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Video Tutorial

 

Primary Care Module in ClinicalConnect – Limited Proof of Concept Project

The Primary Care module in ClinicalConnect is a new module available to authorized users from certain Participant Organizations, and provides access to a sub-set of data contributed from primary care organizations’ Electronic Medical Records (EMRs) that are participating in the Primary Care Data Share (PCDS) Proof of Concept (PoC) project. Data available in this Primary Care module is integrated from eHealth Ontario’s Primary Care Clinical Data Repository (pcCDR). The data available in this module will be only for patients who are rostered to the contributor Family Health Teams (FHTs) participating in the project. Patients who are not rostered with the contributor FHTs will display No Records Found in the module. The pcCDR contains only a sub-set of primary care EMR data and may date back to 2002 if available.

The following data elements are included, if available, from the contributor FHT: Demographics, Medications, Allergies and Adverse Reactions, Current Health Conditions, Past Medical and Surgical History, Immunizations, Risk Factors, Vitals and Vitals Trend

a note icon Provincial repositories such as the pcCDR retrieve information based on the patients Health Card Number (HCN) match. In cases where a HCN is not available or invalid, data from the provincial repositories will not be accessible.

Primary Care Data Consent Directive

A patient has the right to withdraw consent to access and use of their full or partial records from the pcCDR through the current eHealth Ontario process. ClinicalConnect will honour the consent restrictions and display the following message in the patient’s ClinicalConnect record:

Documents were not returned due to an applied consent directive

If access to a blocked record is required, you may contact eHealth Ontario Service Desk Support at 1-866-250-1554 or by email at servicedesk@ehealthontario.on.ca.

Accessing the Primary Care Module

The Primary Care module can be accessed from the modules menu in the patient’s record or by adding the Primary Care module into your Dashboard view as described further in this guide. The module displays information in tabs. These tabs will display only if there is information available in them. If no data is available in a specific tab, that tab will not appear in the view.

Image of the Primary care module tab

 

Primary Care Module – Demographics

The demographic data available in the view can be organized by setting your sort order preferences.
Sorting this information by date will show the most current entry at the top of the list. The data-contributing facility is identified in each tab in the Provider and Source columns as shown below.

a note iconThe Print function is available when the Primary Care module is selected from the module list as shown below. Print functionality is not available in the Dashboard view.

Image of the print function availability in the primary care module

 

Primary Care Module – Medications

The Medications tab displays the prescribed medication information available from the data-contributing facility.

 a note icon The Pharmacy module in ClinicalConnect also contains Hospital Medications information and Home Meds (information from the Digital Health Drug Repository). Clinicians viewing medication information should review the Pharmacy module in addition to the medications listed in the Primary Care module.

To view additional medication details, if available, select the medication from the list and the details will display in the view.

Image of the medication list details in primary care module

 

The following table describes the columns of medication data available in this tab:

Rx Written Date

Written date of the current prescription.

Medication Name

The name assigned to a drug. Medications could be listed using their Brand or Generic names.

Drug Strength

This is represented/measured in various forms/units including: mg, md/vol, %, etc. Unit of Measure is specified when not implicit from the drug from (e.g. puff, inhalation, drops, etc.).

Dosage

Dose amount and unit of measure of medication intended to be consumed during a single administration.

Drug Form

Indicates the form in which the drug product must be, or has been manufactured or custom prepared.

Route

This is the means by which the dispensed drug is to be administered to the patient.

Frequency

The frequency by which the prescribed medication is to be consumed.

Duration

The duration of medication to be dispensed for thr first administration of the prescription.

Quantity

The quantity of the medicationto be dispensed for the first administration of the prescription.

Drug Description

This could be an added description of a drug. This may be used for custom compounds, providing instructions on the composition and creation of the compound such as a topical cream. This can also be used for complex prescriptions.

Refills

Subsequent refills that follow the initial prescription.

Treatment Type

Describes the categorization of the treatment type.
Example: CHRON – Continuous/chronic, ACU – Acute, ONET – One Time, PRN Long-term – As needed, PRN Short-term – As needed

Status

Describes the lifecycle of the prescription. Example: New, Active, Suspended.

Past Medication Indicator

Indicator for discontinuation of medication from the treatment plan.

Rx Instructions

Field to capture additional notes the provider may attach to the prescription record to communicate with the pharmacist.

