ConnectingOntario ClinicalViewer Medications Portlet Trainers Guide CO_Train_20_TrainersGuide_MedicationsPortlet_V_A_v01.potx

Use of this slide deck eHealth Ontario encourages the use of the materials as they are designed for the education and training of users of the ConnectingOntario ClinicalViewer. You are permitted to customize these materials according to your organization’s learning needs with the following exception: You must not change any messaging or wording regarding DHDR as it pertains to the Medications portlet. Any changes require approval from the Ministry of Health and Long-Term Care (MOHLTC). Contact connecting.ontario@ehealthontario.on.ca for more information. This Trainer’s Guide contains key messages which are required for end-user education and provides supplemental information to enhance trainer knowledge

Agenda Medications Portlet – End User Training Overview Digital Health Drug Repository (DHDR) information Privacy/Training requirements Key messages How to use the portlet Consent management Clinical use of DHDR information Help Desk Workflow Education/training materials and resources

Overview Integration of ConnectingOntario and Digital Health Drug Repository The province’s Digital Health Drug Repository (DHDR) is being integrated with ConnectingOntario in Release 9.1 This information will display in a new Medications Portlet – Dispensed Medications tab expanding access to valuable patient information for health care providers’ clinical decision-making in the ConnectingOntario ClinicalViewer

Overview Digital Health Drug Repository The Dispensed Medications tab displays information from the Digital Health Drug Repository (DHDR) for Ontarians with an Ontario Health Number. This includes: Publicly funded drugs and pharmacy services (including monitored drugs) Reflects information the dispensing pharmacy submits to the Ministry of Health and Long-Term Care for reimbursement As of May 2017, includes approximately 7 years of information about: Drugs paid for by the Ontario Drug Benefits (ODB) program. The ODB program includes the Trillium Drug Program (TDP) Most publicly funded drugs paid for by other public drug programs (e.g. Special Drugs Program - SDP) Publicly funded pharmacy services (e.g. MedsCheck), some of which are available to all Ontarians, some to ODB program recipients only Narcotics Monitoring System (NMS) information As of May 2017, includes approximately 5 years of information about monitored drugs (narcotics and controlled substances), dispensed in Ontario, regardless of payor, when the approved identification used was a valid Ontario Health Number

Overview Digital Health Drug Repository DHDR data is limited to: Information that the ministry has the authority to disclose under the terms of the Personal Health Information Protection Act, 2004 (PHIPA) and the Narcotics Safety and Awareness Act, 2010 (NSAA) Information that has been submitted to the Health Network System to date in respect of the drug and pharmacy service data described in section 3.1(DHDR Health Care Provider Guide) DHDR provides more information than what is available in the Drug Profile Viewer (DPV) (Refer to Tip sheet: Dispensed Medications and DPV Comparison) For more information about DHDR visit www.ontario.ca/mydruginfo and Information Available to Health Care Providers through the Digital Health Drug Repository Other limitations described later and in Tip sheet: Dispensed Medications Guide for Clinical Use

Overview Benefits of Digital Health Drug Repository to Providers Access to clinically relevant drug and pharmacy service information enabling the Best Possible Medication History (BPMH); Better integration of available drug data through existing EMRs, provincial digital health assets and other systems to quickly, securely and efficiently access data to enable the BPMH; Enhanced patient safety and continuity of care Improved collaboration between health care providers through the sharing of patient clinical data

Overview Benefits of Digital Health Drug Repository to Patients Enhanced patient experience with the health care system since care will be provided by better informed health care providers Improved patient-centred care by providing health care providers secure electronic access to a patient’s drug and pharmacy service information and allowing them more time for diagnosis, treating and communicating with the patient Improved patient outcomes and decreased risk of adverse drug events

Overview Benefits Realization As of May 2017, 41 sites have access to DHDR in ClinicalConnect in South West Ontario Survey of Guelph General Hospital (GGH) Emergency department (ED) physicians shows that DHDR assists in the following: Ensures meds are continued during transitions of care Improves quality of care provided Identifies drug-seeking behaviour Identifies harmful drug interactions Monitors patients’ compliance

