Clinical (EHR) RemindersClinical (EHR) Reminders

Anatomy & Physiology of a Reminder

What interventions are due?

• Based on Health Maintenance Reminders– National Guidelines and standards of care– Immunization Guidelines

• Sites decide which reminders to implement based on their needs

What does one look like?IHS-ALCOHOL SCREEN 2008 No. 68--------------------------------------------Print Name: Alcohol ScreenClass: NATIONALSponsor: Review Date: Usage: CPRS, DATA EXTRACT, REPORTS Related VA-* Reminder:Reminder Dialog:Priority:Reminder Description: Patients are screened annually for alcohol use starting at age 13

Technical Description: Edit History: Edit date: Jun 13, 2005@16:48:32 Edit by: HAGER,MARY G Edit Comments: Exchange InstallBaseline Frequency: Do In Advance Time Frame: Do if DUE within 3 months Sex Specific: Ignore on N/A: Frequency for Age Range: 1 year for ages 13Y to 110Y Match Text: No Match Text: Patient not in age range for alcohol

screening

Findings: Finding Item: IHS-ALCOHOL SCREEN (FI(1)=RT(63)) Finding Type: REMINDER TERM Use in Resolution Logic: OR Found Text: Alcohol screen found in the computer within the past year Not Found Text: Alcohol screen not found within the past year. Patients should have yearly alcohol screening Finding Item: IHS-ALCOHOL SCREEN (FI(2)=TX(62)) Finding Type: REMINDER TAXONOMY Use in Resolution Logic: OR Finding Item: IHS-ALCOHOL EDUCATION (FI(3)=RT(65)) Finding Type: REMINDER TERM

General Patient Cohort Found Text: General Patient Cohort Not Found Text:General Resolution Found Text:General Resolution Not Found Text: All people over the age of 13 should have a yearly alcohol screen done using the CAGE test. The computer was unable to find this data within the last year Default PATIENT COHORT LOGIC to see if the Reminder applies to a patient: (SEX)&(AGE) Expanded Patient Cohort Logic: (SEX)&(AGE) Default RESOLUTION LOGIC defines findings that resolve the Reminder: FI(1)!FI(2)!FI(3) Expanded Resolution Logic: FI(IHS-ALCOHOL SCREEN)!FI(IHS-ALCOHOL SCREEN)!FI(IHS-ALCOHOL

EDUCATION)

Approach to reminder creation…

Reminder:

• WHO needs the intervention (Cohort)Sex, Age, Disease – include or exclude

• WHEN does the intervention occur (frequency)Once, yearly, every 6 months

• WHAT resolves the reminder (Findings and resolution logic)Lab test, Procedure, Measurement, Medication,

Immunization…

Approach to reminder creation…

Dialog:• WHERE this reminder will likely be resolved

(location/provider)

Help determine if and what type of dialog you need• HOW do you want users to resolve this reminder (info on

today’s visit, historical info – helps you determine needs of dialog)

Helps you determine what you need in your dialog

ANATOMY – baseline frequency

Baseline frequency – how often you want the intervention done

Baseline Frequency DO IN ADVANCE TIME FRAME: 3M// ←if you want reminder to turn on early

SEX SPECIFIC: ←can specify females only or males only

IGNORE ON N/A: Baseline frequency age range set Select REMINDER FREQUENCY: 1Y//←can have different frequency for different age

groups REMINDER FREQUENCY: 1Y// MINIMUM AGE: 51Y// ← if you leave blank, includes all ages

MAXIMUM AGE: 80Y// AGE MATCH TEXT: No existing text Edit? NO// AGE NO MATCH TEXT: No existing text Edit? NO//

ANATOMY – findings

The “parts”

1. Specific pieces of data – Individual findings (lab, med, exam…)

2. Groups of data– Taxonomies (group of diagnosis codes, procedures…)– Terms (set of ed codes, health factors, lab value…)

3. Routines to extract data– Computed Findings (returns due/not due from imm

forecaster)

ANATOMY – findings DR.EntryName to select a DRUG ED.EntryName to select a EDUCATION TOPIC EX.EntryName to select a EXAM HF.EntryName to select a HEALTH FACTOR IM.EntryName to select a IMMUNIZATION LT.EntryName to select a LABORATORY TEST MT.EntryName to select a MEASUREMENT TYPE OI.EntryName to select a ORDERABLE ITEM RP.EntryName to select a RADIOLOGY PROCEDURE CF.EntryName to select a REMINDER COMPUTED FINDING TX.EntryName to select a REMINDER TAXONOMY ← group of ICD9, CPT,

