Clinical (EHR) Reminders: Powerful tools for CDS and tracking chart deficits Adapted from Susan Pierce-Richards, MSN, ARNP Office of Information Technology, EHR Program Archetype Innovations 2015

From the Agency for Healthcare Research and Quality  In her recent review of clinical decision support for the Agency for Healthcare Research and Quality, Eta Berner of the University of Alabama wrote:  “…although EHRs…can improve accessibility and legibility of information, it is unlikely that there will be major improvements in the quality and cost of care from the use of health IT without proper implementation and use of CDS (Clinical Decision Support).” Archetype Innovations 2015

Clinical Reminders are a CDS system Clinical Reminders do a chart review and tell you what the patient needs or which patients need something. Archetype Innovations 2015

Clinical Reminders System  “The Clinical Reminder system allows the care team to track and improve preventive healthcare and disease treatment for patients and ensure that timely clinical interventions are initiated.” (VA Vista Website)  Clinical Reminders perform automatic chart audits and schedule events based on pre-programmed criteria. Archetype Innovations 2015

Clinical Reminders for CDS Archetype Innovations 2015 User Role Encounter Type Reminder Library Patient Findings Applicable Reminders

Clinical Reminders for Reporting Archetype Innovations 2015 Reminder Inclusion & Exclusion Logic Applicable Patients

How are Reminders created? 1. Start with a desired outcome; e.g. All patients over age 1 need annual flu shot. (What) 2. Develop all associated criteria; e.g. patient age Due every 365 days if influenza vaccination is not documented via CPT code~ identify codes. (How) (continued) Archetype Innovations 2015

Other factors in building a Reminder 3. HIM professionals can create reminders using the logic and available “findings” i.e. coded data in patient EHR 4. Determine the resolution logic EHR Reminder Dialog Template and/or Encounter data 5. Determine what types of encounters reminder should be shown for and/or what types of user class should see this reminder (Who) Archetype Innovations 2015

Reminder libraries can be associated with locations or user class Archetype Innovations 2015

Reminder terminology Archetype Innovations 2015

The Cohort (the “Who”)  Patients needing an intervention  >This patient needs a flu shot  Patients you want to see on a report  >Show all patients who need flu shots Archetype Innovations 2015

Applicability  A reminder is APPLICABLE to a patient if they meet the definition of the cohort  They are “in the cohort” Applicable: Colon Cancer screen – patient is 52 and has NO visit diagnosis or problem of colon cancer in chart NOT Applicable: Colon Cancer screen – patient is 48 and has NO visit diagnosis or problem of colon cancer in chart OR patient is 52 and has history of colon cancer Archetype Innovations 2015

Cohort Examples Diabetes HGB A1C Reminder cohort  Patients with an active ICD diagnosis associated with Diabetes in their problem list Colon Cancer Screen cohort  Patients 50 and older  No history of Colon Cancer Cohort Identified Patients over 50 No history of colon CA Archetype Innovations 2015

The Resolution (the “What”)  What will turn this reminder OFF?  Colon Cancer Screen  Recent FOBT, Colonoscopy, etc  Diabetes HGB A1C  Hgb A1C result within the past year Archetype Innovations 2015

Frequency (“How Often”)  How often should this reminder or selected intervention be due for the cohort?  Colon Cancer  FOBT yearly OR Colonoscopy q10yr, etc.  HBG A1C  HgbA1C yearly Archetype Innovations 2015

Finding (Intervention)  A FINDING is a piece of information that the reminder searches for in the computer  A FINDING is Bianary: It’s there or it’s not  Found or Not Found  Must be coded data Examples: Lab, Pt Ed Topic, Exam, Vital Measurement, ICD, Procedure, Medication, etc. Archetype Innovations 2015

Due  A reminder is DUE for a patient if they are in the cohort (applicable) and have not had the needed (frequency) for the intervention (finding) that the reminder is seeking. Archetype Innovations 2015

Resolved  A reminder is considered RESOLVED if the intervention (finding) and frequency defined by the reminder has been met/found. Archetype Innovations 2015

“Applicable” versus “Not Applicable”  A reminder is considered to be “Applicable” for a patient if one or more findings are present in the patient’s chart.  A reminder is considered to be “Not Applicable” for a patient if no findings are present in the patient’s chart. Archetype Innovations 2015

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) Archetype Innovations 2015

Where are EHR reminders?  CPRS: Reminder Icon – the “Reminder Clock” in the Patient Bar  CPRS: Reminder list on Cover sheet tab  CPRS: Ad Hoc Summary on Reports tab  CPRS: Reminder Dialogues in Reminder “drawer” on the Notes tab  VistA: Reminder Manager’s Menu in VistA (CRM) Archetype Innovations 2015

What are Reminder Dialogs?  Reminder Dialogs are templates linked to reminders that can place orders, enter encounter information, enter vitals and mental health data.  Facilitate documentation  Enter information in CPRS at the same time as writing a note in EHR  Generate orders  Meds  Labs  Consults etc. Archetype Innovations 2015

Reminders – Use for reporting PROBLEM:  Need to find DM patients on very expensive TZD therapy without reduction in HgbA1C. INTERVENTION:  Cohort - Identify patients with DM who have had TZD prescription in past 3 months  Due – if no HgbA1C in past 6 months OR last HgbA1C >9  Resolved – when HgbA1C is <9 AND done in past 6 months OR TZD is DC’d REPORT: Shows all patients on TZD with HgbA1C >9 Archetype Innovations 2015

Reminders – Use for CDS (Clinical Decision Support) PROBLEM  Providers/Nurses want ALL information required to make decision when ordering labs, meds for DM patients INTERVENTION  Reminder dialogs enhanced by taking advantage of TIU patient data objects  Can order appropriate labs/med accordingly Archetype Innovations 2015

What can Reminders track?  These findings can be used to COHORT and to RESOLVE reminders.  Specific values can be identified within these findings  DRUG  DRUG CLASS  EDUCATION TOPIC  EXAM  LABORATORY TEST  MEASUREMENT TYPE  ORDERABLE ITEM  RADIOLOGY PROCEDURE  REMINDER TAXONOMY  REMINDER TERM  SKIN TEST  VITAL MEASUREMENT  HEALTH FACTOR  IMMUNIZATION Archetype Innovations 2015

What can you “resolve” in a dialog? In addition to writing a note, the following findings can be entered during dialog processing:  EDUCATION TOPICS  IMMUNIZATION  SKIN TEST  ORDER  EXAM  HEALTH FACTOR  PROCEDURE  ICD10 DIAGNOSIS  VITAL TYPE  MEASUREMENT TYPE  TAXONOMY ORDER DIALOG Archetype Innovations 2015

Clinical Reminders: The reality The bad news…  The package is complex with a steep learning curve.  Reminder dialogs are cumbersome and time consuming to develop and the formatting is imperfect.  Reminders have been written with ICD-9 logic, need to be rewritten with ICD-10s The good news…  Functionality and logic is adaptable and can be enhanced  There’s endless potential The lesson for students…  Preprogrammed reminders and how they work in an EHR  How logic is constructed and how the Reminder reads the logic  Imagine the possibilities… Archetype Innovations 2015

Demonstration Archetype Innovations 2015