Overview Testimonials and examples GEM [Geriatric Emergency Medicine] nurses find the DHDR enables a faster, more reliable BPMH process Emergency Department discharge especially for elderly patients for whom narcotics can be a high risk medication “Helpful for patient presenting with undifferentiated drug overdose to determine prescribed medications and possible interactions or side effects.” – ED Physician, GGH “Currently, all dispensed narcotics are in DHDR, so I can feel comfortable that if the narcotic prescription does not appear, the patient likely is not actually on it. The DHDR helps me be a more responsible prescriber.” Dr. Finnigan, Family Physician, Guelph Family Health Team http://www.ehealthce.ca/Benefits-Realization.htm

Training Requirements Medications Portlet and Digital Health Drug Repository As the Health Information Custodian (HIC) for the DHDR, the Ministry of Health and Long-Term Care (MOHLTC) requires end-users to be educated/trained prior to accessing the information; the method of training is not prescribed, only the communication of key messages The user must also have completed appropriate privacy training consistent with existing requirements for accessing the ConnectingOntario ClinicalViewer Key training messages: Information available in Dispensed Medications Limitations and clinical use of Dispensed Medications information Consent requirements (i.e., informed consent, wet signature)

Accessing the Medications Portlet Medications portlet displays on the first level or row in Summary View The full-sized individual portlet is accessed by clicking the Medications portlet icon in the Navigation bar The Visits/Encounters portlet now displays in the second level, pushing the Diagnostic Imaging and Other Results portlet to the right. The Community Portlet displays on a third level. The user’s screen resolution will determine how much vertical scrolling is required to view the Community portlet Medication Portlet in Summary View

Reference for DHDR Information Header and Data Summary Dispensed Medications tab has been added to the Data Summary This tab contains a link to the MOHLTC’s website which outlines the information available within the Digital Health Drug Repository Click for hyperlink

Medications Portlet Tabs Dispensed Medications Tab DHDR information displays in the Dispensed Medications tab Medications portlet behaves as other portlets in ClinicalViewer More columns display in the Summary List view or Individual Portlet Dispensed Date (reverse chronological) is used for the default sorting order Standard Consent Directive and Override messages appear when directive is in place Sort and Filter is available on all the columns

Medications Portlet Dispensed Medications Views Medications information is available in: Summary View (Condensed Portlet) Summary List View ( Full-size) Individual Portlet (Full-Size) Details Screen (Displayed in Summary List View and Individual Portlet)

Summary View Default/Mandatory columns: Dispensed Date Generic Name Brand Name Strength Form Quantity Customizable columns (click on to add columns: Est. Days Supply Prescriber Prescriber ID Pharmacy Therapeutic Class Sub Classification Name Drug Utilization Review (DUR) indicator is displayed next to the Generic Name; details for DUR are displayed in Details screen in Summary List View or the Individual Portlet

Summary List View 1. Portlet Name 2. Dispensed Medications Tab Name 3 4 6 5 7 1. Portlet Name 2. Dispensed Medications Tab Name 3. Disclaimer Links to Information Available to Health Care Providers through the Digital Health Drug Repository 4. Summary List View Data Fields 5. Drug Utilization Review Indicator 6. Data Source – Digital Health Drug Repository displays in hover over 7. Number of Results Returned

Summary List View Default/Mandatory Columns: List of medications for the selected period can be printed from the individual portlet or summary list view using the Print icon Default/Mandatory Columns: Dispensed Date Generic Name Brand Name Strength Form Quantity Est. Days Supply Pharmacy Prescriber Prescriber ID Customizable columns (click on to add columns: Therapeutic Classification Sub Classification Name

Dispensed Medications Printing Printing is available from the Summary List or Individual Portlet view only Customizable columns can be printed only if added to the portlet

