Patient Messages FAQ – OceanMD

How do I unlock a patient that has been locked out of their Patient Message?

For privacy and security reasons, patients must verify their identity before accessing the secure contents of a Patient Message.

If a patient submits incorrect verification information six times in a row, they will be automatically locked out.
When a patient is locked out, they are unable to access the secure contents of the Patient Message, even if they submit the correct verification information.

To unlock a patient:

Log in to the Ocean Portal.

Open the 'Menu', and click 'Patients'.

Locate and select the patient.
Click 'Clear Lock Out'.
The patient can now re-attempt the identity verification step to access their Patient Message.

Who needs a Patient Engagement Licence to send Patient Messages?

Health care providers who book appointments with patients and see patients independently require a Patient Engagement Licence to send Patient Messages.

When at least one provider in an Ocean Site has been activated to send messages under a Patient Engagement Licence, up to 3 Clinic Support Staff (per Ocean Licence) are also automatically activated to send Patient Messages at no additional cost.

Note: Clinic Support Staff includes all users with any of the following User Roles: MOA/Secretary, Administrator, Nurse, Resident, Medical Student, or Physician Assistant.

Nurse Licensing for Patient Messages

In certain contexts (e.g., remote nursing stations), patient appointments may be booked directly with a Nurse. In this case, the Nurse is considered to be the health care provider who requires a licence since the patient is booked directly in the Nurse's schedule, and the Nurse is independently seeing the patient.

To accomodate for the scenario in which all users on an Ocean Site are considered to be 'Clinic Support Staff', users with the User Role of 'Nurse' can be activated as the provider to send messages under a Patient Engagement Licence.

When does Ocean send Patient Message email notifications, and where do they get sent to?

When sending a Patient Message with secure content, users have the option to enable the 'Notify me when viewed' checkbox for the secure message component, and the 'Notify me when complete' checkbox for the eForm component.
When the patient subsequently views the secure message or completes their eForm(s), the respective email notification will be sent to the message sender to notify them of the update.

Note: By default, email notifications are sent to the email address or Clinical Delegate Emails associated with the message sender’s Ocean user account.

If the message was sent via an EMR user without a linked Ocean user account, email notifications are sent to the Ocean Site's 'Clinical Administrator / Ocean Support Contact'.

A user that has already been notified regarding the secure message or eForm that they sent will not receive notifications for new secure content sent by future users (unless they have since sent a new secure message/eForm with a notification requested).

Example Scenarios

Notify me when viewed

User A sends a secure message to the patient with 'Notify me when viewed' enabled.
The patient views the secure message from User A.
User A receives an email notification that the patient viewed the secure message.
User B sends a secure message to the same patient with 'Notify me when viewed' enabled.
The patient views the secure message from User B.
User B receives an email notification that the patient viewed the secure message.

User A sends a secure message to the patient with 'Notify me when viewed' enabled.
User B sends a secure message to the same patient with 'Notify me when viewed' enabled.
The patient views the secures messages from both User A and User B at the same time.
Both User A and User B receive an email notification that the patient viewed the secure message.

Notify me when complete

User A sends an eForm to the patient with 'Notify me when complete' enabled.
The patient completes the eForm.
User A receives an email notification that the patient completed the eForm.
User B sends an eForm to the same patient with 'Notify me when complete' enabled.
The patient completes the eForm.
User B receives an email notification that the patient completed the eForm.

User A sends an eForm to the patient with 'Notify me when complete' enabled.
User B sends an eForm to the same patient with 'Notify me when complete' enabled.
The patient completes both eForms sent by User A and User B.
Both User A and User B receive an email notification that the patient completed the eForm.

Formatting Your Templates

You are able to format the email body of your templates by using HTML tags. Simply add the text you wish to format between the tags shown in the table below.

Note: HTML tags can only be used in the email body portion of a template.

The secure message area does not support HTML tags.

HTML Tag Example	Resultant Style
<b>Bold</b>	Bold
<u>Underlined</u>	Underlined
<i>Italicized</i>	Italicized

To include a hyperlink in the email body, use the following HTML tag:

<a href="https://www.oceanmd.com/">OceanMD</a>

Replace the URL and text inside the <a> </a> tags with the words you would like to appear hyperlinked. The example above would look like this: OceanMD

What are some examples of commonly used templates?

