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					              #157
Clinical Reminders for Providers
                      Jessica Murphy, MD
      Chief, Office of Clinical Outcomes Improvement &
                       VISN 17 Data Mart
          VA Heart of Texas Health Care Network

                   MaryPat Pousak, NP
             Primary Care/Occupational Health
             VA Ann Arbor Healthcare System



                                                         1
                 Housekeeping
• Please turn off all cell phones
• Please hold all questions until end of the
  session
• Please use the 3”x5” cards to write down
  all questions.
• Questions not answered today will be on
  the VeHU website.



                                               2
               Course Objectives
− Identify how clinical reminders are
  generated
− Use clinical reminder data
− Access and review clinical maintenance
  data
− Describe the use of clinical reminders to
  fulfill performance measures



                                              3
Where do Reminders come from?
http://vaww.oqp.med.va.gov/default.htm




                                         4
Why do we do clinical reminders?




                                   5
      Clinical Reminders Essential Components

The Cohort (the “Who”)

    - Patients needing an intervention

    - Patients you want to see on a report




                                                6
                  Cohort Example
A group of people to be evaluated
All hyperlipidemia patients
All patients on lovastatin
Hyperlipidemia patients on lovastatin
                       Cohort Identified


                               Patients
                                 On
            Hyperlipidemia
                              Lovastatin
            Diagnosis




                                           7
      Clinical Reminders Essential Components
• The Resolution (the “What”)

    What will turn this reminder OFF?


• Frequency (the “How Often”)

    How often should this reminder or selected
    intervention be “due”

    Monthly, Annually, Once in a lifetime, etc
                                                 8
        Other Clinical Reminder Vocabulary
• Applicable           • Finding

• Due                  • Term

• Taxonomy             • Resolved

• Health Factor        • Boolean Logic




                                             9
                  Applicable

• A reminder is APPLICABLE to a patient if
  they meet the definition of the cohort group.
• They are said to be “in the cohort”.




                                              10
                       Due

• A reminder is DUE for a patient if they are
  in the cohort, and have not yet had the
  intervention –
•     - Treatment
•     - Medication
•     - Education
•     - etc.
•     that is being searched for by the
  reminder.
                                                11
                  Resolved

• A reminder is considered RESOLVED (or
  SATISFIED) if the intervention finding
  defined by the reminder has been
  met/found.




                                           12
                  Finding
• A FINDING is a piece of information that
  can be searched by the reminder in the
  computer.
• It is either there or it isn’t
•      -It’s “FOUND” or “NOT FOUND”
• Examples include progress notes of a
  specific title, selected drugs or drug
  classes, laboratory tests, diagnostic codes
  (ICD-9), immunization records, etc.

                                            13
                    Term
• A TERM is a collection of findings grouped
  together to make one concept.
• Terms may contain more than one kind of
  finding.
• For example, a term called
  “MAMMOGRAM” may include all of your
  site’s tests for Mammograms (Screening,
  Bilateral, Unilateral)
• Terms are useful because they make
  defining a reminder more straightforward.

                                           14
                   Taxonomy
• A TAXONOMY is a collection of ICD-9
• (diagnosis) codes and/or CPT
  (procedure)
• codes that defines a condition or
  treatment.
• The taxonomy that defines Diabetes, for
  example, will have all of the ICD-9 codes
  in the 250.xx series.
• Like terms, taxonomies are helpful to
  define a single clinical concept.
                                              15
                 Health Factor
• HEALTH FACTORs are findings created
  for information about a patient that does
  not exist elsewhere in VistA or CPRS.
• Health factors tell you some fact about a
  patient, such as following examples:
•     - Tobacco user
•     - Declined/Refused FOBT testing
•     - Life expectancy < 6 months


                                              16
                Boolean Logic


• A system of symbolic logic devised by
  George Boole used in computers




                                          17
  Clinical Reminder Puzzle Pieces



                Age                           Frequency
               Gender                           for Age
  Findings               Baseline Frequency



Begin   End    Finding          Due in
                                              Boolean
Date    Date    Terms          Advance
                                               Logic
                                   -
                                 Time
   Finding
  Conditions


                                                          18
       Behind the Scenes



Reminder Dialogue +
Definition =


                           19
                The Ultimate Goal




Improve the care of Our Veterans and Outcomes

                                                20
     Using Clinical Reminders as Tools
• Facilitate Documentation

• Generate Orders
  – Meds
  – Consults


• Treatment Algorithms

• Document Co-Managed Care
                                     21
Using Clinical Reminders as Tools



              Reminder Drawer




     Completed Reminder




                                    22
Facilitate Documentation




                           23
Facilitate Documentation




                           24
Facilitate Documentation



                    Dialog




                    Print Text



                   Info/Orders
                                 25
Generating Orders




                    Order Set
                                26
Generating Orders




                    Order Set
                                27
Facilitate Documentation




                           28
              Treatment Algorithm
• Teaching Tool

• Guide providers when resources are
  scarce

• Guide providers to formulary options first

• Use branching logic in dialogs to further
  facilitate treatment algorithm
                                               29
Treatment Algorithm




                      30
Branching Logic


                    Dialog




                  Print Text




                  Info/Orders
                               31
Generating orders




                    Order Set
                                32
              Co-Managed Care
• Health Factor: a computerized component
  that captures patient information that for
  which no standard code exists.
• Allows us to track and capture data that is
  usually text or values not in our system
• Examples:
  – OUTSIDE LDL <100 (Historical)
  – LIPID MGMT PROVIDED OUTSIDE
    (Historical)

                                            33
Co-Managed Care



              Dialog




             Print Text




             Info/Orders
                           34
Where do you find Clinical Reminders?




