256 Did You Know Clinical Reminders

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256 Did You Know Clinical Reminders

• Christopher Lopez, MD
• Orlando VAMC
• JoAnn Seppelt, CRNP
• Philadelphia VAMC

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Objectives

• Provide an intermediate level of understanding of
  clinical reminders
• Take a quick tour of the inner workings of a
  reminder
• Be able to discuss reminders more intelligently
• Provide an array of useful bits of information
• How reminders impact providers
• Have you utter, I didnt know that

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Available Reminders
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Basic Logic
Applicable? Does pt meet cohort criteria?
No
Yes
Not Applicable Folder
Any Exclusions?
Yes
No
Not Applicable Folder
Fulfills resolution criteria?
Yes
No
Reminder Resolved (In Applicable Folder)
Reminder Due (On Cover Sheet)
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Cohort

• The group of people to be evaluated
• Examples
• Diabetic patients
• Heart failure patients
• Patient with history of MI

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Finding or Finding Item

• Information that can be searched by the reminder.
  
• Already exists somewhere else in VistA
• Lab test results (from your sites lab)
• Medications (from med lists)
• Diagnostic codes (from problem lists, encounters)
• Immunizations
• Progress note titles

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Term

• Collection of similar findings grouped together
  to simplify programming
• Example LDL
• Lab may run a direct LDL or calculated LDL
• If either lab is acceptable to satisfy the
  reminder, we can combine both labs into a single
  Term called LDL.

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Taxonomy

• ICD-9 codes and/or CPT codes grouped together to
  describe one disease entity.
• Example
• 250.00 Diabetes Type 2 or unspecified
• 250.01 Diabetes Type 1
• 250.4 Diabetes with renal manifestations
• 250.5 Diabetes with ophthalmic manifestions
• 250.6 Diabetes with neurological manifestations
• 250.9 Diabetes with unspecified complication

Combined into single taxonomy called Diabetes
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Health Factors

• Findings created for information not existing
  elsewhere in VistA.
• Tells you facts about the patient
• Information is typically collected by reminders
• Examples
• refused flu shot
• outside LDL
• life expectancy lt 6 months
• outside colonoscopy result

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How do you get more information?
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Did you know that the top rows and bottom row of
the chart stay constant as you switch tabs?
Did you know the reminder clock is available from
any tab?
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Icon Legend
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Cover Sheet 2 Ways to Access
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Notes Tab gt Reminders Drawer
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Clinical Maintenance

• While completing a reminder dialogue, click on
  Clinical Maintenance button

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Clinical Maintenance

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

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Clinical Maintenance ExampleWhen was my last
tetanus shot?
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Clinical Maintenance - Td example
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Why is pneumovax due in a 35 year old?
Diagnosis of diabetes coded 4/7/99 caused the
reminder to become due.
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For Patient Education Reminders
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Reminder Inquiry
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HEART FAILURE ACE-I OR ARB USE

• 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

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Reminder Description (See handout)

• Reminder Description
• ACE Inhibitor use within 24 months prior to
  admission for
• heart failure was introduced as a VA Performance
• Measure in FY2003. This reminder is designed to
• prompt the provider to consider ACEI use in heart
  failure
• patients with an ejection fraction of lt40,
  unless
• ACE/ARBs are contraindicated. This performance
• Measure was updated in FY2005 to allow use of an
• ARB. (see below)
• Contraindications include to both ACE/ARB
  include
• allergy or intolerance to both types of
  medications,
• bilateral renal artery stenosis or renal artery
  stenosis with
• a single kidney, chronic renal dialysis, moderate
  or
• severe aortic stenosis, pregnancy, K gt5.5 that
  cannot
• be reduced, symptomatic hypotension or other
  reason
• documented by provider.
• Severe cough secondary to an ACE-I should prompt
  the

• of the renin-angiotensin system (RAS) and the
• sympathetic nervous system (SNS) the
  pathophysiology
• of heart failure has resulted in the development
  of drugs
• that have improved morbidity and mortality
  associated
• with HF.
• The cornerstone of proper medical treatment in
  patients
• with heart failure due to left ventricular
  systolic
• dysfunction (as opposed to diastolic dysfunction)
  is the
• prescription of an angiotensin-converting enzyme
• inhibitor (ACEI). Numerous trials have
  demonstrated the
• role of ACEIs in improving HF symptoms and
  functional
• status as well as in decreasing the frequency of
• hospitalization and mortality rate.
• More recent trails demonstrate that ARBs have an
• important role in HF treatment and LVSD. The
  VALIANT
• trial directly compared an ACEI with an ARB (as
  well as
• the combination of the two) in patients with
  signs and

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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.

