# Presentation: 528095

## 309H Clinical Reminders Treasure Chest (Arrgh ... thar be data here!)

- [Automated Reminder Extracts]
- Rob Silverman, PharmD
- Alan Montgomery
- August 21 and 22, 2007

## Objectives

- Define the tools available within clinical reminder extracts functionality
- Demonstrate how a reminder extract can automate routine data collection
- Compare the features of extracts to the performance measures in the OQP technical manual used by EPRP

## Advantages of Reminder Extracts

- Automation
- Once set up, it will run as a tasked job
- Reminder Definition Simplicity
- You can move subtle adjustments to the group of patients to be evaluated (the sample) away from cohort logic and into the extract patient selection setup

## Advantages of Reminder Extracts

- Reviewing performance over time
- Patient lists of the sample are automatically saved with each extract
- You can re-evaluate the same patients to measure progress
- Use Mnn/yyyy format for later reference
- VISN 12 NEXUS CLINIC VETERANS M4/2007 (PL)
- Patient Subsets
- You can look at special VA populations, such as spinal cord injury patients, in the same report

## Advantages of Reminder Extracts

- Performance measure detail
- You can get more discrete information about performance monitors as measured by a clinical reminder
- Instead of “due and applicable”, you can see the individual health factors and other terms that explain the overall result

## Advantages of Reminder Extracts

- “Grayscale” reporting
- My term for the intermediate information about a report that is “black and white”
- Example: Hemoglobin A1c
- Did the patient not meet the indicator because their A1c was over 9.0, or because it wasn’t reported?

## Advantages of Reminder Extracts

- Rule Sets used to create patient lists can be reused as well to create similar but not identical lists
- Caution: using nexus clinic rules to measure OEF/OIF veterans may lead to underreporting

## Patch PXRM*2*6

- Many of the features shown today on the VeHU account require clinical reminders patch 6
- This patch introduces the following enhancements to the extract process
- Display a reminder’s print name in the extract summary
- Change SEQUENCE from 3-digit codes (001, 002, etc.) to true numeric entries (1, 2, etc.)

## Patch PXRM*2*6

- More enhancements
- Correction to exclude No-Show encounters that already have data associated with them
- Display the OPERATION field during use of the Rule Set Test action
- And a bunch more not extract-related, such as new mental health instruments for reminder dialogs

## VISN 12 Report Automation

- These steps are all documented at: http://vista.med.va.gov/reminders/troubleshooting.htm
- What are the steps?
- What is the value of this process?
- Thanks to the reminders development team (Patrick, Anthony, Debbie) for the discussions that led to making this work!

## Report Automation Steps

- Create LOCATION LIST
- PXRM LOCATION LIST MANAGEMENT
- Nexus Clinics
- LOCATION LIST into TERM
- TERM into FINDING RULE
- FINDING RULE into RULE SET

## Report Automation Steps

- Create EXTRACT DEFINITION
- PXRM EXTRACT DEFINITION
- Instructions come from a RULE SET
- Output goes to a PATIENT LIST
- Reminder_s_ are run against the list
- Summary of results is saved
- Manual extract as a test

## Report Automation Steps

- Establishing the automatic task
- FileMan update to the NEXT REPORTING PERIOD
- Creation of an option in file #19
- Scheduling the option with XUTM SCHEDULE
- These steps currently require programming-type access

## Extract Enhancements

- Anchor Visit
- Simplify Reminder Definition
- Add Sub-Cohorts
- Additional Detail via DSF option

## Anchor Visit

- Definition from OQP Technical Manual:
**Outpatient visit anywhere in VHA recorded in AAC File SE at least once during the 13-24 months prior to the study interval. This visit is considered an ‘anchoring’ visit which identifies an ‘established’ patient. **
- VA-ALL LOCATIONS location list is part of PXRM*2*4
- LOCATION LIST into TERM
- TERM into FINDING RULE
- FINDING RULE into *existing *RULE SET
- BDT (extract start) minus 2 years through BDT minus 366