Expand each heading below for examples of templates that can be used for Patient Messaging and automated Patient Reminders.

Patient Messaging

Default - Secure Message

Template Name: Default - Secure Message

Subject Line: A message from your healthcare provider

Salutation: Dear @ptPreferredOrFirstName,

Email Body:

You are receiving this email because you have a new message or form to complete from your healthcare provider.

Our clinic uses a secure, online technology called Ocean to communicate with patients regarding their health. To access your messages or forms, please click on the blue link below to open a secure browser window. You will be asked to confirm your identity by entering your birthdate before proceeding.

[weblink]

<b>Note: This is an outgoing email only. Please do not reply to this email. If you have any questions or concerns, please contact our office directly.</b>

—————————————————————————————

To learn more about Ocean’s secure technology or to see instructions on how to access your message, please visit <a href="ocean.tips/patients">ocean.tips/patients</a>.

Patient Reminders

Default - Appointment Reminder

Template Name: Default - Appointment Reminder

Subject Line: An appointment reminder for your upcoming visit

Salutation: Dear @ptPreferredOrFirstName,

Email Body:

This is a reminder for your upcoming healthcare appointment:

<b>Date</b>: @apptDate

<b>Time</b>: @apptTime

<b>Provider</b>: @providerName

As part of your visit, we may ask you to complete some forms online, using a secure platform called Ocean. Please click the blue link below to confirm your appointment and complete your forms.

[weblink]

If you need to cancel or reschedule your appointment, please call the clinic during regular clinic hours as soon as possible.

<b>Note: This is an outgoing email only. Please do not reply to this email. If you have any questions or concerns, please contact our office directly.</b>

—————————————————————————————

To learn more about Ocean’s secure technology, please visit <a href="ocean.tips/patients">ocean.tips/patients</a>.

Can I recall a message that was sent to a patient through Ocean?

While it is not possible to recall an email that was sent through Ocean, it is possible to revoke access to any secure content that is accessible via the secure weblink in the email body.

This is achieved by purging the specific patient from the Ocean portal, which in turn deactivates the secure weblink found in the email body. Any previously sent unread secure messages, attachments, and/or eForms will be purged along with the patient reference. There is no impact on the existing patient chart in the EMR.

If you initiate a new email to the patient after they have been purged, the patient will resync to the Ocean site under a new reference number, empty eForm queue, and blank secure message history.

How to Purge a Patient from the Ocean Portal

Log in to the Ocean Portal and locate the patient within the "Patients" page. Select the patient by clicking their name.
Press the "Remove Patient" button from the list of actions on the right hand side.

You will be reminded that any data that has not yet been downloaded to the EMR will be lost, and be prompted to confirm the removal of the patient.
Click "Yes - Remove Patient" to purge the patient from Ocean.

What if a patient shares health information in Ocean that requires urgent follow up?

By default, after a patient completes a form, they are taken to a page with the following language:

"Please note that your healthcare provider will not routinely see your answers until the time of your next appointment. If you have an urgent medical problem, you must contact your healthcare provider directly or proceed to the emergency department."

This message is important from a medicolegal perspective since it ensures that patients follow up urgent conditions appropriately.

If you choose to use Ocean's redirect function at the end of your form to direct the patient to a custom URL, we recommend including that language (or similar) on the final page of your form before redirecting.

Can I run a report listing the secure messages I have sent and whether the patient has responded?

Ocean offers several 'canned' reports that can give you insight into how your providers and patients are utilizing Patient Messages and Reminders. They provide record level data that can be exported for analysis. You can access them by logging into the Ocean Portal, clicking on the "Menu" button in the top left corner and selecting "Admin". From the Admin Settings page, click "Reports"

The reports below provide insights into Patient Messages activity.