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Baseline Frequency

• Do In Advance Time Frame Wait until actually
  DUE
• Sex Specific
• Ignore on N/A
• Frequency for Age Range 1 year for all ages
• Match Text
• No Match Text

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Before we cover the rest of the Reminder Inquiry
sheet

• KISS
• The logic is simple
• Abbreviations are simple
• Dont let the long sentences scare you it
  breaks down easily

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Goal Be able to interpret this

• Customized PATIENT COHORT LOGIC to see if the
  Reminder applies to a patient
• FI(1)!FI(8)'(FI(5)!FI(12)!(FI(3)FI(10))!FI(6))
• Expanded Patient Cohort Logic
• FI(VISN 8 HEART FAILURE )!FI(PATIENT STATES
  HISTORY OF CHF)'(FI(VISN 8 EJECTION FRACTION
  40 OR HIGHER)!FI(VISN 8 ACE/ARB NOT USED FOR
  OTHER REASONS)!(FI(VISN 8 ACE INHIBITOR
  CONTRAINDICATED)FI(VISN 8 ARB
  CONTRAINDICATED))!FI(VISN 8 NO ACE-ON VA STUDY))

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Venn Diagrams
2
1
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Boolean Logic

• Boolean (boo'le-?n)
• adj.  
• Of or relating to a logical combinatorial system
  treating variables, such as propositions and
  computer logic elements, through the operators
  AND, OR, NOT, and XOR

Dictionary.com
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1 or 21 ! 2
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1 or 2 or 31 ! 2 ! 3
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1 and 21 2
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1 and 2 and 31 2 3
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not 2 2
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1 and not 21 2
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Population
plant
or
animal
!
Cohort
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Population
plant
and
animal
Cohort
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Population
Not plant
Cohort
40
Population
(
)
plant
or
animal
not
Cohort
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Population
(
)
plant
or
animal
not
Cohort
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Population
(
)
plant
or
animal
not
Cohort
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Parenthesis

• 5 10 5 10
• 5 (10 5) 10
• (5 10) (5 10)
• 5 (10 (5 10))

• 550
• 750
• 100
• 300

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(plant or animal) and not (cat or machine)
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7th step 5th step answer less items found in
6th step (item must be in group 5 but not in
group 6)
6th step calculate cat OR machine
5th step calculate plant OR animal
4th finding item machine?
3rd finding item cat?
2nd finding item animal?
1st finding item plant?
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(plant or animal) and not (cat or machine)
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Population
(plant or animal) and not (cat or machine)
Cohort
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Taxonomy

• What if we were to consider lion and cat to be in
  the same taxonomy called cat?

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Population
(plant or animal) and not (cat or machine)
Cohort
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Population
(plant or animal) and not cat or machine
Cohort
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Boolean Logic

• CUSTOM LOGIC STRING COHORT
• plant or animal flower, cat, lion, dog, squash
• plant and animal no findings
• not (plant or animal) computer
• not plant or animal cat lion dog computer
• (plant or animal) and not (cat or machine)
  flower lion dog squash
• If I define cat and lion to be both the same
  (i.e. in the cat taxonomy)
• (plant or animal) and not (cat or machine)
  flower dog squash

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Now back to Reminders

• In our example, make some simple substitutions.
• Plant diagnosis of heart failure
• Animal patient reports history of heart failure
• Cat EF gt 40
• Machine ACE contraindicated

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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

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Abbreviations/Notations

• A active
• DC drug class
• HF health factor
• I inpatient
• N non-VA medication
• O outpatient
• TX taxonomy
• T today

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Finding Item 1Reminder Taxonomy

• VISN 8 HEART FAILURE (FI(1)TX(79))
• Finding Type REMINDER TAXONOMY
• Use in Patient Cohort Logic AND
• Beginning Date/Time T-2Y

