Clinical Reminders for Providers and

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					#157 Clinical Reminders for
      Providers and
      Administrators
            Janice Canales
      VISN 17 Clinical Reminder Manager

        Jessica Murphy, MD
    VISN 17 Chief Health Informatics Officer
                Housekeeping
• Please turn off all cell
  phones
• Hold all questions until
  end of the session
• Use the 3”x5” cards to
  write down all questions.
• Questions not answered
  today will be on the
  VeHU website.
             Objectives

 Gain a better understanding of clinical
              reminder logic

Learn how to gain more information from
                reminders

Learn strategies to streamline reminders

Learn how to manage reminders at your
                facility
Let’s learn how to speak in
 Clinical Reminder (CR)
         Language
      Why do we do clinical reminders?




“The Clinical Reminders system allows caregivers to track and
   improve preventive healthcare and disease treatment
   for patients and to ensure that timely clinical interventions are
   initiated.”
        VHA – Office of Information clinical reminder website
How to speak Clinical Reminders

 COHORT

 • Who turns ON reminder??”
How to speak Clinical Reminders

 COHORT

 • Who turns ON reminder??”


 RESOLUTION

 • What turnssOFF reminder?
How to speak Clinical Reminders

FREQUENCY

 • How often do you want the
   reminder to turn on?
How to speak Clinical Reminders

FREQUENCY

 • How often do you want the
   reminder to turn on?
     – Once in lifetime
     – Annually
     – Monthly
     – One day
True or False?
True or False?
True or False?
True or False?
True or False?
True or False?
True or False?
            CATS!!!

           Don’t these
            belong to
            the same
             family?
     Be Specific!

 Progress note title
     Be Specific!

 Progress note title
 Drug or drug class
     Be Specific!

 Progress note title
 Drug or drug class
 Laboratory test
     Be Specific!

   Progress note title
   Drug or drug class
   Laboratory test
   Diagnostic codes
     Be Specific!

   Progress note title
   Drug or drug class
   Laboratory test
   Diagnostic codes
   Procedure codes
     Be Specific!

   Progress note title
   Drug or drug class
   Laboratory test
   Diagnostic codes
   Procedure codes
   Immunization record
   Exercise
(please stand)
              Exercise
 COHORT (turns ON reminder)
• Age: 18-75
• DM
• Not life expectancy < 6 months
                Exercise
   COHORT (turns ON reminder)
  • Age: 18-75
  • DM
  • Not life expectancy < 6 months

 RESOLUTION (turns OFF reminder)
  • Lipid Panel within 1y (frequency)
  • Value: LDL <100
                Exercise
   COHORT (turns ON reminder)
  • Age: 18-75
  • DM
  • Not life expectancy < 6 months

 RESOLUTION (turns OFF reminder)
  • Lipid Panel within 1y (frequency)
  • Value: LDL <100

  If you are still standing, you are DUE!
Clinical Reminder
    Back-end
 Reminder Dialog
“Front-end” of the Clinical
        Reminder
Template
Template
Reminder Dialog
                Reminder Dialog
 Able to add
instructional
     text
                Reminder Dialog
 Able to add
instructional
     text




 Able to
add data
 objects
                 Reminder Dialog
  Able to add
 instructional
      text




   Able to
  add data
   objects




Able to view
 progress
 note text
                 Reminder Dialog
  Able to add
 instructional
      text



                                     Add
   Able to                         Hyperlinks
  add data
   objects




Able to view
 progress
 note text
                 Reminder Dialog
  Able to add
 instructional
      text



                                           Add
   Able to                               Hyperlinks
  add data
   objects




Able to view
 progress
 note text                          Ability to add
                                   structured data
Structured Data – the *Health Factor*
Structured Data – the *Health Factor*
          Patient presents with a copy of
         lab report from an outside clinic
          Structured Data – the *Health Factor*
                    Patient presents with a copy of
                   lab report from an outside clinic


 Provider
selects the
 outside
  dialog
 option in
 the note
          Structured Data – the *Health Factor*
                    Patient presents with a copy of
                   lab report from an outside clinic


