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Clinical Reminders Performance Improvement Power Tools Session

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Title: Clinical Reminders Performance Improvement Power Tools Session


1
Clinical Reminders Performance Improvement
Power ToolsSession 276
  • Kathy Montgomery, RN
  • Tuscaloosa VA Medical Center, Quality Management
  • Robert Thornton, MD
  • Tuscaloosa VA Medical Center, Primary Care

2
HOUSE KEEPING
  • We want this to be informal and interactive, but
    please hold your
  • questions during the presentation. Please turn
    off or mute all cell phones and pagers.
  • 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.

3
  • INTRODUCTION OF PRESENTERS
  • Dr. Robert Thornton
  • Board Certified Family Practitioner, member of
    Primary Care Team. At TVAMC for past 15 years.
  • Clinical Champion for Electronic Medical Record
    and for Clinical Reminders.

4
Co-Presenter
  • Kathy Montgomery, RN (14 years)
  • Background in LTC, Rehab and Primary Care,
    Quality Management
  • Began using Reminders when introduced in the
    Primary Care Clinic (From the beginning.?)
  • Served as resource (guinea pig!) in clinic
  • Now creates and utilizes Reminder
    Reports/Extracts/Patient Lists extensively in
    QM/PIC role

5
Course Objectives
  • At the end of this course you should be able to
  • Describe general background of the VA Clinical
    Reminder software
  • List the essential components of clinical
    reminders and performance improvement
  • Identify key participants of a clinical reminder
    workgroup
  • Illustrate examples for utilization of clinical
    reminder reports/extracts
  • Describe how clinical reminder data can be used
    to improve facility performance.

6
Now, really why are you here?
Doing all these reminders takes too much time
away from the patients!
Which reminders do I have to do?
Staff Nurse
Clinician
Wow, look at the May clinical reminder reports
we are now meeting the Flu performance measure!
Bean Counters
7
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

8
And
  • Clinical Reminders
  • Support stakeholders with performance improvement
    power tools to case manage patients
  • Aid in providing comprehensive medical care to
    complex patients
  • Provide valid and useable information with
    minimal data collection burden
  • Allows for feedback to be provided as close to
    real time as possible
  • Reduces reliance on memory for clinicians to
    perform recommended screenings and interventions

9
FOR MOST OF US.CLINICAL REMINDERS ARE
  • The string around your finger or the sticky
    note on the chart!

10
SOME CLINICAL REMINDER TESTIMONIALS!
  • EXAMPLE 1 Reminder reports can allow us to do
    large and small-scale comparisons of clinics,
    divisions, teams, and providers and can help in
    finding patients who have "slipped through the
    cracks." Ever want to know how well your team was
    doing with immunizations or diabetes care or pain
    assessments? Ever want to know who is coming this
    week who needs pneumococcal immunization or who
    needs diabetic foot exam and education or who has
    had a high pain score in the past and needs a
    pain assessment? Would anyone at your site ever
    want to look at a group of patients for a
    research project - patients with a creatinine
    between 1.5 and 5 who do not have diabetes who
    are under the age of 80?

11
CLINICAL REMINDER TESTIMONIAL
  • EXAMPLE 2 On behalf of the nursing staff here
    at VAMC One, I'd like to again thank you for all
    the work it took to develop the clinical reminder
    dialogs. We hit a new record this year in VAMC
    One of gt1000 flu shots given in one day. The
    nurses never would have been able to complete
    this in one day without the Flu Shot Station
    note, which is boilerplated using a clinical
    reminder dialog that captures the CPT and ICD-9
    code.

12
Initial concept of clinical reminders
  • Designed to be clinical Decision Support tools
  • Designed to help bring to a providers attention
    (in real time) that some clinical action needs to
    be accomplished for the patient
  • Focus on measurement means that data are needed
    to analyze processes, identify problems, and
    measure performance.

13
Where did they come from????
  • Initially started as a piece of PCE package
    (approx 14 years ago!)
  • 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 was released 2007 with numerous
    enhancements (even more to learn ?)

