# Presentation: 378133

## Please!!!Disable ringerson pagers – phones – Blackberrys

## Questions ?Please remember to write questions on a 3X5 card and give them to the room assistants. We will answer your questionsat the end of the presentation.

## The Magic of Reminder Dialogs 

- JoAnn Seppelt CRNP
- Thomas Heller R.Ph.

**Notes:**
The implementation of electronic medical records has improved patient safety and brought multiple tools for accountability of care. Along with this has come increased demand for accurate and complete documentation -  translated means workload.
Incorporating reminder dialogs into progress note templates can  help streamline  documentation requirements by prompting providers to address patients specific problems, enter Reminders Elements in to the Patient Care Encounter (PCE) system for resolving reminders, enter needed labs, consults and medication orders while generating the visit note. 

Our goal today is to give examples how reminder dialog have been used in different situations the clinic settings.
We hope what you see will enable you to take the concepts back to your facilities and help initiate them into you facilities 
Your CAC can setup the dialogs
Reference the presentations at web site

Computers have also brought a lot of controversy to the note writing process such as copy & paste, endless check box templates  (The one template fits all), templates with patient data objects (import  the entire chart contents in each note) and notes with consistent  text across patients, providing no variation or useful information . 

We would like to demonstrate a process that uses reminder dialogs to improve the documentation process and end up with a note unique to the patient and provider.

## The Magic of Reminder Dialogs

**Reminders & Reminder dialogs**
- Differences between reminder    dialogs and standard dialogs
- Reports from reminder dialog   elements

**Objectives:**

**Notes:**
Reminders are designed to identify patients with specific health care needs. 

The Reminder Dialog is designed to capture specific information related to the reminder. The information reflects the required documentation of care as identified by Joint Commission, Office of Quality Management, Clinical Practice guidelines and VHA hand books 1120.02 .

## Performance Measures & Practice Guidelines

**VHA HANDBOOK 1120.02 -** identifies requirements for **Health Promotion** and **Disease Prevention** programs
**VHA’s Computerized Patient Record System (CPRS)** includes  the electronic reminders to support performance measures and clinical practice guidelines
- Each **Veterans Integrated Service Networks (VISN)** is tasked to comply with performance measures and clinical practice guidelines

**Notes:**
Standards of care are set forth in  VHA handbooks 1120.02  

CPRS reminder function enables extraction of reminders data nationally to document a standard of care across the VHA  system

providers are expected to complete reminders.   enter data into the patients chart does not require using reminder dialogs in the reminder tab.

## National Clinical Practice Guidelines Council

**(VHA) Directive 2002-007 **established the National Clinical Practice Guideline Council (NCPGC) to coordinate the adoption, implementation, and evaluation of clinical practice guidelines throughout the system.

**(CPGC)**** **

**Notes:**
Nationally coordinated reminders track data and used it to verify  patients’ receive basic standards of care

Patient safety issues are also addressed through reminder dialogs. 

Facility directors evaluations  are based on the reminder completion rates to encourage each facility uses the reminders.  
This increases the pressure on providers to use trackable documentation

## Reminder Dialogs

- 	In the majority of published randomized controlled studies, computerized Clinical Reminders have been effective at improving adherence with established clinical guidelines

**Notes:**
Several studies have shown reminders are effective to improve adherence to guidelines. 

They are not going away. 

## Chronic Disease Index

- Ischemic Heart Disease
- Hypertension
- Chronic Obstructive Pulmonary Disease (COPD)
- Diabetes Mellitus
- Obesity (Body Mass Index >27)

**Notes:**
The disease indexes that are currently monitored in performance monitors, joint commission and quality management.

