1. Clinical (EHR) Reminders Anatomy of a Reminder

2. Session Objectives At the end of this session, participants should be able to: Identify "anatomy" of a reminder – Taxonomies – Terms – age range sets – reminder frequency

3. What interventions are due? Based on Health Maintenance Reminders – National Guidelines and standards of care – Immunization Guidelines Sites decide which reminders to implement based on their needs

4. What does one look like? IHS-PAP SMEAR 2011 No. 109 -------------------------------------------- Print Name: Pap Smear Class: NATIONAL Sponsor: Review Date: Usage: CPRS, DATA EXTRACT, REPORTS Related VA-* Reminder: Reminder Dialog: Priority: Reminder Description: Females every 3 years unless they have had a hysterectomy need a pap smear. Pap smear is determined by CPT code or entry in women's health package Technical Description: Edit History: Edit date: Feb 08, 2011@11:34:34 Edit by: RICHARDS,SUSAN Edit Comments: Exchange Install

5. Baseline Frequency: Do In Advance Time Frame: Do if DUE within 3 months Sex Specific: FEMALE Ignore on N/A: Frequency for Age Range: 3 years for ages 18Y to 99Y Match Text: No Match Text: Findings: Finding Item: IHS-PAP 2009 (FI(1)=CF(40)) Finding Type: REMINDER COMPUTED FINDING Use in Resolution Logic: OR Finding Item: IHS-HYSTERECTOMY 2009 (FI(2)=TX(88)) Finding Type: REMINDER TAXONOMY Use in Patient Cohort Logic: AND NOT General Patient Cohort Found Text: REMINDER DUE: Patient female, 21 with an intact cervix and no Pap Test documented in the past 3 years. This reminder resolves using the RPMS data found by the PCC Health Maintenance Reminder look up. REMINDER ON: 3 months before due date REMINDER ON if due in 3 months

6. General Patient Cohort Not Found Text: General Resolution Found Text: General Resolution Not Found Text: Default PATIENT COHORT LOGIC to see if the Reminder applies to a patient: (SEX)&(AGE)&'FI(2) Expanded Patient Cohort Logic: (SEX)&(AGE)&'FI(IHS-HYSTERECTOMY 2009) Default RESOLUTION LOGIC defines findings that resolve the Reminder: FI(1) Expanded Resolution Logic: FI(IHS-PAP 2009) Web Sites:

7. Approach to reminder creation… WHO needs the intervention (Cohort) Sex, Age, Disease – include or exclude WHEN does the intervention occur (Frequency) Once, yearly, every 6 months WHAT resolves the reminder (Findings and resolution logic) Lab test, Procedure, Measurement, Medication, Immunization…

8. ANATOMY – baseline frequency Baseline frequency – how often you want the intervention done Baseline Frequency DO IN ADVANCE TIME FRAME: 3M// - if you want reminder to turn on early SEX SPECIFIC: - can specify females only or males only IGNORE ON N/A: Baseline frequency age range set Select REMINDER FREQUENCY: 1Y// - can have different frequency for different age groups REMINDER FREQUENCY: 1Y// MINIMUM AGE: 51Y// - if you leave blank, includes all ages MAXIMUM AGE: 80Y// AGE MATCH TEXT: No existing text Edit? NO// AGE NO MATCH TEXT: No existing text Edit? NO//

9. ANATOMY – findings The “parts” Specific pieces of data – Individual findings (lab, med, exam…) Groups of data – Taxonomies (group of diagnosis codes, procedures…) – Terms (set of ed codes, health factors, lab values…) Routines to extract data – Computed Findings

10. ANATOMY – findings DR.EntryName to select a DRUG - Use only when there is no generic drug or drug class. This is entry in drug file – eg. Lisinopril 10mg tab ED.EntryName to select a EDUCATION TOPIC EX.EntryName to select a EXAM HF.EntryName to select a HEALTH FACTOR IM.EntryName to select a IMMUNIZATION LT.EntryName to select a LABORATORY TEST MT.EntryName to select a MEASUREMENT TYPE - this will pull in the IHS measurements from V Measurement file OI.EntryName to select a ORDERABLE ITEM RP.EntryName to select a RADIOLOGY PROCEDURE

11. ANATOMY – findings CF.EntryName to select a REMINDER COMPUTED FINDING - a routine a programmer writes to extract data not otherwise available Examples: TD vaccine is due (or not due) Asthma Control Best Practice prompt is active Allergy to Aspirin

12. ANATOMY – findings TX.EntryName to select a REMINDER TAXONOMY - group of ICD9, CPT, ICD0 RT.EntryName to select a REMINDER TERM - group of findings, or finding w/specific condition ST.EntryName to select a SKIN TEST DC.EntryName to select a VA DRUG CLASS - use this when possible DG.EntryName to select a VA GENERIC - use this when possible VM.EntryName to select a VITAL MEASUREMENT - don’t use, VA vital, not used IHS REF.EntryName to select a REFUSAL TYPE - use judiciously – remember that “unable to screen” is also a refusal file entry – generally

13. ANATOMY – findings Cohort logic Findings can be used in logic to determine WHO Include patients – with Diabetes using Taxonomy (ICD9) – with a measurement over a set level using a Term w/condition Exclude patients – with Colon CA using Taxonomy (ICD9) – with history of Hysterectomy using Taxonomy (CPT, ICD0) – with allergy to Eggs (Computed Finding) – with a measurement over a set level using a Term w/condition

