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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