standard operating procedure emsm sm sop.22oct2018.pdf · ensure mtf personnel follow the...

STANDARD OPERATING PROCEDURE

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STANDARD OPERATING

PROCEDURE

FOR

SECURE MESSAGING


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1. GENERAL:

The Defense Health Agency (DHA) has deployed Secure Messaging (SM) to meet the Military

Health System’s strategic goals of the Quadruple AIM. DHA has authorized SM to be used by

health care provider teams to electronically communicate with beneficiaries and colleagues.

Please note, the use of Microsoft Outlook and other commercial web-based platforms to

communicate clinical information with beneficiaries continues to be prohibited under the Federal

HIPAA statute.

SM is not email. It is a web based, HIPAA compliant communication tool for routine, non-urgent

communications. The National Capitol Region-Medical Directorate (NCR-MD) SM initiative

provides patients a secure method to electronically communicate with their provider team. In

accordance with HIPAA guidelines, access to SM is limited to the patient and healthcare members

with a “need to know.”

SM is designed to deliver high quality care by more efficiently addressing non-urgent issues or

requests for information from patients. When included in standard work, SM improves demand

management by decreasing unnecessary face-to-face appointments and referrals related to routine,

non-urgent issues. SM improves continuity of health care and fosters closer relationships with

patients and health care teams. SM is never appropriate for emergency or other time-critical

clinical issues.

1.1. By registering beneficiaries in SM, health care teams have an opportunity to provide

medical test results, referral results, information/education, and more. Staff-initiated SM

includes: inquiries about a patient’s condition or referral status, giving medical advice, sending

individual appointment reminders, sending broadcast notifications to multiple beneficiaries

(i.e. flu vaccinations, school and sports physicals, medication alerts, MTF closure dates), etc.

Staff can also send preventive medicine reminders to target populations (i.e. pap smears,

mammograms, colonoscopies, coordination of care for Disease Management/Case

Management patients, etc.). Target populations may include, but are not limited to, Wounded

Warriors, patients undergoing disability evaluation, and members at separated units.

1.2. SM features include asynchronous patient-to-provider/team messaging, colleague-to-

colleague messaging, administrative messaging, appointment requests and reminders, referral

requests, medical test results, strategic messaging, and a robust patient education library.

1.3. Specialty clinics and ancillary departments within the MTF are authorized and encouraged

to use SM to communicate with patients, collaborate with other providers/staff on the care

team, and coordinate transitions in care.

2. RESPONSIBILITIES:

2.1. MTF Commander:

2.1.1. Ensure MTF personnel follow the guidelines and procedures outlined in this SOP.


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2.1.2. Monitor and evaluate program metrics reported through the Executive Committee

and professional staff meetings for continued compliance and improvement.

2.1.3. Promote a focused plan of change management and process improvement centered

upon efficient utilization of SM within clinical workflows and operations.

2.1.4. Will appoint a Physician/Provider SM Champion, SM Administrator and SM

Super-Users to implement and sustain the SM program.

2.2. Physician/Provider Champion:

2.2.1. Champion all aspects of SM and provide support/advice in the timely adoption,

training, and utilization of SM as the preferred method of communication with patients in

all clinics.

2.2.2. Promote and support SM utilization between and among providers to facilitate

efficient and effective coordination/collaboration of care (attachment 4 and 5).

2.2.3. Promote and support program needs through the Executive Committee and

professional staff meetings.

2.3. SM Administrator:

2.3.1. Serves as the administrative expert for the sustainment within the MTF and leads

the super users and other users.

2.3.2. Co-leads the SM High Performance Team.

2.3.3. Oversees staff account creation and configuration for the MTF.

2.3.4. Participates in sustainment meetings and teleconferences.

2.3.7. Note: This is an additional duty, preferably placed under the Practice, Clinic or

Business Manager (or equivalent).

2.4. Clinic Leadership:

2.4.1. Serves as the clinical expert for sustainment of SM within the MTF.

2.4.2. Co-leads the SM High Performance Team.

2.4.3. Ensures unit personnel receive needed SM training.

2.4.4. Participates in SM sustainment meetings and teleconferences.


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2.4.5. Ensures staff members ask patients if they have an account at all interactions using

standard scripts (attachment 1).

2.5. Clinical Systems Trainers:

2.5.1. Ensure all new personnel are trained in the use of SM. Provide hands-on training

as well as didactic training in SM.

2.6. Patient Administration:

2.6.1. Encourage beneficiaries at the installation’s central in-processing and/or medical

in-processing to complete SM registration.

