**Clinical Reminders- Enhancing Patient Care and Improving Efficiency**

Presenting today is myself, my name is Alan Montgomery. I\'m a computer
specialist, I work out of the Tuscaloosa, Alabama, Office of
Information. I\'m sure I\'ve already met some of you guys, and I know
some of you from working with you on remedy tickets in the past. We
support clinical reminders, lab, dietetics, and some of the other
clinical packages, progress notes, etc. Co-presenting today is Kathy
Montgomery, she\'s a nurse from the Tuscaloosa VA. She\'s the
performance improvement coordinator, and as you\'ll see as we go through
this presentation, your reminders and your performance improvement, they
kind of go hand in hand. In the exhibition hall if you\'ve looked at any
of the posters, you\'ve seen a lot of the word performance measure, and
if you see that you usually see the word clinical reminder involved with
that.

We want this to be an informal and interactive class as much as
possible. This is a Live Meeting session, so the folks that weren\'t
lucky enough to be here today, they\'re actually seeing the slides,
hearing our voices, so it\'s kind of hard for you guys to raise your
hands and ask questions during the class because the folks at home will
not be able to hear what you\'re asking. But we do have cards available,
the little 3x5 index cards, and if you\'ve been to any classes you know
what those are and how all that works, and hopefully we\'ll have a
little bit of time at the end of the class to answer any questions. You
can just write those down and we\'ll take them and answer them, and
anything we don\'t get answered during the class, we will have all those
posted to the website.

I\'m not going to say anything else about myself really, we\'ll just
keep going.

Kathy I\'ll say a little bit more about her. She is an RN, she\'s been
an RN for 13 years, background in long-term care, rehab and primary
care. She began using reminders when they were introduced in the primary
care clinic, and I happened to be the CAC at that time and I was
building the reminders. She served as a resource there on the next
bullet, called a guinea pig in the clinic, to check and make sure that
what I did worked correctly. Most of the time it didn\'t, we had to make
some changes and get it to working right. Now she utilizes reminder
reports daily, and there\'s no doubt, she\'s always working with
reminder reports, getting data, and I\'m sure if any of you are in
Quality Management you\'re asked for data quite a bit.

This class is intended to offer some insight and suggestions into the
design and implementation of the reminders that are built at your site.
Again, it\'s not technical in nature, so you\'re not going to leave this
class knowing how to build a clinical reminder. So if that was your
aspiration there are some classes for that. There\'s plenty of things
out there on the web for that. But that\'s not what this class is all
about.

Some of the objectives of this course is just to be able to describe the
essential components of a clinical reminder. If you\'re in a
conversation with somebody and the subject clinical reminder comes up,
or if you\'re watching Jeopardy one day and clinical reminders comes up
as a topic, at least you\'ll have an idea because they\'re going to ask
you those central questions. Anyway, you would be able to talk a little
bit knowledgeable in the conversation about clinical reminders. Develop
some strategies to avoid reminder burnout. Anybody heard that term,
reminder burnout? You know what it is. I\'m sure somebody has
complained, my goodness, there\'s 27 reminders on that cover sheet, how
in the world am I going to have time to do all of that plus get all the
other documentation done, the patient was late, can we do something
about getting rid of some of these? That\'s what we\'re talking about
with reminder burnout. Identify some key participants of a clinical
reminder workgroup. And illustrate some examples for utilization of
clinical reminder reports and extracts.

Just to give you a little brief history and maybe a slight look into the
future of clinical reminders, reminders initially started as a piece of
PCE package. It was not its own package. It was just a little bitty
small piece when the initial idea came up back in \'97, I think that\'s
when it was, and it grew and grew, and people said hey, I can see how
this can really, really help. So it became its own package in June of
2000 with the release of Version 1.5. Version 2.0 was released in
February of 2005 with many enhancements which made life easier for the
front-end users, and for those people that were building them and
working with them behind the scenes, it made it harder. Patch 4 of
clinical reminders was released in October of 2006 with more
enhancements, lots of more functionality that we had available to us as
the reminder builder. Again, like the disclaimer there above, it made
life easier but it also made it harder for those people building.
That\'s pretty much a really quick history of the reminders, Patch 6 is
a future patch. We\'re hopefully going to release that this year, and
it\'s going to have many more enhancements in it as well. It\'s going to
have the Braden scale clinical reminder, the interfaces with the Mental
Health Package, it\'s going to have the PHQ2 in it, and self-scoring
stuff as well. So it\'s going to be some nice stuff that\'s going to
help you out that we\'ve struggled with in the past.

