Clinical Reminders Performance Improvement Power Tools Session

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Clinical Reminders Performance Improvement
Power ToolsSession 276

• Kathy Montgomery, RN
• Tuscaloosa VA Medical Center, Quality Management
• Robert Thornton, MD
• Tuscaloosa VA Medical Center, Primary Care

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HOUSE KEEPING

• We want this to be informal and interactive, but
  please hold your
• questions during the presentation. Please turn
  off or mute all cell phones and pagers.
• Questions can be written on the 3X5 card
  provided. These will be answered at the
  conclusion of the presentation, time permitting.
• For questions not answered,
• the question and the answer will be available on
  the web.

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• INTRODUCTION OF PRESENTERS
• Dr. Robert Thornton
• Board Certified Family Practitioner, member of
  Primary Care Team. At TVAMC for past 15 years.
• Clinical Champion for Electronic Medical Record
  and for Clinical Reminders.

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Co-Presenter

• Kathy Montgomery, RN (14 years)
• Background in LTC, Rehab and Primary Care,
  Quality Management
• Began using Reminders when introduced in the
  Primary Care Clinic (From the beginning.?)
• Served as resource (guinea pig!) in clinic
• Now creates and utilizes Reminder
  Reports/Extracts/Patient Lists extensively in
  QM/PIC role

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Course Objectives

• At the end of this course you should be able to
• Describe general background of the VA Clinical
  Reminder software
• List the essential components of clinical
  reminders and performance improvement
• Identify key participants of a clinical reminder
  workgroup
• Illustrate examples for utilization of clinical
  reminder reports/extracts
• Describe how clinical reminder data can be used
  to improve facility performance.

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Now, really why are you here?
Doing all these reminders takes too much time
away from the patients!
Which reminders do I have to do?
Staff Nurse
Clinician
Wow, look at the May clinical reminder reports
we are now meeting the Flu performance measure!
Bean Counters
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THE VA Clinical Reminder System

• Allows caregivers to track and improve preventive
  healthcare and disease treatment for patients
• Ensures that timely clinical interventions are
  initiated
• Is the VA's preferred mechanism for implementing
  clinical practice guidelines, and facilitates
  linking the evidence with the real-time clinical
  reminder, with the action, and with the
  automatically generated documentation, as well as
  with a trail of standardized performance data

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And

• Clinical Reminders
• Support stakeholders with performance improvement
  power tools to case manage patients
• Aid in providing comprehensive medical care to
  complex patients
• Provide valid and useable information with
  minimal data collection burden
• Allows for feedback to be provided as close to
  real time as possible
• Reduces reliance on memory for clinicians to
  perform recommended screenings and interventions

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FOR MOST OF US.CLINICAL REMINDERS ARE

• The string around your finger or the sticky
  note on the chart!

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SOME CLINICAL REMINDER TESTIMONIALS!

• EXAMPLE 1 Reminder reports can allow us to do
  large and small-scale comparisons of clinics,
  divisions, teams, and providers and can help in
  finding patients who have "slipped through the
  cracks." Ever want to know how well your team was
  doing with immunizations or diabetes care or pain
  assessments? Ever want to know who is coming this
  week who needs pneumococcal immunization or who
  needs diabetic foot exam and education or who has
  had a high pain score in the past and needs a
  pain assessment? Would anyone at your site ever
  want to look at a group of patients for a
  research project - patients with a creatinine
  between 1.5 and 5 who do not have diabetes who
  are under the age of 80?

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CLINICAL REMINDER TESTIMONIAL

• EXAMPLE 2 On behalf of the nursing staff here
  at VAMC One, I'd like to again thank you for all
  the work it took to develop the clinical reminder
  dialogs. We hit a new record this year in VAMC
  One of gt1000 flu shots given in one day. The
  nurses never would have been able to complete
  this in one day without the Flu Shot Station
  note, which is boilerplated using a clinical
  reminder dialog that captures the CPT and ICD-9
  code.

