**Transcript of Cyberseminar**

**VIReC Clinical Informatics Series**

**Redesign of an Electronic Clinical Reminder to Prevent Falls in Older Adults**

**Presenter: David Ganz, MD, PhD**

**April 16, 2013**

**Redesign of an Electronic Clinical Reminder to Prevent Falls in Older Adults**

**April 16, 2013**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at http://www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact: virec@va.gov*

Margaret:Welcome everybody. This session is part of the VA information resource center’s ongoing clinical informatics cyber seminar series. The series aims are to provide information about research and quality improvement applications in clinical informatics and also information about approaches for evaluating clinical informatics applications.  Thank you to CIDER for providing technical and personal support for this series. As Heidi said, questions will be monitored during the talk and the Q&A portion of Go To webinar and we will present them to the speaker at the end of the session. Also, a brief evaluation questionnaire will appear when you close Go To webinar at the end of the session. Please take a few moments to complete it. 

At this time, would like to introduce our speaker for today, David Ganz, MD, PhD. Dr. Ganz is the physician in the Geriatric Research Education and Clinical Center - or GREC - at the VA greater Los Angeles Healthcare System, as well as associate director for the VA QUERI, Center for Implementation practice and research support -  or CIPRS. He is assistant professor of medicine at UCLA. His VA, HSR&D career development award focuses on improving implementation of fall prevention programs in older Veterans. Without further ado, may I present Dr. Ganz.

Dr. Ganz:Thanks Margaret. Thank you very much for the nice introduction. Also, thank you to Heidi. I want to thank VIReC for inviting me to present today. Also, a special thank you to Debby Delevan at CIPRS who helped prepare these slides. 

We’re going to be talking about redesign of an electronic, clinical reminder to prevent falls in older adults. If you want to read more about this after the session, our work was published in the journal, *Medical Care*, and the citation is on the very first slide that I’m showing you right now.  This was part of a special supplement that VIReC helped arrange, focusing on the use of information technology in quality improvement projects within the VA. 

So, we’re going to start by talking a little bit about fall as a public health problem in older people. And then, I will jump right into talking about our redesign of an electronic clinical reminder to identify and address fall risk, the methods and results of our implementation strategy and then some further implication.  So, falls are actually quite common and costly in older people. And, among people age 65 or older, about a third will fall at least once during the year. That’s across all community dwellers. Now, most falls do not result in injury, but about 5%-10% of fallers will have serious injuries – including fractures, head trauma, or laceration. For this age group, those who are age 65 and older, falls are the most common mechanism of nonfatal injury treated in the emergency department. This is data from 2001, but I think that it continues to be true. 

Nursing home and hospital falls are even more common that community falls among community dwellers. Falls in the nursing home and hospital occur at a rate of 150 falls per 100 beds per year. Fall injuries cost about $19 billion in the year 2000. Adjusted to today’s dollars, that would probably be around $25 billion. 

So, I’m a geriatrician and so for me, I try to summarize why falls are important. I think the number one reason why falls are important is because they are a marker for underlying functional decline. Some functional decline is not reversible, but some is. So, if we can identify people who are falling, then we can potentially intervene to forestall further functional decline or reverses the functional decline that occurred. 

The second reason falls are important to me as a practioners is that serious injury subsequent to a fall may mean the end of independent living. The classic example is that of an older woman living along – perhaps she’s widowed. She’s living independently in her own home. She falls and has a hip fracture. Then she goes to a nursing home after having a repair in the hospital and never quite gets out of the nursing home. This is the kind of thing we’re trying to prevent. 

Finally, fear of falling itself may cause older adults to restrict their activities. It’s almost like a syndrome of its own rights...in its own right. So, if we can prevent people from falling, potentially we can also help address the fear of falling. This is sort of the rationale for pursuing active screening for falls in older people. 

Now, in terms of the data, we have copious data on fall prevention programs – particularly in exercise programs. Group exercise, Tai Chi, and home based exercise have all been found effective. The relative rate reduction has ranged anywhere from 28% - 32% and has been statistically significant. These fall prevention programs that focus on exercise have been effective at both lower and higher risk patients. You can see the citation below for more information. 

In fact, the US Preventative Services Task Force actually came out with recommendations last year on appropriate treatment for older patients at risk for fall. They gave exercise and vitamin E supplementation a grade B recommendation. This means that they recommend the service, that the evidence may shift over time and potentially change the recommendation, but it’s still a recommended service. Particularly important to us, the Affordable Care Act has actually required that anything that gets a grade A or grade B recommendation by the US Preventative Services Task Force has to be covered by health plans. That may not immediately affect the VA, but it sort of affects our competition – you might say – given that we are potentially going to be competing for patients as time goes on.

Now, multifactorial assessment got a grade C recommendation. Multifactorial assessment is where you go after the individual risk factors for fall and try to address each one. The US Preventative Services Task Force concluded that we should not automatically perform multifactorial assessment but consider individual patient’s risk, benefits, and preferences. And a little later, if I have time at the end, I’ll talk about how this recommendation sort of shaped what we considered important to put into the clinical reminder. 