2.6.2. Provide on-site patient enrollment support.

2.6.3. Ensure patients who are processing for PCS are transferred to the gaining MTF.

2.7. SM High Performance Team:

2.7.1. The High Performance Team will oversee all SM activities within the MTF. The

team will consist of super users from all clinical sections of the MTF.

2.7.2. Lead and participate in all SM sustainment activities for the MTF. Ensure ongoing

marketing and continuing education for staff and beneficiaries. For the most up-to-date

marketing materials for patient information (i.e. brochure, pamphlet), contact Marketing

Office directly.

2.7.3. Participate in the NCR-MD SM Action Team Community Forum on MilSuite.

2.8. Super-Users:

2.8.1. Ensure new staff members have a SM account established.

2.8.2. Remove staff members no longer working in the MTF from SM.

2.8.3. Assist with staff inquiries.

2.8.4. Coordinate with the AM Administrator to facilitate SM training.

2.8.5. Instruct MTF staff on new SM features.

2.8.6 Transfer outgoing providers’ empanelment to the new incoming provider in SM

2.8.7 Will coordinate with clinical systems trainers for required staff training.


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3. ELIGIBLE BENEFICIARIES:

3.1. All patients can register for SM. Registration can be achieved either face-to-face

(attachments 2 and 3) or through a six part verification process over the phone (name, DOB,

address, home phone number, EDIPN and/or SSN, last appointment and reason for

appointment).

3.2. All practices will configure their accounts to automatically separate adolescents from

the parent/guardian (primary account holder) account at age 18. Due to the transient nature

of our beneficiary population and the variety of age-of-consent laws across state

boundaries, DoD adolescent beneficiaries should not be separated earlier than age 18

except at the discretion of the parent/guardian (primary account holder).

3.2.1. SM shall not be used for Protected Health Information related to local age-

of-consent laws (reproductive health, domestic abuse, etc.). Traditional phone or

face-to-face communication will avoid unintentional disclosure.

3.2.2. If a minor is legally emancipated, the minor’s secure messaging account can

be separated from the parent/guardian account, in accordance with the HIPAA.

4. SM PROCESS/WORKFLOW:

4.1. SM should be integrated in the Patient Center Medical Home (PCMH) workflow as

well as specialty clinics and ancillary team workflows.

4.2. Electronic SM communications are intended for non-urgent clinical questions for

established patients. SM will not be used for patients with emergent medical issues.

4.3. Clinical teams can manage non-urgent care via SM and provide answers to patient

requests or concerns that may have previously required face-to-face appointments.

4.4. All patient messages should be acknowledged/resolved in less than 24 hours

(attachment 6).

4.5. Each PCMH team is responsible for answering or initiating virtual encounters daily as

a part of their MTF’s access to care strategy.

4.6. Patient-initiated examples:

4.6.1. A patient describes new symptoms and requests intervention or advice from

the privileged provider.

4.6.2. A patient describes ongoing symptoms from a recent acute problem or

chronic health problem and requests intervention or advice from the privileged

provider to treat ongoing acute problem or chronic health problem.


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4.6.3. A patient requests interpretation of lab or test results with evidence the

privileged provider is giving substantive explanation and possibly making

recommendations to modify treatment plan, revise medications, etc.

4.7. Provider-initiated examples:

4.7.1. A privileged provider makes a new diagnosis and prescribes new treatment.

4.7.2. A privileged provider gives substantive medical advice, revises a treatment

plan, prescribes or revises medication, recommends additional testing, or provides

self-care or patient education information for a new or chronic health problem.

4.7.3. A privileged provider gives extended personal patient counseling to change

the course of treatment and affect the potential health outcome.

4.8. Colleague-to-Colleague initiated examples:

4.8.1. A privileged provider contacts another for a pre-consultation exchange or

formal consultation intended to expedite/prioritize care or clarify need for a referral.

4.8.2. A privileged provider contacts another to discuss shared management or the

principal care for the disease.

4.8.3. A privileged provider contacts another for transfer of the patient to specialty

for the entirety of care.

4.9. Preventive care activities will be facilitated by sending registered patients clinical

preventive service reminders, disease specific education, medical alerts about local risks,

and other messages that actively engage and inform patients of their healthcare needs.

4.10. All patient-to-provider/team communication pertaining directly to healthcare will be

documented within the patient’s medical record. Medical record documentation for

telephone or electronic communication between patient and provider will follow medical

record documentation standards.

4.11. SM is an appropriate tool for reminders related to clinical preventive services.

4.11.1 Other mass communication messages (special events, awareness campaigns,

surveys, service availability, MTF closures, clinic hours, etc.) should be routed

through the unit Public Affairs Officer for distribution in non-secure print and

digital media.

