Clinical (EHR) Reminders- More than just a memory jogger

1. Clinical (EHR) Reminders-More than just a memory jogger LCDR Susan Pierce-Richards, MSN, ARNP Office of Information Technology, EHR Program Susan.Richards@ihs.gov

2. What are Clinical (EHR) Reminders? • “The Clinical Reminders system allows caregivers to track and improve preventive healthcare and disease treatment for patients and to ensure that timely clinical interventions are initiated.” (VA Vista Website)

3. Clinical (EHR) Reminders does a chart review and tell you what your patient needs

5. Types of EHR Reminders National Reminders • PXRM 1.5 Patch 1005 delivers 54 National Reminders and dialogs • Delivered to all sites • Based on same logic as Health Maintenance reminders • Many have associated ‘dialogs’ for data entry/note generation Local Reminders • Written at a local site to solve a particular clinical problem • Can be shared between sites • Can also write associated ‘dialogs’ that can be shared Reminder Reports • Can quickly extract data by provider

6. How are Clinical (EHR) Reminders Similar to Health Maintenance (Health Summary) Reminders? • Both identify groups of patients and related unmet interventions • Colorectal screening due for patient over 50 • Mammogram due for patient over 50 • Both are configurable by the local site • Site can change the PAP frequency to yearly • Site can change the age to begin Mammogram reminder to age 40

7. How do EHR Reminders Differ from Health Maintenance Reminders? • CACs can learn to create local reminders using logic and available “findings” • EHR Reminder Dialogs • Look like Templated • Resolve the reminder (enters info into EHR/PCC) • Create the note … all at the same time! • Reminder Dialog Templates • Can create documentation tools that are not tied to a specific reminder that create a note and enter data into PCC

8. Reminders terminology…

9. The Cohort (the “Who”) - Patients needing an intervention - Patients you want to see on a report

10. Cohort Identified Patients over 50 No history of colon CA Cohort Examples Diabetes HGB A1C Reminder cohort • Patients with an active problem OR visit diagnosis of Diabetes Colon Cancer Screen cohort • Patients 50 and older • NO history of Colon Cancer

11. The Resolution (“What”) • What will turn this reminder OFF? • Colon Cancer Screen • FOBT, Colonoscopy, etc • Diabetes HGB A1C • HgbA1C resulted in the past year

12. Frequency (“How Often”) • How often should this reminder or selected intervention be due • Colon Cancer • FOBT yearly OR Colonoscopy q10yr, etc. • HBG A1C • HgbA1C yearly

13. Applicable • A reminder is APPLICABLE to a patient if they meet the definition of the cohort • They are “in the cohort” Example: Colon Cancer screen – patient is 52 and has NO visit diagnosis or problem of colon cancer in chart

14. Finding • A FINDING is a piece of information that the reminder searches for in the computer • It’s there or it’s not • Found or Not Found Examples: Lab, Pt Ed Topic, POV, Exam, Vital Measurement, Medication, etc

15. Due • A reminder is DUE for a patient if they are in the cohort (applicable) and have not yet had the intervention (finding) that the reminder is seeking.

16. Resolved • A reminder is considered RESOLVED if the intervention (finding) defined by the reminder has been met/found

17. Finding A FINDING is a piece of information that the reminder searches for in the computer. Findings are used in • Reminders – to identify Cohorts (who) and Resolution (what) • Dialogs – to “Resolve” (with a ‘what’) reminder in PCC and notes What can be used as a “finding?” Drug, Ed topic, Exam, HF, Imm, Lab test, Measurement, Orderable, Rad procedure, Skin test, Generic drug or drug class, Refusal, ICD9 code, CPT code, Reminder Taxonomy, Reminder Term Computed finding – a routine that a programmer writes to extract data not otherwise available