Now the VA has been on the forefront of measuring quality of care across the variety of domains including: clinical quality, access, cost and satisfaction. The data that the VA uses to measure quality are collected by electronically and also through manual chart review. They have a program called the External Peer Review Program that does these chart reviews.

It turns out that the fall...measures of quality for falls have actually been followed since fiscal year 2007 and they now have benchmarks. These indicators are collected by a chart review. So, they are literally, typically nurse chart abstractors sitting in front of a computer screen looking at CPRS, looking at what care has been rendered for a fall. 

One of the quality indicators measured by the EPRP is...deals with asking about falls in the past year. The quality indicator basically says for all outpatients age 75 and up, within the past 12 months was the patient asked about the presence/absence of any falls within the preceding 12 months? And, it’s specifically looking for whether the result of that asking was no fall, one fall without injury, one fall with injury, or two or more falls. So, the quality indicator can be passed if there’s evidence that the patient was actually asked about falls. Then, they collect the additional data at the bottom of the slide, which you will see will be relevant to the next indicator we’re going to cover in a couple of slides. 

Here’s a little bit of data from fiscal year 2010, which is around the time of the genesis of this project. What you see here is a graph. On the y-axis is the pass rate for the quality indicator, ranging from 0-100%. Then, along the bottom of the graph, you see three different locations. You see GLA – which stands for VA greater Los Angeles- and a sample size of 223 for that fiscal year, V22 stands for Vision 22 – a sample size of 780 charts reviewed, and then the national data which shows a size of 24,479. What you can see just graphically is that the national performance in fiscal year 2010 for asking about falls in the past year was around 70%. So, 70% of people age 75 and up were asked if they had at least one fall in the past year. The rate was lower for Network 22, which is where I am in Southern California. And then, Greater Los Angeles had an even lower rate. Now, there were no statistical tests run on these data, but this was a persistent finding over multiple fiscal years. 

This is a graph just looking at things a little differently. It shows trends over time. You can see that both nationally and in Network 22 there has been an increase in the rate at which older people are being asked about falls. Again, on the y-axis this is the rate ranging from 0 to 100% and then along the x-axis is the fiscal years over time. And so, both nationally and in Network 22 things have been improving on whether people are asked about falls. I didn’t put up the Greater Los Angeles data because the sample sizes are really too small to make imprints, so they’re sort of quite variable. But, you can see that Vision 22 still lags the national level. 

So that was the first fall indicator, but it’s pretty clear that just asking about falls in the past year, while it may stimulate some providers to do something, it doesn’t necessarily indicate that anything was done to actually help the patient reduce the risk of future falls. So, the next quality indicator – also from the EPRP data – is called basic falls evaluation and action taken. This quality indicator basically says for outpatients age 75 and up with two falls or one fall with injury in the past year, was a basic fall evaluation, to include all of the following, performed? You can see, based on the indicator, that you need to know whether the patient had two falls or one fall with injury. That’s why that data was collected in the previous indicator, looking at how many falls had occurred for that older patient. 

You can see that the fall evaluation is pretty thorough. You have to look at the circumstances of the fall, the medications that the patient is taking, review their chronic conditions – if any, produce some kind of diagnostic plan and therapeutic recommendation, and then what kind of action was taken. 

Here again is the EPRP data for fiscal year 2010 for this indicator about fall evaluation being done and some kind of action taken. Again on the y-axis we see a pass rate ranging from 0-100% and on the x-axis from left to right we have VA Greater Los Angeles, Network 22, and the national data. You'll see that the sample sizes are now much smaller. We can get into that in Q&A if you want, but pretty much the sample sizes drop because if you were not asked about falls in the past year in that preliminary indicator that I showed you earlier, we wouldn’t know necessarily whether you had fallen or not. So, you wouldn’t even  make it into the denominator of this particular sample. 

You can see for the nine cases that Greater Los Angeles had, 100% got some kind of basic fall evaluation. You'll recall that Greater Los Angeles had the lowest pass rate compared to the network and nationally on asking about falls. But, when a patient was assessed for falls, they did do a good job. Network 22 has a slightly lower rate at 80% and the national rate is somewhere around 50%

You can see this is completely of the inverse...shows an inverse relationship between how good screening is for identifying people who have fallen in the past year and the level of action taken in response to the screening. Most likely, clinically what this means is in places that do not have an active screening program for falls, falls are only documented when something bad happens – like when a patient actually falls and injures themselves and consequently, naturally, because there is an injury, some kind of action is taken to help the patient and therefore pass rates are higher for those places that don’t have an active screening program.