14
CLINICAL REMINDERS IN CPRS--
  • On the coversheet they give you a snapshot of
    what the patient may need
  • They are a placeholder for information
  • They can be an efficient way to complete required
    documentation

15
Clinical Reminder CPRS Display
  • Cover Sheet Due or Due soon
  • Clock button on each tab
  • List of Available Reminders
  • Reminder Drawer (Notes tab)

16
Clinical Maintenance The Coversheet Treasure
Chest
  • The clinical maintenance drawer contains
    pertinent information regarding why the reminder
    is DUE or NOT DUE
  • Reminder Builders can add some information to
    this section to help providers better understand
    what the reminder is doing behind the scenes

17
Clinical Maintenance Discovering the TREASURE
Aaargh! We have work to do here!
18
CLINICAL REMINDER DOCUMENTATION IN CPRS
  • WITH JUST A FEW CLICKS THIS IS WHATCAN BE
    DOCUMENTED IN YOUR PROGRESS NOTES
  • EXAMPLE INFLUENZA IMMUNIZATION
  • Patient received influenza vaccine at this
    visit.
  • The patient/caregiver has provided verbal
    consent for the
  • influenza vaccine to be given after
    denying the existence of
  • precautions/allergy and receiving
    education and the Vaccine
  • Information Statement dated 7/16/07
    handout.
  • Left Deltoid
  • Manufacturer Lot Number(s) and Expiration
    Date
  • Flurix Unit Dose Syringe / Lot
    AFLUA294DA Expiration 6-30-08
  • Is patient an employee, volunteer, or
    student?
  • No

19
Patient Care Encounter (PCE) Information
  • When reminders are completed important
    information goes into the PCE software--AUTOMATICA
    LLY
  • This information is important for billing,
    workload and pulling data
  • EXAMPLE PCE Diagnoses VACCIN FOR INFLUENZA
  • Procedures Admin influenza virus vac,
    IMMUNIZATION ADMIN , FLU VACCINE, 3 YRS gt, IM
  • Immunizations INFLUENZA

20
Clinical RemindersThey save time dont they?????
  • Documentation via radio buttons and check boxes
    - less typing time
  • Electronic reports/Extracts instead of time
    consuming chart reviews
  • Information crosses over into the PCE software
    less time completing encounter forms
  • Facilitates entry of orders/consults, etc.
  • ETC.

21
But, Again.Why Oh Why?????
  • The Clinical Reminder software allows caregivers
    to track and improve preventive healthcare and
    disease treatment for patients.
  • Clinical Reminders are point-of-care tools to
    provide information with regard to Clinical
    Practice Guidelines.
  • Clinical reminders help to ensure timely
    clinical interventions are initiated.

22
Where the rubber meets the road
  • EXAMPLE Patient A--65 year old patient with
    diabetes
  • REMINDERS DUE
  • 1. EYE EXAM NEEDED (not done in past 2 years
  • 2. HGBA1C NEEDED (not done in past year)
  • 3. FOOT EXAM NEEDED (not done in past year)

23
Patient A
  • EYE EXAM DONE! No retinopathy?
  • HGB A1C 6.9 ?
  • FOOT EXAM DONE ! New shoes!
  • JOB WELL DONE, CLINICIAN!!!!

24
BUMPS IN THE ROAD
  • Nurse I just gave this patient a flu shot last
    monththis reminder shouldnt be due?????
  • Doctor This patient isnt a diabeticwhy are
    all these diabetic reminders due????

25
And when something goes wrong???
  • Do you know who is responsible for maintaining
    your reminders?
  • Clinical Reminders can stop working properly for
    any number of reasons.
  • Patches
  • CPT code changes
  • Staff changes
  • End users must communicate with clinical reminder
    coordinator(s)

26
YOU CAN BE A GOOD HELPER!
  • CONTACT REMINDER MANAGER AS SOON AS POSSIBLE WHEN
    YOU FIND A BUG
  • KEEP PATIENTS NAME/SSN TO HELP THEM TROUBLESHOOT
  • OFFER SUGGESTIONS TO IMPROVE REMINDERS

27
EXPANDED USES OF CLINICAL REMINDERS
  • PROVIDER PROFILING (REPORT CARDS?)
  • PEFORMANCE MEASURE REPORTS
  • STAFF COMPLIANCE MONITORS
  • FACILITY REPORT CARDS
  • PERFORMANCE IMPROVEMENT PROJECTS

28
Reminder Reports
  • Provider Profiling
  • Monitor of compliance with performance measures
  • Monitor staff compliance with completing required
    reminders

29
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
  • ABCD Help save lives!