18. Taxonomy Reminders Taxonomies are groups of codes that will be used as a single finding: • ICD0 procedure codes • CPT codes • ICD9 codes Reminder Taxonomies are “findings” and can be used to: • Identify a cohort of patients (patients with diabetes, asthma, heart disease, etc. should receive a flu vaccine yearly) • Resolve a reminder (diagnosis of depression in past year resolves the Depression Screen reminder)

19. Term Reminder terms are groups of related information that will be used as a single finding: • Labs, Patient education, Health Factors, Medications, Orderable items, Refusals, Immunizations, Measurements, etc. Reminder Terms are “findings” and can be used to: • Identify a cohort of patients (patients on a specific medication, patients with last BP over 139/89) • Resolve a reminder (HGBA1C resulted in past 1 year resolved DM HGBA1C reminder) ***Terms can incorporate additional logic***

20. Term Some terms must be mapped to local names by CAC • Lab • Medications and orderable items • Quick orders (in dialogs)

21. Applicable? Does patient meet cohort criteria? No Yes Not Applicable Folder Not Applicable (white clock) Any Exclusions? Yes No Not Applicable (white clock) Fulfills resolution criteria? Yes No Reminder Resolved Applicable (blue clock) Reminder Due Due (red clock) Basic Reminder Logic

22. Where are EHR reminders????? • Reminder Icon – the “Reminder Clock” • Cover sheet reminder list • Reminder “drawer” on the Notes tab • Ad Hoc Summary on Reports tab

23. Click here And this opens…. If due they are here too

24. Once you pick a note…

25. The Reminder drawer is available

27. What are Reminder Dialogs? • Facilitate documentation • Enter information in RPMS at the same time as writing a note in EHR • Generate orders • Meds • Labs • Consults etc.

28. Dialog Note Text Entered in RPMS

29. National Reminders • PXRM 1.5 Patch 1005 • Delivers basic set of reminders • Delivers basic set of dialogs • PXRM 1.5 Patch 1006 • Will update Domestic Violence Screen, Alcohol Screen and Tobacco reminder terms and dialog elements with the 2008 Patient Ed topics after the next dictionary patch is released (AUMv9.1 p1) • Will additionally update Patient Ed elements in the Immunization and DM Foot Exam dialogs

30. National Reminders - Immunizations • Pediatric and Adult immunizations • Associated dialogs to enter EHR/PCC data and write note simultaneously

31. National Reminders – Screening Measurements Delivered with dialogs • Blood Pressure • Hearing • Height • Senior Height • Weight • Vision

32. National Reminders – Screening/Early Detection Delivered with dialogs – some informational • Alcohol Screen • Blood Pressure • Depression Screen • DV Screen • Lipids • HGB/HCT • Mammogram • Pap Smear • PPD

33. National Reminders –Other Delivered with information only dialogs • No Allergy Assessment • Asthma • Primary provider • Severity • Plan • Steroids

34. National Diabetes Reminders • Basic set of reminders • Basic set of dialogs • Areas and clinics should review and determine if the logic should be made more stringent based on your population’s needs • CACs can adapt the reminders • Labor intensive • Can be shared • Consider area consensus and deployment

35. National Reminders –Diabetes Care COHORT: Visit Dx or Problem list entry in past 2 years ACE/ARBI • Resolved by active, filled rx for ACEI/ARB so 31 days after last fill will be due • Not applicable if verified allergy to ACEI and ARB • Dialog is information only – CAC will need to develop locally Aspirin • Resolved by active, filled rx for Aspirin so 31 days after last fill will be due • Not applicable if verified allergy to Aspirin • Dialog provides order for Aspirin 81mg, easily adapted to menu of choices Blood Pressure – due every 6 months • Unless SBP over 139 OR DBP over 89, then due next visit • Resolved by appropriate BP (CAC maps to local terms) • Dialog entry of BP