So all that being said, clinical reminders is a moving target, and
hitting that target sometimes is not an easy task, because if you\'re
the person that\'s doing these and you learn how to do them, all of a
sudden more functionality comes along. It changes, I have to learn more,
have to keep learning. So if you are involved with building reminders,
you know what I\'m talking about, reminders are an evolving entity right
now. Lots of things are, stagnant is not the best word, but they\'re
kind of like they are, progress notes don\'t change very much. Some
other things don\'t change very much, but the reminders package changes,
I mean it\'s changing daily right now.

How do clinical reminders help us? Well, I always try to make my classes
a little bit fun, so we\'re going to stop right here. We\'re going to do
a little small skit for you guys, and hopefully for you that have been
working as a nurse, maybe you were on the front line before clinical
reminders came along, before we had electronic record. This will take
you back to the past, and for you guys that are new, hopefully you\'ll
see what it used to be like. So I\'m going to play the role as the
physician, Kathy\'s going to play the role as the nurse.

Alan: Who\'s next?

Kathy: Mr. Jones is coming in today, Mr. Jones, let\'s see, problem list
nothing on it, not up to date. Let\'s see when we saw it last.

Alan: So you\'re telling me that\'s my fault, right? I\'ll work on that,
there\'s just not enough time to do everything.

Kathy: I know.

Alan: Okay.

Kathy: He\'s diabetic. This note refers to him being diabetic.

Alan: I think I remember that, so when was his last A1C? I need to know
his last A1C, his foot exam, his eye exam, those things, you know.

Kathy: Give me 10 minutes.

Alan: Okay. Well, we got other patients waiting.

Kathy: Hemoglobin A1C, 11.1 in 2004.

Alan: How come we haven\'t had this done?

Kathy: I don\'t know. It was on this sticky.

Alan: Well, why didn\'t it get done?

Kathy: Okay. Foot exam. I can\'t see any documentation of a foot exam.
But he does have an eye exam scheduled in September.

Alan: Okay. This is really, really frustrating. There\'s got to be a
better way to do this. We have patients coming in, they\'re not getting
the things that they need to have done for their good health, so
there\'s got to be a better way. Somebody\'s got to come up with
something because we don\'t have time to look through these charts and
find all this information, and then we find that it\'s not even there.

Kathy: I know. And by the way, we do have an appointment this afternoon
at 2:15 with that lawyer. Remember Mr. Smith? Yeah, he\'s got advanced
colon cancer.

Alan: And we didn\'t follow up.

Kathy: Right.

Alan: Okay, familiar to any of you? How about the old paper chart, the
green book, the sticky notes? Hopefully that should have taken you back
in time a little bit, and you guys that are new see what it used to be
like. Well obviously with clinical reminders there is a better way now.
How do they help us? There\'s numerous ways, and I won\'t mention them
all, but one of the things is the improve the documentation with
progress note text associated with the dialogs. Well you\'re aware that
sometimes it\'s not that you say something in a progress note, it\'s how
you say it. EPRP, and whoever the guys are that come in and review, they
may say that\'s not good enough because it wasn\'t worded correctly.
Well, another thing is typing, it takes a little time. It\'s a lot
easier if I can click and have a paragraph of text go into the body of
my progress note, well that\'s much more efficient. So clinical
reminders helps us that way. It helps us with the process of disease
management, i.e. here the little skit we just did. Diabetes, colon
cancer, etc., and you can name many more. I\'m sure you\'re thinking
about them in your heads right now. It\'s an important tool to prompt
the screenings for mental health for instance, depression, PTSD.
Obviously everybody knows what a push we\'re having with the veterans
coming back from Iraq right now with the Iraqi reminders, which includes
PTSD, depression, audit C, a couple of others. Plus you\'ve got the TBI
now. So this is very, very important, and this is another way that that
helps us. Another way is performance measure tracking. I stated a few
minutes ago at the beginning that clinical reminders and performance
measures, they go hand in hand. Most of your performance measures
probably are pulled from clinical reminder reports, the data that\'s in
there.

This initial concept back when it was just a part of PCE there, was to
help bring to a provider\'s attention in real time, when they\'re
actually seeing the patient, that some clinical action needs to be
accomplished for that patient. Again, that would be this is a diabetic
patient, he needs his A1C is due, his foot exam is due, his eye exam is
due.

And obviously this should be very familiar to you. This is a screenshot
of your CPRS cover sheet and right there front and center is the
clinical reminders.

Something you may not know, probably most of you will, but something
again that you can go back and take back is the use of the clinical
maintenance view on your clinical reminders. You can click on those from
the cover sheet, and it gives you kind of a view of why it\'s due, maybe
when it was resolved or when it was last done. Now, does all this happen
automatically? No, it doesn\'t. You go click on your reminders, it may
not show you the information that you may see here. You see at the
bottom it says patient has a diagnosis of hypertension on file. Well,
that doesn\'t just go in there, the reminder builder has to actually put
that in there, so clinical maintenance could be a very, very good tool
for your providers if they learn to use it, if they have time.