## Prevention Index

- Immunizations
- Cancer Screening
- Tobacco Consumption
- Alcohol Consumption

**Notes:**
Prevention Index

## Iraq & Afghan Post-Deployment Screen

**Identifying and support for**
- PTSD
- Depression
- Suicide
- Alcohol abuse
- TBI

## The Magic of Reminder Dialogs

- Reminders & Reminder dialogs
**Differences between reminder dialogs and standard dialogs**
- Reports from reminder dialog elements

**Objectives:**

## Formatted Notes

*Early Templated Note*

**Notes:**
The concept of templated notes has been around a long time. 
Some say templated notes are difficult to read 

Templates can be setup to streamline documentation flow by allowing the provider to be prompted with patient specific issues  and reducing omissions of documentation in busy clinic settings.
Finding the happy median between the checkbox templates and freestyle notes can provide providers with a template that is user friendly and produces an informative note

## TIU Template/Dialogs

## Text Integrated Utility (TIU) Template

- Shared Templates
- Note Title Template
- Consult Reason for Request
- Procedure Reason for Request

**Notes:**
TIU templates/dialogs can be used as a standalone dialog in shared templates. They can be attached to a progress note title. They can also be used d\for the reason for request field in consults and procedures.

## TIU Template Components

- Dialog Template Folder
- Dialog Groups Template
- Template Fields
- Data Objects

**Notes:**
They can be used in dialog folders
Group templates 
They can also include template fields and patient data objects

## TIU Template

## Template Components

**Template Components**

- Template folder

- Dialog Group Template

- Template window name

- The TlU dialog uses  the OK button to move the dialog into the note boilerplate as an unsigned note.

- Toggle fields

- Radio Buttons

**Notes:**
This is a TIU dialog containing template fields,: at the top of each dialog you see the name of the template
Toggle fields function as switches to place an X in front of given text
Radio Buttons in this example promotes the text to the note. Only the checked item shows in the note
Within Shared templates you see template folders  and within the folders you will find a group template.  The group template can contains templates and dialogs. Reminder dialogs can not be grouped with non-reminder dialogs.

## Template Fields

**Notes:**
This dialog shows word processing template fields 
The size of wp fields can be set by the creator to show 2 or more blank lines. The will accept as much text as the user wishes to enter.

The edit box can show as many characters as desired up to 80 characters

## Clinical Reminder Dialogs

## Reminder Dialogs

- Shared Template
- Note Title Template
- Clinical Reminder Dialog

**Notes:**
Reminder dialogs can be setup as stand alone dialogs in shared templates
They can be attached to progress note titles
and they are attached to reminders and can be accessed in the reminders folder

They can not be attached to consults and procedures as a reason for request dialog.
Consults and procedures are orders and the functionality does not support reminder dialogs

## Reminder Dialog Components:

- Elements
- Forced Values
- Dialog Groups
- Additional Prompts
- Template fields
- Data Objects
- Result Group (Mental Health)
- Result Element (Mental Health)

**Notes:**
Reminder Elements are the basic building block for the reminder dialog they contain, data objects template fields and finding items
Forced values in an element enables a value to entered such as a diagnosis as a primary diagnosis.
Dialog groups are made up of elements and can be incorporated in multiple dialog. 

Additional prompts are items like health factors, education factors, immunizations, procedure codes etc. these are items that are added the encounter form for the visit that can be used for billing purposes or for resolving reminders. These factors are trackable and are used to create reminder reports.
Template fields and data objects are the same as those used in TIU dialogs. 

The mental health  result elements and groups are things like AUDT C, PTSD, PHQ2, PHQ9. these groups can be incorporated in to reminder dialogs where they are needed and can resolve the QM tracked reminders.

## Additional Prompt Components

- Health Factors, Immunizations, Skin Tests, Education Topics, Exams
- Taxonomies (ICD Diagnosis, ICD0 Operation/Procedure, CPT Procedure ranges)
- Lab Tests and Radiology Procedures
- Local Drugs, Generic Drugs and Drug Classes
- Vital Signs
- Quick Orders for labs, meds,consults

## Reminder Dialog Advantages

- Save provider time documenting care at the same time satisfying documentation requirements
- Improve functionality by prompting for patient specific reminder information
- Complete Clinical Reminders with embedded factors
- Facilitates data collection for Clinical Guidelines   Reports

**Notes:**
Save provider time document care – satisfy documentation requirements-
prompting for patient specific reminder information 
Complete Clinical Reminders with embedded factors
Facilitates Collection of Clinical Guidelines   Report  data

## Reminder Dialog in Shared Templates

**Notes:**
The alarm clock image indicates reminder dialogs. They can only be launched in an unsigned note. If you try to view them by right click and choosing view, you will not see the dialog.

