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Document Sample
Clinical Reminders 2010 and Beyond
Caroline L. Goldzweig, MD, MS
Carol Achtmeyer, MN, ARNP
Gary Barnas, MD
Terri Murphy, RN, MSN
Bryan Volpp, MD
1
Overview
• VHA National Clinical Reminders Committee
– What is it? What does it do?
– Processes for creating national reminders
– Current and future initiatives
• Best practices in creating reminders
• Challenges to building national reminders
• National AAA Screening reminder – a Case
Study
• Update on new and anticipated reminder
tools
2
Faculty
• Caroline Goldzweig
– Chair, National Clinical Reminders Committee
• Carol Achtmeyer
– Primary Care Provider, former CAC; involved in
MH reminder development and research
• Gary Barnas
– Co-Chair, National Clinical Reminders Committee
• Terri Murphy
– National Center for Health Promotion and
Disease Prevention (NCP), former CAC
• Bryan Volpp
– National CPRS and Reminder expert and
consultant
3
The Story of the NCRC
• Chartered in December 2008 – VHA
Directive 2008-084
– “Components of clinical reminders must be
standardized nationally” through a NCRC
which would “manage [the] VHA National
Clinical Reminder Program”
• Under the supervision of the Chief Patient
Care Services Officer
• Representatives include important
stakeholders across VA
4
Broad-based constituency
• Patient Care Services • Health Information
• Primary Care Program Management
Office • Office of Public Health &
• Clinical Informatics Environmental Hazards
Program Office • Clinical Guidelines
• Pharmacy Benefits Workgroup
Management • OI&T Reminder Team
• National Center for • Health Services
Health Promotion and Research/QUERI
Disease Prevention • Field-based CAC, primary
(NCP) care, mental health,
• Office of Quality and education and informatics
Performance leaders
• Office of Nursing
Services
5
Why an NCRC?
• Widespread use of clinical reminders (CRs)
• Quality of CRs variable across VA
• Local development results in redundant
efforts, inefficiencies and inconsistencies
• Relies on scarce specialized skills not
available at all sites
• Standardization could level the playing field
• Standardization facilitates national electronic
performance reporting
6
Scope of the NCRC
• Develop processes for reviewing and
prioritizing requests for national CRs
• Develop processes for CR development,
dissemination and maintenance
• Recommend improvements to the CR
software package
• Monitor implementation of national CRs
and provide guidance to facilities and
VISNs
7
Sounds easy, right?
8
The rubber hits the road:
Developing a game plan for NCRC
• Prioritization
– Focus on less complex clinical issues
amenable to national data roll-up
• New project requirements
– National clinical stakeholder input and support
– In support of a performance measure
• Improve the reminder package
– Make it easier to recognize and standardize
national health factors
9
What makes a reminder “national”
• All national reminders and reminder extracts
released via patch
• Often available earlier via reminder exchange
• National reminders may be:
– Mandated for use in entirety (e.g. TBI screening
reminder)
– Contain mandatory components
– Have implicit mandates because of national data
collection processes
10
National Reminders
OEF/OIF Post Deployment Screen LDL (IHD QUERI) Reminders
Embedded Fragments Women’s health cancer screening and
review reminders
TBI Screening Reminders AAA Screening Reminder
Depression Screening Reminder H1N1 Vaccine Reminder
PTSD Screening Reminder MHV Reminders (12)
AUDIT C (Alcohol) Screening Multiple reminder extracts
Reminder
PTSD Follow-up Reminder
***37 original national reminders rescinded in 2005
11
Standardization Issues
• To use a reminder nationally, at least
some components need to be
standardized
• Challenges for our committee
– How to achieve this type of standardization
with current status of health factors (e.g. no
ability to “lockdown” or uniquely identify them
as national)
– Difficulties and delays in getting national
reminders (“Class 3”) released as a “Class 1”
patch
12
Initial projects “prioritized” for the NCRC
• AAA Screening Reminder
– Response to OIG report that AAA screening not
standardized across VA
– Released together with NCP guidance via reminder
exchange/CR website Nov ’09; Patch 17 June ‘10
• H1N1 Reminder
– Given evolving policy regarding H1N1, NCRC created
sample reminder, released November ‘09
• PTSD Follow-up reminder
– In response to Secretary request for MH outcome measure
– Released to field October ’09; Patch 17 June ‘10
13
Future projects:
focus on performance measures
• Goals
– Allow for national data roll-up using
