Submitted by: Directors of Records of Ontario Teaching Hospitals

Introduction

The COVID-19 pandemic has sparked a flurry of questions and activities among health information managers and directors in Ontario. These discussions are facilitated by the existence of an organized group of health information management (HIM) leaders who regularly meet to exchange best practices: the Ontario DROTH group. As the pandemic progresses, many issues and impacts are unfolding and the group is seeing an explosion of email exchanges. Issues include changes to HIM staffing, impacts on release of information (ROI), documentation requirements, the legal health record, new methods of delivering care, and registration-related issues.

Remote patient visits  

Many organizations have initiated remote patient visits. Health information professionals must identify and implement protocols for registration and documentation of phone visits and discussions—via telephone, secure messaging, and email. These may be unique visits or follow-ups to a previous in-person or virtual visit. Some organizations offer patient visits using WebEx and require the patient’s consent for the use of email in order to do this. Organizations are grappling with how to obtain and document consent for virtual visits: verbal consent, completion, and return of a designated form, consent via email, etc. It is also necessary to determine the documentation requirements for the capture of WebEx visits. Privacy considerations include verification of patient identification and turning off recording features for WebEx visits. The Ontario Medical Association has provided use of language for verbal consent and many organizations are adapting this and posting it on the corporate website. Patient advocates are being consulted regarding language use relating to patient consent for virtual care.

Screening of staff and visitors entering organizations

HIM leaders are conferring on how to capture the screening of staff and visitors who enter the organization—whether on paper or electronically—and what tools are being used. They are also addressing whether documents relating to the donning of PPE when entering patient rooms and information regarding the identification of staff who enter patient rooms are considered part of the legal health record. For some organizations the answer is ‘yes,’ while that is not the case for others.

Release of information

Release of information (ROI) poses a major challenge as hospitals consider how to handle this activity, tend to bring members of the public into an HIM department. Many hospitals no longer receive ROI requests in person. These organizations have developed online and telephone protocols to address ROI requests, including electronic payment, telephone identity verification, and secure emailing of results. A significant issue is how to respond to the ever-increasing volume of requests for COVID-19 test results. Many organizations are ensuring that these documents are available through their patient portal, while others are referring the requests to public health departments. Some organizations are automatically providing these patients with access to their patient portal so the patients can look up the results once they come in. In many instances, the high volume of requests is related to delays in reporting. Some organizations find that phone call requests for ROI have increased as members of the public follow social distancing rules. Some organizations report a decrease in the volume of requests for ROI, and some report that their staff will go to the ROI requestor at an agreed-upon location in the organization, rather than having the member of the public go to the HIM department. There are a few instances of ROI staff being able to work from home, but this is not common.

Safe handling of paper-based documentation

Another identified issue is how to handle paper-based documentation, as we know that the virus can live on paper for quite some time. Are there any restrictions or protections in place for handling paper records? Some hospitals have implemented glove use by HIM staff who handle paper records.

Capturing COVID-19 assessments and treatment  

Registration and inclusion of mandatory data elements has been shared, including whether COVID-19 assessments are considered emergency department (ER) visits. Best practice is for assessments to be captured as out-patient clinic visits and for treatment to be captured as ER visits, in which case they will be captured as NACRS cases. If an organization is creating an ER visit, another consideration is whether they are using a default triage. Some organizations have established an off-site testing centre that will use a ministry-assigned out-patient location and funding code.

Reporting requirements

There is also a great deal of sharing of ministry directives and memoranda regarding reporting requirements. This includes discussions around the need to request new master numbers and the requirement for new data elements to be reported in daily census summaries for COVID-19 assessment centers. Recently, a leading mental health facility shared notification of changes to mental health consent and capacity board information processing changes as Consent and Capacity Board hearings become virtual.

Staffing in HIM departments

Organizations are sharing the changes within their HIM department to minimize staff risk and ensure continued staff availability. Many organizations already have staff working from home for transcription and coding, as well as for chart completion. With the rapid development of COVID-19, more hospitals are enabling or increasing the volume of remote coding. Some organizations offer remote working for data quality and data analysis staff, as well as for some managers overseeing those functions. On the other hand, other organizations have mandated that all HIM staff must present on site so that they can become part of a pool of staff for reassignment, should the need arise. Similarly, some organizations that have remote coding and data quality analysts have requested that staff voluntarily return on site for deployment, as the need might arise. Some organizations are adjusting the physical spacing of staff to ensure a minimum distance between staff members.

Final note

These are trying times and health information professionals are emerging as key players in the capture of information that will be studied for years to come. We are breaking new ground and creating new protocols that will shape our futures and keep the public safe. When we return to business as usual, I wonder how many of these changes will become the new normal.  

DROTH COVID-19 BULLETIN:

#	Issue	Tactic
1	Virtual patient encounters	Establish registration categories for visits via phone, secure messaging, email, and perhaps televisits.Include a protocol to confirm patient identity, capture patient consent for virtual encounter, and establish documentation requirements.
2	External visitors to HIM	Close the department to external visitors and implement electronic release of information.Incluide a protocol for confirming patient identity, documented patient consent for release, secure electronic transmission of information, and methodology for electronic payment transfer.
3	Protection of HIM staff	Encourage, implement, or increase remote working for HIM staff, especially in the following areas: coding, transription, analysis, ROI, and chart completion, as well as management staff that oversee those functions.Provide protective gloves to staff who handle paper-based documents. Ensure optimal physical spacing between staff.
4	Communication	Share with HIM leaders any communiques that you might receive from Ministries, Public Health Officials and/or Medical Associations.
5	Addressing requests for COVID-19 test results	Automatically sign patients up for the patient portal or inform patients how to obtain their results (i.e., through Public Health).
6	Prepare for all hands on deck	In some organizations, all remote HIM staff may be required or requested to work on site for deployment as required.
7	Identify reporting requirements	Ensure that you are in receipt of any notices regarding data element capture and reporting, including newly established daily census data.
8	Legal health record	Determine whether documentation relating to the donning of PPE or entry/exit of staff from patient rooms will become part of your legal health record.
9	COVID assessments versus visits for treatment	Consider and communicate how visits to assessment centres will be captured (registered and documented) versus visits for treatment/assessment of symptoms.
10	Workload changes	Prepare and plan for potential changes to staff workload as organizations transfer patients, cancel elective surgeries, and establish off-site facilities.