Secure Message Sent - Secure Messages that did not include any eForm attachments
Form Sent Email Link - Patient Messages containing an eForm. If there are multiple forms attached to the Patient Message, the report will include a row for each attachment.
*New Email Invitation Link Created for Patient - All Secure Messages and/or Reminders sent (whether or not they contained an eForm attachment)
Secure Message Confirmed - Secure messages that have been accessed by the patient.
*Form Completed - This report includes the types of forms that were completed during a specific time period (both online or via tablet/kiosk).

NOTE: Reports marked with '*' will also return records related to other Ocean products. These are included in the report description.

How do I send a form to a patient to complete at home (or smartphone)?

Ocean web questionnaires allow you to send forms to patients at home, where they can complete questionnaires on their home computer or mobile device (iPad, iPhone, Android phone, BlackBerry, etc.).

Below is a summary of how to send a web questionnaire depending on which EMR you're using. For more detailed instructions on how to send online messages, please refer to this article. To learn about all the possible secure messages settings, please refer to Patient Messages Settings.

Simply add the Ocean eForm/custom form to the patient chart as you normally do for tablet use. Click the "Email Patient" link, which will open a browser window with an email template containing pre-populated patient information.

You can set up and use a custom CDS link to open up the Patient Messages editor.
To learn how to set up custom CDS links, please refer to Configure the CDS Menu for Quick Access to Ocean.

You can send emails using the Ocean Portal. Find or create the patient in the "Patients" view and click the patient. From the pop up box, select "Email Patient".

Once you're in the Patient Messages Editor:

Within the email dialogue box, select the forms you want the patient to complete. You may also choose to include a secure message at this step.
Hint: You can use the "Templates" menu in the top right corner to save default email messages and/or settings for later use. Refer to Patient Messages Templates for more information.

Why is it prompting me to sign in when I send a message from my EMR?

As of the Ocean release on Feb 15, 2017:

Users who are sending Patient Messages directly from the EMR, without using an Ocean account, may see this message when they click "Send".

Signing in with an Ocean Account will enable the "notifications" are triggered by the following options in the "Send Email" dialog: (1) Notify me when viewed, (2) Notify me when complete, and (3) Notify me if no response after: __.
For security reasons, Ocean forces the email sender to have an Ocean account to remove any ambiguity as to who the email is sent from and where it was sent.
If any EMR users are sending Ocean emails right now without an Ocean account (a.k.a. "anonymous EMR users"), they will be prompted with the following message:
"To continue using notifications for all users, please ensure that all your Ocean message senders proceed to sign up for an Ocean account in the usual manner. Your Ocean site administrator will need to either invite them or add them to your site."

Once the user's account is created, he or she can proceed to email the patient from the EMR and "link" the user's EMR account to their Ocean account by clicking on the button at the top of the email dialog.

Alternatively, you can change your email templates to avoid using the notification options above.

Can I edit and save the text that will appear in the body of an email when emailing out a form to a patient?

Yes, you can do this with templates.
Templates allow you to save the subject, email body, secure message, and eForms that you have previously sent to a patient, making the standard message available for you to select when you email another similar patient.
For more details on how to configure your templates, please refer to Customizing Your Templates.

Will it cause problems to use web questionnaires if two patients share an email address?

No, this will not be a problem.

Each patient will get a personalized and individual link in the email, each with different access keys and encryption keys. However, the emails will end up in the same inbox (Gmail, Yahoo, etc.), which may trigger privacy concerns that would apply for any sort of clinical email to the shared email address.

It's generally a good idea to warn patients about the privacy implications of sharing email addresses in a email consent form that a patient must review prior to receiving clinical web questionnaires. There are some very well-thought out email consent forms in the eForms view of your Ocean Portal if you don't already have one.

How do I change the "From" address to my clinic name on emails sent to my patients?

By default, emails sent to patients through Ocean will be sent from "no-reply@cognisantmd.com". You can change this setting so that your patients know that the email is coming from your clinic.

Login to the Ocean Portal. Click the "Menu" button in the top left corner and select "Admin".
From the Admin Settings page, click "Site Account" and type in your clinic name in the "Email Friendly Name" field and save your changes.

Note: You may also need to update your clinic name in your email templates as well.

Are there limits to the number of files I can attach to a patient message?