30
Sample Report Card
31
AND OF COURSE, PRETTY CHARTS AND GRAPHS
32
(No Transcript)
33
Report DONTS
  • Dont use reports as a club!
  • Dont report to management without verifying data
    is correct

34
USING REPORTS FOR POSITIVE REINFORCEMENT--
  • Identify Best Practices
  • Highlight Star Performers
  • Teams that STANDOUT in performance
  • Processes that result in top outcomes

35
ABCs of Clinical Reminders Performance
Improvement
  • A. PI relies on the guiding principles of
    teamwork, systems and processes, patient focus,
    and measurement
  • B. Focus on the patient emphasizes that services
    should be designed so as to meet the needs and
    expectations of patients and community
  • C. Focus on measurement means that data are
    needed to analyze processes, identify problems,
    and measure performance.
  • DOING THE RIGHT THING RIGHT

36
Where do Clinical Reminders fit in?
  • A. Clinical reminders help pull it all
    together--guiding processes of care to assure
    timely patient interventions optimizing medical
    outcomes
  • B. CRs are designed to meet patient needs
    through conformance to clinical practice
    guidelines AND meet provider needs by improving
    efficiency of documentation
  • C. CRs provide the data needed to analyze
    processes, identify problems, and measure
    performance

37
Moving forward
  • After reporting functionality was created, data
    could be extracted to see how a site was doing
    in regards to performance measures
  • GEC referral and IHD data are already extracted
    nationally through the extract functionality each
    month

38
EXTRACTS The New Frontier!
  • Here we go!!!!!!!!!

Clinical Reminder Extracts
39
What can you expect with extracts?
  • Enhanced ability to generate automatic data
    retrievalmonthly, quarterly extracts
  • Reduction in system use
  • More to come.mining for gold!

40
Exactly what makes up a Clinical Reminder?
  • This is actually a very simple question!
  • NO!it is a very complicated question!

41
Essential Clinical Reminder Componentsthe simple
answer
  • 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 or completed
  • Monthly, Annually, Once in a lifetime, etc.

42
Essential Clinical Reminder Componentsa little
more complex
  • Researching the task
  • Talk to your subject matter experts
  • Discuss with the requestor
  • Ask WHO, WHAT, HOW OFTEN

43
More essential components.
  • Resolution????
  • What makes the reminder resolved or go away
  • This is where you must dialog with subject matter
    experts and research the performance manual!
  • THINK THINK THINK THINK --- THINK

44
The WHO (PATIENT COHORT)
  • Usually the who is the first step
  • Below is from the previous performance measure
    for diabetic patients to have annual exams
  • Cohort Ages 18-75 Diagnosis of diabetes
  • Exclusions Life Expectancy lt6 months bilateral
    Amputee

45
Cohort Exercise Wake up!!!
  • Some of us learn better by DOING!

46
HOW OFTEN???
  • Sounds simple, but.
  • Annual tests easy annual frequency
  • But, what if the frequency is different for
    different ages? Or if the frequency is different
    depending on risk factors?
  • YEP it is not always easybut it is doable!

47
Review 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

48
More Lingo
  • Clinical Reminders use a number of types
  • of FINDINGS.
  • Findings are like on/off switches.
  • They make a reminder DUE,
  • or RESOLVE the reminder.

49
Clinical Reminders use a number of types of
FINDINGS.Findings are like on/off switches.
They make a reminder DUE, or RESOLVE the
reminder.
  • Here is a list of all the different types of
    Findings
  • DRUG
    IMMUNIZATION
  • EDUCATION TOPIC
    LABORATORY TEST
  • EXAM
    ORDERABLE ITEM
  • HEALTH FACTOR
    RADIOLOGY PROCEDURE
  • MENTAL HEALTH INSTRUMENT TAXONOMY (list of
    codes)
  • REMINDER COMPUTED FINDING REMINDER TERM
  • SKIN TEST
    VA DRUG CLASS
  • VA GENERIC
    VITAL MEASUREMENT