Drug Utilization Review Indicator Note: A name which is truncated may have a DUR indicator which is not visible. To view: Extend the column header, or, Select the row to view in the Details screen below Drug Utilization Review information is historical information from DHDR on DUR alerts that were communicated to the pharmacy when the drug claim was submitted for payment DUR information is displayed in the Details Screen: Reason for DUR (Alert Type): e.g., drug/drug interaction potential Action taken: action by pharmacist in response to the DUR alert Additional information: includes severity level of the drug to drug interaction Note: At this time, historical DUR alert information is limited to drug to drug interactions between publicly funded drugs contained in the DHDR

Details Screen Summary List View or Individual Portlet View 1 2 3 4 5 To view the DUR details for a result, Click on a result to select it Scroll down to the Details screen View DUR information at bottom left of screen Printing of the Details screen is not available in this release Drug Information Additional Drug Information Prescriber Information Pharmacy Information Drug Utilization Review – Reason for DUR, Action Taken, Additional Information

Details Screen Displayed Information Fields (Reference Information) Dispensed Date Generic Name Brand Name Strength Form Quantity Est. Days Supply DIN/PIN Therapeutic Class Sub Classification Name Prescription Number Medical Condition/ Reason for use Drug Information Additional Drug Information Prescriber Prescriber Phone Number Prescriber ID Prescriber ID Reference Pharmacy Pharmacy Phone Number Pharmacist Reason for DUR Action Taken Additional Information Prescriber Information Pharmacy Information Drug Utilization Review

No Patient Information Available Messages Displayed in Portlet Dispensed Medications information is available only for Ontarians who have a valid Ontario Health Number (HN) For patients without an Ontario HN, a yellow warning banner will appear DHDR may contain no data for a patient during the selected timeline. In this case, “No results available” is displayed in place of the results count message

Medications Portlet Consent Management for all Portlets in ConnectingOntario ClinicalViewer Note: An override in the ConnectingOntario ClinicalViewer will result in all portlets with a consent directive to be unmasked. Although the data in the Dispensed Medications tab may not be required to provide care, an override in another portlet will also release this data and you must complete the express consent form in addition to the Consent Override Dialogue box Risk of Harm overrides will not unmask information in the Lab and Pathology Portlet or Dispensed Medications tab

Medications Portlet Consent Management for all Portlets in ConnectingOntario ClinicalViewer Before you perform an override on any portlet in the ConnectingOntario ClinicalViewer: Confirm if a block is placed on the Dispensed Medications tab. If it is blocked, you must print a hard-copy express consent form. This can be obtained from the Consent Directive Dialogue Box Inform patient or substitute decision maker (SDM): the reason for overriding consent the override will apply to any other information or portlet where a block has been applied they may refuse to permit the override the information will be available: If the patient agrees to the override and the Dispensed Medications tab is blocked, obtain consent and document the receipt of consent by requesting a signature from the patient or substitute decision maker on the express consent form and complete the Consent Directive Dialogue Box Data Source Duration and Users Who May Access ConnectingOntario Clinical Data Repository (All portlets except Lab and Pathology and Medications-Dispensed Medications) Up to 11:59pm on the day that the override was initiated to the user that requested the override. Lab and Pathology Portlet: Ontario Laboratories Information System (OLIS) and Dispensed Medications: DHDR Available for 4 hours to all users at the organization or practice where the override occurred.

Medications Portlet Consent Management for DHDR Patients may place a consent directive to block all records in DHDR Temporary consent override is available in the Dispensed Medications tab (i.e., DHDR) The MOHLTC requires all users who override a consent directive in DHDR to print a hard-copy express consent form and receive a signature from the patient or substitute decision maker This form may be printed from the Consent Override Dialogue box directly from the ConnectingOntario ClinicalViewer and should be retained as part of the patient’s record A consent directive override without patient or Substitute Decision Maker (SDM) explicit consent for access to DHDR data is not permitted A consent directive override for risk of harm is not permitted