 Provider                                              Provider enters
selects the                                             data into note
 outside
  dialog
 option in
 the note
          Structured Data – the *Health Factor*
                    Patient presents with a copy of
                   lab report from an outside clinic


 Provider                                                Provider enters
selects the                                               data into note
 outside
  dialog
 option in
 the note




                                               Structured
                                              data- HF has
                                                just been
                                               entered into
                                                the chart
   Dialog Review
Clinical Maintenance
   Dialog Review
Clinical Maintenance



         Clinical Reminder
               window
   Dialog Review
Clinical Maintenance
              Reminder
                clock



         Clinical Reminder
               window
   Dialog Review
Clinical Maintenance
              Reminder
                clock



         Clinical Reminder
               window
   Dialog Review
Clinical Maintenance
   Dialog Review
Clinical Maintenance
                  Dialog Review
               Clinical Maintenance




Outside LDL result data
    Date: 1/8/2010
      Value: 99
Using Clinical Maintenance
Using Clinical Maintenance
                          Status
                         Due Date
                        Last Done
   Using Clinical Maintenance
                             Status
Cohort                      Due Date
                           Last Done
     Using Clinical Maintenance
                               Status
 Cohort                       Due Date
                             Last Done


Resolution
      Using Clinical Maintenance
                                Status
  Cohort                       Due Date
                              Last Done


Resolution



Information
Managing Reminders at the
         Facility
   Role of the Administrator
   The Reminder Problem
“Everything begins
 to look like a nail
when your only tool
   is a hammer”
   The Reminder Problem
“Everything begins     • Overused
 to look like a nail
when your only tool
   is a hammer”        • Not well defined

                       • Concrete logic for ill
                         defined measures

                       • Reminder fatigue
 Examples of “Bad Reminders”
Nurse, Repeat BP
 • Reminder due when
   BP was greater than
   140/90
 Examples of “Bad Reminders”
Nurse, Repeat BP
 • Reminder due when
   BP was greater than
   140/90



  Don’t Make
  Reminders to
    Replace
    Training
 Examples of “Bad Reminders”
Clerk, Give Packet
 to Patient
  • Reminder due for all
    patients annually
 Examples of “Bad Reminders”
Clerk, Give Packet
 to Patient
  • Reminder due for all
    patients annually



    Don’t make
   reminders for
   administrative
     purposes
 Examples of “Bad Reminders”
Follow up Positive
 Hep C Antibody
  • Reminder due for any
    positive Hep C to order
    confirmation lab
 Examples of “Bad Reminders”
Follow up Positive
 Hep C Antibody
  • Reminder due for any
    positive Hep C to order
    confirmation lab


    Don’t make
    reminders to
      replace
     processes
Combating the “Bad” Reminders
• Establish a Clinical Reminder Committee

  – Multidiscipline with clinical focus

  – Set Limits

  – Final Authority
Other Reminder Issues



           Overly Complex
              Reminder
            Too many moving parts
Other Reminder Issues
           Immediate Action
              Reminders
              The refresh issue
Other Reminder Issues
           Immediate Action
              Reminders
              The refresh issue
Clinical Reminder SuperUser
Clinical Reminder SuperUser
              • Core group of Clinical
                Reminder Testers
Clinical Reminder SuperUser
              • Core group of Clinical
                Reminder Testers

              • Front line Providers
Clinical Reminder SuperUser
              • Core group of Clinical
                Reminder Testers

              • Front line Providers

              • Defense against the
                overly complex
                reminder
Clinical Reminder SuperUser
              • Core group of Clinical
                Reminder Testers

              • Front line Providers

              • Defense against the
                overly complex
                reminder

              • Build provider Trust
Reminder Fatigue
          Reminder Fatigue
• Lack of education
          Reminder Fatigue
• Lack of education

• Reminder resolution
  is not clear
          Reminder Fatigue
• Lack of education

• Reminder resolution
  is not clear

• Used to punish
          Reminder Fatigue
• Lack of education

• Reminder resolution
  is not clear

• Used to punish

• Truly too many
  reminders
Fight Reminder Fatigue
           • Organize Cover
             Sheet

