1. Introduction to Reminder Dialog Templates

2. Session objectives Identify the building blocks of a reminder dialog template –Elements –Groups –Prompts –Findings Understand basic operation of a reminder dialog template How to configure a Reminder Dialog template to show in EHR

3. Definitions EHR USER Template- what your EHR interface looks like (vuecentric template) EHR NOTE Template- brings in data Reminder DIALOG Template- brings in data and enters data

4. EHR USER TEMPLATE

5. EHR Note Template

6. EHR Reminder Dialog Template linked to a Clinical Reminder

7. Dialog template- stand alone

8. 8 What are Dialogs, and why use them ?? One of the documentation interfaces available in EHR. Look, feel, and act like a note template BUT they are not note templates. Primarily used to document the processing of Clinical Reminders (resolve them) Can also be utilized as Note templates, without specific association to a Clinical Reminder. A dialog is a special note template that streamlines writing progress notes, ordering, and data collection via a point & click interface. Text is inserted into progress notes. ICD-9 and CPT Codes, Exams, Education Topics, and Immunizations, Health Factors and Measurements may be passed to Patient Care Component (PCC).

9. continued… Orders can be placed automatically (meds,labs,consults) Supports treatment algorithms Reminders and Dialogs can be SHARED between sites Reminder dialogs can be linked with a note title or with several different titles that may use the same dialog. Reminder dialogs can also be placed in the Shared Template folder and used as Quick Notes

10. Info also goes into RPMS (PCC) Writes note Enter info in dialog

11. Live examples Height reminder Immunization Intake bundle Pharmacy IMM Nursing Care Medication Reconciliation

12. How is a dialog template built? Built in RPMS, need to log back into EHR to see final product. A dialog is like a house. The dialog makes up the outside walls. A group is like a room in the house used to bring like items together yet separate them from the other items within the reminder dialog shell. The elements are pieces of furniture in the room or they can be in the house by themselves. The prompts are accessories that accent the furniture. Can be added to an element for comments or checkbox selection.

13. Dialog Pieces BEH-REM-DLG-DLG will get you here Choose from: D Reminder Dialogs E dialog element F forced value G dialog group P prompts R reminders RG* result group (MH) RE* result element (MH) *MH not used in IHS – These are the building blocks of the dialog – Prompts are the smallest piece – Prompts go on elements – Elements go into dialogs or they can go into groups – Groups go in dialogs

15. Dialog Note Text Entered in RPMS Group Element Prompts

17. Dialog Creation Auto-generated or Manually (preferred) Before you create a dialog you need to make an outline first. What should the dialog look like? Are there items that when selected should open to another section? Are there like items that can be grouped together such as ordering? Should text display in the dialog one way but appears in the note differently?

18. How do Dialogs get Created? Auto-generated once Reminder has been established –Auto generates elements –Does NOT auto generate groups –Once created user will need to confirm that all elements meet user needs & group them if they prefer dialog groups Manually Created –Create your own dialog elements –Create your own dialog groups –Create your additional prompts –Create your own dialogs to support guidelines

19. Pros and Cons of Auto-Generated Dialogs Pros: Automatically linked to a reminder Includes all elements for the reminder findings Auto creates the appropriate prompts Cons: Includes all the elements for the findings Requires you to review them to ensure they are all appropriate Does not generate groups, only elements

20. Pros and Cons of Manually Generated Dialogs Pros: Don’t have a lot of unwanted auto generated prompts to clean up Cons: Requires you to link the dialog to the reminder in separate step (if needed) Must have naming convention Must know what dialog prompts to associate the finding item

21. Basic Building Blocks for Dialog Resolution: Where was it done? In clinic vs historical How was it done? Ordered vs Other Did it get done? Refused (imms only) Finding Item: What was done? Immunization, Orderable Item (quick order-med lab,consult)), Health Factor, Exam, etc Additional Prompts: Allows you to completely document the finding item Document lot #, injection site, comments, etc.

22. Resolution Types Done at encounter Capture items such as exams, immunizations in the note without having to jump from the note tab to the health factor/exam tab Done elsewhere Historical entries such as colonoscopy, mammograms, paps, HIV screening, exams, immunizations, etc Ordered Order a consult, lab, med, radiology, nurse order, etc as soon as you complete the note Contraindicated This resolution type does not work for IHS Other Use for health factors Patient Refused Only works for Immunizations currently

23. FINDING ITEMS Any of the following (data) can automatically be entered into EHR/RPMS by a single click in a reminder dialog: ED. = EDUCATION TOPIC IM. = IMMUNIZATION ST. = SKIN TEST EX.=EXAM HF. = HEALTH FACTOR CPT. = PROCEDURE ICD9.= ICD9 DIAGNOSIS MT. = MEASUREMENT TX. = REMINDER TAXONOMY Q.=ORDER DIALOG 23

