through Meaningful Use Norms Dashboards.
Why does it matter?
An important determinant of patient recovery, and risk for return for emergency or inpatient care, is effective patient and family communication at transitions from hospital to community care. Information may be received from one or more providers, including those with roles focused on patient education. Ample evidence confirms that patients suffering from chronic health care conditions do better when empowered with education, health information and access to tools promoting self-management.
The AVS and MyAHS Connect empower patients and their families, provides consistent and pertinent information in one place, and makes it easier for patients to participate in coordinated continuity of care.
Who is responsible?
The discharging prescriber is responsible for ensuring that patient-facing discharge documentation is appropriate and complete.
Designated inpatient care team members (e.g., ward clerk) are responsible for ensuring that the printed AVS package (AVS, Green Sleeve, Handouts) is provided to the patient or designated decision-maker at the time of discharge.
Designated inpatient care team members are responsible for presenting patients and families with MyAHS Connect sign-up information as soon as possible during an admission, with reinforcement and support as discharge nears.
How is it done?
Minimum use activities, like medication and problem reconciliation, determine the content of parts of the AVS.
In addition, completing all steps of the Discharge Navigator will ensure prescriber awareness of tools for adding to, or revising, AVS content.
Facilitates rapid selection of healthcare providers who will participate in post-discharge follow-up care, with the ability to add comments about how appointments will be made (e.g., "clinic will call to arrange").
Additional Appointment Instructions
Free-text field for adding any additional narrative about follow-up arrangements.
Education and Handouts
One or more patient handouts can be selected from an Alberta-optimized library (same as MyHealth and HealthLink resources, to provide high quality information about medications, interventions or health conditions.
Stock handouts can be edited by the provider for customized inclusion in the AVS.
A free text field can be used to provide overarching guidance in addition or instead of handouts.
This final step in the Discharge Navigator allows the discharging prescriber to preview how all information (including medication reconciliation instructions) will appear to the patient.
Hospitalization provides an important opportunity to promote patient sign-up for MyAHS Connect patient portal services, particularly since the portal provides a "Day at a Glance" feature that helps patients and families anticipate important inpatient events.
Posters and flashcards are prominent in most inpatient units. In addition, inpatient charts provide visual indicators of patient portal activity at the top of the (left column) Storyboard. Clicking on the MyAHS Connect icon opens a tool for inviting or re-inviting sign-up with email or printed prompts.
How is compliance promoted?
Feedback about adherence to patient information support meaningful use norms is provided to through a "Connect Care Meaningful Use Norms Feedback" display available in the Hyperspace "Dashboards" activity, available to all inpatient providers.
Consistent provision of AVS documents to patients is built-in to Connect Care discharge workflows. Whether patients actually receive the intended documents is not known to the clinical information system but can be the subject of periodic quality assurance spot-checks on inpatient units.
Whether providers take advantage of AVS features for post-discharge support can be reflected by measures of the proportion of AVS documents that contain non-null "Additional Instructions", "What's Next", "Instructions" and "Attached Information" sections.
Whether inpatient providers succeed in promoting MyAHS Connect uptake is reflected in the proportion of patients at discharge whose patient portal status (including in standardized discharge summaries) is "Active" or "Pending" or "Declined".
Derivation of these metrics is explained further in the Connect Care Builder Handbook, with links to data quality definitions.