ICD0 RT.EntryName to select a REMINDER TERM ←group of findings, or finding

w/specific condition

ST.EntryName to select a SKIN TEST DC.EntryName to select a VA DRUG CLASS DG.EntryName to select a VA GENERIC VM.EntryName to select a VITAL MEASUREMENT ←don’t use, VA vital

REF.EntryName to select a REFUSAL TYPE

ANATOMY – findingsUse for Cohort:

Findings can be used in logic to determine WHO• Include patients

– with Diabetes using Taxonomy (ICD9)– with a measurement over a set level using a Term

w/condition

• Exclude patients– with Colon CA using Taxonomy (ICD9)– with history of Hysterectomy using Taxonomy (CPT, ICD0)– with allergy to Eggs (Computed Finding)– with a measurement over a set level using a Term

w/condition

ANATOMY – findingsUse for Resolution: Findings can be used in logic to determine WHAT• Weight (MT.Weight)• Exam (EX.Alcohol Screening)• Generic drug (DG.Aspirin)• Taxonomy of codes (TX.IHS-PAP)

An appropriate CPT code for a PAP test, or the acquisition of cervicalcytology would resolve the PAP reminder

• Term (RT.IHS-ACE/ARB)A current filled rx for a medication in the ACE or ARB class would resolve

reminder• Term (RT.IHS-LIPID LAB TESTS)

Findings with local lab names must be added to the term itselfAny of the labs in the term would resolve the reminder

Special Cases - Taxonomies

• Taxonomy is a group of ICD9, ICD0 or CPT codes• Can be used to define

WHO (Cohort)

WHAT (Resolution)• Enter the low and the high number to include a range

of codes• Several ranges can be used in the same taxonomy• If the computer finds any item in the list, the finding is

true

Example of a TaxonomyREMINDER TAXONOMY INQUIRY Jun 16, 2005 3:15:57 pm Page 1-------------------------------------------------------------------------------- NUMBER: 62 IHS-ALCOHOL SCREEN----------------------------------- Brief Description: codes for alcohol screen Class: VISNSponsor:Review Date: Edit History: Edit Date: JUN 13,2005 16:48 Edit By: HAGER,MARY G Edit Comments: Exchange Install Patient Data Source: en,pl

ICD9 Codes: Range V11.3-V11.3 Code ICD Diagnosis ---- ------------- V11.3 HX OF ALCOHOLISM Range V79.1-V79.1 Code ICD Diagnosis ---- ------------- V79.1 SCREENING FOR ALCOHOLISM Range 303.00-303.90 Code ICD Diagnosis ---- ------------- 303.00 AC ALCOH DEP INTOX-UNSPEC 303.01 AC ALCOH DEP INTOX-CONTIN 303.02 AC ALCOH DEP INTOX-EPISOD 303.03 AC ALCOH DEP INTOX-REMISS 303.90 ALCOH DEP NEC/NOS-UNSPEC

Code ICD Diagnosis ---- ------------- 357.5 ALCOHOLIC POLYNEUROPATHY Range 291.0-291.9 Code ICD Diagnosis ---- ------------- 291.0 DELIRIUM TREMENS 291.1 ALCOHOL AMNESTIC SYND 291.2 ALCOHOLIC DEMENTIA NEC 291.20 DEMENTIA ASSOC W/ETOH, UNSPEC 291.21 DEMENTIA ASSOC W/ETOH, MILD 291.22 DEMENTIA ASSOC W/ETOH, MOD 291.23 DEMENTIA ASSOC W/ETOH SEVERE 291.3 ALCOHOL HALLUCINOSIS 291.4 PATHOLOGIC ALCOHOL INTOX 291.5 ALCOHOLIC JEALOUSY 291.8 ALCOHOLIC PSYCHOSIS,NEC 291.81 ALCOHOL WITHDRAWAL 291.89 OTHER SPEC ALCOHOLIC PSYCH,NEC 291.9 ALCOHOLIC PSYCHOSIS NOS