This is the national data for looking at basic fall evaluation and action taken. I’m not showing you the network level data and the physicality level data because those sample sizes are way too small to really make any inference about the data. But what you can see here - the y-axis again 0-100 and then along the bottom of the graph is basically fiscal years over time – You can see that the rate at which some kind of action is taken on people who’ve fallen twice or once with an injury in the past year, is somewhere between the high 30% range and the low 50% range. There really isn’t the clear trend. It looked like there was going to be a trend until fiscal year 12 data came up. So what this shows is that despite the higher rate of screening for falls and identifying people at risk, action being taken hasn’t really improved. 

So, the goal for our Quality of Care Project at the VA Greater Los Angeles is to try to improve our care. Also, at the same time, because we are doing implementation science, we want to learn better strategies for implementing programs to support vulnerable elders. So, the dual mission of quality indicator and research is built into this project. 

Now we’re going to jump into the actual meat of the project – the actual redesign of the electronic clinical reminder. A little bit of background: this project didn’t start from scratch. There was actually a national falls reminder workgroup that was convened by the Office of Geriatrics and Extended Care under the leadership of Ken Shay. This workgroup met during 2007-2008 to develop a clinical reminder. This reminder was developed by a national committee using a series of conference calls. So, this was basically a first attempt and it was done over the phone. That has to be part of the background of understanding where we were starting from. 

The indicator was...the reminder was specifically designed to meet EPRP requirements – the ones that I had shown you before – and also recommended care from guidelines in quality measures – particularly the American Geriatric Society guideline and the assessing care of vulnerable elders quality measures. Now, this reminder was originally one reminder. But, for practical reasons it was split into two. It was split into a nurse screening reminder where the nurse asked the patients whether they’ve fallen or not and then a primary care provider follow-up reminder – which would basically handle those cases that had screened positive, who had a fall or a gait or balance problem in this case.

We actually did some local testing of this national reminder. This local testing was a quality improvement kind of project. This was not for the purpose of research. I’m going to refer to the national reminder that I just talked about as the first generation reminder just to be completely clear. This reminder was tested in the three VA Greater Los Angeles community-based outpatient clinics that we were working with at that time. And, a little bit of background is that part of my VA Career Development Award, we established a fall prevention workgroup at VA Greater Los Angeles to try to improve care for falls. And, one of the members of the workgroup worked in two of the three community-based outpatient clinics. So that was the connection that got the testing of this first-generation reminder going.

So we rolled out the reminder in two phases. First we started the nurse screening reminder up in March of 2009 and then we started the provider follow-up reminder in September of 2009. That underwent beta testing, but our clinical champion – who was part of the workgroup that I mentioned – and it was then revised and feedback from colleagues was solicited, and then the reminder was launched. And then again, in November of 2009, the nurse screening reminder was revised because it was found that the nurses were sending a lot of people with gait abnormalities to the providers but many of the gest abnormalities were not new. So, basically the providers were feeling overwhelmed with the number of positive screens they were getting. So, some of the reminders were revised accordingly.

We did get some basic data from our clinical applications coordinators about how the first-generation reminder was being used. During the period from March 1, 2009 to February 28, 2010 839 positive screens for falls were recorded at the three clinics. From that sample, 483 fall provider reminders were completed during the second half of that period. As I mentioned, the provider reminders were only started in September of 2009. Now, the importance to us, during this sort of first, you might say, planned due study act cycle, 84% of the providers checked that no further fall assessment was needed. So, they basically opted out of using their reminder. Five percent of providers ordered a consult, and 11% performed any kind of fall assessment. 

The thought that we had as a group, the workgroup, in terms of the strengths and weaknesses of this first-generation reminder, it was very nice and gratifying to see that nurses actively screened for fall risk and found patients who were at high risk. But, the weakness was that the providers often opted out of the template. Also, that if they did want to offer physical therapy, there were long waits for physical therapy. So, it wasn’t clear how they would be able to take action on the information that they were generating from the reminder. But, I want to emphasize this point about providers often opting out. We have allowed them an opt out option because we knew this reminder was just being tested. We didn’t want to force them to use it, given we knew there were still a lot of kinks in it. 

So, this actually...all of this work led to submission of a VA QUERI Rapid Response Project proposal. This was also supported just through the protected time that I had from the HA HSR&D Career Development Award. We proposed a new reminder that was built on the first one but redesigned. The goal would be to improve usability of reminders, improve the front end, and then the other thing we thought we could do is improve data capture on the backend – in other words, be able to generate clinical reminder reports that would at least decrease the need for manual chart review. As I mentioned, all of the EPRP data is collected through manual chart review, but if clinics could get their own data from reminder reports they could act more rapidly on it for quality improvement purposes. 

When the QUERI project was funded, we did a site visit to these three community based outpatient clinics that we had been working with. This is now August 2010. The goal of the site visit was to study clinic workflow, discuss the rolls and responsibilities particularly as the staff nurses and the primary care providers. And, we needed to vet the logic model we had for how basically the care would be delivered. So we met with nurse and primary care provider representatives at each clinic. This was extremely informative. 