Medications Portlet Consent Management When a consent directive is in place on the Medications Portlet, the standard messaging and override button appear 1 2 Override Consent Button Before Consent Override Warning Message Express consent from the patient or substitute decision maker is required for unmasking of DHDR information. This includes informing the patient or SDM: the reason for overriding consent DHDR information will be displayed for four hours to all users at the organization where the override occurred the override will apply to any other information or portlet where a block has been applied they may refuse to permit the override

Medications Portlet Requirements for Consent Override for DHDR After clicking the Override Consent button, the Override Consent window displays The provider completing the override must print the required consent form, obtain the patient or SDM’s signature and retain the consent form for audit purposes A link to the consent form is available in the Override Consent window and in the ClinicalViewer header’s Applications menu Consent directive override for Risk of Harm is not permitted

Medications Portlet Requirements for Consent Override for DHDR Consent Form

Medications Portlet Consent Management for DHDR 1 1. After Consent Override Warning Message: appears when blocked information is unmasked When a consent directive override is performed The DHDR information will be viewable to any user at the health information custodian organization for a 4-hour period The patient will receive notification from the MOHLTC whenever their consent directive in DHDR is overridden The Privacy Officer at your organization will receive an email from the eHealth Ontario Privacy Office to investigate the access. The Privacy Officer will verify express consent was received by the individual for access to DHDR by reviewing the express consent form

Privacy and Patient Inquiries and Requests Informing Patients and Substitute Decision Makers MOHLTC has undertaken a broad public notice campaign to inform Ontarians of the disclosure of their drug and pharmacy service information with all health care providers for the purpose of providing care. This campaign included: Notice to Ontarians published in several daily, multicultural and indigenous newspapers Notice to Patients posted at all pharmacies in the province, refer to slide 32 Poster and Patient handouts are available on the MOHLTC website: Notice to Ontarians Direct patients to ServiceOntario INFOline toll-free at 1-800- 291-1405 (TTY: 1-800-387-5559) for all: privacy-related inquiries or complaints requests for corrections to his/her drug and pharmacy service information in the DHDR requests to find out who in Ontario has accessed his/her drug and pharmacy service information via the DHDR in a given timeframe requests regarding what drug and pharmacy service information the MOHLTC makes available through the DHDR requests to block or unblock access to his/her information in the DHDR (consent directive)

Notice of Disclosure (on Ministry website and newspaper ads)

Notice to Patients “Yellow Poster” (in All Pharmacies)

Clinical Use of DHDR Information Limitations of Data - Considerations DHDR information is advisory only and is not intended to replace sound clinical judgment It may not represent a patient’s complete medication history as it may not include all the current medications a patient is taking at any time, or all the pharmacy services that a patient has received

Clinical Use of DHDR Information Limitations of Data - Considerations Key considerations include: the information should be discussed and confirmed with the patient or other source(s) the patient may not have picked up their medications or may not be taking them as prescribed the patient may be taking other medications such as over-the-counter or privately-paid medications (excluding narcotics and controlled substances) it does not include hospital-dispensed medications it does not reflect details such as: whether a prescription is new or a refill changes to drug therapy (e.g., discontinued, dosage) current use of medication instructions for use (e.g., frequency) Contact the dispensing pharmacy or prescriber for additional information or clarification

Clinical Use of DHDR Information Limitations of Data – Important Term Descriptions Dispensed Date: transaction date when the prescription drug was dispensed or the pharmacy service was rendered; it does not indicate if the medication was picked up Strength: strength of the prescription drug dispensed, amount of active ingredient in the drug; for topical and liquid medication it may be shown as a percentage or ratio Quantity: quantity of medication dispensed; may be the number of items dispensed, or, for topical and liquid medication (e.g., Methadone) it may refer to dose, total volume or volume of drug concentrate Estimated Days Supply: estimated days of treatment based on the directions for use on the prescription, and/or the pharmacist’s judgment on usage; estimating usage accurately may not be possible for some prescriptions (e.g., PRN)