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VISN 8 Heart Failure Taxonomy

• Following information available only to reminder
  managers who have additional VistA menus
• Ascertain which specific ICD9 codes are included
• FY03 codes for heart failure added
• 428.20-428.43
• Edit Date JAN 4,2003 1755
• Edit By ________________
• Deleted codes
• 428.30-428.33 (diastolic heart failure without
  systolic component)
• Patient Data Source EN,IN,-INM,PL

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Finding Item 8Health Factor

• PATIENT STATES HISTORY OF CHF (FI(8)HF(673542))
• Finding Type HEALTH FACTOR
• Health Factor Category REMINDER FACTORS
• Use in Patient Cohort Logic AND
• Beginning Date/Time T-1M

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Finding Item 2Reminder Term

• VISN 8 OUTSIDE ACE INHIBITOR (FI(2)RT(221))
• Finding Type REMINDER TERM
• Use in Resolution Logic OR
• Beginning Date/Time T-1Y
• Mapped Findings
• Mapped Finding Item HF.OUTSIDE MED - ACE
  INHIBITOR
• Health Factor Category OUTSIDE ACE
• Beginning Date/Time T-1Y
• Mapped Finding Item DC.CV800
• RX Type N
• Status List ACTIVE

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FI(2) More InfoAccessible only for reminder
managers

• Description Use of outside ACE-Inhibitor
  medication findings
• Edit History
• Edit Date NOV 12,2003 1838 Edit By
  ________
• Edit Comments Copied from VISN 8 OUTSIDE
  ACE INHIBITOR
• Edit Date NOV 9,2004 2127 Edit By
  ________
• Edit Comments Added non-VA meds ACE-I
• Edit Date JAN 16,2005 1609 Edit By
  ________
• Edit Comments
• Findings
• Finding Item OUTSIDE MED -
  ACE INHIBITOR (FI(1)HF(673100))
• Finding Type HEALTH FACTOR
• Health Factor Category OUTSIDE ACE
• Beginning Date/Time T-1Y

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Finding Item 3Reminder Term Health Factor

• VISN 8 ACE INHIBITOR CONTRAINDICATED
  (FI(3)RT(215))
• Finding Type REMINDER TERM
• Use in Patient Cohort Logic AND NOT
• Mapped Findings
• Mapped Finding Item HF.ACE INHIBITOR
  CONTRAINDICATED
• Health Factor Category CONTRAINDICATED MEDS

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Finding Item 4 Drug Class

• CV800 (FI(4)DC(66))
• Finding Type VA DRUG CLASS
• Use in Resolution Logic OR
• Beginning Date/Time T-14D
• Ending Date/Time T90
• Rx Type A
• Status List

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Finding Item 5 Reminder Term Health Factor

• VISN 8 EJECTION FRACTION 40 OR HIGHER
  (FI(5)RT(219))
• Finding Type REMINDER TERM
• Use in Patient Cohort Logic AND NOT
• Beginning Date/Time T-5Y
• Mapped Findings
• Mapped Finding Item HF.EJECTION FRACTION 40 OR
  HIGHER
• Health Factor Category EJECTION FRACTION

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Finding Item 9Reminder Term

• VISN 8 ACTIVE USE OF VA ACE-I (FI(9)RT(223))
• Finding Type REMINDER TERM
• Use in Resolution Logic OR
• Beginning Date/Time T-1M
• Mapped Findings
• Mapped Finding Item HF.PATIENT ON ACE FROM THIS
  VA
• Health Factor Category REMINDER FACTORS

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Finding Item 9Health Factor

• VISN 8 ACTIVE USE OF VA ACE-I
  No.223
• --------------------------------------------------
  --------------------------
• Class VISN
• Sponsor
• Date Created
• Review Date
• Description
• Describes active VA ACE-Inhibitor use. This
  term may be used when local
• sites use batch computer processing of
  Pharmacy prescriptions to indicate
• "released" or when the current pharmacy
  profile does not accurately
• indicate the supply of ACE-I medication.
• Edit History
• Edit Date NOV 12,2003 1842 Edit By
  _______
• Edit Comments Copied from VISN 8 ACTIVE
  TREATMENT WITH VA ACE-I
• Edit Date NOV 13,2003 0019 Edit By
  _______