standardized reminder extracts
– Obviate need for expensive over-sampling
– Allow EPRP chart reviews to focus on more
complex areas
• Potential targets
– MH screening measures
– LDL measures for DM and IHD cohorts
– Women’s health cancer screens
14
Additional projects
• High dose influenza reminder dialog
– Standardize immunization file entry until CPT
codes are created nationally
• Taxonomy updates based on new
CPT/ICD codes or changes to cohort
definitions
• Advocate for reminder upgrades to
support use of SNOMED and other
standardized elements
• Consult on ICD-10 conversion project
15
Anyone can submit a request
• Must be supported by national guidance,
VHA guideline or VHA performance
measures
• Must have a national-level
stakeholder/program office sponsor to
provide clinical expertise
• Clinical issue addressed is easily
assessed/tracked using clinical reminder
technology
16
Challenges for the NCRC
• Relies on volunteers to build, test and
disseminate national reminders
• Maintenance of reminders
• Support for the field
• Advocating for enhancements to
reminders and reminder functionality
17
More information on the NCRC
https://vaww.portal.va.gov/sites/ncrcpublic/default.aspx 18
Best Practices for Clinical
Reminder Development
Carol Achtmeyer, ARNP
Puget Sound VA Primary Care
SUD QUERI
19
Developing Best Practice
• Best Practice
– A process judged as the ultimate way to reach
a goal; a model to be learned from or followed
• Increasing national CR development
– Attention to best practices even more crucial
• Developing Best Practices
– Lessons from research on CR’s can augment
our experience
20
Lessons from research: Barriers
• CR Usability and Workload
– No standardization of dialogs
– Too much detail, too time consuming
– Redundant documentation
– Too many reminders (“reminder fatigue”)
• Role confusion
– Who is responsible to process which CRs
Fung CH et al. Gen Intern Med. 2008
Saleem JJ et al. J Am Med Inform Assoc. 2005, 2007
Patterson ES et al J Biomed Inform 2005
21
Lessons from research: Barriers
• Lack of flexibility
– Requiring Completion
• Does this lead to faulty documentation?
– CR does not apply to patient
• Erroneous diagnosis
• Recommendation conflicts with provider judgment
22
Conveying the critical message
23
How can we improve?
• Usability and Workload
– What is required to resolve CR
– Standardize reminder dialog lay out
• “Who” “What” “When” framework
– Designate who is responsible for CR
• Integrate responsible person into CR print name
24
The Who-What-When
Make text brief
and efficient.
Map headings
names to existing
sections.
25
The Who-What-When
Make text brief
and efficient.
Map headings
names to existing
sections.
26
How can we improve?
• Usability and Workload
– Include only essential text
– Minimize # of clicks
– Use CR dialog templates that also satisfy reminders
– Limit number of CRs
• Flexibility
– Consider “other” free text field
– Avoid use of “required” parameter
• Can encourage faulty documentation
27
The developing role of the NCRC
• Consultant
• Advise reminder developers re: dialog layout
• Standardization
– Develop standardized layouts for dialogs
• Feedback
– Development of national feedback process
• Technical
• End-user
28
Survey Links:
CLINICAL Users
TECHNICAL Staff and CACs
29
Challenges to Creating
National Clinical Reminders
Gary Barnas, MD
Milwaukee VAMC
30
Key issues
• How do we ensure standardization of
reminder data nationally?
• How do we achieve interoperability when
reminders rely heavily on locally
developed Health Factors?
• How do we keep track of on-going
changes to national codes and ensure
taxonomies are up-to-date?
31
What are Health Factors?
• Locally named data element within CPRS
to hold information entered via templates
or reminder dialogs
• Can have an associated date and
comment field
• Example: CURRENT TOBACCO USER
» DATE: 3/23/2010
» COMMENT: 2 ppd
32
Benefits of Health Factors
• Allow entry of a discrete data element that
describes any type of patient-related
information
• Extremely useful when no nationally
recognized coded data elements exists
(e.g. patient declines care)
• Innovative tool not available in all
electronic decision support systems
33
Limitations of Health Factors
• If no longer applicable, a second HF must
be set to override or negate the original
• Example: FORMER TOBACCO USER
• To determine most recent status, HF’s
must either be in the same HF category
(e.g. TOBACCO STATUS) or a reminder
must use MRD (most recent date) logic
34
Limitations of Health Factors
• Difficult to store numeric results within HF
– Computed Finding or Function Finding can be
used to extract numeric value from a
comment field.