Clinical Use of DHDR Information Limitations of Data- Clinical Example DUR information if available is displayed in the Details screen of the Medications portlet Prescriber and Pharmacy contact information is available in the Details screen of the Medications portlet Example of Printed Medication List Use caution extrapolating the frequency from the Quantity and Estimated Days Supply Based on the example above, 90 tablets of Metoprolol 50 mg was filled for an estimated 30 days supply. (Quantity / Estimated Days Supply) = 3 tablets per day. The instructions may have been 75 mg (1.5 tablets) twice a day, 50 mg (1 tablet) three times a day or another variation. Estimated Days Supply may not be accurately estimated, further compounding the problem

Clinical Use of DHDR Information Limitations of Data- Clinical Example DUR information if available is displayed in the Details screen of the Medications portlet Prescriber and Pharmacy contact information is available in the Details screen of the Medications portlet Example of Printed Medication List The DHDR does not indicate if a prescriber intended current use of a medication The patient may have been instructed to take Metoprolol and Verapamil together, stop one and continue the other, or stop both Changes to medication therapy are not known The patient may have been given alternate dosing instructions (e.g., to decrease the Metoprolol dose to 25 mg (0.5 tablet) three times a day)

Clinical Use of DHDR Information Limitations of Data- Clinical Example DUR information if available is displayed in the Details screen of the Medications portlet Prescriber and Pharmacy contact information is available in the Details screen of the Medications portlet Example of Printed Medication List The DHDR reflects an historic record of drug and pharmacy service information. There is no functionality for medications to be marked as discontinued, placed on hold, or to record adverse events or allergies. It cannot be assumed from the appearance of a record that a patient was successfully treated or can tolerate a specific medication

Local Help Desk Support Updates and DHDR support

Local Help Desk Support DHDR Support All DHDR calls for privacy should be directed to ServiceOntario INFOline with the exception of: If you are a health care provider and would like to request a correction to your provider information associated with a DHDR record (e.g. missing or incorrect prescriber / pharmacy information) please contact the eHealth Ontario Service Desk at 1-866-250-1554 If you require DHDR audit reports: Contact the eHealth Ontario Service Desk at 1-866-250-1554 and request an audit report by user or audit report by organization. The eHealth Ontario Service Desk will open a ticket on your behalf Any tickets sent to eHealth Ontario Service Desk where PHI is required for the ticket must be zipped and encrypted to minimize exposure of PHI Do not send PHI unless necessary Follow File Encryption and Transfer Guideline (refer to ConnectingOntario Operations Guide for Site Help Desks or DHDR Health Care Provider Guide) Refer to eHealth Ontario Service Interaction Guide and DHDR Site Support Guide

Education and Training Resources Medications Portlet Resources available at www.ehealthontario.on.ca/en/support/connecting-ontario (Documents and Training section) Messaging regarding DHDR can not be modified without Ministry approval Tip sheets: How to Use Medications Portlet Medications Portlet: Dispensed Medications Guide for Clinical Use ConnectingOntario ClinicalViewer – Dispensed Medications and Drug Profile Viewer (DPV) Comparison Help Desk Workflow (revised) Data summary (revised) Guides: (DHDR guides available at http://www.ehealthontario.on.ca/en/support/dhdr) DHDR Health Care Provider Guide DHDR Site Support Guide eHealth Ontario Service Interaction Guide ConnectingOntario Operations Guide for Site Help Desks MOHLTC website www.ontario.ca/mydruginfo: FAQ’s Notice to Ontarians Reference: Information Available to Health Care Providers through the Digital Health Drug Repository

Education and Training Resources Medications Portlet Toolkit Materials: Medications Portlet: Trainer’s Guide Medications Portlet: End-User Presentation Medications Portlet: Demo video (TBD) Questions? Email: connecting.ontario@ehealthontario.on.ca Support? Contact: eHealth Ontario Service Desk Toll Free: 1-866-250-1554 Email: servicedesk@ehealthontario.on.ca