1. Clinical (EHR) Reminders Physiology of a Reminder

2. Session Objectives At the end of this session, participants should be able to: Understand basic "physiology" of a reminder Cohort logic Resolution logic Reminder term conditions

3. “Physiology…” Boolean logic is the foundation of reminders… the reminder parts can be combined using Boolean logic to determine: Cohort (inclusion and exclusion) Resolution

4. Physiology… Boolean Logic AND A and B must be true for the statement to be true Example: Patient has diabetes AND hypertension OR A or B must be true for the statement to be true Example: Patient has Alcohol Screen exam OR CAGE recorded NOT (used mostly for exclusion criteria) If A is not found, the response is true If A is found, the response is false Example: Female patient, 21-65 AND NOT hysterectomy

5. What expressions look like… Findings are expressed as Finding 1, Finding 2 and abbreviated in logic statements: FI (1), FI(2) Findings are not found/false = 0 found/true = 1 Logic statements are false = 0 true= 1 AND: FI(1)&FI(2) OR: FI(1)!FI(2) AND NOT: FI(1)&’FI(2)

6. Physiology… AND AND FI(1) & FI (2) = DMHTNStatement Result TTT TFF FTF FFF AND (&) FI(1)&FI(2) -both must be true for the statement to be true -if either are false then the statement is false Example: Cohort = Patients with both DM FI(1) and HTN FI(2) Patient has DM and HTN FI(1) =1 and FI(2) =1 Statement =1 Patient has DM. Patient does not have HTN FI(1) =1 and FI(2) =0 Statement = 0 Patient does not DM. Patient has HTN FI(1) =0 so Statement =0 HTNDM AND

7. Physiology… OR OR FI(1) ! FI (2) = Alcohol ExamCAGEStatement Result TTT TFT FTT FFF OR (!) FI(1)!FI(2) -if either is true, then the statement is true -both must be false for the statement to be false Example: Resolution = Alcohol Exam FI(1) or CAGE FI(2) to resolve Patient has had Alcohol Exam and CAGE recorded FI(1) =1 or FI(2) =1, Statement =1 Patient has had Alcohol Exam. No CAGE recorded. FI(1) =1 or FI(2) =0, Statement = 1 Patient has not had Alcohol Exam. CAGE is recorded. FI(1) =0 or FI(2) = 1, Statement =1 Patient has had neither Alcohol Exam or CAGE FI(1) =0 or FI(2) = 0, Statement =0 Alcohol Exam or CAGE

8. Physiology… NOT AND NOT AGE & ‘FI (1) = AGE resultFI(1) Result (result after NOT operator) Statement Result TT (F)F TF (T)T FT (F)F FF (T)F NOT (‘) If found/true then the NOT converts this to false in the logic statement. AND NOT (&’) AGE&’FI(1) Only if the first finding is found, and the second finding is NOT found is the statement true Example: Cohort= I want patients age over 50 (AGE) and no h/o colon CA FI(1) 51yo and colon cancer. AGE =1, FI(1) =1 NOT FI(1) = 0, Statement = 0 51yo and no colon cancer. AGE =1, FI(1) =1 NOT FI(1) = 1, Statement =1 49yo and no colon cancer. Age = 0, Statement = 0. 49yo and colon cancer. Age = 0, Statement = 0.

9. Physiology… NOT NOT placed before a finding makes a false true and true false… it is used to exclude NOT (’) If found/true then the NOT converts this to false (0) in the logic statement. ________________________________________ Example: Resolution = I want patients with h/o abnormal PAP with an intact uterus FI(1) &’FI(2) = Abnormal Pap and NOT h/o hysterectomy. Patients with hysterectomy are excluded Abn Pap and not hysterectomy Patient has Abn Pap and has not had a hysterectomy. FI(1) is true. FI(2) is not found so this is also true. Statement is true. Patient has Abn Pap and has had a hysterectomy. FI(1) is true. FI(2) is found, so this is false. Statement is false. Patient has no history of Abnormal Pap FI(1) is false. The statement is false

10. Boolean Logic - precedence Precedence (), Not, And, Or If no parenthesis, it evaluates them using the precedence rules A and B or C works the same as (A and B) or C Both A and B must be true or C can be true. A or B and C works the same as A or (B and C) If A is true then the statement is true If A is false, then both B and C need to be true to make the second half true You can change the logic by changing the order of the findings, OR by adding parenthesis

11. Boolean Logic - precedence A or B and C or D Default precedence is: A or (B and C) or D DM or Pre-DM and HTN or Elevated BP DM or (Pre-DM and HTN) or Elevated BP You really want (A or B) and (C or D) (DM or Pre-DM) and (HTN or Elevated BP) You can use Custom Logic to force the items to evaluate in the way you want

12. Sample cohort logic Age over 2 AND high risk diseases AGE&FI(1) Age over 50 AND NOT Colon Cancer AGE&’FI(1) Female AND age 21-65 AND NOT hysterectomy SEX&AGE&’FI(1) Diabetes AND NOT end stage renal disease FI(1)&’FI(2)

13. Sample Resolution Logic HGBA1C lab test FI(1) Alcohol exam or CAGE or pt ed code or Alcohol dx FI(1)!FI(2)!FI(3)!FI(4) Mammo in Rad file or Mammo CPT or Mammo recorded in WH package or Refusal FI(1)!FI(2)!FI(3)!FI(4)

14. Basic Reminder Logic Does patient meet cohort criteria? NoYes Any Exclusions? Yes Fulfills resolution criteria? No Yes No Reminder Resolved Applicable (blue clock) Reminder Due Due (red clock) Reminder not applicable (white clock) No Yes Reminder not applicable (white clock) Yes

15. Cohort Logic AGE and SEX are built into the system If you don’t enter anything its all ages, both sexes Examples: What is the result? – Pap Smear: AGE and SEX and not HYST – Pap Smear: AGE and SEX or not HYST – Flu shot: AGE or DIABETES

16. Resolution Logic What turns the reminder off? Examples: – Using lab tests: Lipid Test: LDL or HDL or LDL (Calc) or Lipid Profile or cholesterol Lipid Test: LDL or LDL-Calc and HDL HDL and LDL or LDL-Calc (LDL or LDL-Calc) and HDL – Reminder Term Lipid Test: Lipid Tests

17. National Reminders Distributed with dialogs in PXRM 1.5 p1005 Updated in PXRM 1.5 p1006, 1007, 1008 The patch loads reminders to the Reminder Exchange Reminders will not display in the EHR until: – Installed from exchange – Reminder system is activated – Reminders are added to the display list National Reminders cannot be edited. Sites can copy the national reminder, edit it and then use

18. National Reminders Many national reminders need to have sites map their own local terms to the reminder terms, especially those reminders with lab test results TEST, TEST, TEST before the general public uses the reminders. Be sure they are working properly

19. Questions & Discussion