Clinical Reminders


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1 : Developed by the VHA Clinical Reminders! This presentation was developed by the Veterans Health Affairs
2 : Developed by the VHA Clinical Reminders, Reminder Dialogs and Reminder Reports
3 : Developed by the VHA Decision Support Tools Order Checks – real time Notifications – View Alerts Orders Templates for documentation Clinical Reminders useful for guideline implementation
4 : Developed by the VHA Clinical Reminders Basics Setup Customization Reminder Dialogs Examples Reminder Reports
5 : Developed by the VHA This session Wide variation in prior exposure Wide variation in background I’m going to lose some of you Basic understanding of the reminders is critical for understanding problems with them and with the reports
6 : Developed by the VHA Goals of Reminder Use Improve Care Standardize Improvements Implement Guidelines Improve Efficiency
7 : Developed by the VHA
8 : Developed by the VHA Clinical Reminders Electronic reminders based on diagnoses or patient characteristics Set to return at a given frequency Based on Boolean logic Can be made to apply, not apply or be satisfied by any data recorded as a data element in VistA
9 : Developed by the VHA Old Clinical RemindersLimitations Types of data (findings) not readily usable: Drugs Values Orderable items Limited logic
10 : Developed by the VHA Old Clinical Reminders:Separate Processes View a reminder Order tests Write progress note Enter encounter information
11 : Developed by the VHA Enhancements withClinical Reminders 1.5 Drug findings Values for some findings (VS, lab, orders) Orderable items No more “target” findings 2 logic strings – Cohort and Resolution Complex resolution logic possible
12 : Developed by the VHA Enhancements with Reminders 1.5 Web links Education topics Processing of reminders in the CPRS GUI Grouping of reminders Reminder Terms
13 : Developed by the VHA Linking of Processes Orders, text, encounter information can be entered in the process of evaluating and viewing what is needed.
14 : Developed by the VHA Clinical Reminders Clinical reminders can appear for any patient based on patient characteristics Must be some “coded” information about patients - must be a data field Triggered by age, sex, diagnosis, etc.
15 : Developed by the VHA Applicable or NASatisfied or Due Applicable or not applicable If a reminder is applicable for a patient, then the reminder is either due or satisfied Reminders can work well to facilitate completion of a step in a guideline
16 : Developed by the VHA Diabetes Microalbumin Reminder Urine microalbumin is due for patients with diabetes who have a neg/trace urine protein and who do not already have diabetic renal disease and it is satisfied by a urine microalbumin result, an outside urine microalbumin result or a 24 hour urine protein.
17 : Developed by the VHA Urine Microalbumin Applicable: To all Diabetics (all sexes, all ages) with normal/trace urine protein without diabetic renal dz. Not applicable: To non-diabetics or to pts. with previously diagnosed renal disease or to patients who have no urine protein recorded.
18 : Developed by the VHA Diabetes Microalbumin Reminder Applicable: (SEX) and (AGE) and (TX:diabetes) and (Lab: urine protein neg) and not (TX: diabetic renal disease)  Resolved: (Lab: urine microalbumin) or (HF: outside urine microalbumin result) or (Lab: 24 hour urine protein)
19 : Developed by the VHA Basic Reminder Triggered to apply to a group of patients by some characteristic or combination Due at a given frequency Satisfied by some characteristic, action or test result Findings – characteristics, codes, results, items that trigger or satisfy a reminder e.g. Age, sex, DM, DM renal dz, Microalbumin, Urine protein, 24 hr urine, outside result
20 : Developed by the VHA What types of findings are there? ICD & CPT codes Immunizations Skin tests Education Topics Exams Health Factors Lab Tests Radiology Tests Drug (dispense drug) Generic Drug (50.6 - National Drug) Drug Class Mental Health Tests Orderable Items Computed Finding
21 : Developed by the VHA What role do Findings have? Findings can make a reminder applicable, not applicable or satisfied Combinations of findings can be required Findings can change the frequency that a reminder is due Values for many findings can be usede.g. BP values, lab values, status of orders
22 : Developed by the VHA Findings: Taxonomies A taxonomy is a collection of ICD or CPT codes E.g. Diabetes, High risk for pneumonia, Cirrhosis, Vesting codes Taxonomies can be set to include all codes, or combinations of codes from PL, PTF, PCE (from PTF – all, DXLS or Primary DX