Okay, moving forward. Reporting functionality, after it was created they
found that data could be extracted to see how a site was doing in
regards to performance measures. That\'s a big thing obviously,
performance measures. It has to do with how well we\'re treating our
patients, and kind of the bad side, it also has to do with money. I\'m
sure some of you guys are aware of that.

We told you we would give you the answers to some of those Jeopardy
questions if you were ever asked. So some of the essential components of
reminders is the cohort. That means the who. Who is this reminder
applicable to? What patients need an intervention, or what patients do I
want to see on a report? The resolution. What makes it go away? That\'s
what everybody wants to know, make that get off my screen. And that is
the what. The third thing is the frequency, and that\'s the how often.
When I do resolve this reminder, when is it going to come due again? Is
it going to be once in a lifetime, if I resolve it it\'s gone forever,
or depending on how I resolve it, is it going to change the frequency
from maybe one year to two years? That\'s the how often.

Some more clinical reminder lingo is applicable, that means the patient
is in the reminder cohort. If he\'s a diabetic, you have a diabetic
reminder, that reminder is applicable to him. Due, don\'t have to say a
whole lot about that. Something needs to be done, it\'s time. Resolved
or satisfied, that means the clinical action has been taken to make that
reminder go away.

How can you help develop a good clinical reminder? Well, research your
task. Very, very important. You cannot just sit down as part of a group
and just by flying by the seat of your pants design a clinical reminder.
It takes thought into those questions of who, how often, and the what.

Working together. No one person is going to develop a good clinical
reminder. I promise you that. If you\'ve tried and succeeded, you\'re
one of the very, very few. You need to talk to your subject matter
experts that your reminder will deal with because, as you know,
reminders touches almost every piece of CPRS. We can make our reminder
applicable based on just about anything. A lab, a pharmacy, a drug, any
orderable item, consult, health factors, mental health tests, diagnoses,
CPT codes. There\'s about 15 things that reminders actually touches that
we can make it applicable to those patients. So whenever you\'re
designing a clinical reminder you need to make sure you talk to those
experts in those areas.

Validate your reminder. Here\'s a big thing. How many of you have ever
had a reminder, and you said this should not be due on this patient?
This is not right, it\'s not due. Or, I know I did what I was supposed
to do to make it go away, but it\'s still there. Well that\'s the
validation of your reminder. Before that thing goes out there, you need
to make sure you\'re part of that group. I\'ll encourage you to go back,
and if you\'re interested in reminders and helping your site provide
better care, be a part of a group that works on clinical reminders.
Anyway, back to here. You need to test all the scenarios of your
reminder. Before that reminder goes to the cover sheet, it needs to work
correctly. Nobody likes to have broken software. Same thing with
physicians, that right there helps lead to what we said reminder burnout
a while ago. So make sure they\'re correct. Have certain users at your
site test the reminder and provide feedback. Again, you\'re probably not
going to be the reminder builder, most of you. But you can at least have
that input and say hey, make sure this reminder goes out to two or three
people because we do have that ability to just give it to two or three
individuals, and that\'s what I did with Kathy. I would send the
reminder to her plus two or three other people, then they would give me
feedback on what needed to be changed.

Clinical reminder reports. Provider profiling, you probably heard of
that term. Kathy\'s going to talk about that a little bit later. Monitor
of compliance with performance measures. Monitor staff compliance with
completing required clinical reminders.

Report don\'ts. You can see the little policeman there. Don\'t use
reports as a club. You may have been a person this has already happened
to, and they came to you and said I\'ve got this report here and it says
your clinic was 10% below what it\'s supposed to be. What are you going
to do about it? So make sure those reports, whoever is running those,
that they\'re not used as something that beats you up, because again
that leads to reminder burnout and makes you want to go home for the
rest of the day. If you are asked to report to management, make sure
that that data is correct. Again that\'s the verifying step we talked
about a couple of slides ago.