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Cohort Logic

• Customized PATIENT COHORT LOGIC to see if the
  Reminder applies to a patient
• FI(1)!FI(8)'(FI(5)!FI(12)!(FI(3)FI(10))!FI(6))
• Expanded Patient Cohort Logic
• FI(VISN 8 HEART FAILURE )!FI(PATIENT STATES
  HISTORY OF CHF)'(FI(VISN 8 EJECTION FRACTION
  40 OR HIGHER)!FI(VISN 8 ACE/ARB NOT USED FOR
  OTHER REASONS)!(FI(VISN 8 ACE INHIBITOR
  CONTRAINDICATED)FI(VISN 8 ARB
  CONTRAINDICATED))!FI(VISN 8 NO ACE-ON VA STUDY))

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Cohort Logic - Expanded

• FI(1)!FI(8)'(FI(5)!FI(12)!(FI(3)FI(10))!FI(6))
• is exactly the same thing as
• FI(VISN 8 HEART FAILURE)!FI(PATIENT STATES
  HISTORY OF CHF)'(FI(VISN8 EJECTION FRACTION 40
  OR HIGHER)! FI(VISN8 ACE/ARB NOT USED FOR OTHER
  REASONS)!(FI(VISN8 ACE INHIBITOR
  CONTRAINDICATED)FI(VISN8 ARB CONTRAINDICATED))!F
  I(VISN8 NO ACE-ON VA STUDY))

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Customized Patient Cohort Logic

• FI(1)!FI(8)'(FI(5)!FI(12)!(FI(3)FI(10))!FI(6))
• (1 or 8) AND NOT (5 or 12 or (3 and 10) or 6)
• 1 heart failure taxonomy
• 8 pt states has history of heart failure
• 5 EF 40
• 12 ACE and ARB not used for other reasons
• 3 ACE contraindicated
• 10 ARB contraindicated
• 6 Involved in study where ACE not given

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Resolution Logic

• Default RESOLUTION LOGIC defines findings that
  resolve the Reminder
• FI(2)!FI(4)!FI(9)!FI(11)!FI(13)!FI(14)!FI(15)
• Expanded Resolution Logic
• FI(VISN 8 OUTSIDE ACE INHIBITOR)! FI(CV800)!
  FI(VISN 8 ACTIVE USE OF VA ACE-I)! FI(VISN 8
  OUTSIDE ARB)! FI(CV805)! FI(VISN 8 NON-VA MEDS
  ACE/ARB)! FI(ACE COMBINATION MEDICATIONS)

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Resolution Logic

• What resolves the reminder
• FI(2)!FI(4)!FI(9)!FI(11)!FI(13)!FI(14)!FI(15)
• 2 OR 4 OR 9 OR 11 OR 13 OR 14 OR 15
• 2 FI(VISN 8 OUTSIDE ACE INHIBITOR)
• 4 FI(CV800) ACE-I
• 9 FI(VISN 8 ACTIVE USE OF VA ACE-I)
• 11 FI(VISN 8 OUTSIDE ARB)
• 13 FI(CV805) ARB
• 14 FI(VISN 8 NON-VA MEDS ACE/ARB)
• 15 FI(ACE COMBINATION MEDICATIONS)

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Branching Logic

• What is it?
• Ability to control the content of a reminder
  dialog based on evaluation of a REMINDER TERM
• The dialog display changes based on the
  evaluation of a Reminder Term

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Branching Logic Example
Patient Has Diabetes
Insulin
Not on insulin
Not on insulin
Reminder dialog
Reminder dialog
Insulin - teaching
Insulin Teaching
Diabetes Education
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Branching Logic Reminders
Insulin
Not on insulin
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Branching Logic Example

• If NOT on insulin the term will evaluate as false
  and display the dialog for diabetic education
• If ON insulin the term will evaluate as true
  and display the education that pertains to
  insulin use.