Ocean does not limit the number of individual files that are attached to a patient message.

A single file attachment cannot exceed 10 MB in size. The total size limit for all attachments per message is 50 MB (i.e., the sum of all attachments on a single message cannot exceed 50 MB).

My clinic uses a VPN to remotely access our EMR. How can we review and create Ocean Patient Messages when accessing the EMR remotely?

Unfortunately, accessing Ocean through a remote VPN is out of scope for our support as it may involve VPN settings established by a clinic's IT staff. Ocean servers are monitored 24/7 for errors, issues and speed and our staff respond to changes quickly as they arise. Clinics can troubleshoot this kind of issue by attempting to access Ocean via the clinic VPN, then attempting to access Ocean using a different connection. If the issue persists while using the VPN only, it's likely related to the clinic's VPN.

If you are experiencing issues with Ocean when accessing your EMR through a VPN remotely, we encourage you to send patient messages directly through the Ocean Portal.

In your EMR, ensure your patient has an email address and has provided email consent.
Login to the Ocean Portal. If you aren't already in the Patients view, click the "Menu" button in the top left corner and select "Patients".
Use the search bar on the left under "Find Patients". You can double click the contents of the search bar and search by the patients surname.
1. If the patient isn't in Ocean, search for the patient's health card number in your EMR. Copy this number and paste it in the field under Upload From EMR (located in the Patients view side bar, under Walk-In Patients).
Once you've found your patient in Ocean, click on their name. A window will appear where you can click Email Patient. This will open the secure messaging feature of Ocean.
Compose your email or select from your templates list and click "Send" to send your secure message to your patient.

Email Patients Using Your Own Email Address

What does this mean?

By default, Patient Messages are sent from Ocean using "no-reply@cognisantmd.com" as the "From" email address. However, you are able to change this to your own custom address if you own your own domain name, such as "no-reply@myclinic.com".

Using your own email address has the following benefits:

The email is less likely to be routed to your patient's spam folder.
It's more likely to capture your patient's attention.
In the event that the patient's email address is incorrect, any email 'bounce back' messages can be returned to you instead of being lost.

To use this feature, you must use your own domain name and have the ability to modify your DNS records with your domain name registrar.

Specifically, you must add either an SPF TXT record or DKIM DNS records instructing email providers (like Google and Yahoo) to use Ocean’s domain key to verify email from your domain was sent by Ocean.

While Ocean will use your custom “From” email address when either SPF or DKIM are setup correctly, we recommend all the following DNS records be created for the best deliverability:

SPF TXT record allowing Ocean to send email on your behalf.
DKIM CNAME records using Ocean’s domain key.
DMARC TXT record telling email providers like Google and Yahoo what they should do if an email message cannot be verified to be legitimate. (This can be the case if an email is sent by somebody pretending to be you).

How do I do it?

As this change requires technical expertise and owning your own domain name, it's not for everyone.

Warning: We strongly recommend consulting an IT professional to assist with DNS record modification, as mistakes can result in your emails being improperly flagged as spam, or issues with your website.

SPF

Go to your DNS provider's website and check if you have an existing SPF TXT record. Existing SPF TXT records look something like this:
```
"v=spf1 ip4:192.0.2.0/24 ip4:198.51.100.123 -all"
```
If you don't have an existing SPF TXT record, we recommend consulting an IT professional to create one.

SPF TXT record construction is outside the scope of this article but your domain registrar should have detailed instructions on how to create one.

All SPF records are of type "TXT". Once your SPF TXT record has been created, please refer to Step 3 below.

Note: Only TXT records in SPF format are supported. The SPF DNS record type may not be used.
If you have an existing SPF TXT record, add the following after v=spf1and before -all:
```
include:_spf.cognisantmd.com
```

The finished product in the example above would look something like this:

"v=spf1 include:_spf.cognisantmd.com ip4:192.0.2.0/24 ip4:198.51.100.123 -all"

or this:

"v=spf1 include:_spf.cognisantmd.com -all"

Save the new record and allow DNS changes time to propagate. (This may take an hour or even 1-2 days, depending on your DNS settings.)

