EHR Reminders - Overview LCDR Susan Pierce-Richards, MSN, ARNP

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) They are visible in the RPMS-EHR in 4 places: –“Alarm clock” icon on the toolbar –Reminders list on the Cover Sheet –“Reminders drawer” on the Notes tab –Reminder VA Health Summary components on the Ad Hoc Summary on the Reports Tab

What are EHR Reminders? Simple terms: Clinical (EHR) Reminders chart reviews for you and tell you what the patient needs

Click here And this opens….

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

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

Reminders terminology…

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

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 Cohort Identified Patients over 50 No history of colon CA

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

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

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

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

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.

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

Finding A FINDING is a piece of information that the reminder searches for in the computer. Findings are used in Reminders and Dialogs –Reminder Taxonomy, Reminder Term, Drug, Ed topic, Exam, HF, Imm, Lab test, Measurement, Orderable, Rad procedure, Skin test, Generic drug or drug class, Refusal –Computed finding – a routine that a programmer writes to extract data not otherwise available

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)

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)

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

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

How do EHR Reminders Differ from Health Maintenance Reminders? CACs can learn to create local reminders using logic and available “findings” EHR Reminder Dialogs –Looks like a Template –Resolves the reminder (enters info into EHR/PCC) –Creates 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

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

Dialog Note Text Entered in RPMS

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

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

Immunization Dialog

National Reminders – Diabetes Care Delivered with dialogs ACE/ARBI Aspirin Dental Exam Eye Exam Foot exam HgbA1C Microalbumin Blood Pressure Depression Screen Lipid

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

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

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

National Deployment 1. Submit EHR Site Tracking Record for Reminders and EHR Reminder Metrics to your Area CAC 2.Coordinate your deployment with your Area CAC 3.Follow steps on the “Roadmap to Reminders Deployment” An initial cohort of clinics has already been selected for initial deployment. During this time, a WebEx training will be recorded and become available to CACs and IT to assist with initial installation and activation. Additional recorded WebEx trainings will be available and are designed to respond to the expected learning needs along the CAC learning curve.

Roadmap Do anytime Site tracking record EHR Reminder metrics Review manuals Identify which reminders you plan to implement (with QI and Clinical Leadership) –Consider a functional suite of reminders based on clinical condition or delegation of work Prepare for testing – find groups of patients for each patient you plan to implement –Use iCare, Qman or other search mechanism –Find patients that will be applicable, not applicable, due, not due for each reminder Create local Quick Orders and Objects that are used in reminders (see Roadmap)

Roadmap (cont.) Do after load Reminders and before Installing reminders Create Quick orders and Objects if not done so previously Create required taxonomies Installation, Activation, Testing and Deployment ***Coordinate this with your Area CAC*** Follow the web ex “EHR Reminders – National Reminder start to Finish Document “Turning on reminders” will assist you in activating Reminders in your EHR Configure your first group of reminders TEST TEST TEST Train Users Deploy

Roadmap (cont.) After Deployment Monitor deployed reminders for problems Obtain feedback –Users –Clinical Leadership –QI committee

Roadmap (cont.) Customizing reminders and dialogs This is based on input from QI, Clinical Leadership and Users. Customize reminders and dialogs – responding the needs of your site –Recorded web ex: EHR Reminders – Copying and Customizing National Reminders EHR Reminders – Customizing National Dialogs Import reminder and dialog from another site – don’t reinvent the wheel if someone else has already created the solution you need! –Recorded web ex EHR Reminders – Sharing Local Reminders & Dialogs

Manuals and Guides Clinical (EHR) Reminders Patch 1005 National Reminder Set Up guide will be released with the patch and patch notes. Clinical (EHR) Reminders Manual ftp://ftp.ihs.gov/pubs/EHR/Training/Guides/EHR Reminders Guide.doc EHR Site tracking record for reminders s EHR Reminder Metrics Other Reminders documents will be posted to the link below: (including “Roadmap to Clinical (EHR) Reminder Deployment) ftp://ftp.ihs.gov/pubs/EHR/Training/Guides/EHR%20Reminders/

Trainings Recorded WebEx sessions will be added as they become available. Availability will be announced on the ListServ. You may also check for RECORDED WebEx presentations at the link below. hhs&service=7 EHR Reminders Overview and Road Map EHR Reminders – National Reminder Start to Finish EHR Reminders – Copying and Customizing National Reminders EHR Reminders – Customizing National Dialogs EHR Reminders – Sharing Local Reminders & Dialogs Future WebEx presentations EHR Reminders – Creating a Local Reminder from start to finish EHR Reminders – Creating a Local Dialog from start to finish EHR Reminders – Dialog Template from start to finish EHR Reminders – Reminder reports