## Simplify Reminder Definition

- VISN 12 Reporting Reminders are designed to mimic EPRP standards
- Performance is measured on VETERAN patients only
- Extract allows use of CF.VA-VETERAN to be moved from the reminder definition to the extract definition’s rule set

## Simplify Reminder Definition

- With the VA-VETERAN finding no longer part of the reminder definition, you can use the same reminder to evaluate provider actions at your facility without excluding care provided to non-veterans

## Add Sub-Cohorts

- Some OQP Performance Measures are defined against subgroups of the Nexus cohort
- Spinal Cord Injury
- Nexus Mental Health
- Nexus Non-Mental Health
- Extracts allow each to be calculated separately

## Adding Reminder Detail

- One of the extract definition parameters is to collect “COMPLIANCE TOTALS” or “COMPLIANCE AND FINDING TOTALS”
- Using the finding totals as well allows collection of data about any terms present in the reminders
- Examples
- A1c Reminder: Term with all labs,  not just <9
- Influenza Reminder: Term with Refusals

## Panels vs. Encounters

- PANEL
- Pro: “Your patients”, runs fast, identifiable to you in a primary care (gatekeeper model)
- Con: Not recently seen, nexus clinics to other providers
- ENCOUNTER
- Pro: definitely seen by you
- Con: cross coverage, slower report
*Do patient lists overcome these differences?*

## Hands-On Experience

## Steps to be done in class

- Create a reminders location list
- Use a couple of the nexus clinic stop codes
- Put the location list into a term
- Finding rules always use terms
- Put the term into a finding rule, and the finding rule into a rule set
- This is a routine process worth the time to become familiar with it

## Steps to be done in class

- Create a reminder extract definition
- 2 extract sequences = 2 patient lists
- Extract Sequence #1
- All patients for reminders about
- Post MI patients, LDL < 100 mg/dL
- Diabetic patients, A1c ≤ 9%
- Extract Sequence #2
- Veterans only for a reminder about
- CHF patients on an ACE/ARB

## Steps to be done in class

- Run a manual reminder extract
- This will be the primary output of the hands-on process
- Observe a timed automatic run
- Compare extract results to the data obtained via a reminder report generated prior to the class

## Extract Results

**Extract Summary               Jul 06, 2007@14:51:41          Page:    1 of    1 **
**Extract Summary Name: aaa PERFORMANCE MEASURES 2007 M06**
**      ****Extract Period: 06/01/2007 - 06/30/2007   Created: 07/06/2007@14:51:10**
** ****Item  Patient List/Station/Reminder        Total   Appl.    N/A    Due  Not Due**
**   ****1 aaa NEXUS CLINICS M06/2007 (PL)                                              **
**     ****500/LDL<100 Post Myocardial Infarcti      48      24     24      4     20  **
**     ****500/Diabetes - HgbA1c                     48      24     24      7     17 **
** **
**   ****2 aaa NEXUS CLINIC VETERANS M06/2007 (PL)                                      **
**     ****500/Congestive Heart Failure - ACE/A      42      17     25      2     15****  **

## Reminder Report Comparison

** ****Jul 13, 2007 11:35:35 am  Page 2**
**                 ****Clinical Reminders Due Report - Summary Report**
**Facility: CAMP MASTER  500**
**Reminders due 7/13/2007 - PRIMARY CARE/MEDICINE 323 for 6/1/2007 to 6/30/2007**
**                                                  ****# Patients with Reminders**
**                                                  ****Applicable           Due**
**                                                  ****----------           ---**
**1    Congestive Heart Failure - ACE/ARB                 23              4**
**2    Diabetes - HgbA1c                                  24              7**
**3    LDL<100 Post Myocardial Infarction                 24              4**
**Report run on 48 patients.**

## Scheduled Option

**NAME: PXRM EXTRACT VEHU 2007 309H**
**  ****MENU TEXT: VeHU 2007 309H Auto Reminder Extract**
**  ****TYPE: action                          **
**  ****CREATOR: CPRSPROGRAMMER,ONE**
**  ****PACKAGE: CLINICAL REMINDERS           **
**  ****E ACTION PRESENT: YES**
**ENTRY ACTION: **
**D AUTO^PXRMETX("aaa PERFORMANCE MEASURES","Y") <-purge**
**  ****SCHEDULING RECOMMENDED: YES**
**  ****UPPERCASE MENU TEXT: VEHU 2007 309H AUTO REMINDER E**