Everything so far that was said is summed up here. Good reminder design
can best be accomplished by a group of people who have a vested
interested in the clinical reminder, or you\'ve heard the term
\"they\'ve got a horse in the race\". Here is just some examples of some
people that might have a vested interest in a reminder. Physicians,
nurse practitioners, RNs, LPNs, PIC type people, chief of staff maybe. A
group discussion will help the reminder to have all the essential pieces
necessary for quality design. Well that\'s true, but you always find you
probably forgot something. But with the group and with testing you can
always usually get that in there and have it working correctly when it
goes out to all users. The design of a clinical reminder request form
for possible new reminders for group discussion and possible
implementation. You need to have a process if somebody has an idea that
you think might be able to be used as a clinical reminder, you need to
have a process and a request form that they can submit and then take it
to a group of people that are working on that, and you guys talk about
it. Because anybody that has an idea, if they came to the reminder
person and said hey, I\'ve got an idea for a reminder, well we would
have a list too long to fill up that middle window on your cover sheet.
It would have to be stretched and you wouldn\'t be able to see all the
other information, because there would be so many reminders. Some of you
may have that happen already at your site.

This is just a really, really basic clinical reminder request form.
What\'s the purpose of it? Give us your idea. Then you got to go through
the essential components, the who, the what, and the how often. And then
maybe some other comments. Again, this is really, really basic, you can
expound upon this and take it and add things to it.

And now Kathy is going to talk about the reporting part of clinical
reminders.

Kathy: Good morning. Just for those people on Live Meeting, I want to
take a quick poll of the audience here and kind of see who\'s in the
room. How many of you are actually nursing staff? Very good. How many of
you are front-line nurses? How many of you are data people that work
with performance measures? Well for those of you who didn\'t raise your
hand and say that you were data people working with performance
measures, I have news for you. Because if you work for the VA, you work
with data, and you work with performance measures. That\'s our life.
It\'s how directors get their bonuses, it\'s how some of you get
bonuses, it\'s how we gauge quality care in the VA system. So hopefully
when you leave here today you\'ll understand a little bit more how
clinical reminders can enhance that whole process, can help us, and have
some value. As Alan said, I\'ve been a nurse for about 13 years, did
some time in long-term care, worked in the clinic for about six years,
and that\'s when clinical reminders came about during that period of
time that I was in the clinic. Sometimes I loved them, and sometimes I
hated them, and sometimes that\'s still true. I\'ve had to adjust in my
role and learn more about the technical aspects of a clinical reminder,
so I can tell you from both viewpoints that they\'re tough, they\'re
very, very valuable, but they\'re kind of challenging to get them right.
So hopefully when you leave here today you\'ll know a little bit more
how you can help in that process and make sure that the clinical
reminders at your site are the very best that they can be, and that they
actually do enhance patient care and improve efficiency. Number one that
I wanted to talk about was how we utilize them in our site and I\'m sure
a lot of you do, profiling for your providers. We do kind of a report
card format. We use clinical reminder reporting to get the data for
those report cards. These help us to identify areas that we may need to
improve on. We utilize this data to improve our clinical performance,
and then to monitor and see are we sustaining that improvement, is the
trend lines going up, or do we need to start another cycle of
improvement? Clinical reminders allow us to do real-time sampling. Many
VISNs have data warehouses, data mining, but usually we find that
they\'re behind. Some of them are four to six weeks behind and all that
data that\'s transmitted, where does it go, to Austin. You don\'t get
that right back. You have to wait for them to mine it and then pull up
your reports. So clinical reminders, you can run the report today. For
those of you that work in a clinic, you can look to see at the end of
the day how certain things were done within your clinic with a clinical
reminder report. So in summary with this, you do A, and you do B, you do
C, and D, and actually this can help save lives.

Here\'s just a sample of the report cards that we utilize at our
facility. How many of you have some sort of report card format? Okay.
Well one thing that you might find in classes like this, and in looking
at posters and whatever, is samples and different ways of doing this
that make it easier for you. So network, get to know each other, and you
might get some good ideas.

One thing it helps us do is identify our best practices or our star
performers. I know every year I\'m asked at my site to identify say a
clinical champion or someone who\'s really done well and stands out. I
get it from the report card data. We look at that and see who\'s met the
performance measure things that we\'re measuring, and see who\'s done
the most and the best. Sometimes it\'s really close, and it\'s nice to
have that data at hand for whoever at your site works with this kind of
data, that it helps you to identify those people for any kind of awards
or whatever. And it helps you to identify teams. We work in teams in our
primary care, and you can look at your teams and give them some sort of
positive reinforcement based on the data that you have. You know, hey,
you all are leading this year in number of flu vaccines given, or your
team is doing best with getting all your patients their diabetic foot
exam, what are you doing? We want to model that in another area. And it
also helps you identify processes that result in good outcomes.
Sometimes you\'ll look at this data and you\'ll think hmm, I wonder
what\'s going on with this, this seems to be working. And our VISN right
now, well actually I think nationally they\'re offering this through
Office of Quality and Performance, for people to partner, different
facilities are partnering. We\'re going to partner with Manchester, New
Hampshire, because they\'re doing really well with lipid management and
that\'s been an area that we\'re struggling with. So we\'re going to see
what processes they have going on that\'s helped them so much.

