# Presentation: 689386

## 204 Clinical Reminders - Enhancing Patient Care and Improving Efficiency 	

**Co-Presenters:**
- Alan Montgomery, Computer Specialist, OIFO, Tuscaloosa
- Kathy Montgomery, RN, Performance Improvement Coordinator, Office of Quality Management, Tuscaloosa VAMC

## HOUSEKEEPING

- This is an 80 minute lecture class
- Restrooms are located...
- Cell Phones
- Please turn off or change to vibrate
- 	If you must answer a call, please leave the room.

**Notes:**
Before we get started we need to take care of some Housekeeping issues. Restrooms are located..
If you have any questions please write them on the 3X5 card provided. Answers to your questions will be posted on the VEHU website. So please check the website when you return home.

## HOUSEKEEPING

- We want this to be informal and interactive, but please hold your
- questions during the presentation.
- Questions can be written on the 3X5 card provided. These will be answered at the conclusion of the presentation, time permitting.
- For questions not answered,
- the question and the answer will be available on the web.

**Notes:**
Before we get started we need to take care of some Housekeeping issues. Restrooms are located..
If you have any questions please write them on the 3X5 card provided. Answers to your questions will be posted on the VEHU website. So please check the website when you return home.

- INTRODUCTION OF PRESENTERS:
- Alan Montgomery
- Lab background
- Clinical Reminders launching during time as Primary Care AdPac
- Currently supporting reminders as well as other VISTA packages in OIFO

## Co-Presenter

- Kathy Montgomery, RN
- RN for 13 years
- Background in Long Term Care, Rehab and Primary Care
- Began using reminders when introduced in the Primary Care Clinic
- Served as resource (guinea pig!) in clinic
- Now utilizes reminder reports extensively in Quality Management/Performance Improvement Coordinator role

## This class is intended to offer some insight and suggestions into the design and implementation of clinical reminders at your site.  It is not technical in nature nor does it teach one how to create a clinical reminder.

## Course Objectives

***At the end of this course you should be able to:***
- Describe the essential components of a clinical reminder;
- Develop strategies to avoid reminder burnout by becoming a part of the process;
- Identify key participants of a clinical reminder workgroup;
- Illustrate examples for utilization of clinical reminder reports/extracts.

## Some history and a brief look into the future of clinical reminders

- Initially started as a ‘piece’ of PCE package
- Released as its own package, V1.5, in June of 2000
- Version 2.0 released February 2005 with many enhancements which made life easier and harder!
- Patch 4 released October 2006 with more enhancements (see disclaimer above )
- Patch 6 to be released this year (hopefully) with more enhancements, (should I mention the disclaimer?)

**Notes:**
Initially started as a piece of PCE package-this is why you see some of the menus still include PCE in the menu text

## So, as you can see, the clinical reminders package is a moving target and hitting the bulls eye is not always an easy task!!

## How do clinical reminders help us?

- Improve documentation with “Progress Note Text” associated with dialogs
- Help with process of disease management, i.e. Colon Cancer, Diabetes, etc.
- Tool to prompt important screenings, i.e. Depression, PTSD, etc.
- Performance measure tracking

## Initial concept

- Help bring to a provider’s attention (real time) that some clinical action needs to be accomplished for the patient

## CPRS Coversheet

## Use of clinical maintenance view

## Moving forward

- After reporting functionality was created, data could be extracted to see how a site was doing in regards to performance measures

## Essential components:

**The Cohort (the “Who”)**
- Patients needing an intervention
- Patients you want to see on a report
**The Resolution (the “What”)**
- What will turn this reminder OFF?
**Frequency (the “How Often”)**
- How often should this reminder or selected intervention be “due”
- Monthly, Annually, Once in a lifetime, etc.

**Notes:**
This class is not technical in nature, but just wanted to give you a few terms you might hear when discussing reminders with your peers.  For those of you who actually build the reminders, these should be all to familiar to you!!

## More Clinical Reminder “Lingo”

**Applicable – **Patient is “in” the reminder cohort logic
**Due** – Some clinical action needs to be taken in order to resolve this reminder
**Resolved/Satisfied** – Clinical action has been taken for patient.  Reminder will be due again according to the frequency defined

## How can I help develop a “good” clinical reminder

- Research your task
- Don’t fly by seat of your pants
- Gather information for the “who”, “what” and “how often”  - these are **essential** to the success of your reminder

## How can I help develop a “good” clinical reminder?

- Work Together
- You cannot accomplish this alone
- Talk to subject matter experts that your reminder will deal with, i.e. lab test, drugs, orderable items, etc.