24. There’s more! Adding Additional Findings within an Element Adding additional findings automatically “stuffs” the code (Pt Ed, ICD, CPT, etc) into PCC. — As with superbill associations, use judiciously and only when it is true every time it is done. — Remember codes don’t update themselves. If you stuff a code and new ICD9 codes come out, you have to update these manually — ONLY use unique codes as additional findings – don’t use the same additional finding in multiple dialogs (so don’t use ED.CA- TESTS for Pap, Mamm and Colon Cancer – use education unique to the element) Look at the EHR to get an idea what prompts you will need (if any) to enter appropriate information for your findings and additional findings — Pt Ed needs Level of Understanding, Length, etc — Exams need result — Imms need lot #, dose, route, vis, etc — Comments are generally a good thing to offer the user

25. FINDING ITEM: <<<<<<<<<<<<<<<< GROUP CAPTION: PUT A BOX AROUND THE GROUP: SHARE COMMON PROMPTS: MULTIPLE SELECTION: HIDE/SHOW GROUP: GROUP HEADER DIALOG TEXT: Edit? NO// GROUP HEADER ALTERNATE P/N TEXT: Edit? NO// EXCLUDE FROM PROGRESS NOTE: SUPPRESS CHECKBOX: NUMBER OF INDENTS: INDENT PROGRESS NOTE TEXT: Select ADDITIONAL FINDINGS: <<<<<<<<<<<<<<< In Groups or Elements

26. Reminder Dialog Template no additional findings

28. Dialog Menu

29. Definitions PromptDescription NAMEThis is the name of the dialog entry. Reminder dialog entries will default to the name of the reminder for ease in identifying the reminder dialog entry. Dialog elements that are auto-generated use the following naming convention: Finding type prefix _Name from finding file_ _Resolution Status. Your site might want to create one or more special namespaces for dialog entries that you create locally. SOURCE REMINDERThis identifies which reminder definition is associated with this "Reminder Dialog" entry. "Reminder Dialog" type entries are the only entries that require this field. DISABLEThis field disables use of this dialog when it contains text. The text should be a short message explaining why the use of this dialog has been disabled, because it will be displayed if this dialog is selected. Dialogs are disabled when installed from the reminder exchange. CAPTIONThe caption is used for prompt, dialog group, and reminder components. When a prompt has a caption defined, this is the text that should be used whenever the prompt is asked (i.e., Comment:). A dialog group can use the caption field to specify a header to use on a box around the group of dialog elements. The reminder dialog component can use the caption to specify a header to use on a box around the dialog elements for a reminder. PUT A BOX AROUND THE GROUP This option is used to determine whether the components in a group will be presented to the user in a box. If the caption field is defined, it will appear as header text within in the top line of the box. NUMBER OF INDENTSThis is the number of indents that should be made before presenting the group's components/elements. Indent is used only for dialog groups. (optional) SHARE COMMON PROMPTSThis field is used only for a dialog group where different dialog elements have common prompts. Prompts will be shared for all dialog element unless otherwise selected. MULTIPLE SELECTIONThis is used for dialog groups only. 1 indicates that only one element in the dialog group can be selected (radio button and one must be checked) 2 indicates that one or more elements must be selected. (check boxes, at least 1 must be checked) 3 indicates that either none or one selection is required. (radio button, can be left blank) 0 or null indicates no selection required. (check boxes, no restrictions)

30. COMPONENTS (Multiple) SEQUENCE This field contains the components that are used to process a reminder. Generally the components relate to the TYPE of entry in the REMINDER DIALOG file: Reminder dialogs have dialog group or dialog element components. Dialog groups have a combination of dialog element components. Dialog elements have prompt and forced value components. This field specifies the order in which this item will be displayed or processed. (multiple field). OVERRIDE PROMPT CAPTION This text will override the caption for this component in the reminder dialog, when the component is a prompt. When the text is blank, the caption from the prompt entry will be used. START NEW LINEThis flag allows the user to have some control of the display of prompts related to a dialog element. EXCLUDE FROM PN TEXT This flag controls whether or not a component will be excluded from the progress note text when the component is acted upon REQUIREDAdditional prompt must be checked (defaults to not required) RESOLUTION TYPEThis field contains what type of resolution is represented by this dialog entry. FINDING TYPEThe mnemonics allowed are: CPTProcedure EDEducation Topic EXExam HFHealth Factor IMImmunization OIOrderable Item POVDiagnosis (ICD9) STSkin Test MTVital Measurement FINDING ITEMThis field contains the finding item represented by this dialog entry. (elements and groups) ORDERABLE ITEMOrderable item from the reminder definition. <<< generally not used, use quick order finding instead ADDITIONAL FINDINGSIf additional finding items should be posted if the dialog is checked, then they should be entered in this field. The field is relevant to both dialog element and dialog group type records. DEFAULT VALUEThis is the default value for an additional prompt (user sees the value and can change it) FORCED VALUEThis is the value used for a forced value type prompt (user does not see value and does not know what result was stuffed – use extremely judiciously!) EXCLUDE FROM PROGRESS NOTE This field indicates that the question text of the dialog element will be excluded from the progress note. (optional).