On the other side of the coin, it also helps you to identify weak
performers and areas where you might need to offer a little bit of help.
Compliance issues, you may see that you have a new nurse in a clinic
that didn\'t get oriented really well and they don\'t know which
reminders they\'re supposed to do, or a new doctor that comes in. We
have problems sometimes with our locum tenens when we have vacancies.
Reminders aren\'t real important to them, or they haven\'t seen them
somewhere before, and you can run reports and see who\'s completing the
clinical reminders and who isn\'t. And it also helps you, like I said,
identify processes that may not be working very efficiently or
effectively.

Here\'s just a really good example. I think everybody can look at that
chart and see there\'s a problem, there\'s a problem area. Our chief of
staff would call that the parado effect, or you identify your
low-hanging fruit, all those buzz words in the data world. It helps you
when you display your data like this to your staff, and if they\'re
let\'s see number 13 down here on the end, they may not want you to post
that in the clinic. If anyone would to know who that was, but then
number one over there is real proud of their accomplishment. But that
helps you, it helps you to target those staff, maybe provide them a
little more support or education. It could be that you\'ve had a vacancy
on that team or something that has impacted the performance.

NEXUS sampling. Now that\'s something that may be changing I understand
this year, but for those of you who work with data and are familiar with
the Office of Quality and Performance and EPRP, this was a method of
sampling that the EPRP used to pull together our patient cohort that
they come and do chart reviews on every month. It\'s a formula, it
consists of various stop codes, types of visits, you may have heard
anchor visit at any facility, and they\'ve been seen in any of these 40
something clinics, then they could possibly be pulled. We actually had
developed a system of reporting where we could look at a sample very
close to that. One thing I have learned is it\'s never perfect, you\'re
not ever going to get everybody. It can be so technical and hard to pull
that you\'re going to get a good sample, you may get 99%, but there will
be a few patients that probably don\'t actually need it. But you can
look at that, run reports against it, let\'s just say you pull your
NEXUS sample for the month of July and you look at how many patients in
that sample had their eye exam done, their foot exam, all their diabetic
performance measures. Then you would get a pretty good idea of okay, say
the EPRP came and pulled all of our patients, then we would be doing
really well, we would be meeting that performance measure. And hopefully
if your site\'s like ours, we really rely more on that data than the
EPRP because EPRP is a smaller sample, and your data may not be as
reflective of what your actual performance is.

And how do we use this to improve our clinical performance? Well, we can
identify patients that require specific clinical actions, just like you
saw in our skit. We saw a patient that hadn\'t had that done because we
didn\'t have something to remind us. Right here I\'m going to add
something in because of a conversation that I had yesterday at another
class. The comment was made that we\'re making it where our providers
don\'t have to think anymore, but having these reminders telling them
what to do. Now it may just be someone\'s opinion, but my opinion is I
would rather that providers be reminded than for us to miss something.
And it\'s something that you probably will hear when you go back if you
work in a clinical reminder workgroup or something, you may hear
comments like that, so you may want to do a little bit of thinking about
it. Another way that we utilize clinical reminder reports is with patch
4 that came out you can start creating patient lists. These can be used
in a variety of ways. You can print out this list in a format that has
their addresses, their phone numbers, specific lab values if that\'s one
of your findings. You can use these to do patient specific letters
reminding them of something that needs to be done. I know a lot of you
are probably gearing up for flu campaigns this year, our VISN actually
sends out letters to the high risk patients letting them know it\'s flu
season coming up, we want to make sure you get immunized. Our site is
actually planning to send out letters letting patients know that have
maybe difficulty getting to the facility that we\'re going to do a
drive-in clinic. I know a lot of people are doing drive-in flu clinics.
That\'s where you get your data. You can run a clinical reminder report
on those patients, print it out in a format that can do a merge list,
and you can do a mass mailing. They\'re very useful tools for case
management. One of the areas that we\'re looking at in Tuscaloosa is the
OIF/OEF veterans that are coming back. We have identified through
looking at their data that we have some compliance issues, especially
with immunizations. If you\'ve ever worked in the clinic, I\'ve worked
there just a little bit, but oftentimes they come back and they\'re like
no, you\'re not giving me another shot, I had plenty before I went, I
don\'t want any more shots. So sometimes it\'s difficult to get them to
comply with getting their immunizations. But the clinical reminder
reports have enabled us to really identify and narrow down a population
that we feel like is in need of some more specific case management.