4.11.2. The MTF Commander (or designee) may authorize mass communication

SMs if deemed necessary and pertinent to the patient care experience.


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5. CODING.

5.1. In accordance with current business practices, when a reviewing provider is required

to complete the telephone consultation (T-CON) encounter note, they shall apply the

appropriate ICD, CPT, and E&M code, before electronically signing.

5.2. Privileged Provider

For privileged providers to use the following codes, communications via telephone

or electronic media must be initiated by an established patient. Documentation must

contain evidence of medical decision making by a licensed provider directly

responsible for the management of the patient’s care. The following E&M code is

only reported once for the same episode of care during a 7-day period.

99441 Telephone evaluation and management service provided by a privileged

provider to an established patient, parent, or guardian not originating from a related

E&M service provided within the previous 7 days nor leading to an E&M service

or procedure within the next 24 hours or soonest available appointment; 5-10

minutes of medical discussion

99442 Telephone evaluation and management service; 11-20 minutes of medical

discussion

99443 Telephone evaluation and management service; 21-30 minutes of medical

discussion

99444 Online evaluation and management provided by a privileged provider to an

established patient, guardian, or health care provider not originating from a related

E&M service provided within the previous 7 days, using the internet or similar

electronic communications network.

Inter-professional Telephone/Internet Assessment and Management Service

Provided by a Consultative Physician (Colleague-to-Colleague

communication). An inter-professional telephone/Internet consultation is an

assessment and management service in which a patient’s treating physician or other

qualified healthcare professional requests the opinion and/or treatment advice from

a specialty physician (consultant/specialist), without the consultant seeing the

patient face-to-face. The patient may be a new patient to the consultant or an

established patient with a new problem or an exacerbation of an existing problem.

These services are typically provided in complex and/or urgent situations where a

timely face-to-face service with the consultant may not be feasible (e.g. geographic

distance). Review of pertinent medical records, lab studies, imaging studies,

medication profile, pathology specimens, etc. may be required and transmitted via

fax or mail before or after consultation. Review of data is included in the service

and not reported separately.


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The majority of the service time reported (>50%) must be devoted to the medical

consultative verbal/Internet discussion. The consultative physician may use one of

the following codes:

99446 Interprofessional telephone/Internet assessment and management service

provided by a consultative physician including a verbal and written report to the

patient’s treating/requesting physician or other qualified health care professional;

5-10 minutes of medical consultative discussion and review

99447 Interprofessional telephone/Internet assessment and management; 11-20

minutes of medical consultative discussion and review

99448 Interprofessional telephone/Internet assessment and management; 21-30

minutes of medical consultative discussion and review

99449 Interprofessional telephone/Internet assessment and management; 31

minutes or more of medical consultative discussion and review

DO NOT report these codes more than once within a 7 day interval or if the

consultant/specialist has seen the patient in a face-to-face encounter within the last

14 days.

5.3. Non-Privileged Provider

For nurses and technicians (including Independent Duty Medical Technicians) to

use the following codes, communications via telephone or electronic media must

be initiated by an established patient.

98966 Telephone assessment and management service provided by a non-

privileged provider to an established patient, parent, or guardian not originating

from a related assessment and management service provided within the previous

seven days nor leading to an assessment and management service or procedure

within the next 24 hours or soonest available appointment; 5-10 minutes of medical

discussion

98967 Telephone assessment and management; 11-20 minutes of medical

discussion

98968 Telephone assessment and management; 21-30 minutes of medical

discussion

98969 Online assessment and management provided by a non-privileged provider

to an established patient, guardian, or health care provider not originating from a

related assessment and management services provided within the previous 7 days,

using the internet or similar secured electronic communications network.


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5.4. If patients send external documents (e.g. referral results, stress test results, radiology

reports, etc.) via SM, it will be uploaded into HAIMS or the AHLTA note associated with

the encounter.

5.5. SM must have a standard header "Online Medical Evaluation” vs “Virtual Encounter"

proceeding each message copied and pasted into AHLTA and each "Reason for T-CON"

placed in AHLTA must have the same standard header stating "Online Medical Evaluation"

if it is related to an electronic SM.

6. ETIQUETTE:

MTF personnel must never use foul language, anger, sarcasm, harsh criticism, and libelous

references or any other unprofessional language or images in messages. Likewise, MTF

personnel must avoid using medical abbreviations, "texting" or other internet slang and are

responsible for any misuse of SM. Proper ranks and/or titles will be used to address

beneficiaries when available. Messages should reflect careful, professional and courteous

drafting.

