Clinical (EHR) Reminders: Powerful tools for CDS and tracking chart deficits Adapted from Susan...

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).”


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.


Clinical Reminders for CDS


Clinical Reminders for Reporting


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 1-105. Due every 365 days if influenza vaccination is not documented via CPT code~ identify codes. (How)

(continued)


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 logicEHR 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)


Reminder libraries can be associated with locations or user class


Reminder terminology


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


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


Cohort ExamplesDiabetes HGB A1C Reminder cohort

Patients with an active ICD diagnosis associated with Diabetes in their problem list

Colon Cancer Screen cohortPatients 50 and olderNo history of Colon Cancer

Cohort Identified

Patients over 50

No history of colon

CA


The Resolution (the “What”)

What will turn this reminder OFF?

Colon Cancer ScreenRecent FOBT, Colonoscopy, etc

Diabetes HGB A1CHgb A1C result within the past year


Frequency (“How Often”)

How often should this reminder or selected intervention be due for the cohort?

Colon CancerFOBT yearly OR Colonoscopy q10yr, etc.

HBG A1CHgbA1C yearly


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.


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.


Resolved

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


“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.


Basic Reminder Logic

Applicable? Does patient meet cohort criteria?

Not Applicable Folder

No Yes

Any Exclusions?

Yes

Fulfills resolution criteria?

No

Yes No

Reminder Resolved Applicable (blue clock)

Reminder DueDue (red clock)

Not Applicable (white clock)

Not Applicable (white clock)


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)


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.


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


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


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


Clinical Reminders: The realityThe 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…


Demonstration


Clinical (EHR) Reminders: Powerful tools for CDS and tracking chart deficits Adapted from Susan...

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