The feedback we got on the first-generation reminder was that the nurse reminder was generally okay. There was pretty good acceptability. On the other hand, we heard that the first-generation primary care provider reminder was too complex and time consuming for routine use. So, I guess it’s no surprise that people were opting out of it. This feedback didn’t exactly surprise us. We heard it, I think it was helpful for the providers to actively voice this issue to us.

The other thing that was really interesting is that one of the elements of a good fall evaluation in some patients at least is doing orthostatic vital signs – checking the blood pressure lying down, sitting, and standing up. We heard, and I had already sort of been aware of this, but we heard again that orthostatic vital sounds are difficult to routinely do in clinic due to time and space constraints. We took this information to heart.

We also studied the workflow of how the primary care providers do their work. To our surprise, most of the primary care providers in the clinics we visited generally had only one exam room. This is not true in some places, particularly - for example – when I worked at UCLA. We usually had two exam rooms to work with. But, where we were looking here, they only had one exam room. Consequently what this meant was that when patients checked in and saw the nurse, they went back to the waiting room. They didn’t get put into an exam room. Then, the primary care provider would go and retrieve the patient from the waiting room when he/she was ready to see that patient.

Based on all of this information, we decided to simplify the primary care provider reminder to allow gait, balance, and strength exams to start in the waiting room. How this works is sort of neat. The patient presumably is sitting while they’re waiting, typically. So, one of the tests of strength is to see whether a patient can get up from a chair without using their arms. They can do that by basically asking the patient to get up from the waiting room chair without using their arms. Then, while the two people  - the patient and the provider – walking back to the exam room, the provider can observe the patient’s gait. Then, finally, when the provider and patient gets to the exam room and are in the exam room the provider can test the patient’s balance. This was the proposed workflow and it directly stemmed from observations we made of how work was going in clinics. I don't think we would have been able to propose this had we not done this kind of direct observation and interviewed people. 

The other decision we made was we removed anything from the second-generation falls reminder that would be addressed elsewhere for all people age over 75. This was in response to the provider saying sorry, we can’t do the first-generation. There are too many things in it. So, we removed a requirement for the eye exam. We removed the requirement for cognitive evaluation. We removed the requirement for functional status assessment and we removed a requirement for medication review. 

Now, for some geriatricians this would be heresy, but we realize the care doesn’t all necessarily need to be delivered in a single visit. Later one, ironically, as I showed you the _____ [00:24:45] supported us doing this because we ended up focusing on gait, balance, and strength and referrals to exercise programs. As you saw, in the end the US Preventative Services Task Force actually came out in favor of exercise, but did not routinely recommend the more thorough multifactorial assessment that includes some of these elements that we actually dropped.

Then, the third decision we made was to actually not cover orthostatic vital signs in the reminder. That was for a different reason than for the other items I just mentioned. It just seemed we couldn’t get the workflow to work. We didn’t want the purpose to be the enemy of the good. We thought that some care delivered to prevent falls was better than none. So, we actually let this slip. That was a conscious decision on our part, realizing ideally this was something that would have been checked.

Okay, so now what I’m going to do is pull up some screen shots from the second-generation reminders so you all can see a little bit what it looks like. So, what you're...

Margaret:David, did you want to run that...

Dr. Ganz:Pardon?

Margaret:David, did you want to run that poll question first?

Dr. Ganz:Sure. I think that’s a great idea. 

Margaret:Okay.

Dr. Ganz:Yeah, let’s wait and do the poll. 

Margaret:We’re just checking if you use CPRS. That’ll just give David a better idea of people’s experience with the product before he goes too far into it here. 

Dr. Ganz:Okay.

Margaret:And there are your results. There you go. Thank you.

Dr. Ganz:Thanks. Thanks everyone for filling out the poll. It’s about two thirds of you use CPRS and about a third don’t. So, I’m going to try to just sort of walk through what the screen...an explanation of what the screens are. Basically what we’re looking at here is the beginning of the nurse screening reminder. There’s an initial screening question that asks if the patient is completely non-ambulatory. If they are non-ambulatory that shuts off the reminder because everything that follows really relates to people who are ambulatory. 

Down at the bottom here you're going to see this health factors thing that says FS – fall screen performed. That’s important just to notice because it means that we're capturing all this information on the back end so that we can produce a report. I’ll show you a little bit of data from the reports later. 

I’m just going to go on to the next screen. This is basically a continuation of the nurse screening reminder. Basically what you can see is that the next question is an overall screening question, to find out whether the patient has fallen in the past year or been afraid of falling because of balance or walking problems. If the nurse puts yes in there then the reminder expands and it asks for more information – have you fallen once with injury or without injury, and importantly, what happened? What were the circumstances of the fall? Now, this was our attempt to delegate from the providers to the nurses, some of the data collection aspects to try to decrease provider workloads. You can see some of this basic information could be gathered by the nurse. 