• Multiple duplicated HF’s from different
templates or reminder dialogs
– LIFETIME NON-TOBACCO USER
– LIFETIME NON-USER OF TOBACCO
– TOBACCO LIFETIME NON-USER
• HF definitions may not be standardized
across sites
35
NCRC New Service Request (NSR)
• Enhance Identification and Function of
National Health Factors
– Identify type of HF: national, VISN, local
– Separate HF name, “print name”, and
description field with lock-down of national
(VHA) HFs
– Ability to consolidate multiple duplicative HFs
– Standardize entry of outside information
– Outside numeric lab data entered with cross-
reference to lab location and date
36
Alternatives to Health Factors
• Use of nationally standardized coding
systems:
– CPT codes
– HCPCS codes
– SNOMED codes
37
CPT-4 Codes
• “F” Series codes used to represent Quality
Measures
• Standardized definitions
• Exchangeable outside the VA system
• Stored in CDW (corporate data
warehouse)
• An historical encounter date can be
attached
• Example: 3048F = LDL<100
38
HCPCS Codes
• Level 2 – National Codes developed for
CMS (Center for Medicare and Medicaid
Services)
• Temporary codes used before official CPT
codes available
• Example: G8586 = Anti-lipid therapy not
indicated
39
SNOMED Codes
• Systematized Nomenclature of Medicine
• Consists of >1 million medical Concepts
• Example: 110483000 = Tobacco user
• Concepts can be combined for complex
descriptions:
• 284196006|Burn of skin|:
246112005|Severity|=24484000|severe,
363698007|Finding Site|=(113185004|Structure of
skin between fourth and fifth toes|:
272741003|Laterality|=7771000|left)
40
SNOMED Codes
• SNOMED not currently available for use in
CPRS or by clinical reminders
• VA has proposed using SNOMED in the
Problem List with mapping to ICD codes for
billing purposes
• NCRC evaluating option for NSR to allow
reminder package to map directly to
SNOMED codes
• Could obviate need for Health Factors in
many situations
41
Taxonomy Updates
• Taxonomies contain a series of CPT or
ICD-9 codes
– ICD-9 mainly used to identify patient cohorts
eligible for or excluded from a reminder
– CPT mainly used to identify procedures that
include or exclude patients from reminders or
document that a service was provided
42
Taxonomy Update Problems
• CPT and ICD-9 codes are updated on a
regular basis and taxonomies need updating
to keep up with code changes
– Some codes are inactivated
– New codes can be added beyond or within
existing code ranges
– Local sites may have difficulty tracking coding
changes and updating taxonomies
– Existing national taxonomies may not be up-to-
date
43
Taxonomy Update Solutions
• NCRC interfacing with National Health
Information Management and OI&T staff to
systematically identify when taxonomies
may need updating
– HIM staff/NCRC committee members review
codes for those possibly relevant to reminders
– National Reminder sponsors asked to review
codes and determine from clinical standpoint
whether revisions to taxonomies are needed
44
Taxonomy Update Solutions
• Taxonomy updates also required for
changes to performance measure cohort
definitions
– Goal to work with OQP to ensure national
taxonomies always reflect performance
measure cohort definitions
45
The AAA Screening
Reminder: How a national
reminder is developed
Terri Murphy, RN, MSN
National Center for Health Promotion
and Disease Prevention (NCP)
46
Decision to Create a Clinical
Reminder for AAA Screening
• New national clinical
reminders committee
• Evidence and Policy in
place
• OIG recommendations
• Launch of NCP Clinical
Preventive Services
Guidance Project
47
What is an Abdominal Aortic
Aneurysm (AAA)?
AAA is expansion of the aorta
below the renal arteries to a
diameter of 3.0 cm or larger.
48
Evidence & Policy Basis for Screening
• US Preventive Services Task Force (2005):
– The USPSTF recommends one-time screening for abdominal aortic
aneurysm (AAA) by ultrasonography in men aged 65 to 75 who
have ever smoked.
Grade: B Recommendation.
– The USPSTF makes no recommendation for or against screening
for AAA in men aged 65 to 75 who have never smoked.
Grade: C Recommendation.
– The USPSTF recommends against routine screening for AAA in
women.
Grade: D Recommendation.
• VHA Technology Assessment Review (2005)
• VHA Information Letter 10-2007-011 (2007)
49
VA Office of Inspector General
(December 2008)
Recommendations:
1.We recommended that the Under Secretary
for Health advise clinicians to consider
patients’ risk factors for AAA when ordering
abdominal imaging studies, and when
appropriate expand the scope of studies to
include the aorta.
2.We recommended that the Under Secretary
for Health develop a plan, within the context of
available resources, to implement AAA
screening for male smokers 65–75 years old.