## Influenza

## Immunization Note Dialog

- Each Immunization makes up a dialog group.

- Progress note title

- Reminder Dialogs are activated by clicking the Finish button.

**Notes:**
This RD is attached to the progress not “Immunization” 
The header in this case displays the progress note title

## Reminder Dialog

- Blank Influenza dialog

- Progress Note Text

- Encounter Information

- clicking Finish enters progress note text and encounter information

## Progress Note Text

## Cover Sheet Immunizations Display

## Procedure Code on Encounter Form

- Procedure Code is entered from the additional prompt field

## Immunization Code on Encounter Form 

## Health Factors on Encounter Form

## “Type of Visit” Field on Encounter Form

## Neuroleptic Injection Dialog 

## Dialog for Neuroleptic Injection

## Diagnosis Entered in Encounter Form

**Notes:**
This shows schizophrenia as the primary diagnosis

## Procedure Code in Encounter Form

**Notes:**
This show the procedure code for the injectable. In this case with a procedure code, a visit type is not required.

## Health Factor in Encounter Form

**Notes:**
This health factor is used for the reminder that is used to track patients receiving long acting neuroleptic medication

## Restricted Medications Dialog

## Reminder Dialog in Shared Templates

## Restricted Medication Dialog

## Restricted Medication Dialog

- Patient Data Object displaying patients last Calculated Body Mass Index

- Patient Data Object displaying patients last Three Blood Gloucose Levels.

## Restricted Medication Dialog

- The reminder group for entering lab orders

## Restricted Medication Dialog

**Order fields checked**

## Restricted Medication Dialog

- Quick Order Set with Lab order menu

**Notes:**
With the glucose order the provider is given options since the patient may be seen in a CBOC where they draw and run the glucose test.
Lipid and HGB A1C are only done in one palace

## Restricted Medication Dialog

- Pharmacy Quick Order

## Restricted Medication Progress Note Text

## Mental Health Clinic Intake Note  withIraq & Afghan Screens Imbedded

## Mental Health Note Dialogwith AUDC Screen

## AUDC Screen

- The AUDC Score from this dialog will resolves AUDC Screen in other reminders

## AUDC Score as it shows in note

## Tobacco Use Screen

## Tobacco Screen Health Factor

## Hep C Risk Screen

## PTSD Screen 

## PHQ-2 Depression & Suicide Screen

## New MHC Intake & Evaluation

**Notes:**
To go along with the education requirements MH incorporated the barriers and learning methods. These elements enter education factors in the encounter form and enable them to be viewed in the health summary reports.

## Health Summary Report

- Interdisciplinary Patient Education

## Physician Discharge Instruction

## Physician Discharge Instruction

- Branching logic
- Patient with Active Warfarin Order

## Physician Discharge Instruction

## Depression Reminder

- Not Completed

## Depression and Alcohol Screen 

- Previously Completed

## Reminder Reports

## The Magic of Reminder Dialogs

**Objectives:**

- Reminders & Reminder dialogs
- Differences between reminder dialogs and standard dialogs
**Reports from reminder dialog elements**

## Understanding the Reports

- There is a lot of data in VA that is available to use in managing performance and operations
- The key is to try and understand how the process created the results you are getting
- If you don’t understand, then you won’t be able to ensure better performance in the future

**Notes:**
So why are we talking about reminder/provider reports in a magic template presentation.  Well I see the remidner dialog templates as magic as they cut down my work..meaning I don’t have to go into the reminder drawer and click on all those reminders because some of them are done while I am charting and being in primary care, if we set up the templates for some of sub specialist, then they can complete reminders and not even know they are doing it.   A little sneaky but effective.  Anyway back to reminder reports and magic templates. One of the reasons for this presentation in the provider tract is to show you what is possible.  You are here for a reason, either you are interested in informatics, you are in a decision making role...or at least an influence ...or maybe you are just one of those folks who like to be in Florida in July...but whatever the reason it is important to know what is possible so when you go back to your medical center you can speak to your CAC with knowledge to request what you want.  No one can read each others mind.  The same needs to hold true for the reports that are being generated about your practice/team/medical center. You should understand how your reports are generated so you can understand your results.  We will also talk about some of the possible variations of reports that can be generated. 