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Initial concept of clinical reminders

• Designed to be clinical Decision Support tools
• Designed to help bring to a providers attention
  (in real time) that some clinical action needs to
  be accomplished for the patient
• Focus on measurement means that data are needed
  to analyze processes, identify problems, and
  measure performance.

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Where did they come from????

• Initially started as a piece of PCE package
  (approx 14 years ago!)
• Released as its own package, V1.5, in June of
  2000
• Version 2.0 released February 2005 with many
  enhancements which made life easier and harder!
• Patch 4 released October 2006 with more
  enhancements (see disclaimer above ?)
• Patch 6 was released 2007 with numerous
  enhancements (even more to learn ?)

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CLINICAL REMINDERS IN CPRS--

• On the coversheet they give you a snapshot of
  what the patient may need
• They are a placeholder for information
• They can be an efficient way to complete required
  documentation

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Clinical Reminder CPRS Display

• Cover Sheet Due or Due soon
• Clock button on each tab
• List of Available Reminders
• Reminder Drawer (Notes tab)

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Clinical Maintenance The Coversheet Treasure
Chest

• The clinical maintenance drawer contains
  pertinent information regarding why the reminder
  is DUE or NOT DUE
• Reminder Builders can add some information to
  this section to help providers better understand
  what the reminder is doing behind the scenes

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Clinical Maintenance Discovering the TREASURE
Aaargh! We have work to do here!
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CLINICAL REMINDER DOCUMENTATION IN CPRS

• WITH JUST A FEW CLICKS THIS IS WHATCAN BE
  DOCUMENTED IN YOUR PROGRESS NOTES
• EXAMPLE INFLUENZA IMMUNIZATION
• Patient received influenza vaccine at this
  visit.
• The patient/caregiver has provided verbal
  consent for the
• influenza vaccine to be given after
  denying the existence of
• precautions/allergy and receiving
  education and the Vaccine
• Information Statement dated 7/16/07
  handout.
• Left Deltoid
• Manufacturer Lot Number(s) and Expiration
  Date
• Flurix Unit Dose Syringe / Lot
  AFLUA294DA Expiration 6-30-08
• Is patient an employee, volunteer, or
  student?
• No

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Patient Care Encounter (PCE) Information

• When reminders are completed important
  information goes into the PCE software--AUTOMATICA
  LLY
• This information is important for billing,
  workload and pulling data
• EXAMPLE PCE Diagnoses VACCIN FOR INFLUENZA
• Procedures Admin influenza virus vac,
  IMMUNIZATION ADMIN , FLU VACCINE, 3 YRS gt, IM
• Immunizations INFLUENZA

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Clinical RemindersThey save time dont they?????

• Documentation via radio buttons and check boxes
  - less typing time
• Electronic reports/Extracts instead of time
  consuming chart reviews
• Information crosses over into the PCE software
  less time completing encounter forms
• Facilitates entry of orders/consults, etc.
• ETC.

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But, Again.Why Oh Why?????

• The Clinical Reminder software allows caregivers
  to track and improve preventive healthcare and
  disease treatment for patients.
• Clinical Reminders are point-of-care tools to
  provide information with regard to Clinical
  Practice Guidelines.
• Clinical reminders help to ensure timely
  clinical interventions are initiated.

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Where the rubber meets the road

• EXAMPLE Patient A--65 year old patient with
  diabetes
• REMINDERS DUE
• 1. EYE EXAM NEEDED (not done in past 2 years
• 2. HGBA1C NEEDED (not done in past year)
• 3. FOOT EXAM NEEDED (not done in past year)

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Patient A

• EYE EXAM DONE! No retinopathy?
• HGB A1C 6.9 ?
• FOOT EXAM DONE ! New shoes!
• JOB WELL DONE, CLINICIAN!!!!

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BUMPS IN THE ROAD

• Nurse I just gave this patient a flu shot last
  monththis reminder shouldnt be due?????
• Doctor This patient isnt a diabeticwhy are
  all these diabetic reminders due????

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And when something goes wrong???

• Do you know who is responsible for maintaining
  your reminders?
• Clinical Reminders can stop working properly for
  any number of reasons.
• Patches
• CPT code changes
• Staff changes
• End users must communicate with clinical reminder
  coordinator(s)

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YOU CAN BE A GOOD HELPER!