50
Guidance on Clinical Preventive
Services on NCP intranet website:
vaww.prevention.va.gov/
• A Clinical Preventive Service
is a service delivered in the
clinical setting for the primary
prevention of disease or for
the early detection of disease
in persons with no symptoms
of the target condition.
• The goal of the service is to
prevent or minimize future
morbidity and mortality.
• Clinical preventive services
typically include screenings,
immunizations, health
behavior counseling, and
preventive medications.
51
Contributors to Development of AAA
Guidance Statement & Reminder
Sub-committee VACO
of National stakeholders and
Clinical experts: NCP,
Reminders PC, Radiology
Committee etc.
Staff at pilot sites Technical staff
52
Thank you to pilot sites!
Nine versions were tested at these sites:
• Tampa • West Palm
• Milwaukee • Las Vegas
• Greater LA • Long Beach
• Northern Cal • Clarksburg
53
Decision 1: Who to screen
• Men ages 65 through 75 who ever smoked
– Defined as a lifetime consumption of at
least 100 cigarettes
– Evidence of the association between
tobacco use and AAA is largely
restricted to cigarette smoking. Other
forms of tobacco, such as cigars, pipes,
and smokeless tobacco, have not been
studied as well with respect to aneurysm
risk.
54
What about people who were already
screened but at a younger age?
Answer: Tests done when the patient was 60 to
64 years old will “count” for screening purposes
as long as the infra-renal aortic diameter was
measured and documented.
– Rationale: Studies have shown that the
incidence of new AAAs over a period of 10
years after a normal screen is low, (0 to 4%)
and that newly discovered AAAs were often
of smaller size and thus of lower risk for
rupture.
56
Decision 2: Who not to screen
• Patients already diagnosed with AAA
• Patients with life expectancy less than 6
months; under the care of hospice; cancer
of the esophagus, liver or pancreas
• Patients not a candidate for surgical repair
– Guidance from 2005 VHA TAP was reviewed
and determined to still be up to date so a link
to a summary of this information is provided in
the reminder
57
Exclusion Options in Reminder Dialog
58
Decision 3: How to screen
• Abdominal Ultrasound is recommended
• Not all abdominal ultrasounds are done for AAA
screening
• Sites need to identify the radiology procedure
(usually just one) that always includes
screening for AAA. This is the only procedure
that will “automatically” resolve the reminder.
• This will resolve the reminder even if image was
inadequate to screen
59
Rationale for Decision
– Proceeding to other studies should not be
automatic
– Other tests such as CT and MRI
–Not studied in trials of screening
–May expose the patient to additional harms
– If a shared decision between the provider
and the patient is made to proceed, a low
dose, non-contrast CT scan of the abdomen
is recommended
60
What about other tests that may include
visualization of the abdominal aorta?
• There are many.
• There was no way to know electronically if
they did or did not include screening for AAA.
• If these are on record for patient, they show
in the reminder dialog.
• PCP can review and use the “Record Prior or
Outside AAA Screening” option if the testing
was adequate to fully evaluate for AAA.
61
62
New Radiology Diagnostic Codes
• As a long term solution, Radiology developed
new diagnostic codes, released on 9/2/09 in
patch RA*5*97 :
– ABDOMINAL AORTIC ANEURYSM PRESENT
– ABDOMINAL AORTIC ANEURYSM NOT
PRESENT
– DOES NOT SATISFY SCREEN FOR AAA
• The first 2 of these codes plus a non-specific
procedure resolves the reminder.
63
Decision 5: What if patient declines ?
• If patient declines screening, reminder is
resolved permanently.
• Sites may configure this differently and
choose a different timeframe.