## How can I help develop a “good” clinical reminder

- Validate your reminder
- Test all scenarios of your reminder
- Have certain users at your site “test” the reminder and provide feedback

## Clinical reminder reports	

- Provider Profiling – Kathy will discuss later
- Monitor compliance with performance measures
- Monitor staff compliance with completing required clinical reminders

## Report “DON’TS”

- Don’t use reports as a club!
- Don’t report to management without verifying data is correct

## All that to say this!

- Good reminder design can best be accomplished by a group of people who have a vested interest in the clinical reminder, or should we say “a horse in the race!”
- A physician
- Nurse Practitioner
- RN
- LPN
- Performance Improvement/Quality Management person familiar with OQP technical manual and the interpretation of the measures
- Chief of Staff
- Group discussion will help the reminder to have all essential pieces necessary for quality design
- Design a clinical reminder request form for possible new reminders for group discussion and possible implementation

## Clinical Reminder Request Form:

**Clinical Reminder Request Form**
- Purpose of the Clinical Reminder:
- Who will this reminder be applicable to:
- What “things” will resolve this reminder (make it go away):
- How often should this reminder come due, i.e. yearly, monthly, etc.:
- Other comments:

## Clinical reminder reporting

- A - Useful for Provider “Profiling” – Report Cards
- B - Identify areas of improvement
- C - Improve Clinical Performance
- D - “Real Time” reporting of 100% sample
- A+B+C+D = 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.

## Sample report card

## Identify “Best Practices”

- “Star Performers” –
- Teams that “STANDOUT” from the rest
- Processes that result in top outcomes

**Notes:**
Have any of you ever been asked “who is the top clinical performer?”  Well, if you have the data it’s an easy answer.  Kind of like keeping stats in baseball – you already know who has the highest batting average!  And, further you also know who the winning team is – all you have to do is set up a worksheet to reflect “team” data instead of individual statistics.  Further analysis will provide you with data that reveals where processes in place are effective.

## Identify areas for improvementinitiatives		

*Weak Performers*
*Compliance issues – reminders not done*
*Processes that don’t work efficiently/effectively*

**Notes:**
On the other side of the coin, analysis can identify staff who may need some education or additional assistance and encouragement and processes that need to be put on an improvement plan!  Reports can be set up to reflect which staff consistently complete clinical reminders and those that don’t.

## Slide 29

**Notes:**
As you can see, once the data is displayed in this graphical format, it is easy to identify your top performers as well as providers who are struggling!  Just remember to always reference your data source on any graph you prepare to clarify to your audience where the data came from and the time period.  This allows you to compare “apples to apples” in future presentations of the data.

## NEXUS Sampling

-  EPRP (External Peer Review) from Office of Quality and Performance (OQP) utilizes NEXUS for sample of patients (Cohort)
- NEXUS is a “formula” consisting of visit types and timeframes and specific stop codes
- Clinical reminder reports can be pulled utilizing this same NEXUS sample
- Allows for “like” sampling and comparison

**Notes:**
How many of you are familiar with the EPRP process and the use of NEXUS Sampling?  As the slide states, the Office of Quality and Performance developed this method of “randomizing” samples based on patient’s having an “anchor” visit and a visit to one of the clinics that meet the NEXUS cohort – which is simply a group of clinic stops.  Clinical Reminder Reports can be set up to pull a list of patients meeting the same criteria as EPRP uses in NEXUS samples.  This allows you to create your own NEXUS sample patient list and pull data on it to “mimic” the EPRP pulls only you can look at 100% of the patients meeting that criteria.  It makes more sense to base decisions on 100% of your sample than the small sample utilized by EPRP which may over sample a segment of your patient population (for instance at our site we tend to get over sampled in the Mental Health patients).  

## Improving clinical performance

- Reports can identify patients requiring specific clinical actions
- Patient lists created with addresses for “mail merge” into letters for patient education or prompts for specific appointments
- Useful tools for case management

**Notes:**
Clinical Reminder reports and patient lists can assist providers in case managing their patient panels.  You can extract all diabetics in a provider’s panel with Hgb A1c and LDL in poor control.  You can identify female patients that have not had a mammogram or pap smear within the acceptable time frame and notify them of the need to complete the important screenings.  This is the best part of using the data for me!  I love being able to get down to the patient level and truly use the data to make a tangible difference!