31. PROMPT CAPTIONThis is the caption that will be used for this prompt. This caption can be overridden by the OVERRIDE PROMPT CAPTION field in the ITEMS multiple, which can be more specific for the instance of the prompt. DIALOG/PROGRESS NOTE TEXTThis field is only required if the text on the progress note differs from the dialog text. ALTERNATE PROGRESS NOTE TEXT This field defines alternate text to add to the progress note when the progress note text needs to be different from the dialog text. (i.e., Dialog/ Progress Note Text displayed is "Place Influenza Order," but the Alternate Progress Note Text is "Ordered Influenza Vaccine at this encounter."). If there is no text in this field the dialog text will be added to the progress note. *CHECKBOX SEQUENCEComment prompts can have a number of checkboxes associated with the comment prompt. HIDE/SHOWGROUPThis is used for dialog groups. 1 indicates that the group will be hidden until checked; 0 indicates that the group will be displayed. SUPPRESS CHECKBOXIf the field is set to SUPPRESS the dialog element or group header will be displayed without a checkbox. Otherwise the text will be presented with a checkbox. INDENT PROGRESS NOTE TEXTIn a dialog group, the dialog questions can be indented. This field allows the progress note text to be indented also. CLASSThis is the class of definition. National definitions cannot be edited. N NATIONAL V VISN L LOCAL (most common, what you will use in creation) SPONSORThis is the name of a group or organization that sponsors the reminder. REVIEW DATEThe review date determines when the definition should be reviewed to verify that it is current with the latest standards and guidelines.

32. Example: Prompt Checkbox Sequence

33. Example: Checkbox sequence In a prompt, set up checkbox sequences with text

34. Dialog Group Definitions PromptDescription DISABLEDialog will not be displayed in the EHR if there is anything in this field. RESOLUTION TYPEUsed for future reporting. (Optional) FINDING ITEMFinding item to be posted to orders, if the group is checked (optional). GROUP CAPTIONText to appear as box caption if there is a box around the group (not included in P/N) (optional). PUT A BOX AROUND THE GROUPA box will be drawn around the elements in the group - defaults to no box. SHARE COMMON PROMPTSIf elements in the group have a common additional prompt (i.e., comment) this will be displayed only once. (optional) MULTIPLE SELECTIONEnter 1 for one selection only. Enter 2 for one or more. Enter 3 for none or one selection. Enter 0 for no selection required. 1 ONE SELECTION ONLY (radio button, must select one) 2 ONE OR MORE SELECTIONS (check box, at least one must be checked) 3 NONE OR ONE SELECTION (radio button, can leave blank) 0 NO SELECTION REQUIRED (check box, can leave blank) HIDE/SHOW GROUPHide the group elements until the group checkbox is checked - defaults to show. GROUP HEADER DIALOG TEXTText for the group checkbox (this will be added to the Progress Note). GROUP HEADER P/N TEXTText for the P/N if this differs from the field above. (optional) EXCLUDE FROM PROGRESS NOTEExclude the group header text from the P/N. (optional) NOTE: This now only applies to the group header text. Individual elements in the group must now be marked EXCLUDE FROM P/N individually using the ED option in the group edit. SUPPRESS CHECKBOXDisplay group header with no checkbox - defaults to do not suppress. NUMBER OF INDENTSNumber of indents for elements in the group. (optional) INDENT PROGRESS NOTE TEXTIndent P/N the same as the dialog - defaults to no indent. (optional) ADDITIONAL FINDINGSAdditional finding items to be posted to orders, when the dialog group checkbox is checked. (optional) SEQUENCEDisplay sequence number and dialog elements (multiple field).