In addition to asking whether the patient has fallen, we asked whether the patient was afraid of falling because of balance or walking problems. The fear of falling is known to be a risk factor for future falls. That was the motivation. The other motivation for having this question is that we’re trying to prevent falls before they happen, so we’d like to at least capture some patients prior to them having a serious fall rather than waiting for the fall to have happened. 

I’m going to continue to go on. You'll see that the next part of the nurse screening reminder asks for information about the use of assisted devices including a cane, a walker, or a wheel chair. Importantly, we don’t just want to know whether the patient has the device, but whether they use it because that can then help guide counseling around assisted device use. 

Then, I think importantly, we really felt that it was within the nurse’s scope of practice, and the nurses agreed with us on this, for the nurses to do some education with the patient. Optionally, you can see that the nurse had the opportunity to provide a home safety check list or fall education to the patient. These blue hyperlinks here, these actually link directly to PDF files that pop up if you click on them. They were basically national, usually national, products from either the National Institute on Aging or the CDC. The only things that are local are these two: the non-VA community centers for fall prevention and the YMCA active senior programs. We actually helped the sites, working with their social worker to compile a list of local resources. We thought it was very important to try to find out what kind of non-VA resources were available, because oftentimes it’s easy within our system to sort of get stuck within CPRS and order only those things you can get to via CPRS.  This was a particular thing, sort of hallmark of this project that I hope we can continue in future projects. 

This is the end of the nurse reminder. What happens is, after the nurse reminder is completed, if the patient screens positive for fall risk either by falling or because of fear of falling, the provider reminder then shows up on the provider’s dashboard for what’s due – which reminders are due. What’s neat about this is that what shows up is the result of the nurse screening. We made a big point about this because we recognize that it was very unlikely that providers were going to necessarily go back and read the nursing notes. Rather than assuming the provider would read the nursing notes, we made sure the information actually showed up for the provider so they would know exactly why the patient screened positive and all the work that the nurse did  about gathering history in terms of whether the patient tripped or stumbled over something or you know, what the assisted device used was. All that information is available to the provider. 

Then the provider has a choice. The provider can say sorry, now is not a good time. Or maybe – as you'll see in a bit – maybe no action is needed because everything has already been done. Or, the provider can assess the patient’s gait, balance, and strength now. There’s this other little link here at the bottom - GLHS Clinical Reminder Feedback. This was for testing purposes so that providers could let us know if there were problems with the reminder so we could try to fix it. 

If the no action needed now box is checked there are few choices. The patient can say...I mean, the provider can say you know what, this fall, it doesn’t sound like it’s due to a gait or balance problem. It sounds like the person fainted - for example. Maybe they need a cardiology evaluation. Or, maybe they need a neurology evaluation because it sounds like they had a seizure. Or, if the patient was admitable, they could go to West Los Angeles Fall Clinic for evaluation. This option was unlikely to be used because these three clinics were at least...like, I would say somewhere  between 90-160 miles away from West Las Angeles. But, we nevertheless wanted to make this option available for special cases.

Finally, if a patient was already being managed by a specialist for a fall or gait problem, these are basically the four opt out options for the provider. But, what you can see from that is that we tried to make the opt out options specific because as you saw from the previous first-generation reminder, providers tended to routinely opt out without doing anything if they had a generic opt out option. 

Now, if the provider opted to do the gait, balance, and strength exam now, what we have here basically mirrors the workflow that I talked about a few minutes ago. The provider can either indicate the patient can rise from a chair without using their arms or they cannot, whether the gait appeared to be normal or abnormal, and whether the balance appeared to be normal or abnormal. Now again, to some of my geriatrician colleagues, this may seem like a really dumbed down fall evaluation for gait, balance, and strength. But we got the clear feedback from the providers that if it wasn’t simple they weren’t going to do it. So, we made it really, really as simple as we could. 

There’s this option, which is not required, to perform the specific test of balance. It walks the provider through. I’ll show you that in the next screen. We realize that you know educational sessions are helpful, and we did do them, but we wanted to have something that is available at the point of care. So what you can see here is that we walked the provider through how to do a test of balance that involved having the patient put their feet side-by-side with the feet touching and the toes lined up. If the patient was able to do that then to test the patient using a semi-tendon stance where the feet are side-by-side touching and the toe of one foot is at the arch of the other foot. If that test was passed, then to do the full tandem - this is to have the toe of one foot touching the heel of the other foot. Then finally, optionally, I would say...in this case it was mandatory. There’s the sternal nudge. This is to basically press against the patient’s breast bone and see whether the patient is able to catch themselves. This was optional. The whole process was optional, but this was the sequence that we suggested. This is sort of like a point of care educational tool. 

Finally, the provider had options in terms of what to do or what to recommend to the patient. I’ve shown you some of the options here. For example – physical therapy could be recommended. You'll notice that there are these options like had physical therapy in the last six months or the patient refuses physical therapy. We put this in here so that the provider could get credit for basically having thought about physical therapy or having offered physical therapy because again, you'll remember on the backend we’re monitoring how providers are using this reminder. So, we didn’t want people to say oh, well the patient declined. So, you're not capturing that information. 