- Queued for 8-21@1400, 8-22@0930
- Rescheduling Frequency would be “Monthly“

## FileMan Setting for Auto Extract

**REMINDER EXTRACT DEFINITION FILE (#810.2)**
**NAME: aaa PERFORMANCE MEASURES           **
**TYPE OF TOTALS: COMPLIANCE TOTALS ONLY**
**  ****REPORT FREQUENCY: MONTHLY **
**NEXT REPORTING PERIOD/YEAR: M06/2007**

## Auto Extract Appearance

**Examine/Schedule Extract      Jul 11, 2007@13:07:10          Page:    1 of    1 **
**          ****Extract Name: aaa PERFORMANCE MEASURES**
**   ****Next Extract Period: M7/2007**
**      ****Scheduled to Run:                          View: Creation Date Order**
** ****Item    Extract Summary          Date Created         Transmission Date   Auto **
**    ****1 aaa PERFORMANCE MEASURES 200 07/11/2007@13:05:40  Not Transmitted       Y****  **
**    ****2 aaa PERFORMANCE MEASURES 200 07/06/2007@14:51:10  Not Transmitted       N **
**------------------------------------------------------------------------------**
**Extract Summary Name: aaa PERFORMANCE MEASURES **_**2007 M06/01**_
**      ****Extract Period: 06/01/2007 - 06/30/2007   Created: 07/11/2007@13:05:40**
** ****Item  Patient List/Station/Reminder        Total   Appl.    N/A    Due  Not Due**
**   ****1 aaa NEXUS CLINICS M06/2007 (PL)/01                                           **
**     ****500/LDL<100 Post Myocardial Infarcti      48      24     24      4     20  **
**     ****500/Diabetes - HgbA1c                     48      24     24      7     17  **
**   ****2 aaa NEXUS CLINIC VETERANS M06/2007 (PL)/01                                   **
**     ****500/Congestive Heart Failure - ACE/A      42      17     25      2     15 **

## [Optional] Re-using Saved Patient Lists from Extracts

- Each RULE SET in an extract creates a saved patient list
- The lists are “private”
- Seen by the creator (or the scheduler of the tasked extract option)
- Seen by holders of key PXRM MANAGER
- The lists can be used to run reminder reports later
- Evaluate the progress of a reminder for the same cohort of patients as was reported in the extract

## Reminder Report from Patient List

- This example shows use of a patient list (all nexus clinic visits) and the reminder that was run against nexus clinic veteran visits only during the extract (effectively the same as a reminder report)

##  Item  Patient List/Station/Reminder        Total   Appl.    N/A    Due  Not Due

** ****Item  Patient List/Station/Reminder        Total   Appl.    N/A    Due  Not Due**
**   ****2 aaa NEXUS CLINIC VETERANS M06/2007 (PL)/01                                   **
**     ****500/Congestive Heart Failure - ACE/A      42      **_**17**_**     25      **_**2**_**     15**** **
- ----------------------------------------------------------------------------------------------------------------------------
- Jul 13, 2007 11:20:11 am  Page 1
-                  Clinical Reminders Due Report - Summary Report
-           Patient Sample:       Patient List
-           Patient List:         aaa NEXUS CLINICS M06/2007 (PL)
-           Effective Due Date:   7/13/2007
-           Date run:             7/13/2007 11:19:07 am
- _______________________________________________________________________________
-                                                 Jul 13, 2007 11:20:12 am  Page 2
-                  Clinical Reminders Due Report - Summary Report for 7/13/2007
-                                                   # Patients with Reminders
-                                                   Applicable           Due
-                                                   ----------           ---
- Congestive Heart Failure - ACE/ARB                 _23_              _4_
- Report run on 48 patients.
- End of the report. Press ENTER/RETURN to continue...