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1
2
3
Branching logic also can suppress part of a
reminder that has already been completed.
However, the reminder will not resolve until all
parts are done.
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2
3
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3
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Functional Findings (FF)

• Perform a computation on the result of a
• regular findings
• Functions available
• MRD (most recent date)
• Count
• Min_Date (minimum dateoldest date)
• Max_Date (maximum datemost recent date)

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Functional Findings (FF)
MRD (1) gt MRD (13)
FI(1) IHD diagnosis FI(13) Inactivate IHD
reminder
FF is true if the most recent date of FI (1) is
greater than the Most recent date of FI (13)
1999 Patient incorrectly coded with IHD
diagnosis 2005 Patient does not have IHD
selected on reminder 2007 Patient now has a new
diagnosis of IHD. When information
is entered on the encounter form,
the IHD reminder will again become due for this
patient.
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Patient has a diagnosis of Ischemic Heart
Disease FI (1)
From the reminder, patient Does not have
Ischemic Heart Disease is checked (creates a
health factor) FI (13)
Reminder is resolved until a New diagnosis of
Ischemic Heart Disease is entered on the
encounter form
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Function Findings

• Allows the reminder to turn on and off for very
  specific reasons.
• Count function allows you to turn off the
  reminder once some something has been done.
• Smoking counseling done three time
• Occurrence count- searches for up to the N for a
  finding. Default1
• For a HbA1c with an occurrence count of 3, the
  clinical maintenance will display the last 3
  HbA1cs

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Where Health Factors Appear

• Information bits collected by clinical reminders
• Appears in the bottom pane of a progress note
• Ad hoc health summaries
• Entered automatically in encounter forms

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Where do Health Factors Appear?
Findings entered by reminder dialogs
are displayed at the bottom of the progress note
Important to check after completing reminders
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Where do Health Factors Appear?
Encounter form under Health Factors tab
List of health factors completed at this visit
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Where does information go?

• Health factors get stored in a database in Austin
• Many health factors have national mapping

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How is Information Extracted?

• KLF
• Proclarity
• Clinical Reminder Reports

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Accessing Remote Clinical Reminders

• Occasionally patients split time between multiple
  VA sites
• Clinical reminder data can be retrieved through
  Remote Data or VistaWeb
• Can avoid duplication
• Dependent on individual sites as to which
  reminders show up

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That cant be right!
but I guess it is.
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Reports

• If information is entered correctly and the right
  question is asked, it is possible to run
  statistics on providers in a short period of
  time.
• Summary Reports vs. Detailed Reports

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Managing Reports

• Detailed reports on individual reminders to
  identify specific patients with that reminder due
• Single reminders for individual providers
• Single reminders for groups of providers
• Save reports that can be used every month
• Helpful for huge lists of reminders and clinics
• Can import data into Excel for manipulation of
  data
• Can store reports securely on Sharepoint for easy
  distribution

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Effective Dates

• Reminder reports can be run for both future and
  past dates
• Past dates
• To determine if a facility, clinic or individual
  is improving on a measure
• To evaluate performance
• Future dates
• Run detailed reports ahead of time so patients
  can be scheduled before the reminder is actually
  due

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Reminder Reports
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Report Card
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Sample Report Card
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Nobody Wants to be the Worst
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Patient Lists

• A list of patients with a due reminder can now be
  sent to a patient list.
• The list can then be
• Copied to a new list.
• Copied to a OERR team list
• Used as the patient list in a reminder report

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Patient Lists

• Can be assigned to specific users public or
  private
• Can be used to create health summaries on the
  list of patients
• Can be used to get demographics

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Patient Lists

• Demographics
• Address
• Phone number
• Age
• Inpatient episodes
• Next appointment
• Reminder Due/Last Done Status

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Reporting System

• 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
• Need let end users know who to contact.

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Summary

• Brief tour of clinical reminders
• Defined basic construct and basic logic
• Showed ways of finding information on reminders
• How clinical reminder information is used
• Hopefully interested some to continue to more
  advanced classes

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For More Information

• If interested in learning to build your own
  clinical reminders, take Clinical Reminders
  Distance Learning class.
• Organized by Jerry Rutherford
• Taught by Alan Montgomery, Anne Rega, Rob
  Silverman, and Dr. Bryan Volpp

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For More Information

• Sharepoint Classes
• Was offered Monday 8/20/07
• Excel Classes
• Was offered Monday 8/20/07
• Power Point Classes
• Was offered Monday 8/20/07
• Also available on Web Based Training
• VeHU e-Xpress train
• vaww.vehu.med.va.gov/Search/eXpresstrain.cfm

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Questions?