Again, for the exercise programs we have the same handouts available that were available in the nurse reminder in case the provider wanted to offer those and go over them with the patient. You'll see again that there’s this option that the patient already had an exercise program. Then, you'll see we have options for offering a new assisted device, durable medical equipment, home care, and a few other options. Where we have the opportunity, we linked all of these options to available consults. So, if you clicked on one of these options then the consult would pop up after you close the reminder so that you could not have to wait through multiple screens to get to the consult. 

Finally, you'll see down here at the bottom there’s this option for patient has advanced dementia or life expectancy of less than six months. This is to exempt the patient from certain quality indicators - for example – the exercise program, because clearly it’s not necessarily applicable in that particular instance.

I’m going to go back to my Power Point slides now. I want to talk about the methods and results of the implementation strategy. We talked about the list of local community resources. We talked about the educational handout. We also went and did a provider education session in February of 2001. That was an in-service specifically on how to use the second-generation, that is the redesigned clinical reminder. We also offered a special session on prescription and use of assisted devices to help nurses and providers to figure out which ones to offer to patients. 

Then, the reminder went live in mid-February in 2001. Before I go onto the next slide, I should mention we did a lot of back and forth between us and the clinical applications coordinator to develop the second-generation reminder. This clinical application coordinator was part of VA Greater Las Angeles. We didn’t hire a specialized person to do the programing, but what we did do is we did have help in developing the reminder schema, which was then presented in a word document to the clinical applications coordinator. So, we basically specified exactly what we wanted – both on the frontend in terms of the reminder display, and on the backend in terms of gathering data for the reminder report. Then we entered in a protracted process of negotiation because what we wanted was not always achievable within CPRS and it was a priority of our to do everything within CPRS so that it could be used immediately.

We gathered data from reminder extract reports. The final piece of the implementation strategy was to do another site visit to look at what was going on now that the reminder was in use. That occurred between July and September 2011. The evaluator went and watched how patients flowed through the clinic. They did a walk through with dummy patient records. We basically created scripts, which you can look at – they’re part of your handouts – where we walked through the nurse clinical reminder and the provider clinical reminder using a dummy patient record and got live feedback from the providers about the reminder. At the same time that we did the reminder walk through we did semi structured interviews to learn about how things were going with the reminder. 

This is a graph of monthly clinical reminder activity. On the y-axis is the number of patients and on the x-axis is the month. You'll see that the squares, the line that has the squares in it, that’s the number of nurse fall reminders that are completed. The line that has the triangles in it is the number of primary care provider fall reminders that were completed. All this data comes from those reminder extract reports. 

Now because the reminders started in February, you'll see that the number in February of reminders completed is lower than the number in March. So, you really need to multiply the February number by two to get a real sense of what the rate of completion was. So, if you actually multiply it by two, it would be pretty close to the March result. You may ask why is the number of completed reminders declining over time. The answer is this is an annual requirement. That’s how the reminder was set up. So, at the beginning nobody had yet been screened for falls. But, as time passes and patients come back for repeat visits during the year, they’ve already completed the fall screen. So, as a result, there are fewer patients who need to be screened over time. 

One important lesson for people who are considering new reminders is that there’s going to be a large volume of activity at the beginning when the reminder is turned on. You might want to encourage whoever is using the reminder not to necessarily do it on the first visit in which the reminder comes available or listed as due and to wait till a later visit to help sort of even out the workload. We had been prepared for this because of other projects that involved fall screening. This is the first time we could illustrate it graphically.

In terms of our findings, we found that almost 3,000 patients were seen at the three clinics between February 2011 and January 2012. The nurse reminder was completed for 77% of those patients. Of those 2,264 patients, 21% screened positive for either having two falls or more in the past year, at least one fall with injuries since the last visit, or fear of falling. 

Of the 472 cases who screened positive, 49% had some gait, balance, or strength exam performed. Of those 231 patients, 70% had a gait, balance, or strength problem. And then, of the patients with a gait, balance, or strength problem 24% or 39 had either physical therapy or exercise offered. You saw that included recent physical therapy or refusal of physical therapy. It also included the recent exercise program. This is a generous definition of physical therapy or exercise.

In terms of feedback that we got from the nurses and providers about the reminder, what you see here are the number of comments that we received. This is part of the semi-structured interview process I mentioned when we went back to how the reminder was being used. You can see that most of the positive comments were coming from nurses because the nurse comments are in green. You can see more of the negative comments are coming from the primary care providers, which are shown in red. Then, in terms of the number of suggested changes, it’s sort of half and half between the providers and the nurses. These comments come from eight nurse and five primary care provider interviews, which were a convenient sample that we were able to sort of round up when we went there. 