35. GROUP options NAME: DISABLE: CLASS: LOCAL// SPONSOR: REVIEW DATE: RESOLUTION TYPE: ORDERABLE ITEM: FINDING ITEM: GROUP CAPTION: PUT A BOX AROUND THE GROUP: SHARE COMMON PROMPTS: MULTIPLE SELECTION: ONE SELECTION ONLY// ? Enter 1 for one selection only. Enter 2 for one or more. Enter 3 for none or one selection. Enter 0 for no selection required. Choose from: 1 ONE SELECTION ONLY 2 ONE OR MORE SELECTIONS 3 NONE OR ONE SELECTION 0 NO SELECTION REQUIRED MULTIPLE SELECTION: ONE SELECTION ONLY// HIDE/SHOW GROUP: SHOW// GROUP HEADER DIALOG TEXT: GROUP HEADER ALTERNATE P/N TEXT: EXCLUDE FROM PROGRESS NOTE: SUPPRESS CHECKBOX: NUMBER OF INDENTS: INDENT PROGRESS NOTE TEXT: Select ADDITIONAL FINDINGS:

36. Group setting examples Multiple (1) One or more – check boxes, one or more must be selected Group caption (no), box around group (no), Hide - before checking box to open

37. Group setting examples Multiple (1) One – radio button one, must be selected Group caption (no), box (no), Hide - AFTER checking box to open

38. Group setting examples Multiple (0) None required, checkboxes none, one or more may be checked Group caption (populated), box (yes), SHOW, suppress checkbox (yes)

39. Group setting examples Multiple (2) One or more, check boxes one or more must be selected Group caption (populated), box (yes), SHOW, suppress checkbox (yes)

40. Group setting examples Multiple (3) None or 1 selected, radio button, none or 1 may be selected Group caption (populated), box (yes), SHOW, suppress checkbox (yes)

41. Display text and Progress Note Text These two can be different (used in elements and groups) The display text is what the person entering the note sees in the dialog (grey box) Example: DIALOG/PROGRESS NOTE TEXT: Alcohol Screening - Enter results of the CAGE test ALTERNATE PROGRESS NOTE TEXT: CAGE test scores

42. example

43. Menu option in RPMS BEH-REM-DLG-DLG will get you there

44. DI- Reminder Dialogs Opens up to the reminders View Use CV to see the other items

45. Dialog Pieces Choose from: D Reminder Dialogs E dialog element F forced value G dialog group P prompts R reminders RG* result group (MH) RE* result element (MH) *MH not used in IHS – These are the building blocks of the dialog – Prompts are the smallest piece – Prompts go on elements – Elements go into dialogs or they can go into groups – Groups go in dialogs

46. D for dialogs Always check for where you are Is it linked? AD for adding Check Status

47. Auto-Generate a Dialog Select Item: Quit// ad Add Reminder Dialog GENERATE DIALOG AUTOMATICALLY: Y// SELECT REMINDER TO GENERATE DIALOG FROM: IHS-ALCOHOL SCREEN NATIONAL ENTER A UNIQUE DIALOG NAME: IHS-ALCOHOL SCREEN// OVERWRITE EXISTING REMINDER DIALOG ? YES// LINK DIALOG TO REMINDER: YES// ENABLE DIALOG: NO// - May want this to be a yes REPLACE ANY EXISTING DIALOG ELEMENTS? NO// –Be very careful if you ever set this to YES

48. Look at the dialog

49. Look at the Progress Note Text

50. It’s very messy….

51. Clean it up Delete items not needed Edit what it says in the progress note Add new elements if desired Auto-generate does NOT make any groups. It does make the elements You can choose to re-make the dialog and put the elements into groups if desired

52. After a lot of editing, and grouping it can look like this…

53. Here’s an example immunization dialog with prompts.

54. Naming conventions Use consistent prefix!!!! Make sure you know its yours – consider appending with site names if you make significant changes and for groups HD text CPT ICD9 ED EX IMM (national uses IM, consider using IMM for locally created ones) HF TX taxonomy GP groups (Consider GP for locally created ones) PR prompts

55. Recommended Process Write out what you want to create Then answer these questions: Resolution: (important if linking to a clinical reminder) –Where was it done? In clinic vs historical –How was it done? Ordered vs Other –Did it get done? Refused Finding Item: –What was done? Immunization, Orderable Item, Health Factor, Exam, etc –Is there any other additional findings? “Stuffing” of CPT code, and patient education when giving an immunization Additional Prompts: –Allows you to completely document the finding item Document lot #, injection site, comments, etc.

56. draw it on paper

57. How to show a dialog in EHR See script

58. Resources New Reminder classes- check schedule FTP folder –ftp://ftp.ihs.gov/pubs/EHR/Training/Manuals/EHR%20 Reminders/ Recorded WebEx trainings –Reminders start to finish (several done by Mary Hager) –Getting started series (several done by Susan Richards) Road map to deployment Reminders – copy and customize Dialogs – customize Importing/Exporting reminders

59. QUESTIONS & DISCUSSION Live example (time permitting)