36. National Reminders –Diabetes Care COHORT: Visit Dx or Problem list entry in past 2 years Dental Exam – due yearly • Resolved by Dental Exam code, ICD9 or ADA codes • Dialog entry of Dental Exam code or historical dental exam Eye Exam – due yearly • Resolved by Eye Exam code or CPT codes • Dialog entry of Eye exam code or historical eye exam Foot exam – due yearly • Resolved by Foot Exam code • Dialog entry of Foot Exam code AND templated documentation of normal/abnormal examination

37. National Reminders –Diabetes Care COHORT: Visit Dx or Problem list entry in past 2 years HgbA1C – due yearly • Resolved by lab (CAC maps to local terms) • Dialog provides order of lab Microalbumin – due yearly • Resolved by lab (CAC maps to local terms) • Not applicable if has End Stage Renal Disease • Dialog provides order of lab Lipid – due yearly • Resolved by lab (CAC maps to local terms) • Dialog provides order of lab

38. National Reminders –Diabetes Care COHORT: Visit Dx or Problem list entry in past 2 years Tobacco – due yearly • Resolved by Tobacco Health Factors • Dialog provides entry of Health Factors, Pt Ed, To Clinic consult Alcohol – due yearly • Resolved by Alcohol exam code, CAGE health factors, alcohol related dx • Dialog entry of Alcohol exam code, CAGE health factors Depression Screen – due yearly • Resolved by Depression exam code or depression screen, depression dx • Dialog entry of Depression screen code, includes display of PHQ-2 questions

39. National Reminders –Diabetes Care COHORT: Visit Dx or Problem list entry in past 2 years Flu – due every season based on Imm Forecaster • Resolved by Flu vaccine • Not applicable if NOT forecasted OR verified Egg allergy in ART package • Dialog provides entry of vaccine, historical vaccine, refusal and pt ed Pneumovax – due once based on Imm Forecaster • Resolved by Pneumovax vaccine • Dialog provides entry of vaccine, historical vaccine, refusal and pt ed

40. How to look at reminders… The reminders “clock”

41. How to look at reminders… The VIEW menu allows the user to display various configurations of the folders AND reminder icon legend displays the icons you will encounter for reference

42. Right Click on a reminder: Clinical Maintenance Describes reminder, who is in cohort and what has last resolved reminder Ed Topic Definition – links to “standard” Reminder Inquiry – technical description Reference Information – links to websites Evaluate Reminder – “refreshes” and updates Reminder Icon Ledged How to look at reminders…

43. You have the same options for viewing reminders on the Notes tab Reminder Drawer Describes cohort and when due What and how reminder was last resolved Right clicking on a reminder here or from the coversheet dialog box (last slide) will give you these options

44. Clinical Maintenance examples Reminder is applicable –found a DM dx within 2 years. It then tells you the last resolutions found. The Computed Finding “looks” ever day but if it finds what it is looking for (the ADA codes, it returns a different date. It also found a ICD code or dental health visit.

45. Clinical Maintenance examples Reminder is applicable – both age and DM dx within 2 years. It then tells you the last resolutions found. Found Depression Screening Diagnosis. Found Depression Screening exam.

46. Clinical Maintenance examples Reminder is applicable –found a DM dx within 2 years. It then tells you the last resolutions found. Found lab test A1C.

47. Clinical Maintenance examples Reminder is applicable –found a DM dx within 2 years. It then tells you the last resolutions found. Found the ACE however it has been more than 30 days since the last fill so it is DUE again.

48. National Dialog examples

49. National Dialog examples

50. A Word about National Dialogs • Needs of clinicians vary from site to site • Code sets, particularly labs, meds, quick orders, TIU objects vary dramatically from site to site • Immunizations, Exams and Health factors are more standardized from site to site • Immunization dialogs, Exam dialogs, HF dialogs (DV, ETOH, Depression, Eye, Foot, Dental, Tobacco) are delivered highly functional • The remaining dialogs are very “vanilla” and will likely need to either be enhanced by your CAC or your CAC may wish to import tools from another site