23 : Developed by the VHA Findings: Immunizations/Skin tests Immunizations from the IMMUNIZATION file Skin tests from the SKIN TEST file Entry of the immunization or skin test is coupled with entry of the CPT code and vice versa
24 : Developed by the VHA Findings: Education Topics Education topics are defined in the EDUCATION TOPICS file Education topics can have goals and standards defined in that file Level of understanding can be entered with education
25 : Developed by the VHA Findings: Exams Defined in the EXAM file Not mapped to CPT codes E.g. Diabetes foot inspection, Rectal exam Qualifier of normal or abnormal can be entered
26 : Developed by the VHA Findings: Health Factors A Health Factor is any patient characteristic (history, family history, refusal, outside result, screening) Can be used to record any data that is not easily captured using another type of finding or code E.g. No risk factors for Hep C, Outside HbA1c result, Fam Hx of breast cancer, CAGE score, Research Patient
27 : Developed by the VHA Findings: Lab Test Any CH/HE subscripted lab test can be used Values for lab tests can be used E.g. Creat, Hb A1c>8, CD4 <200, LDL >130, Urine Microalbumin > 3
28 : Developed by the VHA Findings: Drugs Drug, generic drug, drug class Drug - Dispense drug (dosage forms) Generic Drug - National drug Drug Class - ACE inhibitors, Beta blockers Date is calculated based on last fill date plus days supply
29 : Developed by the VHA Findings: Mental Health Test Instruments recorded in the MH package Values for scores can be used Access to the results may depend on keys in the MH package
30 : Developed by the VHA Findings: Orderable Items Orderable items are anything that can be ordered – lab order, pharmacy order, nursing item ordered Any orderable item can be used E.g. Daily Wt, Occult Blood Panel order, Immunizations, Restraint order, Nursing pneumovax order
31 : Developed by the VHA Findings: Computed Findings Mumps routine that returns information from another field somewhere in Vista E.g. Progress note title, Period of service Exported standard CFs VA-BMI VA-DATE OF BIRTH VA-DATE OF DEATH VA-PRIMARY CARE PROVIDER VA-PRIMARY CARE TEAM VA-RACE
32 : Developed by the VHA Findings: Reminder Terms Groups of items that mean the same thing E.g. Pneumovax: Pneumovax outpatient nursing orderable, pneumovax drug findings Oral inhaler: 3 drug classes Mapping of local terminology to a national Reminder Term to allow standardization of local items to national terms Each finding in a reminder term can have the following fields set: EFFECTIVE PERIOD, USE INACTIVE PROBLEMS, WITHIN CATEGORY RANK, CONDITION, MH SCALE
33 : Developed by the VHA Finding Types ICD & CPT codes Immunizations Skin tests Education Topics Exams Health Factors Lab Tests Radiology Tests Drug (dispense drug) Generic Drug (50.6 - National Drug) Drug Class Mental Health Tests Orderable Items Computed Finding
34 : Developed by the VHA Findings Virtually ANY characteristic recorded as a data element and not text, can be used in a reminder as a finding Some things are easier to include in a reminder – standard findings A finding can make a reminder applicable or not applicable to a group A finding can satisfy or change the frequency of any reminder
35 : Developed by the VHA New version: Examples Inhaler education for drug class oral inhalers Diabetic and BP>140/85 needs anti-HTN Microalbuminuria and an ACE Inhibitor INH and liver enzymes AIMS test based on drug class Afib and anticoag PFTs and bleomycin TSH>10 and levothyroxine Hep C and need for Hep A Ab/vaccine Hep C and evaluation for therapy
36 : Developed by the VHA Reminder Management RL List Reminder Definitions RI Inquire about a Reminder Defin RE Add/Edit Reminder Definitions RC Copy Reminder Definition RA Activate/Inactivate Reminders
37 : Developed by the VHA Reminder Setup: Reminder Edit DIABETES - URINE MICROALBUMIN Select one of the following: A All reminder details G General B Baseline Frequency F Findings L Logic D Reminder Dialog W Web Addresses
38 : Developed by the VHA G - General PRINT NAME: Diabetes - Urine Microalbumin RELATED REMINDER GUIDELINE: INACTIVE FLAG: REMINDER DESCRIPTION: Patients with diabetes should have a yearly urine microalbumin. . . . TECHNICAL DESCRIPTION:. . . PRIORITY:
39 : Developed by the VHA B - Baseline Baseline Frequency DO IN ADVANCE TIME FRAME: 1M// SEX SPECIFIC: IGNORE ON N/A: *// Baseline frequency age range set Select REMINDER FREQUENCY: 0Y// REMINDER FREQUENCY: 0Y// MINIMUM AGE: MAXIMUM AGE: AGE MATCH TEXT: AGE NO MATCH TEXT:
40 : Developed by the VHA F - Findings Findings: HF LIFE EXPECTANCY < 3 MONTHS LT MICRO ALBUMIN LT POTASSIUM LT URINE PROTEIN (QUANT) RT HTN MEDS TX DIABETES TX DIABETIC RENAL DISEASE VM BLOOD PRESSURE DC CV800