• CONTACT REMINDER MANAGER AS SOON AS POSSIBLE WHEN
  YOU FIND A BUG
• KEEP PATIENTS NAME/SSN TO HELP THEM TROUBLESHOOT
• OFFER SUGGESTIONS TO IMPROVE REMINDERS

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EXPANDED USES OF CLINICAL REMINDERS

• PROVIDER PROFILING (REPORT CARDS?)
• PEFORMANCE MEASURE REPORTS
• STAFF COMPLIANCE MONITORS
• FACILITY REPORT CARDS
• PERFORMANCE IMPROVEMENT PROJECTS

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Reminder Reports

• Provider Profiling
• Monitor of compliance with performance measures
• Monitor staff compliance with completing required
  reminders

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Clinical Reminder Reporting

• A - Useful for Provider Profiling Report
  Cards
• B - Identify areas of improvement
• C - Improve Clinical Performance
• D - Real Time reporting of 100 sample
• ABCD Help save lives!

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Sample Report Card
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AND OF COURSE, PRETTY CHARTS AND GRAPHS
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(No Transcript)
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Report DONTS

• Dont use reports as a club!
• Dont report to management without verifying data
  is correct

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USING REPORTS FOR POSITIVE REINFORCEMENT--

• Identify Best Practices
• Highlight Star Performers
• Teams that STANDOUT in performance
• Processes that result in top outcomes

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ABCs of Clinical Reminders Performance
Improvement

• A. PI relies on the guiding principles of
  teamwork, systems and processes, patient focus,
  and measurement
• B. Focus on the patient emphasizes that services
  should be designed so as to meet the needs and
  expectations of patients and community
• C. Focus on measurement means that data are
  needed to analyze processes, identify problems,
  and measure performance.
• DOING THE RIGHT THING RIGHT

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Where do Clinical Reminders fit in?

• A. Clinical reminders help pull it all
  together--guiding processes of care to assure
  timely patient interventions optimizing medical
  outcomes
• B. CRs are designed to meet patient needs
  through conformance to clinical practice
  guidelines AND meet provider needs by improving
  efficiency of documentation
• C. CRs provide the data needed to analyze
  processes, identify problems, and measure
  performance

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Moving forward

• After reporting functionality was created, data
  could be extracted to see how a site was doing
  in regards to performance measures
• GEC referral and IHD data are already extracted
  nationally through the extract functionality each
  month

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EXTRACTS The New Frontier!

• Here we go!!!!!!!!!

Clinical Reminder Extracts
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What can you expect with extracts?

• Enhanced ability to generate automatic data
  retrievalmonthly, quarterly extracts
• Reduction in system use
• More to come.mining for gold!

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Exactly what makes up a Clinical Reminder?

• This is actually a very simple question!
• NO!it is a very complicated question!

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Essential Clinical Reminder Componentsthe simple
answer

• The Cohort (the Who)
• Patients needing an intervention
• Patients you want to see on a report
• The Resolution (the What)
• What will turn this reminder OFF?
• Frequency (the How Often)
• How often should this reminder or selected
  intervention be due or completed
• Monthly, Annually, Once in a lifetime, etc.

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Essential Clinical Reminder Componentsa little
more complex

• Researching the task
• Talk to your subject matter experts
• Discuss with the requestor
• Ask WHO, WHAT, HOW OFTEN

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More essential components.

• Resolution????
• What makes the reminder resolved or go away
• This is where you must dialog with subject matter
  experts and research the performance manual!
• THINK THINK THINK THINK --- THINK

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The WHO (PATIENT COHORT)

• Usually the who is the first step
• Below is from the previous performance measure
  for diabetic patients to have annual exams
• Cohort Ages 18-75 Diagnosis of diabetes
• Exclusions Life Expectancy lt6 months bilateral
  Amputee

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Cohort Exercise Wake up!!!

• Some of us learn better by DOING!

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HOW OFTEN???