## Clinical Reminder Reporting

- Useful for Provider Performance
- 	 – Report Cards
-  Identify Areas of Improvement
-  Improve Clinical Performance
- “Real Time” reporting
- 100% sample

**Notes:**
Some of the “buzz words” at my facility include:   Data Driven Decision Making – From front line staff to management, data assists us in identifying problems, best practices, strong providers, or compliant employees.  Data provides “evidence”  or a framework to base decisions or take action on.  The data derived from Clinical Reminders can be used for Provider Profiling – we compile monthly, quarterly, and baseline “report cards” on Primary Care Providers at our site.  This enables us to quickly identify the strong and weak providers, the areas where everyone is struggling, and any performance measures that need close attention.  This data is included in the Providers Performance Improvement folders which are used in the re-credentialing process.  Strong providers can be rewarded for their performance and/or the improvements they make.   This is why it is SOOOO important to be able to provide real time reports and always assure the data is valid.

## Reminder Reports

- Evaluate one or more Clinical Reminders on a group of patients
- Report contains
- Total number of patients in the group
- Number of patients for whom the reminder is applicable
- Denominator
- Patients for whom the reminder is due
- Number of patients with the reminder due – _**summary**_
- List of patients with the reminder due – _**detailed**_

**Notes:**
Basic reporting is on a clinical reminder.  Take the diabetic foot exam reminder –pretty basic.  They ether got the exam or they did not. Your report reflects all your pt’s that had that exam.  This can be run as a summary report (which is how most provider reports are reported or the report can be set up as a detailed report and list the patients with the reminder still due.

## Summary Report

## Detailed Report

## 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

**Notes:**
Future dates can help in a variety of settings.  Pre printing the list of flu reminders due to individul clinics  - can help with staffing during a busy flu season. Or if you have a clinic where many of your OIF/OEF vets are seen. A list of patients with the remidner still due can be printed and given to the clinic on a regular basis.  They are many uses to run a report with future dates

## Reporting Reminders

- You can get more detailed information about performance than just the clinical reminder
- Instead of “due and applicable”, you can see the individual health factors and other terms that explain the overall result
- Example:
- Did the patient not meet the criteria because their A1c was over 9.0, or because it wasn’t reported?
- How many flu vaccines were refused as opposed to not being offered

## Slide 73

## Reporting Reminders

## 
   Understanding the Numbers 
AND
Follow the Trends

-    Understanding the Numbers
- AND
- Follow the Trends

## Slide 76

## Panels vs. Encounters

- PANEL
- Pro: “Your patients” identifiable to you in a primary care (gatekeeper model).  Managing your entire panel and not those just recently seen
- Con: May not have been seen by you for a long time
- ENCOUNTER
- Pro: definitely seen by you recently
- Con: Does not reflect your entire panel

## Other Reports Available

- KLF
- Proclarity

## Clinical Reminder Reporting

- Useful for Provider Performance
- Identify Areas of Improvement
-  Improve Clinical Performance
- “Real Time” reporting

- Help Save Lives

**Notes:**
Some of the “buzz words” at my facility include:   Data Driven Decision Making – From front line staff to management, data assists us in identifying problems, best practices, strong providers, or compliant employees.  Data provides “evidence”  or a framework to base decisions or take action on.  The data derived from Clinical Reminders can be used for Provider Profiling – we compile monthly, quarterly, and baseline “report cards” on Primary Care Providers at our site.  This enables us to quickly identify the strong and weak providers, the areas where everyone is struggling, and any performance measures that need close attention.  This data is included in the Providers Performance Improvement folders which are used in the re-credentialing process.  Strong providers can be rewarded for their performance and/or the improvements they make.   This is why it is SOOOO important to be able to provide real time reports and always assure the data is valid.

## For More Information

- vaww.vehu.med.va.gov/Search/eXpresstrain.cfm

## Slide 81

## Slide 82

## Questions??