## What does NEXUS really mean?		

- Definition of NEXUS:  A* connected series or group; the means of connection between things linked in series*
- Does that help you?

## Sample patient list containing lab value:

- ---------- EIGHT,PATIENT DFN=3 ----------
- Address Data
-  PHONE NUMBER: 222-555-8235
- Demographic Data
-  SSN: 0008
- Finding Data
-  **VEHU HGBA1C,"VALUE": 7**
- ---------- EIGHTEEN,PATIENT DFN=149 ----------
- Address Data
-  PHONE NUMBER: 222-555-8235
- Demographic Data
-  SSN: 0018
- Finding Data
-  **VEHU  HGBA1C,"VALUE": 7**

## Clinical Reminder Workgroups

- Collection of diverse staff with both clinical and technical expertise
**“****No man is an ISLAND”** – Clinical Reminders require a **TEAM** approach
- Clinical Reminder builders/coordinators  rely on input from the group to develop quality products

## Key Players	

- Technical expert – ISS, CAC, whoever is designated at your site as Clinical Reminder Manager
- Medical representative – Physician, APN, PA
- Psychiatry representative – Psychiatrist, Psychologist, APN, Advance Practice Nurse, etc.
- Nursing staff
- Lab, Pharmacy, Radiology, Rehab Medicine may be affiliate members and used as needed

## Standardization	

- National Standardization – Several standard reminders already in use, i.e. OIF/OEF, TBI, etc.
- Allows for comparison of “apples to apples”

## VISN Standardization

- Some VISN’s are working to standardize clinical reminders
- Same rationale as the National Reminders—improves ability to compare performance across facilities

## Soooo much to do...AVOIDING BURNOUT

- Have you ever heard (or spoken!), “There are just too many reminders to do!”
- Are these clinical reminders of any value?
- Where do these come from?

## Where do they come from?

- Most sites utilize the Performance Measures to develop Clinical Reminders
- Performance Measures are developed in the Office of Quality and Performance
- Based on the Clinical Practice Guidelines

## http://vaww.oqp.med.va.gov/default.htm

**http://vaww.oqp.med.va.gov/default.htm**

## Keys to understanding 

- Is there any **value** to Clinical Reminders?
- Clinical Reminders are the “post it” note you need to provide quality care to patients!

## The “Value”

- Makes a difference in patient care – saves lives!
- Makes a difference in user satisfaction—provides a “safety net”

## THE VA Clinical Reminder System:

**Allows** caregivers to track and improve preventive healthcare and disease treatment for patients
**Ensures** that timely clinical interventions are initiated
- Is 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

## Prompting important clinical actions		

**Reminds** providers to immunize patients
**Identifies** high risk patients who need specific interventions, i.e. Diabetics that need eye exams, foot exams, labs, etc
**Prompts** providers to get lab levels for specific medications, i.e. Coag studies for patients on Coumadin

## Get on board!	

- Volunteer to be a member of local group
- Websites – past **VEHU** courses
- Attend **VEHU** – then ***pass on what you learn!***
- Look at the **DATA**

## Let’s Review...

- Remember when:
- Charts consisted of papers filed in a plastic binder;
- You had to “call the File Room” to get a chart;
- There were little sticky notes or messages in “green books” to remind providers “TO DO” something

## Not Anymore!

- Charts are now a “keystroke” away!
- Clinical Reminders have replaced the sticky notes and green books!

## Putting it all together!!!!	

- Clinical Reminders have been around awhile – 6+ years!
- They prompt clinical action, document the action, and allow for data collection
- Reports help “Drill Down” data to provider and patient specific levels
- Clinical reminders enhance patient safety by prompting clinical actions

## Once again – What are the building blocks of reminders?	

- Cohort – the **WHO**
- Resolution – the **WHAT**
- Frequency – the **HOW OFTEN**

## What can we do with these building blocks?	

- Create patient lists – mass mailings, etc.
- Create reports, charts, graphs (The Joint Commission loves these!)
- Develop Report Cards – Everyone likes to know how well they do their job!
- Anything else?  That’s what we want you to think about!

## Resources:

- Office of Quality and Performance (Clinical Practice Guidelines):
- http://vaww.oqp.med.va.gov/default.htm
- Archived VEHU Courses:
- http://vaww.vehu.med.va.gov/vehu/eXpressTrain.cfm
- Attend Poster Sessions-Networking!!

## Wrap – up 

- We will take questions now
- Any questions not answered today will be available on the website