1. Clinical (EHR) Reminders Anatomy & Physiology of a Reminder

2. 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

3. What does one look like? IHS-ALCOHOL SCREEN 2008 No. 68 -------------------------------------------- Print Name: Alcohol Screen Class: NATIONAL Sponsor: Review Date: Usage: CPRS, DATA EXTRACT, REPORTS Related VA-* Reminder: Reminder Dialog: Priority: Reminder Description: Patients are screened annually for alcohol use starting at age 13

4. Technical Description: Edit History: Edit date: Jun 13, 2005@16:48:32 Edit by: HAGER,MARY G Edit Comments: Exchange Install Baseline Frequency: Do In Advance Time Frame: Do if DUE within 3 months Sex Specific: Ignore on N/A: Frequency for Age Range: 1 year for ages 13Y to 110Y Match Text: No Match Text: Patient not in age range for alcohol screening

5. Findings: Finding Item: IHS-ALCOHOL SCREEN (FI(1)=RT(63)) Finding Type: REMINDER TERM Use in Resolution Logic: OR Found Text: Alcohol screen found in the computer within the past year Not Found Text: Alcohol screen not found within the past year. Patients should have yearly alcohol screening Finding Item: IHS-ALCOHOL SCREEN (FI(2)=TX(62)) Finding Type: REMINDER TAXONOMY Use in Resolution Logic: OR Finding Item: IHS-ALCOHOL EDUCATION (FI(3)=RT(65)) Finding Type: REMINDER TERM

6. General Patient Cohort Found Text: General Patient Cohort Not Found Text: General Resolution Found Text: General Resolution Not Found Text: All people over the age of 13 should have a yearly alcohol screen done using the CAGE test. The computer was unable to find this data within the last year Default PATIENT COHORT LOGIC to see if the Reminder applies to a patient: (SEX)&(AGE) Expanded Patient Cohort Logic: (SEX)&(AGE) Default RESOLUTION LOGIC defines findings that resolve the Reminder: FI(1)!FI(2)!FI(3) Expanded Resolution Logic: FI(IHS-ALCOHOL SCREEN)!FI(IHS-ALCOHOL SCREEN)!FI(IHS-ALCOHOL EDUCATION)

7. Approach to reminder creation… Reminder: 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. Approach to reminder creation… Dialog: WHERE this reminder will likely be resolved (location/provider) Help determine if and what type of dialog you need HOW do you want users to resolve this reminder (info on today’s visit, historical info – helps you determine needs of dialog) Helps you determine what you need in your dialog

9. 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//

10. ANATOMY – findings The “parts” 1.Specific pieces of data –Individual findings (lab, med, exam…) 2.Groups of data –Taxonomies (group of diagnosis codes, procedures…) –Terms (set of ed codes, health factors, lab value…) 3.Routines to extract data –Computed Findings (returns due/not due from imm forecaster)

11. ANATOMY – findings DR.EntryName to select a DRUG 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 OI.EntryName to select a ORDERABLE ITEM RP.EntryName to select a RADIOLOGY PROCEDURE CF.EntryName to select a REMINDER COMPUTED FINDING 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 DG.EntryName to select a VA GENERIC VM.EntryName to select a VITAL MEASUREMENT ←don’t use, VA vital REF.EntryName to select a REFUSAL TYPE

12. ANATOMY – findings Use for Cohort: 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

13. 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-PAP) An appropriate CPT code for a PAP test, or the acquisition of cervical cytology would resolve the PAP reminder 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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.90

21. 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//

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

23. 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

24. 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)

25. Physiology… AND 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. FI(2) =1 Statement =1 Patient has DM. Patient does not have HTN FI(1) =1. FI(2) =0 Statement = 0 Patient does not DM. Patient has HTN FI(1) =0. Statement =0 DM HTN AND AND FI(1) & FI (2) = DMHTNStatement Result TTT TFF FTF FFF

26. Physiology… OR 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, FI(2) =1, Statement =1 Patient has had Alcohol Exam. No CAGE recorded. FI(1) =1, FI(2) =0, Statement = 1 Patient has not had Alcohol Exam. CAGE is recorded. FI(1) =0, FI(2) = 1, Statement =1 Patient has had neither Alcohol Exam or CAGE FI(1) =0, FI(2) = 0, Statement =0 OR FI(1) ! FI (2) = Alcohol ExamCAGEStatement Result TTT TFT FTT FFF Alcohol Exam or CAGE

27. Physiology… NOT 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 no colon cancer. AGE =1, FI(1) =0, NOT FI(1) = 1, Statement =1 51yo and colon cancer. AGE =1, FI(1) =1, NOT FI(1) = 0, Statement = 1 49yo and no colon cancer. Age = 0, Statement = 0. 49yo and colon cancer. Age = 0, Statement = 0. 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 Abn Pap h/o hyst

28. 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 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 hysterecomy. 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 Abn Pap h/o hyst

29. 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) 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

30. 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 may 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

31. 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)

32. 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)

33. 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)

34. 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

35. 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

36. National Reminders Distributed with dialogs in PXRM 1.5 p1005 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

37. 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