                                    35
Where do you find Clinical Reminders?




                                    36
Available Reminders




                      37
Clinical Reminder Options




                            38
Clinical Reminder Options




                            39
            Clinical Reminder Treasures

•   Clinical Maintenance
•   Education Topic Definition
•   Reminder Inquiry
•   Reference Information
•   Evaluate Reminder
•   Reminder Icon Legend




                                          40
              Clinical Maintenance

•   Status
    -Due Date
    -Last Done
•   Cohort
•   Why it is done for this patient
•   Resolution of reminder



                                      41
Clinical Maintenance Example

When was my last tetanus shot?




                                 42
Clinical Maintenance - Td example




                                    43
Elevated HBA1C Example




                         44
Elevated LDL Example




                       45
Elevated LDL Example




                       46
Why is pneumovax due in a 35 year old?




Diagnosis of diabetes coded 4/7/99
                                     47
caused the reminder to become due.
Patient Education Reminders




                              48
Reminder Inquiry




                   49
                       Reminder Inquiry
• HEART FAILURE ACE-I OR ARB USE No. 209
• --------------------------------------------
• Print Name:                     Heart Failure ACE or ARB Use
• Class:                      LOCAL
• Sponsor:
• Review Date:
• Rescission Date:
• Usage: CPRS, REPORTS
• Related VA-* Reminder:
• Reminder Dialog:                   HEART FAILURE ACE
  INHIBITOR USE
• Priority:

                                                                 50
             Reminder Inquiry Continued

• Reminder description

• Technical description

• Baseline frequency

• Findings



                                          51
                                          Reminder Description
Reminder Description:
ACE Inhibitor use within 24 months prior to admission for       of the renin-angiotensin system (RAS) and the
heart failure was introduced as a VA Performance                sympathetic nervous system (SNS) the pathophysiology
Measure in FY2003. This reminder is designed to                 of heart failure has resulted in the development of drugs
prompt the provider to consider ACEI use in heart failure       that have improved morbidity and mortality associated
patients with an ejection fraction of <40%, unless              with HF.
ACE/ARBs are contraindicated. This performance
Measure was updated in FY2005 to allow use of an                The cornerstone of proper medical treatment in patients
ARB. (see below)                                                with heart failure due to left ventricular systolic
                                                                dysfunction (as opposed to diastolic dysfunction) is the
Contraindications include to both ACE/ARB include:              prescription of an angiotensin-converting enzyme
allergy or intolerance to both types of medications,            inhibitor (ACEI). Numerous trials have demonstrated the
bilateral renal artery stenosis or renal artery stenosis with   role of ACEIs in improving HF symptoms and functional
a single kidney, chronic renal dialysis, moderate or            status as well as in decreasing the frequency of
severe aortic stenosis, pregnancy, K+ >5.5 that cannot          hospitalization and mortality rate.
be reduced, symptomatic hypotension or other reason
documented by provider.                                         More recent trails demonstrate that ARBs have an
                                                                important role in HF treatment and LVSD. The VALIANT
Severe cough secondary to an ACE-I should prompt the            trial directly compared an ACEI with an ARB (as well as
provider to switch to an Angiotensin receptor blocker           the combination of the two) in patients with signs and
(ARB) or angiotensin II receptor antagonist (AIIRA).            symptoms of heart failure or LVSD after acute
                                                                myocardial infarction. In this trial, the ARB was
FY05 Update Rationale: Pharmacologically, the value of          statistically "non-inferior" to ACEIs in this patient
diuretics, ACE inhibitors, B-blockers and digitalis has         population. This study was the first to demonstrate the
been established by the results of numerous large scale         equivalence of ARBs in the patient after myocardial
clinical trails, and the evidence supporting a central role     infarction. As a result, effective January 1, 2005, the
for their use is compelling and persuasive. Over the past       CMS/JCAHO Technical Measures has approved the
                                                                inclusion of ARBs in measures AMI-3 and HF-3.
several years, understanding of the effect of activation



                                                                                                                            52
                          Technical Description
Technical Description:
  This reminder is due for patients with a diagnosis on file of heart
  failure unless there is entry of one of the following health factors:
    A) ACE CONTRAINDICATED and B) ARB CONTRAINDICATED
    C) EJECTION FRACTION 40% OR HIGHER (resolves reminder for 3 years)
    D) NO ACE-ON VA STUDY
    E) ACE/ARB NOT USED FOR OTHER REASONS

An entry in the allergy/adverse reaction package will satisfy EPRP reviewer for this
   measure. However clinical reminders are not able to use entries in the
   allergy/adverse reaction package at this time.

