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) “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 PXRM 1.5 Patch 1005 delivers 54 National Reminders and dialogs Delivered to all sites Delivered to all sites Based on same logic as Health Maintenance reminders Based on same logic as Health Maintenance reminders Many have associated ‘dialogs’ for data entry/note generation Many have associated ‘dialogs’ for data entry/note generation Local Reminders Written at a local site to solve a particular clinical problem Written at a local site to solve a particular clinical problem Can be shared between sites Can be shared between sites Can also write associated ‘dialogs’ that can be shared Can also write associated ‘dialogs’ that can be shared Reminder Reports Can quickly extract data by provider 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 Both identify groups of patients and related unmet interventions Colorectal screening due for patient over 50 Colorectal screening due for patient over 50 Mammogram due for patient over 50 Mammogram due for patient over 50 Both are configurable by the local site Both are configurable by the local site Site can change the PAP frequency to yearly Site can change the PAP frequency to yearly Site can change the age to begin Mammogram reminder to age 40 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” CACs can learn to create local reminders using logic and available “findings” EHR Reminder Dialogs EHR Reminder Dialogs Look like Templated Look like Templated Resolve the reminder (enters info into EHR/PCC) Resolve the reminder (enters info into EHR/PCC) Create the note Create the note … all at the same time! … all at the same time! Reminder Dialog Templates Reminder Dialog Templates Can create documentation tools that are not tied to a specific reminder that create a note and enter data into PCC 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 Examples Diabetes HGB A1C Reminder cohort Patients with an active problem OR visit diagnosis of Diabetes Patients with an active problem OR visit diagnosis of Diabetes Colon Cancer Screen cohort Patients 50 and older Patients 50 and older NO history of Colon Cancer NO history of Colon Cancer Cohort Identified Patients over 50 No history of colon CA

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

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

13. Applicable A reminder is APPLICABLE to a patient if they meet the definition of the cohort A reminder is APPLICABLE to a patient if they meet the definition of the cohort They are “in 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 A FINDING is a piece of information that the reminder searches for in the computer It’s there or it’s not It’s there or it’s not Found or Not Found 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. 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 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) Reminders – to identify Cohorts (who) and Resolution (what) Dialogs – to “Resolve” (with a ‘what’) reminder in PCC and notes 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 ICD0 procedure codes CPT codes CPT codes ICD9 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) 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) 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. 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) 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) 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 Lab Medications and orderable items Medications and orderable items Quick orders (in dialogs) Quick orders (in dialogs)

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

22. Where are EHR reminders????? Reminder Icon – the “Reminder Clock” Reminder Icon – the “Reminder Clock” Cover sheet reminder list Cover sheet reminder list Reminder “drawer” on the Notes tab Reminder “drawer” on the Notes tab Ad Hoc Summary on Reports 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 Facilitate documentation Enter information in RPMS at the same time as writing a note in EHR Enter information in RPMS at the same time as writing a note in EHR Generate orders Generate orders Meds Meds Labs Labs Consults Consults etc. etc.

28. Dialog Note Text Entered in RPMS

29. National Reminders PXRM 1.5 Patch 1005 PXRM 1.5 Patch 1005 Delivers basic set of reminders Delivers basic set of reminders Delivers basic set of dialogs Delivers basic set of dialogs PXRM 1.5 Patch 1006 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 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 Will additionally update Patient Ed elements in the Immunization and DM Foot Exam dialogs