Special Cases – Reminder Terms

• Allows you to make groups of other findings

• Examples are lab tests, drugs, education topics, health factors, vital signs

• If the computer finds one, the result is true and it quits

• Can use conditions in a reminder term such as SBP>139 or HgbA1c > 7.0

Example of a Reminder TermIHS-ALCOHOL SCREEN No.43 ---------------------------------------------------------------------------- Class: VISN Sponsor: Date Created: Review Date: Description: Edit History: Edit Date: DEC 3,2006 13:54 Edit By: STANDING BEAR,CORRINE J Edit Comments: Exchange Install Findings: Finding Item: CAGE 0/4 (FI(1)=HF(32)) Finding Type: HEALTH FACTOR Finding Item: CAGE 1/4 (FI(2)=HF(33)) Finding Type: HEALTH FACTOR Finding Item: CAGE 2/4 (FI(3)=HF(34)) Finding Type: HEALTH FACTOR Finding Item: CAGE 3/4 (FI(4)=HF(35)) Finding Type: HEALTH FACTOR Finding Item: CAGE 4/4 (FI(5)=HF(36)) Finding Type: HEALTH FACTOR

Example of a Reminder term -with condition

IHS-HIGH BP 2007 No.86 ---------------------------------------------------------------------------- Class: LOCAL Sponsor: Date Created: Review Date: Description: Edit History: Edit Date: AUG 4,2008 13:17 Edit By: RICHARDS,SUSAN P Edit Comments: Exchange Install Findings:

Finding Item: BP (FI(1)=MT(4)) Finding Type: MEASUREMENT TYPE Condition: I ($P(V,"/",1)>139)!($P(V,"/",2)>89) ←true if SBP >139 OR DBP.90

Special Cases – computed findings

• Allows a programmer to write a routine to get data out of ANY RPMS file and use it in a reminder

• Used in national reminders to get data from the immunization forecaster files

• Example:NAME: IHS-HEPA//ROUTINE: BPXRMIM1//ENTRY POINT: HEPA//PRINT NAME: HepA//

“Physiology…”

Boolean logic is the foundation of reminders…

the reminder parts can be combined using Boolean logic to determine:

Cohort (inclusion and exclusion)

Resolution

Physiology… Boolean Logic

AND• A and B must be true for the statement to be true Example: Patient has diabetes AND hypertension

OR• A or B must be true for the statement to be true

Example: Patient has Alcohol Screen exam OR CAGE recorded

NOT (used mostly for exclusion criteria)• If A is not found, the response is true • If A is found, the response is false

Example: Female patient, 21-65 AND NOT hysterectomy

What expressions look like…

Findings are expressed as Finding 1, Finding 2 and abbreviated in logic statements: FI (1), FI(2)

Findings are not found/false = 0 found/true = 1Logic statements are false = 0 true= 1 AND: FI(1)&FI(2)OR: FI(1)!FI(2)AND NOT: FI(1)&’FI(2)

Physiology… ANDAND (&)FI(1)&FI(2) both must be true for the statement to

be true if either are false then the statement is

false

Example: Cohort = Patients with both DM FI(1) and HTN

FI(2) Patient has DM and HTN

FI(1) =1. FI(2) =1 Statement =1Patient has DM. Patient does not have HTN

FI(1) =1. FI(2) =0 Statement = 0Patient does not DM. Patient has HTN

FI(1) =0. Statement =0

DM HTN

AND

AND FI(1) & FI (2) =

DM HTN Statement Result

T T T

T F F

F T F

F F F

Physiology… OROR (!)FI(1)!FI(2) if either is true, then the statement is true both must be false for the statement to be

false

Example: Resolution = Alcohol Exam FI(1) or CAGE FI(2) to

resolve

Patient has had Alcohol Exam and CAGE recorded FI(1) =1, FI(2) =1, Statement =1

Patient has had Alcohol Exam. No CAGE recorded. FI(1) =1, FI(2) =0 , Statement = 1

Patient has not had Alcohol Exam. CAGE is recorded. FI(1) =0, FI(2) = 1, Statement =1

Patient has had neither Alcohol Exam or CAGE FI(1) =0, FI(2) = 0, Statement =0

OR FI(1) ! FI (2) =

Alcohol Exam CAGE Statement Result

T T T

T F T

F T T

F F F

Alcohol Exam

or CAGE

Physiology… NOTNOT (‘) If found/true then the NOT converts this to false in the logic statement. AND NOT (&’)AGE&’FI(1) Only if the first finding is found, and the second finding is NOT found is the statement true

Example: Cohort= I want patients age over 50 (AGE) and no h/o colon CA FI(1)51yo and no colon cancer.