Definitions (updated from FY05 technical manual):
Excludes patients with:
     Documentation of participation in a clinical trial testing alternatives to ACEIs or ARB
         as first-line heart failure therapy
     One or more of the following reasons for not prescribing ACEI or ARB documented
         in the medical record:
           1. ACEI and ARB allergy
           2. Moderate or severe aortic stenosis
           3. Other reasons documented by MD/DO/NP/PA. Note must explicitly link the
    reason with           the non-prescription of both ACEI and ARB.

                                                                                          53
          Reminder Frequency Fields

• Baseline Frequency
  - Do in advance time frame
  - Sex specific
• Baseline frequency age range set
  - Select reminder frequency
  - Minimum age
  - Age match text
  - Age no match text

                                      54
            Do In Advance Time Frame
• As a reminder’s due date approaches, this field
  lets you set a reminder to begin displaying as
  “DUE” earlier than the actual date
• Example: Patient received Hypertension
  education on December 7, 2007..reminder
  frequency of 1 year makes it due on December
  7, 2008
• DO IN ADVANCE setting of one month will begin
  showing the reminder on November 7, 2008, so
  that the opportunity to address the reminder is
  not lost should the patient’s appointment be just
  prior to the actual due date

                                                 55
                   Sex Specific

• Reminders can be set applicable for just
  males (PSA) or females (Pap smear)




                                             56
             Reminder Frequency

• A reminder can have more than one
  baseline frequency
  - Each frequency is associated with an
  age range
  - Example: Annually <1Y> for ages 40-69,
  every two years <2Y> for ages 70+
  - These are just BASELINE frequencies..
  you can also adjust the frequency based
  on specific findings or function findings

                                          57
              Special Frequencies

• Special Frequencies
  - 0Y Not Applicable

 - 99Y Once in a lifetime…used to indicate
 a reminder that is resolved permanently
 when done once




                                             58
Baseline Frequency CHF Example




                             59
Baseline Frequency FOBT Example




                                  60
           Finding Type Examples
•   Drug
•   Education topic
•   Health factor
•   Orderable item
•   Radiology procedure
•   Reminder taxonomy
•   Reminder term
•   Exam
•   Lab values

                                   61
Colorectal Cancer Screen Finding
            Example




                                   62
          Reminder Inquiry Continued

• Default Patient Cohort Logic

• Expanded Patient Cohort Logic

• Default Resolution Logic

• Expanded Resolution Logic


                                       63
                                    Basic Logic

            Applicable?
    Does pt meet cohort criteria?


      No                    Yes


Not Applicable
Not Applicable
    Folder
    Folder                  Any Exclusions?


                      Yes                   No

            Not Applicable               Fulfills resolution criteria?
                Folder

                                              Yes                        No

                                     Reminder Resolved            Reminder Due
                                    (In Applicable Folder)      (On Cover Sheet)
                                                                                   64
                  Boolean Logic
• AND (&) – all items must be true
  - True & True = True
• OR (!) – only one item needs to be true
  - True ! False = True
• AND NOT (&’) and OR NOT (!’)
  - True=False
  - False =True
• Examples
  - Simple: X & Y & Z
  - Complex: X & (Y or Z)
                                            65
           Abbreviations/Notations

•   !   Or
•   &   And
•    ’  Not
•   FI  Finding item
•   ()  Used around a number signifies the
        order in which it was programmed
• FI(5) Finding item 5 = the 5th finding item
        defined by the reminder author
• ()    Also used to group and nest
                                            66
          Abbreviations/Notations

•   A    Active
•   DC   Drug class
•   HF   Health factor
•   I    Inpatient
•   N    Non-VA medication
•   O    Outpatient
•   TX   Taxonomy
•   T    Today

                                    67
Colorectal Cancer Screen
        Example




                           68
Exercise Scrn/Ed Logic Example




                                 69
Reference Information




                        70
Reference Information




                        71
Reminder Icon Legend




                       72
Reminder Icon Legend




                       73
       Getting More Out of Reminders
• Panel management

• Future needs

• Assess performance

• Provider Report Cards


                                       74
Panel Management




                   75
Panel Management
         ^=shift 6




                     ENTER




                             76
Panel Management


   Multiple providers OK




                           77
Panel Management




                   78
Panel Management




                   79
80
Panel Management




                   81
          Provider Report Card

Performance = (applicable-due)/applicable

       Applicable-due=completed


       Performance = (221-62)/221


    Performance = (221-62)/221 = 72%

               Goal = 79%
                                            82
Provider Report Card




                       83
   Quality Improvement Cycle




Clinical Reminder   Performance
      Reports         Measures




              Clinical
             Reminders
                                  84
                The Ultimate Goal




Improve the care of Our Veterans and Outcomes

                                                85
#157 Clinical Reminders for
         Providers


  Questions
     ?
                              86

				
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