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

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

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

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

34. National Diabetes Reminders Basic set of reminders Basic set of reminders Basic set of dialogs 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 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 CACs can adapt the reminders Labor intensive Labor intensive Can be shared Can be shared Consider area consensus and deployment 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 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 Not applicable if verified allergy to ACEI and ARB Dialog is information only – CAC will need to develop locally Dialog is information only – CAC will need to develop locallyAspirin Resolved by active, filled rx for Aspirin so 31 days after last fill will be due Resolved by active, filled rx for Aspirin so 31 days after last fill will be due Not applicable if verified allergy to Aspirin Not applicable if verified allergy to Aspirin Dialog provides order for Aspirin 81mg, easily adapted to menu of choices 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 Unless SBP over 139 OR DBP over 89, then due next visit Resolved by appropriate BP (CAC maps to local terms) Resolved by appropriate BP (CAC maps to local terms) Dialog entry of BP 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 Resolved by Dental Exam code, ICD9 or ADA codes Dialog entry of Dental Exam code or historical dental exam Dialog entry of Dental Exam code or historical dental exam Eye Exam – due yearly Resolved by Eye Exam code or CPT codes Resolved by Eye Exam code or CPT codes Dialog entry of Eye exam code or historical eye exam Dialog entry of Eye exam code or historical eye exam Foot exam – due yearly Resolved by Foot Exam code Resolved by Foot Exam code Dialog entry of Foot Exam code AND templated documentation of normal/abnormal examination 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) Resolved by lab (CAC maps to local terms) Dialog provides order of lab Dialog provides order of lab Microalbumin – due yearly Resolved by lab (CAC maps to local terms) Resolved by lab (CAC maps to local terms) Not applicable if has End Stage Renal Disease Not applicable if has End Stage Renal Disease Dialog provides order of lab Dialog provides order of lab Lipid – due yearly Resolved by lab (CAC maps to local terms) Resolved by lab (CAC maps to local terms) Dialog provides order of lab 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 Resolved by Tobacco Health Factors Dialog provides entry of Health Factors, Pt Ed, To Clinic consult 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 Resolved by Alcohol exam code, CAGE health factors, alcohol related dx Dialog entry of Alcohol exam code, CAGE health factors Dialog entry of Alcohol exam code, CAGE health factors Depression Screen – due yearly Resolved by Depression exam code or depression screen, depression dx Resolved by Depression exam code or depression screen, depression dx Dialog entry of Depression screen code, includes display of PHQ- 2 questions 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 Resolved by Flu vaccine Not applicable if NOT forecasted OR verified Egg allergy in ART package Not applicable if NOT forecasted OR verified Egg allergy in ART package Dialog provides entry of vaccine, historical vaccine, refusal and pt ed Dialog provides entry of vaccine, historical vaccine, refusal and pt ed Pneumovax – due once based on Imm Forecaster Resolved by Pneumovax vaccine Resolved by Pneumovax vaccine Dialog provides entry of vaccine, historical vaccine, refusal and pt ed 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. How to look at reminders… Right Click on a reminder: Clinical Maintenance Clinical Maintenance Describes reminder, who is in cohort and what has last resolved reminder Ed Topic Definition – links to “standard” Ed Topic Definition – links to “standard” Reminder Inquiry – technical description Reminder Inquiry – technical description Reference Information – links to websites Reference Information – links to websites Evaluate Reminder – “refreshes” and updates Evaluate Reminder – “refreshes” and updates Reminder Icon Ledged Reminder Icon Ledged

43. 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 You have the same options for viewing reminders on the Notes tab Reminder Drawer

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

50. A Word about National Dialogs Needs of clinicians vary from site to site Needs of clinicians vary from site to site Code sets, particularly labs, meds, quick orders, TIU objects vary dramatically 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 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 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 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

51. Local Reminders … Endless potential

52. Clinical (EHR) Reminders – a tool in problem identification and intervention Modifying National Reminder logic to target your population Modifying National Reminder logic to target your population Modifying National Dialogs to your site’s needs Modifying National Dialogs to your site’s needs Problem identification and tracking through Reminders and Reminder reports Problem identification and tracking through Reminders and Reminder reports Problem intervention through development of local Reminders and/or Reminder dialogs Problem intervention through development of local Reminders and/or Reminder dialogs Problem intervention through development of local Reminder dialogs converted to Dialog Templates. Problem intervention through development of local Reminder dialogs converted to Dialog Templates. Dialog tool are particularly suited to case management Dialog tool are particularly suited to case management I see a great future for Dialogs in Nursing, DM Education, Nutrition and Pharmacy run clinics! I see a great future for Dialogs in Nursing, DM Education, Nutrition and Pharmacy run clinics! I’ll provide you with a couple of examples… but the possibilities are endless…

53. Gathering Data – Reminder Reports You can utilize reminders with the sole purpose to run a report You can utilize reminders with the sole purpose to run a report Set up cohort and resolution logic Set up cohort and resolution logic Need patients assigned PCP Need patients assigned PCP Run report Run reportEXAMPLES: How many patients who are have DM in past 2 years who are on ACE/ARB have SBP under 125? How many patients who have had a TZD RX in past 3 months have a HGBA1C done in past 6 months that is <7.