Note: Only one of SPF or DKIM is required for Ocean to send email from your domain. We do however strongly recommend you setup both (as well as DMARC) for the best email deliverability.

DKIM

Go to your DNS provider's website.
Create a CNAME record with the following values:
- Record Name: oceanmd1._domainkey.your_domain
- Record Value: oceanmd1._domainkey.cognisantmd.com
- Save the new record and allow DNS changes time to propagate. (This may take an hour or even 1-2 days, depending on your DNS settings).
Create a second CNAME record with the following values:
- Record Name: oceanmd2._domainkey.your_domain
- Record Value: oceanmd2._domainkey.cognisantmd.com
- Save the new record and allow DNS changes time to propagate. (This may take an hour or even 1-2 days, depending on your DNS settings).

Note: Only one of SPF or DKIM is required for Ocean to send email from your domain. We do however strongly recommend you setup both (as well as DMARC) for the best email deliverability.

DMARC

Go to your DNS provider's website.
Search for a record named: _dmarc
If you have an existing DMARC record already set up, you do not need to change it. You can skip the rest of these DMARC steps.
If you do not have an existing DMARC record set up, we recommend creating one.
Create a TXT record with the following values:
- Record Name: _dmarc.your_domain
- Record Value: v=DMARC1; p=none
Save the new record and allow DNS changes time to propagate. (This may take an hour or even 1-2 days, depending on your DNS settings).

Note: This is a minimal DMARC policy record. Configuring it further is outside the scope of this article. Please consult with an IT professional for assistance.

Send Test Email

It's a good idea to send some test emails using your usual email client to ensure they aren't flagged as spam

You can verify your SPF and / or DKIM configuration by inspecting the full, unformatted email body. In GMail, you can view this by clicking the three dot icon in the top right and selecting "Show original". The summary should show a section with SPF PASS, DKIM PASS, or both.

Tips

The macOS terminal command "dig yourdomainname txt" will confirm whether the SPF record is saving as expected. It should eventually display your SPF record once propagated. Note, however, that there may still be other delays before email providers recognize this change.
The macOS terminal command “dig oceanmd1._domainkey.your_domain cname” will confirm whether your new DKIM record has been saved as expected. It should eventually display your DKIM record once propagated. Note, however, that there may still be other delays before the email providers recognize this change.
- Verify the second DKIM record with the macOS terminal comment “dig oceanmd2._domainkey.your_domain cname”.

Enable Your Custom "From" Email Address in Ocean

Once you have your DNS records configured properly, login to the Ocean Portal, click 'Menu' in the top left corner, select 'Admin', and then select 'Site Account'.

Enter your email address in the 'Email 'From' Address' field.

How Ocean Validates Your DNS Records

Upon entering your custom email address in the 'Email 'From' Address' field, Ocean will validate that your DNS records allow us to send email on your behalf:

If a green status icon appears, it means that SPF and DKIM are valid and supported by a DMARC record. This is the recommended configuration.

If a yellow status icon appears, it means that SPF is valid or DKIM is valid. This means the minimum configuration requirement has been met.

If a red status icon appears, it means that neither SPF or DKIM records are valid. This is the minimum configuration requirement. The custom 'From' email address will not be used.

If Ocean finds your DNS records to be valid (i.e., a yellow or green status icon appears), an email will be automatically sent to the OceanMD Support team for manual approval.

Until it is approved by the OceanMD Support team, the configuration is not complete.

If your DNS records cannot be validated (i.e., a red icon appears) , or the OceanMD Support team does not approve your custom address, Ocean will not send using your custom address. In this situation, please review your DNS configuration to ensure that it is correct and/or contact the OceanMD Support team to follow up on your approval.

Once successfully configured and approved, Ocean will continue to automatically validate your custom "from" address periodically to ensure that SPF, DKIM (SPF or DKIM must always be configured correctly) and DMARC (not required but recommended) DNS records still allow us to send email on your behalf when present.

If validation fails, Ocean will revert to using Ocean's default "no-reply" email address automatically, so no action is required on your part.

If you ever change the custom email address, the OceanMD Support team will need to re-approve the new address.