And again, the NEXUS, what does it really mean? If you look it up in the
dictionary, NEXUS is just a connected series or groups. It\'s the means
of connection between things linked in series. I don\'t know if that
helps you or not. And like I say, I have heard from some calls that
I\'ve attended, and maybe some of you have, that the NEXUS sample will
change in this next performance year, so if that is true, and
unfortunately we don\'t get our technical manual until the end of
September, that we\'ll all be gearing up to look at the population in a
different way and see who they\'re going to pull.

This is just a sample list, shows you how it comes out of the computer
with their identifying data, phone number, social security number, and
this one has a finding on there of their hemoglobin A1C. So you can take
that data, copy it over, put it into an excel sheet, and have a real
useful tool. And I\'m going to just kind of digress a bit here, but you
see the field that says social security number 0008 on your first
patient? Actually when this patch was in testing I think, you think that
you don\'t have any interaction with those people who are up there
working, but I started working with these lists and I told Alan, I said
you know, I get these lists of patients and it\'s Joe Smith, Joe Smith,
Bob Jones, Robert Jones, and I don\'t have a social security number to
tell me exactly which one it was. So he in turn talked to the developer,
and that\'s how that field go there was just the need from a user. So
when you think that you can\'t impact how these are done, think further,
because you really do. You are the users that the people that are
developing these want to please. They want you to have what you need to
work with. So be thinking of ways that you might help in that process.

Clinical reminder workgroups. At our site we have a workgroup, it\'s
called clinical outcomes workgroup, and we look at ways that clinical
reminders can enhance the processes that support performance measures
mainly. It\'s a collection of diverse staff that have both clinical and
technical expertise. Remember like Alan says, you can\'t build clinical
reminders by yourself. I don\'t know who does that at your sites. I know
it varies across the country where it may be a CAC, it may be someone in
a data workgroup. I met some that work in quality management. But
whoever it is, they can\'t do it by themselves, so make sure that they
have a team to support them. Clinical reminder builders/coordinators,
they rely on the input from that group to develop a quality product.

And some of the key players, like he mentioned before, technical expert,
ISS, CAC, whoever that designated person is, you need a medical
representative, a physician, an APN, it might be a physician\'s
assistant at your site. We have a very large mental health population at
our facility, so we try to have someone from the mental health side of
the house at least available when we need them, and as you have seen,
the mental health measures have grown so probably every workgroup needs
to have someone identified from the mental health side of the house.
Nursing staff, they have so many reminders to use, they definitely need
to be represented, you need their input. And if you are that person you
need to be providing it. You may need to call in lab, pharmacy,
radiology, someone from rehab medicine, they can be affiliate members or
you can just call on them if you need them as a subject matter expert.

Standardization. That\'s another buzz word. There are efforts, as you
know, to standardize certain reminders so that the data that we get we
can compare our apples to apples. The OIF/OEF reminders are a good
example. The Traumatic Brain Injury reminder, there\'s reminders for the
Women\'s Health Package, IHD, and they extract data from these. You may
be a front-line user and you\'re entering in very important data based
on let\'s say the OIF/OEF reminder. Have you ever wondered where that
goes and what\'s being done with it? Well it\'s being compiled and
looked at. I\'m sure that data will probably give someone information on
this population of veterans coming out of this conflict what service
connections might be applicable to these people and other things. What
is the VA going to need in the future to take care of this population?
Well, they will find that out from looking at the data that comes out of
these reminders. How many Traumatic Brain Injury patients are we going
to be dealing with over the long haul, and what do we need to have in
place to take care of them?

Some VISNs are also standardizing their reminders. Our VISN, VISN 7, has
a workgroup working hard to standardize mainly reminders that are
related to performance measures. And I will tell you, this is a
monumental task. Mainly because processes at every facility are so
diverse and so different. They create havoc with trying to standardize a
single clinical reminder because your lab may not all be named the same
thing, your process to refer a patient to mental health if they are a
positive depression screen and need to be seen that day. At my facility
I may have an integrated primary care mental health team where I can
send them next door, but you may have to send them to another building
and do a consult, or some other type of order that has to be entered. So
a VISN reminder workgroup can be very, very frustrating and challenging.
I see some of you shaking your heads. How many of you are on a workgroup
like this? Do you all agree, is it a challenge? Okay. But it\'s
basically the same rationale as your national reminders. It improves
your ability to compare your performance across facilities. And it
allows you to compare apples to apples, if you get it all together.

Okay, so much to do. Burnout. Alan alluded to burnout. What can you do,
the people in this room, how can you help? Have you ever heard there\'s
just too many reminders to do, and are these clinical reminders of any
value, and where do they come from?