Dispense Interval

Indicates a minimum amount of time that must occur between dispenses.

Substitution Not Allowed

A prescriber's instruction that a specific prescribed product be dispensed as is, or not. Valid values:

Yes (Y) – substitution not allowed or,

No (N) - substitution allowed

Past Medication Indicator

Indicator for discontinuation of medication from the treatment plan.

 

Primary Care Module –Allergies and Adverse Reactions

The Allergies and Adverse Reactions tab displays information available from the source primary care facility.

a note icon Currently, the allergy information available in this module will not generate an Allergy alert flag in the patient’s header as shown in this example even if there is an Allergy identified. Clinicians should check the Allergies module in ClinicalConnect if additional allergy information from other data-contributing facilities is available.

Image of the no known allergies in primary care tab

 

The following table describes the information in the Allergies and Adverse Reaction tab:

Date

NOTE: In some cases this field may be blank.

Allergy

Text description of offending agent, whether drug or non-drug.

Reaction Type

Identifies reaction as an allergy or adverse reaction (includes intolerance and side effects).

Reaction

The description of the patient’s reaction to a drug or a non-drug Examples: rash, lip swelling.

Severity

Severity of the allergy or adverse reaction as identified by the provider.

e.g. Moderate, Light.

Notes

Additional notes about an allergy or adverse reaction.

 

Primary Care Module – Current Health Conditions

Image of the primary care current health conditions tab

 

The following table describes the information in the Current Health Conditions tab:

Date of Onsent

a note icon  In some cases this field may be blank.

Diagnosis

A description that identifies the patient's condition or diagnosed disease.

Problem Description

A description of the problem reported.

Notes

Field for the provider to capture additional notes about a condition.

Problem Status

The status of the problem or the diagnosed disease.

 

Primary Care Module – Past Medical Surgical History

Image of the Primary Crae module with past medical surgery history tab

 

The following table describes the information in the Current Health Conditions tab:

Date of Onset

a note icon In some cases this field may be blank.

Diagnosis/Procedures

A description that identifies the patient's problem or diagnosed disease.

Procedure/Intervention

A description that identifies the patient's procedure or intervention.

Notes

Field to capture additional notes about past medical and surgical history.

 

Primary Care Module – Immunizations

Image of the Immunizations tab in the primary care module

 

The following table describes the information in the Immunization tab:

Immunization Date

The actual date the immunization was provided to the patient.

Name

Immunization Name is based on the brand name. (Eg. Adacel, Havrix 720)

Type

Immunization Type is the Immunogen component of the Vaccine Type as prescribed in the ‘Canadian Immunization Guide’.

(Eg. Tetanus, diphtheria – adult [Td], Hepatitis A)

Lot #

The product lot number corresponding to the administered immunization.

Refused Indicator

Identifies whether an immunization was refused. (Yes or No)

 

Primary Care Module – Risk Factors

Image of primary care risk factors tab

 

The following table describes the information in the Risk Factors tab:

Start Date

Date or an approximate date of identified risk.

Description

Description of risk factor

Examples: nicotine, alcohol, asbestos, etc.

Exposure Details

Specific agent details of the exposure.

Notes

Field to capture additional notes about a risk factor.

 

Primary Care Module – Vitals

The Vitals tab displays Height, Weight, Blood Pressure and BMI values. The values in this tab can be customized using the Preferences icon as described below. The Vitals Trend is a complementary tab that graphs the values.

Image of the primary module vitals tab

 

Primary Care Module – Vitals Trend

The Vitals tab displays Height, Weight, Blood Pressure and BMI values. The values in this tab can be customized using the Preferences icon as described below.

Image of the Vitals trend tab in the primary care module

 

Adding the Primary Care module to Your Patient Dashboard

To add the Primary Care module into your Dashboard view, click on the Primary Care module icon and drag it into the Dashboard.

Image of how to add primary care module to the patient dashboard

 

Print Function

The PDF icon in the previous version of ClinicalConnect has been replaced with the Print a print icon  icon, to conform to industry standards.

The Print function is available from each module’s List or Details view.

The Patient Dashboard does not contain a Print function.

More info: https://info.clinicalconnect.ca/CC/healthcare/resource-centre-printing


PDF ClinicalConnect Primary Care Module: Accessing Data from eHealth Ontario's Primary Care Clinical Data Repository