In terms of thoughts about the second-generation reminder, it was still time intensive especially for the primary care providers, despite our trying to simplify it. Providers wanted the generic opt out option back. The other question that remained persistent from the first to the second-generation  reminder was the issue about whether the downstream options – such as physical therapy – are actually available if needed. Some of the strengths were that they found...the nurses found the assisted device training that we did useful. Nurses really like the printable handouts that we had built into the reminder. 

I’ll just briefly discuss further implications before we turn to the Q&A period. We found that the implementation process we used was well liked by clinicians and staff at the Community Based Outpatient Clinic. We were actually able to generate screening rates that are on par with the national average. Now, that was that 77% number I showed you just a few slides ago that showed that 77% of people who were eligible for the reminders were screened. But, the thing that we found that was quite striking is there is a very low yield from the screening process to actual interventions that might make a different citation – mainly the exercise program and the physical therapy. We found that people had mixed feelings about the reminder, with nurses still more positive than the providers. 

Limitations of the study is that it was really a local effort. It was tested at three community based outpatient clinics within one particular VA health system. The reminder reports were not validated against chart reviews. So, it’s possible that physical therapy was offered, but outside of the reminder system. Therefore, we didn’t capture it. So, our estimates may underestimate the true rate of physical therapy or exercise prescription.

We use a convenient sample for semi structured interviews. We tried hard to get these interviews scheduled in advance, but it wasn’t always possible when we actually got there. We have no data on health outcomes. Our focus was entirely on implementation feasibility for this particular project – which was a rapid response project. 

I think if I could summarize sort of what I’ve taken home from this project, there’s really an inverse relationship between usability and complexity. While we knew this from Diffusion of Innovations Theory, which sort of says that simplicity is an important aspect of what makes innovation spread. It still was something that we struggled with despite our efforts to simplify the provider reminder down to the absolute minimum. This particularly is illustrated through the nurse verses the primary care provider components in the reminder. The nurse reminder is much simpler. It’s much quicker to get through. It’s pretty straightforward. It doesn’t involve physical exams. It mostly involves history taking and provision of education. 

Whereas the provider component requires physical exam and it requires complex decision-making at the backend that we couldn’t completely structure because it depends on the particular patient’s needs. I think the primary care provider component was more complex and therefore, less acceptable. I think that we sort of tried to reduce it to its absolute minimum and that this sort of reflects the nature of geriatric care itself and the difference between geriatric care and treating some general medical conditions - for example – such as hypertension. 

The other thing that I think you probably will have gleamed from the numbers I showed you a little earlier, the likelihood that the reminder affected population health is pretty low because of the low prescription of exercise. I think this could actually be a concern nationally because the quality indicators I showed you at the beginning of this particular webinar don’t reflect downstream intervention. They basically reflect asking about falls and then what the provider has tried to do to help the patient prevent falls, but they don’t really tell us whether interventions are actually taking place – interventions such as exercise for example. 

There’s a lot of good work going on, however, to try to help some of these complexity issues Natural Language Processing of Free Text is making headway. There are folks in Tampa who are actually working on something like this right now. So, it’s possible that in the future some of the data gathering aspect can be simplified through natural language processing. But, I think at the end of the day it’s still going to involve an interaction between a human being and a human being, that is a provider interacting with a patient, and at some element a behavior change, mostly behavior change on the provider’s part – to care and to spend the extra time to do this geriatric evaluation. Also, a behavior change on the part of patients to try to take on new health habits that might be difficult to adopt. This is a tall order but one I’m quite passionate about as a geriatrician. 

In terms of what we’ve done, we’ve made the reminder code and the screen shots available to other sites and also to the Geriatric Scholars Program – which focuses...it’s part of the Office in Rural Health...Office in Rural Health effort to increase knowledge about geriatrics to primary care providers in community based outpatient clinics, particularly rural clinics around the country. Anybody can contact me for more information about getting a hold of the reminder.

I just wanted to thank our research team on the left-hand side and all the people on the right-hand side who either participated in this project or helped guide the project or helped support the project. I’m going to stop there and see if there are any questions. Thank you.

Margaret:Thank you very much. That was a great talk. There are a few questions.  I think probably people will be typing some more questions in as we start. The first one: Is this template currently in production? I’m wondering if the health factors are being captured by CBW?

Dr. Ganz:That’s a great question. The health factor capture is currently a local effort. I don't know what happens after that data are captured at our end – at VA Greater Los Angeles. But, our CAC – our clinical applications coordinator – is Lee Ochotorena. And you can either email him directly to find out more if you want to know more or you can email me and I can connect you with him.

Margaret:Another question: Is the National Falls Reminder mandatory at a national level, the first-generation? 

Dr. Ganz:No. So the National Falls Reminder was mainly designed as an educational tool for sites to use and potentially adopt or modify. The philosophy of the Office of Geriatrics and Extended Care – I don't want to speak for them directly, but the philosophy that I’ve observed, talking with Ken Shay over the years, is that we don’t want to force people to adopt a particular formulation. We want local adaptation to local needs. We’ve never made mandatory, but what I do know from talking to various sites across the country is that people have sort of taken up different versions of a fall screening. That is what I attribute to this increased rate of fall screening that I showed you in the earlier slides where those trends of fall screening rates went up year after year, monotonically. 