Well, where do they come from? Well most sites utilize performance
measures to develop clinical reminders. Now you may see some reminders
at your site that are for something specific. It may be a business end
reminder, I know we worked with one user who wanted to create something
to remind the provider that the travel requirements for that patient,
patients that you actually pay for their beneficiary travel to come in,
needed to be done. So you may see some things like that. But most of the
times it\'s going to be based on your performance measures. And the
performance measures are developed in the Office of Quality and
Performance, and they\'re based on evidence-based medicine clinical
practice guidelines.

This is just a snapshot here of what the cover sheet from Office of
Quality and Performance website looks like. You all all have access to
these slides and these references. If you haven\'t ever perused this
website, it is full of very valuable information. I know everybody is
strapped for time, but it really is a good website to get familiar with,
because they have all of the minutes coming out from their conference
calls where you find out things like what\'s coming up next year. And as
you know, the performance measure year starts in October. Well, you\'ve
got to start gearing up now. We\'re scrambling now, we know there\'s
some things that are changing, changing in the mental health package,
changing in the way our patients are going to be pulled, and we\'re
trying to listen and learn and get ready because you have to have time
to get your reminders in place, get your users involved and informed,
work out your processes, how are we going to do the referral to mental
health if you have a patient who screens positive for depression and
then screens that they are a suicide risk. I think everybody\'s probably
working on that process right now. And that\'s all going to have to be
incorporated into the existing clinical reminders, so you have to have
time to get them built, your users trained, and as you know, usually
when they first come out, got some compliance issues, people don\'t like
change, so sometimes we don\'t have enough time to get that all in place
before the performance measure year starts. And then if you add into
that that your VISN wants them all standard, then you really can get
behind the 8 ball pretty quick.

One way that I found that helps users not feel so burned out is just
educating. Letting them know that there\'s value to clinical reminders.
And as you saw, it used to be you used post-it notes and stickies all
over the place, and sometimes this post-it note might have fallen off or
just gotten overlooked. But clinical reminders have become our post-it
notes to provide the quality care to our patients.

Do they make a difference? Well, I\'ll let you all gauge. I think it
does, I think clinical reminders make a difference in patient care, and
I\'ve got a couple of examples I want to tell you about from when I
worked in the clinic. I had a patient that was needing to have some
follow-up diabetic care. He had been one of our patients that you kind
of saw frequently, and you got to know he and his family. We\'re a small
site, and we also have one nurse to one provider try to keep that
continuity going. I was in the women\'s clinic, but also the provider in
that clinic saw a regular panel of patients as well. So this was one of
our frequent fliers, and when I called to tell him that he needed to go
and get his eye exam, that we had it scheduled for him, that we had
scheduled his foot exam for the same day because he hadn\'t had that
done, he said well I\'m not going to be able to come because I just had
surgery. And of course you dialog with him a little bit, well it was
surgery for colon cancer, and he had had to have a colostomy. So I was
doing my note that day and documenting what he had said and why he
wasn\'t going to be able to come and have these interventions that
needed to be done, and I looked back in the chart, just kind of to
review what had happened the last time we saw him, and I saw a positive
FOBT from about 8 months before. Well, I couldn\'t let it go. I had to
do a little more research and figure out why did we miss it. Well this
is before we had a positive FOBT clinical reminder. This is also before
we had really any process in place to remind our providers that there
was a positive FOBT. They were having to go back in the chart and look,
remember. Well you have 20 patients a day, it\'s very difficult to go
back and look. So this kind of started a chain of events where I worked
with provider staff, lab staff, we got a system in place to remind our
providers, it actually now is a critical result I think, any positive
FOBT. We created a positive FOBT reminder, and we follow up on those. We
even have case managers who as kind of a second step, a safety net so to
speak, they look at all positive FOBTs and make sure that they\'re
followed up on appropriately. So do they have value, do they make a
difference? I would say yes.

The VA says that the clinical reminder system allows caregivers to track
and improve preventive healthcare and disease treatment for patients.
They ensure that timely clinical interventions are initiated. They are
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.

They remind providers to do immunizations, like I said, we\'re gearing
up at our facility right now, there\'s actually a meeting in Charleston
starting either this afternoon or tomorrow where we\'re looking at how
the campaign went last year and what we\'re going to do this year to
make sure that we improve on our past performance in immunization. It
identifies your high risk patients who need specific interventions, such
as your diabetics. Prompts providers to get lab values. I think it may
be actually a new performance measure coming out, is on anticoagulation
and making sure patients are properly followed up. As clinicians you all
know how important that is.