14. ANATOMY – findings Use for Resolution: Findings can be used in logic to determine WHAT Weight (MT.Weight) Exam (EX.Alcohol Screening) Generic drug (DG.Aspirin) Taxonomy of codes (TX.IHS-DEPO ADMIN) – CPT code for Depo Provera administration Term (RT.IHS-ACE/ARB) A current filled rx for a medication in the ACE or ARB class would resolve reminder Term (RT.IHS-LIPID LAB TESTS) Findings with local lab names must be added to the term itself Any of the labs in the term would resolve the reminder

15. Special Cases - Taxonomies Taxonomy is a group of ICD9, ICD0 or CPT codes Can be used to define WHO (Cohort) WHAT (Resolution) Enter the low and the high number to include a range of codes Several ranges can be used in the same taxonomy If the computer finds any item in the list, the finding is true

16. Example of a Taxonomy REMINDER TAXONOMY INQUIRY Jun 16, 2005 3:15:57 pm Page 1 -------------------------------------------------------------------------------- NUMBER: 62 IHS-ALCOHOL SCREEN ----------------------------------- Brief Description: codes for alcohol screen Class: VISN Sponsor: Review Date: Edit History: Edit Date: JUN 13,2005 16:48 Edit By: HAGER,MARY G Edit Comments: Exchange Install Patient Data Source: en,pl if you are using ICD0 procedure codes, you must also include IN (inpatient) for data source

17. ICD9 Codes: Range V11.3-V11.3 Code ICD Diagnosis ---- ------------- V11.3 HX OF ALCOHOLISM Range V79.1-V79.1 Code ICD Diagnosis ---- ------------- V79.1 SCREENING FOR ALCOHOLISM Range 303.00-303.90 Code ICD Diagnosis ---- ------------- 303.00 AC ALCOH DEP INTOX-UNSPEC 303.01 AC ALCOH DEP INTOX-CONTIN 303.02 AC ALCOH DEP INTOX-EPISOD 303.03 AC ALCOH DEP INTOX-REMISS 303.90 ALCOH DEP NEC/NOS-UNSPEC

18. Code ICD Diagnosis ---- ------------- 357.5 ALCOHOLIC POLYNEUROPATHY Range 291.0-291.9 Code ICD Diagnosis ---- ------------- 291.0 DELIRIUM TREMENS 291.1 ALCOHOL AMNESTIC SYND 291.2 ALCOHOLIC DEMENTIA NEC 291.20 DEMENTIA ASSOC W/ETOH, UNSPEC 291.21 DEMENTIA ASSOC W/ETOH, MILD 291.22 DEMENTIA ASSOC W/ETOH, MOD 291.23 DEMENTIA ASSOC W/ETOH SEVERE 291.3 ALCOHOL HALLUCINOSIS 291.4 PATHOLOGIC ALCOHOL INTOX 291.5 ALCOHOLIC JEALOUSY 291.8 ALCOHOLIC PSYCHOSIS,NEC 291.81 ALCOHOL WITHDRAWAL 291.89 OTHER SPEC ALCOHOLIC PSYCH,NEC 291.9 ALCOHOLIC PSYCHOSIS NOS

19. Special Cases – Reminder Terms Allows you to make groups of other findings Examples are lab tests, drugs, education topics, health factors, vital signs If the computer finds one, the result is true and it quits Can use conditions in a reminder term such as SBP>139 or HgbA1c > 7.0

20. Example of a Reminder term IHS-ALCOHOL SCREEN No.43 ---------------------------------------------------------------------------- Class: VISN Sponsor: Date Created: Review Date: Description: Edit History: Edit Date: DEC 3,2006 13:54 Edit By: STANDING BEAR,CORRINE J Edit Comments: Exchange Install Findings: Finding Item: CAGE 0/4 (FI(1)=HF(32)) Finding Type: HEALTH FACTOR Finding Item: CAGE 1/4 (FI(2)=HF(33)) Finding Type: HEALTH FACTOR Finding Item: CAGE 2/4 (FI(3)=HF(34)) Finding Type: HEALTH FACTOR Finding Item: CAGE 3/4 (FI(4)=HF(35)) Finding Type: HEALTH FACTOR Finding Item: CAGE 4/4 (FI(5)=HF(36)) Finding Type: HEALTH FACTOR

21. Example of a Reminder term -with condition IHS-HIGH BP 2007 No.86 ---------------------------------------------------------------------------- Class: LOCAL Sponsor: Date Created: Review Date: Description: Edit History: Edit Date: AUG 4,2008 13:17 Edit By: RICHARDS,SUSAN P Edit Comments: Exchange Install Findings: Finding Item: BP (FI(1)=MT(4)) Finding Type: MEASUREMENT TYPE Condition: I ($P(V,"/",1)>139)!($P(V,"/",2)>89) - true if SBP >139 OR DBP>89

22. Special Cases – computed findings Allows a programmer to write a routine to get data out of ANY RPMS file and use it in a reminder Used in national reminders to get data from the immunization forecaster files Example: NAME: IHS-HEPA// ROUTINE: BPXRMIM1// ENTRY POINT: HEPA// PRINT NAME: HepA//

23. Questions & Discussion