54. Local Reminders – Endless potential PROBLEM: DM patients on very expensive TZD therapy without reduction in HgbA1C. DM patients on very expensive TZD therapy without reduction in HgbA1C. Needed a way to easily document interventions. Needed a way to easily document interventions.INTERVENTION: Cohort - Identify patients with DM who have had TZD prescription in past 3 mo Cohort - Identify patients with DM who have had TZD prescription in past 3 mo Due – if no HgbA1C in past 6 months OR last HgbA1C 9 or over Due – if no HgbA1C in past 6 months OR last HgbA1C 9 or over Resolved – when HgbA1C is <9 AND done in past 6 months OR TZD is d/c’ed Resolved – when HgbA1C is <9 AND done in past 6 months OR TZD is d/c’ed

56. Local Reminders – Endless potential PROBLEM Providers/Nurses wanted ALL information required to make decision when ordering labs, meds for DM patients Providers/Nurses wanted ALL information required to make decision when ordering labs, meds for DM patientsINTERVENTION Local dialogs enhanced by taking advantage of TIU objects and TIU Flow sheet objects Local dialogs enhanced by taking advantage of TIU objects and TIU Flow sheet objects Can order appropriate labs/med accordingly Can order appropriate labs/med accordingly

58. The reality of Local Reminders… The bad news… The package is complex with a steep learning curve. The package is complex with a steep learning curve. Dialogs are cumbersome and time consuming to develop and the formatting is imperfect. Dialogs are cumbersome and time consuming to develop and the formatting is imperfect. The good news… Much work can be shared between sites with some modest modification. Much work can be shared between sites with some modest modification. Functionality and enhanced logic will be greatly improved when we can move to Version 2.0 after Code Set Versioning is complete. Functionality and enhanced logic will be greatly improved when we can move to Version 2.0 after Code Set Versioning is complete. We have a robust, growing network of CACs interested in Reminders and have already begun sharing information! We have a robust, growing network of CACs interested in Reminders and have already begun sharing information! Find out if someone else has created your desired Reminder intervention before you create it on your own. If you create a successful intervention through Reminders, SHARE!

59. What questions can you ask reminders? These are the findings you can use to COHORT and to RESOLVE reminders: within these categories, you can define specifics – such as a level or range of values on a measurement or lab, a specific exam result, the status of an order, etc within these categories, you can define specifics – such as a level or range of values on a measurement or lab, a specific exam result, the status of an order, etc DRUG DRUG VA DRUG CLASS VA DRUG CLASS VA GENERIC VA GENERIC EDUCATION TOPIC EDUCATION TOPIC EXAM EXAM HEALTH FACTOR HEALTH FACTOR IMMUNIZATION IMMUNIZATION LABORATORY TEST LABORATORY TEST MEASUREMENT TYPE MEASUREMENT TYPE ORDERABLE ITEM ORDERABLE ITEM RADIOLOGY PROCEDURE RADIOLOGY PROCEDURE REMINDER COMPUTED FINDING REMINDER COMPUTED FINDING REMINDER TAXONOMY REMINDER TAXONOMY REMINDER TERM REMINDER TERM SKIN TEST SKIN TEST VITAL MEASUREMENT VITAL MEASUREMENT REFUSAL TYPE REFUSAL TYPE

60. What can you “resolve” in a dialog? In addition to writing a note, the following findings can be entered into PCC during dialog processing: EDUCATION TOPICS EDUCATION TOPICS IMMUNIZATION IMMUNIZATION SKIN TEST SKIN TEST EXAM EXAM HEALTH FACTOR HEALTH FACTOR PROCEDURE PROCEDURE ICD9 DIAGNOSIS ICD9 DIAGNOSIS VITAL TYPE VITAL TYPE MEASUREMENT TYPE MEASUREMENT TYPE TAXONOMY ORDER DIALOG TAXONOMY ORDER DIALOG

61. DemonstrationDiscussionandQuestions

62. EHR REMINDERS RESOURCE LINK: ftp://ftp.ihs.gov/pubs/EHR/Training/Guides/EHR %20Reminders/ ftp://ftp.ihs.gov/pubs/EHR/Training/Guides/EHR %20Reminders/ Contact info: LCDR Susan Pierce-Richards, MSN, ARNP Email: Susan.Richards@ihs.gov Susan.Richards@ihs.gov Cell: 505-975-4233 (Pacific Time Zone)