64
Dissemination and Evaluation
• Dissemination:
– Reminder exchange route (November, 2009)
– Inclusion in Patch 17 (June, 2010)
• Educational calls for primary care,
radiology and technical staff
• Feedback options available on NCRC
SharePoint
65
2010 and Beyond:
Reminder Software
Updates
Bryan Volpp, MD
66
Recent and Upcoming Updates
• PXRM*2*12 – November 2009
• PXRM*2*17 – June 2010
• Immunization Standardization
• Reminder Order Checks – CPRS v28
• Future directions
67
Patch 12 – Reminder Exchange
• Reminder Exchange enhanced to allow
exchange of:
– Reminder Dialogs
– TIU Health Summary Objects
– Reminder Terms, Taxonomies
– Location Lists
– Extracts
68
Patch 12 – Computed Findings (VA-)
• BSA
• DATE FOR AGE
• EMPLOYEE
• IS INPATIENT
– Allows search for Attending, Provider, Treating
Specialty, Admission Date/time
• ADMISSIONS FOR A DATE RANGE (list)
• DISCHARGES FOR A DATE RANGE (list)
• CURRENT INPATIENTS (list)
69
Patch 12 – Other Additions
• Dialog checking and messages for
disabled items
• Mail messages for drug class updates
• Reports:
– Additions for stop codes
– Changes to prevent any missing reports
– % available in reports
– Owner for reports
70
Patch 12 – Reminder Updates
• New National Reminders/Dialogs/Extracts
– Embedded Fragments – Screening & Evaluation
– OEF/OIF Screen Extract
• Updates:
– MH: Depression Screen, Pos AUDC Evaluation
– TBI, OEF/OIF Post Deployment
– MHV reminders: BMI, CRC
– Multiple Taxonomies
• High Risk for Flu/High Risk for Pneumonia
71
Patch 17 - Polytrauma
• Provide a mechanism for the Polytrauma/TBI
teams at each facility to identify patients who
meet the criteria for OEF/OIF Combat
Polytrauma
• New Computed Finding
– VA-ASU USER CLASS
• Allows this reminder to only show as due if
the user is in a specific user class
• New Reminder Parameter (ORQQPX NEW
REMINDER PARAMS): generates mail
message local and national
• In use at most sites since 2001-2002
72
Patch 17 -
• New Computed Findings (VA-)
– WAS-INPATIENT
• Allows searching by:
– admit date
– discharge date
– LOS
– ACTIVE PATIENT RECORD FLAGS
• Search for flags by type, name
73
Patch 17 – Other Updates
• Taxonomy Inquiry option – search for a
code
• Fix MST synchronization problem
• Distribute released national reminders
– VA-AAA SCREENING
– VA-PTSD REASSESSMENT (PCL)
74
Updating National Entries- Issues
• Merge & Overwrite Options do not cover all scenarios
– OEF/OIF and depression screening
• Dates for conversion to use of the Mental Health
Assistant not implemented at all sites
– VA-INFLUENZA H1N1 IMMUNIZATION
• Removed from patch 17 so as not to overwrite lot
#s
• Local copies of national entries are not updated
– High risk for flu/pneumonia
– MHV reminders for patient display – 35 sites set local
reminders to display to patients that should not have
• Timely updates to taxonomies
– Need Sponsors to participate in changes
– Review of code set updates prior to distribution
75
Immunization Standardization
• Immunization and Skin Tests will be
standardized just like VS, Allergies
• Standard list as recommended by the CDC
• Local entries can be renamed to match
national standard – converted to national
• Local entries can be mapped to national
entries
• Reminders and dialogs will be updated during
the process of conversion
76
Reminder Order Checks
• Available as part of CPRS version 28
• Identify a list or group of orderable items that
should trigger an order check
– Create that list
• Write a rule based on a reminder or a
reminder term that evaluates the patient for a
specific characteristic (diagnosis, age, lab
result)
• Define the text that will display when
– The item being ordered is on the list, and
– The patient meets the criteria
77
Reminder Order Checks- Examples
• Fall Risk and Risky Meds
– Orderable items: anti-psychotics, tricyclics,
benzodiazepines, some anti-hypertensives
– Patient: >70, or high fall risk, or a high risk diagnosis;
– Order check: This medication may increase the risk
for falls in this patient who is at high risk for falling.
• Angle closure glaucoma and medications
– Orderable items: anti-cholinergic, adrenergic
(includes 1st generation anti-histamines)
– Patient: Diagnosis of closed angle glaucoma
– Order check: This medication may precipitate acute
elevation of intraocular pressure in this patient.
78
Reminder Order Check - Diazepam
Only displays for patients with a fall in the past year or a high risk diagnosis
79
Reminder Order Check - Diphenydramine
80
Other Future Reminder Changes
• Standardization of data elements
– Mapping items to available codes
• Health factors, Education Topics to CPT,
SNOMED
– Dissemination of national terms for mapping
local entries to national definitions
• Increased use of Extracts for
Measurement
– Larger sample sizes
– Based on nationally required data elements
81
Summary
• Multiple enhancements have been made to the
Clinical Reminders software over the last 12
months
– Take advantage of national reminders when possible
• My HealtheVet reminders – need attention
• Check the status of the new reminder parameter
– ORQQPX NEW REMINDER PARAMS
• Immunization standardization is coming
• Reminder Order checks may be very useful in
some specific situations – cautious use
82
Questions????
83