           • Instructional Text

           • Standardization

           • Provider Education
    Clean up the Cover sheet
• Remove Obsolete
  Reminders

• Reminder Folders

• Naming Convention

• Operational vs
  Reporting
Reminder Folders
Reminder Folders
Reminder Folders


             Not Applicable




              Resolved




                 Due
Reminder Naming Convention
              • Consistent Naming
                V17 = VISN Reminder


              • Legend
                P = Provider
                N = Nursing


              • Same Case

              • Alphabetize
Operational Reminders

Combine like reminders into one
operational reminder and several
      reporting reminders
Operational Reminders

Combine like reminders into one
operational reminder and several
      reporting reminders
Lipid Operational Reminder
Lipid Operational Reminder
Lipid Operational Reminder
Lipid Operational Reminder
Reminder Clinical Maintenance
Reminder Clinical Maintenance
Lipid Reminders
Lipid Reminders
Lipid Reminders
Lipid Reminders
Hyperlinks
Instructional text
Reminder Standardization


           Standardization
                 is not a
              dirty word!
Reminder Standardization


           Standardization
                 is not a
              dirty word!
Reminder Standardization

• Uniform Cover Sheet

• Standard Naming Convention

• Consistent Instruction Text
Reminders Standardization
    Reminders Standardization
Definition
• Standard logic – same
  requirements
• Standard data elements –
  health factors
    Reminders Standardization
Definition                   Dialog
• Standard logic – same      • Local edit is a must
  requirements               • Reflects different
• Standard data elements –     processes or local needs
  health factors
Standardization Benefits
Standardization Benefits
      • Match EPRP
       – One set of rules
     – Predict performance
Standardization Benefits
      • Match EPRP
       – One set of rules
     – Predict performance


    • DataWarehousing
Standardization Benefits
      • Match EPRP
       – One set of rules
     – Predict performance


    • DataWarehousing

         • Future
     – Electronic measures
“To Click or Not to Click?”

              • Do you have to “click”
                every reminder?
“To Click or Not to Click?”

              • Do you have to “click”
                every reminder?



                    NO
              • Instructional text can
                answer this question
“To Click or Not to Click?”
“To Click or Not to Click?”
          Provider Education
• Repetition

• PowerPoint

• SuperUser Group

• Live Training
The “Other” Reminder
    Clinical Reminder Reports
• Actionable Lists

• Provider Report Cards
Clinical Reminder Reports
Clinical Reminder Reports
Clinical Reminder Reports

                            Type
Clinical Reminder Reports

                            Type

                               Enter
Clinical Reminder Reports

                            Type

                               Enter




              Type P
Clinical Reminder Reports
Clinical Reminder Reports

             Type
Clinical Reminder Reports

               Type

          Enter or add more
Clinical Reminder Reports

               Type

          Enter or add more




              Type P
Clinical Reminder Reports

               Type

          Enter or add more




              Type P

                              Date
Clinical Reminder Reports
Clinical Reminder Reports

          Type D
Clinical Reminder Reports

          Type D


                    Same
Clinical Reminder Reports

          Type D


                           Same




                   STOP!
Remedial VISTA
Clinical Reminder Report
Clinical Reminder Report


                      NO
Clinical Reminder Report


                      NO




       STOP!
Clinical Reminder Report


                                  NO




       STOP!   Screen   Printer   Spool
Clinical Reminder Reports
Clinical Reminder Reports




            Compliance
              Totals
Limitations of Reminder Reports
Limitations of Reminder Reports

• Slows VISTA
Limitations of Reminder Reports

• Slows VISTA

• Limited Cohorts
  – Extracts correct
Limitations of Reminder Reports

• Slows VISTA

• Limited Cohorts
  – Extracts correct


• Limited Output
Limitations of Reminder Reports
Limitations of Reminder Reports


• Snapshot in time
Limitations of Reminder Reports


• Snapshot in time



• Black and White
  – Process improvement
Clinical Reminder Reports
               Conclusion
• Understand Reminder Logic
  – Black and White


• Understand Reminder Dialog
  – Structured data


• Clinical Maintenance
              Conclusion
• Managing Reminders
  – Clinical Reminder Committee
  – SuperUser Group


• Combat Reminder Fatigue

• Benefits of Standardization and Reminder
  Reports
Questions

				
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posted:11/30/2012
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