• Sounds simple, but.
• Annual tests easy annual frequency
• But, what if the frequency is different for
  different ages? Or if the frequency is different
  depending on risk factors?
• YEP it is not always easybut it is doable!

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Review Reminder Lingo

• Applicable Patient is in the reminder cohort
  logic
• Due Some clinical action needs to be taken in
  order to resolve this reminder
• Resolved/Satisfied Clinical action has been
  taken for patient. Reminder will be due again
  according to the frequency defined

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More Lingo

• Clinical Reminders use a number of types
• of FINDINGS.
• Findings are like on/off switches.
• They make a reminder DUE,
• or RESOLVE the reminder.

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Clinical Reminders use a number of types of
FINDINGS.Findings are like on/off switches.
They make a reminder DUE, or RESOLVE the
reminder.

• Here is a list of all the different types of
  Findings
• DRUG
  IMMUNIZATION
• EDUCATION TOPIC
  LABORATORY TEST
• EXAM
  ORDERABLE ITEM
• HEALTH FACTOR
  RADIOLOGY PROCEDURE
• MENTAL HEALTH INSTRUMENT TAXONOMY (list of
  codes)
• REMINDER COMPUTED FINDING REMINDER TERM
• SKIN TEST
  VA DRUG CLASS
• VA GENERIC
  VITAL MEASUREMENT

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Types of Clinical Reminder Findings

• Here is a list of all the different types of
  Findings
• DRUG
  IMMUNIZATION
• EDUCATION TOPIC
  LABORATORY TEST
• EXAM
  ORDERABLE ITEM
• HEALTH FACTOR
  RADIOLOGY PROCEDURE
• MENTAL HEALTH INSTRUMENT TAXONOMY (list of
  codes)
• REMINDER COMPUTED FINDING REMINDER TERM
• SKIN TEST
  VA DRUG CLASS
• VA GENERIC
  VITAL MEASUREMENT
• COMPUTED FINDINGS

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How can I help develop a good Clinical Reminder

• Work Together
• You cannot accomplish this alone
• Talk to subject matter experts that your reminder
  will deal with, i.e. lab test, drugs, orderable
  items, etc.

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How can I help develop a good Clinical Reminder

• Research--Research--Research
• Dont fly by seat of your pants
• Gather information for the who, what and how
  often - these are essential to the success of
  your reminder
• Know your topic Knowledge is POWER!

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How can I help develop a good Clinical Reminder

• Validate your reminder results
• Test all scenarios of your reminder
• Have certain users guinea pigs at your site
  test the reminder and provide feedback

Yepthis is just what I wanted Diabetic
patients that need to have their eyes checked!
Gee, thanks!
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Clinical Reminder Workgroups

• Collection of diverse staff with both clinical
  and technical expertise
• No man is an ISLAND Clinical Reminders
  require a TEAM approach
• Clinical Reminder builders/
• coordinators/managers rely on input from the
  group to develop quality products

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Key Players

• Technical expert ISS, CAC, whoever is
  designated at your site as Clinical Reminder
  Manager
• Medical representative Physician, APN, PA
• Psychiatry representative Psychiatrist,
  Psychologist, APN, Advance Practice Nurse, etc.
• Nursing staff
• Lab, Pharmacy, Radiology, Rehab Medicine may be
  affiliate members and used as needed

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All that to say this!

• Good reminder design can best be accomplished by
  a group of people who have a vested interest in
  the reminder, or should we say a horse in the
  race!?
• Group discussions will help gather all
  essential pieces necessary for quality design
• Design a Clinical Reminder request form for
  possible new reminders for group discussion and
  possible implementation

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Clinical Reminder Request Form

• Clinical Reminder Request Form
•  
• Purpose of the Clinical Reminder
•  
•  
•   
•  
• Who will this reminder be applicable to
•   
•  
•  
• What things will resolve this reminder (make it
  go away)
•  
•   
•  
• How often should this reminder come due, i.e.
  yearly, monthly, etc.
•  
•   
• Other comments