Margaret:Okay. Next question: Does the primary care provider always check CPRS before calling the patient into the exam room so the provider has a chance to see that the fall risk should be evaluated and evaluated as the patient is coming into the exam room?

Dr. Ganz:That’s a great question. Thank you for whoever asked that. So we tried to develop a workaround to deal with that because we recognize that the provider may have already started their note and they may not go back to the cover screen and refresh the patient information to see that the patient is now screened positive. At least one of the clinics there was a little face sheet that traveled with the patient that they could flag the information. But, this is a defect in our system, I think, in the sense that the information doesn’t pop up at you. You have to actively go and find it. I mean, obviously there are pluses and minuses to each approach, but on the coversheet you have to actively look for the reminders being due and be fresh to that patient information. So, this is a limitation.

What we thought with that, if for whatever reason the provider missed it on that particular visit we would encourage them to do it on the next visit. Admittedly, the data are not quite as timely if they’re provided on a subsequent visit, but we still thought it would be useful information to the provider. That was the way we tried to deal with it. We did try to have a face sheet, but I don't know how successful that actually was because it involved paper. It may not have happened as well as we would like.

Margaret:Okay. Do you know how much time would be involved in implementing your second-generation reminder at another facility in terms of CAC time again or setting up the clinical reminder reports?

Dr. Ganz:Right. So, first of all yes, I think that there are aspects of the reminder that are generalizable across sites. If you have the code you could basically adopt many of the templates. The part that would require a lot of work on the programing side is linking to the appropriate consult options in your local environment, recreating the local community resource list for exercise programs, and other options that are important for patients who fall. So, there are some aspects that would require local tailoring. I don't know how much CAC time. I think it would be less than what it took for us because you wouldn’t be starting from complete scratch. The reminder reports were done initially through the standard clinical reminder report and then later through reminder extract reports. But, again, if there’s interest I can refer you to Lee Ochotorena who would probably know  more about the actual amount of time that it took.

Margaret:Okay. Next question: Was input obtained from the nurses and PCP’s when the reminders were developed?

Dr. Ganz:Yes. The first site visit in August of 2010 occurred before the reminders were developed. That was when we sat down with them going over...let me back up and say the first-generation reminder developed by the National Workgroup, no. There was no input other than the people who are on the committee. But, our reminder where we consciously thought to redesign the first-generation reminder, yes we definitely sought input from both nurses and PCP’s prior to the redesign. That’s how we got to the particular format that you actually saw in front of you.

Margaret:Okay. One last question here unless more are typed in: Were you able to make any changes in terms of availability of physical therapy at your C-Box or at the main medical provider?

Dr. Ganz:Yes. We worked very hard to address this barrier because we saw this as a huge barrier. One of the things that we learned was that many of the patients at these three C-Box were dual users of VA and Medicare. It occurred antidotal that some of the providers would refer them out to outpatient physical therapy through Medicare. While this policy is not a matter of VA policy to refer patients out because the VA is obliged to provide similar benefits to all of its members – the Veterans. We certainly...it’s not prohibited for a provider to write a prescription for physical therapy that could be filled outside through Medicare. We reminded providers of this option. We can’t really track how often that option was used because we don’t have the data, but this is what a chart review would have an advantage of over just the reminder report. We could actually look in CPRS and see whether a referral to outside physical therapy was  made. So, this is a limitation of this project because of the budget that we could not...and the timeline, that we could not do a manual chart review to look for cases where outside physical therapy referrals were made. 

Margaret:Okay. Another question has come in: Was completing the reminder a part of clinician’s performance evaluation?

Dr. Ganz:No, it was not. Part of the reason it was not was because it was still an exploratory phase. We really...you know, coming at it from a provider perspective, I sort of started with the assumption that this reminder was optional until we figured out how to make it work well. It seemed unfair to basically force the providers to use it until we could figure out if it was functioning well from a usability perspective. So, that would have been the next step, to incorporate audit and feedback. We did provide feedback to the nurse managers and site directors in terms of what we were finding in terms of completion rates, but not at the individual provider level. I think we were still focusing on getting the reminder more usable.

Margaret:Okay. Thank you very much. We are just about at the top of the hour. There are no more questions. So thank you very much for developing this talk and presenting it. If anybody has any further questions they can submit them to VIReC’s helpdesk, virec@va.gov. I want to let the audience know about our next session which is scheduled for Tuesday, May 21st. The title of the presentation is: The My Healthy Vet Personal Health Record Portal In 2013, New Features, Study Findings, and Opportunities. The speakers will be Drs. Kim Nazi and Fran Weaver. We hope you can join us. Thank you again Dr. Ganz and have a good afternoon everybody.

Dr. Ganz:Thank you. 

00:58:26END OF TAPE

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