41 : Developed by the VHA Finding: Taxonomy Diabetes FINDING ITEM: DIABETES// MINIMUM AGE: MAXIMUM AGE: REMINDER FREQUENCY: 1Y// FOUND TEXT: A serum creatinine, lipid profile and a HbA1c are recommended annually for all diabetic patients. NOT FOUND TEXT: No history of diabetes on file. RANK FREQUENCY: USE IN RESOLUTION LOGIC: USE IN PATIENT COHORT LOGIC: AND// EFFECTIVE PERIOD: 2Y// USE INACTIVE PROBLEMS: N//
42 : Developed by the VHA Finding: Drug Class FINDING ITEM: CV800// MINIMUM AGE: MAXIMUM AGE: REMINDER FREQUENCY: FOUND TEXT: Pt. Currently or previously on an ACE Inhibitor. NOT FOUND TEXT: RANK FREQUENCY: USE IN RESOLUTION LOGIC: USE IN PATIENT COHORT LOGIC: EFFECTIVE PERIOD:
43 : Developed by the VHA Finding: Health Factor FINDING ITEM: LIFE EXPECTANCY < 3 MONTHS MINIMUM AGE: MAXIMUM AGE: REMINDER FREQUENCY: FOUND TEXT: NOT FOUND TEXT: RANK FREQUENCY: USE IN RESOLUTION LOGIC: OR// USE IN PATIENT COHORT LOGIC: EFFECTIVE PERIOD: 3M// WITHIN CATEGORY RANK: CONDITION:
44 : Developed by the VHA Condition (values) FINDING VALUE Education Topic Level of Understanding Exam Result Health Factor Level/severity Immunization Series Laboratory Test Value Mental Health Inst Raw score Orderable Item Status Computed Finding Determined by programmer Skin Test Results Vital Measurement Rate
45 : Developed by the VHA Rules for Findings The finding that makes the reminder due the most often will be used if 2 findings have the same RANK FREQUENCY Health Factors in the same category – only the most recently entered will be used, unless If the WITHIN CATEGORY RANK is set to ‘0’ then any HFs in the same category will be evaluated as if they were in separate categories For HFs in the same category, the WITHIN CATEGORY RANK determines which one will be used if more than one is entered for a visit
46 : Developed by the VHA More Rules for Findings Findings that are not part of the cohort or resolution logic and do not change the frequency are informational findings EFFECTIVE PERIOD defines how long a finding should be valid. When the effective period has passed, the finding will be ignored
47 : Developed by the VHA L - Logic PATIENT COHORT LOGIC: PCL FOUND TEXT: PCL NOT FOUND TEXT: RESOLUTION LOGIC: RESL FOUND TEXT: RESL NOT FOUND TEXT:
48 : Developed by the VHA Modified Logic PATIENT COHORT LOGIC: FI(1)& (FI(2)!FI(3)) RESOLUTION LOGIC:
49 : Developed by the VHA D - Dialog Reminder Dialog REMINDER DIALOG: DIABETES - URINE MICROALBUMIN//
50 : Developed by the VHA W - Web Addresses Select URL: http://va.gov/nchp WEB SITE TITLE: VA National Center for Health Promotion WEB SITE DESCRIPTION: VA Website for NCHP
51 : Developed by the VHA Reminder Setup: Reminder Edit DIABETES - URINE MICROALBUMIN Select one of the following: A All reminder details G General B Baseline Frequency F Findings L Logic D Reminder Dialog W Web Addresses
52 : Developed by the VHA Testing Use on health summary Run reports using the reminder and validate the data Reminder Test option Have clinicians validate the reminder in clinic
53 : Developed by the VHA Setup Reminder Display Add to health summaries Add to cover sheet of the CPRS GUI By user, location, service, division, system Add to Reminder Group(s) Groups can be set for display by user, etc. Add to Reports
54 : Developed by the VHA Reminder Dialogs
55 : Developed by the VHA Build a Dialog Dialog Management… Dialog Parameters… Reminder Resolution Status Health Factor Resolutions General Finding Type Parameter Finding Item Parameters Taxonomy Dialog Parameters Reminder Dialogs
56 : Developed by the VHA Reminder Dialogs Dialogs are associated with and/or built from a specific reminder Only one dialog can be assigned to each reminder A dialog can be auto-generated from a reminder – each finding in the reminder is included in the dialog Each auto-generated element has characteristics as defined in the Dialog Parameters
57 : Developed by the VHA Reminder Dialog Components Dialog Elements – are assoc. with specific findings (HF, orders, exams) Forced Values Additional Prompts Result Group (Mental Health) Result Element (Mental Health) Groups May contain multiple elements
58 : Developed by the VHA
59 : Developed by the VHA
60 : Developed by the VHA Clinical Reminders:New Features Processing of reminders Point and click resolution of a reminder Progress note text, data, orders Reminder, note, data, action tied to one process
61 : Developed by the VHA Clinical Reminders: New Features Grouping of reminders Diabetes, Nurse, ID Clinic, Preventive Health, Health Tech, Hepatitis Access to Education Topics Web links Improved Reminder set up and logic
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