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Clinical Reminders Champion

• Clinical Input is an essential component of the
  successful team which designs and implements
  clinical reminders. Many sites have one or more
  clinicians who function as Clinical Reminders
  Champion (clinical reminders advisor)
• The Clinical Reminders Champion should have a
• Working understanding of
• Clinical Medicine
• Current VA Performance Measures
• Clinical Reminder software
• Commitment to staying current with national VHA
  changes to performance measures

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Clinical Reminders Champion

• Role may vary at different VAs.
• Acting as consultant to the clinical reminders
  coordinator
• Acting in a more hands-on role with access to
  run clinical reminder reports and/or create
  clinical reminders and dialogs
• Role may include formal or informal liaison
  between informatics staff and clinical staff

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Efforts toward Standardization

• Some VISNs are working to standardize clinical
  reminders especially those dealing with
  national performance measures
• Rationale Ability to compare facilities and
  know that the data is coming from the same
  source

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More on Standardization

• National Standardization Several standard
  reminders already in use, i.e. OIF/OEF, TBI, etc.
• Enhance collection of data by providing 100
  sample of real time data
• Allows for comparison of apples to apples

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SO MUCH TO DOAVOIDING BURNOUT

• Have you ever heard (or spoken!), There are just
  too many reminders to do!
• Are these clinical reminders of any value?
• Where do these come from?

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SO MUCH TO DOAVOIDING BURNOUT

• Staff Education keys to understanding
• Get staff involved in the process
• Take back innovation from VeHU experience in the
  field

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You know its the right thing to do, but

• Performance improvement is all about getting buy
  in from those who actually do the work!
• Staff must use them or we lose them!

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Where do they come from?

• Most sites utilize the Performance Measures to
  develop Clinical Reminders
• Performance Measures are developed in the Office
  of Quality and Performance
• Based on the Clinical Practice Guidelines

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http//vaww.oqp.med.va.gov/default.htm
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Keys to Understanding (the WHY?)

• Is there any value to Clinical Reminders?
• Clinical Reminders are the post it note you
  need to provide quality care to patients!

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Once againTHE VA CLINICAL REMINDER SYSTEM

• Allows caregivers to track and improve preventive
  healthcare and disease treatment for patients
• Ensures that timely clinical interventions are
  initiated
• Is the VA's preferred mechanism for implementing
  clinical practice guidelines, and facilitates
  linking the evidence with the real-time clinical
  reminder, with the action, and with the
  automatically generated documentation, as well as
  with a trail of standardized performance data

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Prompting Clinical Actions (Where the rubber
meets the road again)

• Reminds providers to immunize patients
• Identifies high risk patients who need specific
  interventions, i.e. Diabetics that need eye
  exams, foot exams, labs, etc
• Prompts providers to get lab levels for specific
  medications, i.e. Coag studies for patients on
  Coumadin

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GET INVOLVED!

• Volunteer to be a member of local group
• Websites past VEHU courses
• Attend VEHU then pass on what you learn!
• Look at the DATA

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LETS REVIEW

• Remember when
• Charts consisted of papers filed in a plastic
  binder
• You had the clerk call the File Room to get a
  chart
• There were little sticky notes or messages in
  green books to remind providers TO DO
  something

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Not Anymore!

• Charts are now a keystroke away!
• Clinical Reminders have replaced the sticky notes
  and green books!

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Putting it all together!!!!

• Clinical Reminders have been around awhile, they
  are here to stay, and they get more powerful each
  day
• They prompt clinical action, document the action,
  and allow for data collection
• Reports help Drill Down data to provider and
  patient specific levels
• Enhance patient safety by prompting for clinical
  actions

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Just to review Building Blocks of Reminders--

• Cohort the WHO
• Resolution the WHAT
• Frequency the WHEN

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What can we do with these building blocks?

• Assure quality patient care through timely
  interventions
• Create patient lists mass mailings, etc., case
  management tools
• Create reports, charts, graphs (The Joint
  Commission loves these!)
• Develop report Cards Everyone likes to know how
  well they do their job!
• YOUR job is to add to this list!!!

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Wrap - up

• We will take questions now
• Any questions not answered today will be
  available on the website