Secure Messaging for mass notification to patients (unless patient care or patient safety is

adversely affected) is to be kept at an absolute minimum, if not avoided completely, and

Colleague to Colleague Messaging will not be used to send out mass notification (spam)

messages for advertising purposes.


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Attachment 1

SM SCRIPT FOR CLINIC STAFF

FRONT DESK STAFF:

Hello. Are in you enrolled in Secure Messaging?

Secure Messaging through Relay Health is an online messaging service that allows you to

communicate directly to your healthcare team offering efficient/timely electronic exchange. It

allows for a more secure exchange of health information compared to using a personal email

account.

Here are some things you are able to do with Secure Messaging:

▪ Request your next appointment

▪ Request medication renewals

▪ Receive test and lab results

▪ Communicate online with your provider about non-urgent concerns

▪ Request a copy of your immunization records

It is highly recommended that everyone sign up for Secure Messaging. Here are some benefits:

▪ Only you and your healthcare team have access to your Relay Health messages

▪ Getting written advice that might be misunderstood if communicated verbally

▪ Avoiding the annoyance of waiting in phone trees and playing "telephone tag"

▪ Close monitoring of health issues through confidential online communications

without the inconveniences of traffic, parking, or lost days at work

▪ Getting attention and direct contact with your healthcare team for non-urgent

matters

▪ Requesting medication refills, or lab, radiology, and medical test results

▪ Requesting to arrange lab, radiology, medical tests, or appointments

▪ Obtaining patient education through a web-based application that gives you

access to an extensive library reviewed by board-certified healthcare professionals

from leading health institutions in the U.S.

It only takes a few minutes. Let me sign you up now.

PROVIDERS:

Are you enrolled in Secure Messaging?

It’s a great way to communicate with myself and the team without playing phone tag or waiting

by your phone for someone to call back. You can request your test results, medication refills, and

also request a routine or follow up appointment.

Let’s get you signed up now. All we need is your ID and a personal email address. When you

check your email, look for a message from Relay Health. Make sure you check your spam or

junk folder as well as it may show up there instead of your inbox. Once you accept the invitation

in your email, you are ready to use the system.

If a provider orders a test during an appointment:

You can request your lab results in 3-5 business through Secure Messaging. Let’s get you signed

up.


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Attachment 2

SM FACE-TO-FACE REGISTRATION WORKFLOW – WITHIN THE CLINIC


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Attachment 3


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Attachment 4

SM FOR COLLEAGUE TO COLLEAGUE COMMUNICATION

Interprofessional Internet Assessment and Management (Colleague-to-Colleague

communication C2C) provides non-urgent secure, asynchronous, electronic communication to

facilitate efficient and effective coordination/collaboration of care between and among providers.

It improves HIPPA-sensitive flow of communication which increases access to care, quality of

care and patient/provider satisfaction throughout the National Capital Region (NCR).

A. Medical Home (Primary Care):

1. Open the SM portal at www.TOLSecureMessaging.com

2. Generate a non-urgent colleague message under “Colleague Message” in the left

hand column of your personal inbox.

3. Search for the desired clinic by typing in the “Colleague” search field (i.e.

Gastroenterology, Endocrinology, Infectious Disease etc.) or name of a specific

colleague if known.

4. Select name of the clinic and location from the drop-down menu (look for the double

computer screen icon ). Please click “Advanced Search” for a more

comprehensive list of enrolled clinics and providers.

5. Type in the “Subject” and “Message” under “Compose Message” then click

“Send”

B. Specialty Services:

1. Assign one or multiple clinical reviewers for C2C “proxy provider inbox”

a) On the HOME screen, under the section “At a Glance”, look under “Other

Inboxes” and select “proxy provider INBOX” designated with your clinic

which looks like the following example (i.e. NCR-Walter Reed,

Endocrinology Clinic).

b) To move the proxy provider INBOX from “Other Inboxes” to your

Displayed Inboxes, click the left (<) arrow and Save at the bottom of the

screen. From this point on, the proxy provider Inbox will display on your

home page.

2. Check the “proxy provider INBOX” throughout the day.

3. Review the question/message and “Reply” accordingly.

4. Create a T-con in AHLTA, copy/paste the clinical information and code accordingly

using MHS coding guidelines (or use your specialty-specific coding procedure).

5. If the question/discussion leads up to a referral for a face-to-face visit, reply and ask

the referring provider to enter a referral in CHCS/AHLTA and follow the appropriate

IRMAC guidelines for booking and appointing.

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Attachment 5


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Attachment 6

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