So we need help. So what can you do? We need you to get on board. We
need you to volunteer to be a member of your local group, participate,
help this hard working group of people develop the best clinical
reminders they can for your site. There are websites, past VeHU courses.
How many of you are here for the first time? Oh wow, that\'s great. I\'d
like to hear from you when you leave, kind of what your feelings are and
how you think you can use this when you go back. I was on the nursing
planning committee this year, and that\'s one of the things that we
looked at. Becky Kellum was on that workgroup as well. And actually this
class is in response to the feedback that we got from last year. We
heard that a lot of nursing staff had entered classes like I have in the
past, where I went to sit in because I wanted to learn more about
clinical reminders, and very quickly I was so lost that I closed the
computer and said I can\'t do this, because it was too technical in
nature. I don\'t do real well in hands-on classes anyway. So hopefully
this is meeting a certain need and we certainly will appreciate any
feedback that we get. And then when you go back to your site, can you
think of some ways maybe that you can utilize what you\'ve learned here
in your practice and in passing it on to your co-workers? Not everybody
can attend, and thankfully we do have the Live Meeting sessions, and
that will help to enlarge our audience, but sometimes I found in the
clinic especially, that if you are that person that has kind of got a
good handle on CPRS and the processes and the computer, you\'re often
asked hey, how did you do that, what are the shortcuts? So this is one
thing that you can do when you get back to your site, you can take back
to the people that you work with and share your knowledge. And then
lastly, look at your data. Hopefully whoever is preparing reports at
your site, has made them available to the end users. If you\'re an LPN
working in a busy clinic, and you\'re giving flu shots during the flu
season, it can be a real boost if you see something posted like we had
earlier, hey, my bar\'s all the way up to the top, I\'m doing really
good, I\'m like 90 something percent. And then conversely, if you see
that you\'re not doing so well it might actually improve the performance
in that area. So if you\'re one of those data people, try to make sure
that that is presented in such a way that everybody who looks at it
understands it and gets something from it. And that all the people who
need to see it, see it.

Now just in recapping, remember when we had charts that looked like
that, the plastic one, we had the little green book, you sat with the
doctor and you tried to go over the patients for that day, or the
patients on your unit. You had to call the file room to get the chart,
and then you had all those little messages of things to do.

Well not anymore. It\'s a keystroke away. Clinical reminders have
replaced those sticky notes and green books.

They\'ve been around for over six years now, they serve to prompt
clinical actions, do the documentation like Alan said earlier. It\'s
much easier to click on a dialog box that stuffs that progress note text
in, and we all know how important that can be. During our recent Joint
Commission survey we were cited because on our flu clinical reminder we
did document that we had given the patient a vaccine information
statement, however, we did not put the date of that vaccine information
statement on there. It\'s on there now, it will be documented for every
immunization given. So a lesson learned, but I would hate to be a nurse
in clinic and have to sit there and type all of that information in
every time I gave a flu shot, and more than likely you wouldn\'t get it
done. Reports, they help you to drill down your data, drill it down to
provider and patient specific levels. Clinical reminders enhance patient
safety by prompting the clinical actions. And they also provide you a
safety net that your documentation is there if it\'s ever needed,
because of some kind of legal action or some outcome in a patient that
was less than what they thought it should be.

Just to recap so when you do your Jeopardy. The cohort, anybody know
what the cohort is? The cohort is the who. The resolution, that\'s the
what. The frequency, that\'s the how often. Alan tells me all the time
clinical reminders are simple, it\'s just those three basic things. He
lies. They are not that simple.

What can you do with the building blocks? You can create your patient
list, do mass mailings, target specific patients for specific actions,
you can create reports, charts, graphs, we all know the Joint Commission
loves these. Develop report cards, everyone likes to know how well they
do their job. Like we said, don\'t club them over the head with it.
Approach your providers in a positive way, hey look how good you\'re
doing here and here and here. And you may have to do a little extra work
here, but you are doing really well in these areas. Sometimes you have
to look really hard to find something positive. Hey, I looked at your
last year\'s, and you\'ve improved by 1%, but this is the target, this
is the goal out here, what can we do to help you? And anything else that
you can think of? Hopefully we have given you something here that you go
back to your site and you can think of other ways that you can utilize
clinical reminders.

Here\'s just a page that I put in that has the links to the Office of
Quality and Performance, like I said, that\'s a very, very valuable
website. Also the archived VeHU courses. These courses will be on there.
Go to the poster sessions, network, take those cards home, get to know
those people. I have gotten a wealth of information from people that I
have met at VeHU and gone back and I might be working on something and
just can\'t figure out where do I need to go next, or isn\'t there a
better way, and I\'ll pull out some of these posters or cards that I\'ve
gotten at VeHU and call them. And they do the same with me.