AGE =1, FI(1) =0, NOT FI(1) = 1, Statement =151yo and colon cancer.

AGE =1, FI(1) =1, NOT FI(1) = 0, Statement = 149yo and no colon cancer.

Age = 0, Statement = 0.49yo and colon cancer.

Age = 0, Statement = 0.

AND NOT AGE & ‘FI (1) =

AGE result FI(1) Result (result after NOT operator)

Statement Result

T T (F) F

T F (T) T

F T (F) F

F F (T) F

AbnPap

h/o hyst

Physiology… NOTNOT placed before a finding makes a false true and true false… it is used to excludeNOT (‘) If found/true then the NOT converts this to false in the logic statement.________________________________________

Example: Resolution = I want patients with h/o abnormal PAP with an intact uterus

FI(1) &’FI(2) = Abnormal Pap and NOT h/o hysterecomy. Patients with hysterectomy are excluded

Abn Pap and not hysterectomy Patient has Abn Pap and has not had a hysterectomy. FI(1) is true. FI(2) is not found so this is also true . Statement is

true. Patient has Abn Pap and has had a hysterectomy.

FI(1) is true. FI(2) is found, so this is false. Statement is false.Patient has no history of Abnormal Pap FI(1) is false. The statement is false

AbnPap h/o hyst

Boolean Logic - precedence

• Precedence (), Not, And, Or

If no parenthesis, it evaluates them using the precedence rules

• A and B or C works the same as (A and B) or C Both A and B must be true or C can be true.

• A or B and C works the same as A or (B and C) Both B and C need to be true to make the second half true

• You can change the logic by changing the order of the findings, OR by adding parenthesis

Boolean Logic - precedence

• A or B and C or D

Default precedence is: A or (B and C) or D

DM or Pre-DM and HTN or Elevated BP

DM or (Pre-DM and HTN) or Elevated BP

You may want (A or B) and (C or D)

(DM or Pre-DM) and (HTN or Elevated BP)• You can use Custom Logic to force the items to evaluate

in the way you want

Sample cohort logic

Age over 2 AND high risk diseases

AGE&FI(1)

Age over 50 AND NOT Colon Cancer

AGE&’FI(1)

Female AND age 21-65 AND NOT hysterectomy

SEX&AGE&’FI(1)

Diabetes AND NOT end stage renal disease

FI(1)&’FI(2)

Sample Resolution Logic

HGBA1C lab test

FI(1)

Alcohol exam or CAGE or pt ed code or Alcohol dx

FI(1)!FI(2)!FI(3)!FI(4)

Mammo in Rad file or Mammo CPT or Mammo recorded in WH package or Refusal

FI(1)!FI(2)!FI(3)!FI(4)

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)

Cohort Logic

• AGE and SEX are built into the system

• If you don’t enter anything its all ages, both sexes

• Examples: What is the result?– Pap Smear: AGE and SEX and not HYST– Pap Smear: AGE and SEX or not HYST– Flu shot: AGE or DIABETES

Resolution Logic

• What turns the reminder off?• Examples:

– Using lab tests:• Lipid Test: LDL or HDL or LDL (Calc) or Lipid

Profile or cholesterol• Lipid Test: LDL or LDL-Calc and HDL

HDL and LDL or LDL-Calc (LDL or LDL-Calc) and HDL

– Reminder Term• Lipid Test: Lipid Tests

National Reminders

• Distributed with dialogs in PXRM 1.5 p1005• The patch loads reminders to the Reminder Exchange• Reminders will not display in the EHR until:

– Installed from exchange– Reminder system is activated– Reminders are added to the display list

• National Reminders cannot be edited. Sites can copy the national reminder, edit it and then use

National Reminders

• Many national reminders need to have sites map their own local terms to the reminder terms, especially those reminders with lab test results

• TEST, TEST, TEST before the general public uses the reminders. Be sure they are working properly