50
Types of Clinical Reminder Findings
  • Here is a list of all the different types of
    Findings
  • DRUG
    IMMUNIZATION
  • EDUCATION TOPIC
    LABORATORY TEST
  • EXAM
    ORDERABLE ITEM
  • HEALTH FACTOR
    RADIOLOGY PROCEDURE
  • MENTAL HEALTH INSTRUMENT TAXONOMY (list of
    codes)
  • REMINDER COMPUTED FINDING REMINDER TERM
  • SKIN TEST
    VA DRUG CLASS
  • VA GENERIC
    VITAL MEASUREMENT
  • COMPUTED FINDINGS

51
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.

52
How can I help develop a good Clinical Reminder
  • Research--Research--Research
  • Dont fly by seat of your pants
  • Gather information for the who, what and how
    often - these are essential to the success of
    your reminder
  • Know your topic Knowledge is POWER!

53
How can I help develop a good Clinical Reminder
  • Validate your reminder results
  • Test all scenarios of your reminder
  • Have certain users guinea pigs at your site
    test the reminder and provide feedback

Yepthis is just what I wanted Diabetic
patients that need to have their eyes checked!
Gee, thanks!
54
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/managers rely on input from the
    group to develop quality products

55
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

56
All that to say this!
  • Good reminder design can best be accomplished by
    a group of people who have a vested interest in
    the reminder, or should we say a horse in the
    race!?
  • Group discussions will help gather all
    essential pieces necessary for quality design
  • Design a Clinical Reminder request form for
    possible new reminders for group discussion and
    possible implementation

57
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

58
Clinical Reminders Champion
  • Clinical Input is an essential component of the
    successful team which designs and implements
    clinical reminders. Many sites have one or more
    clinicians who function as Clinical Reminders
    Champion (clinical reminders advisor)
  • The Clinical Reminders Champion should have a
  • Working understanding of
  • Clinical Medicine
  • Current VA Performance Measures
  • Clinical Reminder software
  • Commitment to staying current with national VHA
    changes to performance measures

59
Clinical Reminders Champion
  • Role may vary at different VAs.
  • Acting as consultant to the clinical reminders
    coordinator
  • Acting in a more hands-on role with access to
    run clinical reminder reports and/or create
    clinical reminders and dialogs
  • Role may include formal or informal liaison
    between informatics staff and clinical staff

60
Efforts toward Standardization
  • Some VISNs are working to standardize clinical
    reminders especially those dealing with
    national performance measures
  • Rationale Ability to compare facilities and
    know that the data is coming from the same
    source

61
More on Standardization
  • National Standardization Several standard
    reminders already in use, i.e. OIF/OEF, TBI, etc.
  • Enhance collection of data by providing 100
    sample of real time data
  • Allows for comparison of apples to apples

62
SO MUCH TO DOAVOIDING 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?

63
SO MUCH TO DOAVOIDING BURNOUT
  • Staff Education keys to understanding
  • Get staff involved in the process
  • Take back innovation from VeHU experience in the
    field

64
You know its the right thing to do, but
  • Performance improvement is all about getting buy
    in from those who actually do the work!
  • Staff must use them or we lose them!

65
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

66
http//vaww.oqp.med.va.gov/default.htm
67
Keys to Understanding (the WHY?)
  • Is there any value to Clinical Reminders?
  • Clinical Reminders are the post it note you
    need to provide quality care to patients!

68
Once againTHE 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

69
Prompting Clinical Actions (Where the rubber
meets the road again)
  • 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

70
GET INVOLVED!
  • Volunteer to be a member of local group
  • Websites past VEHU courses
  • Attend VEHU then pass on what you learn!
  • Look at the DATA

71
LETS REVIEW
  • Remember when
  • Charts consisted of papers filed in a plastic
    binder
  • You had the clerk call the File Room to get a
    chart
  • There were little sticky notes or messages in
    green books to remind providers TO DO
    something

72
Not Anymore!
  • Charts are now a keystroke away!
  • Clinical Reminders have replaced the sticky notes
    and green books!

73
Putting it all together!!!!
  • Clinical Reminders have been around awhile, they
    are here to stay, and they get more powerful each
    day
  • They prompt clinical action, document the action,
    and allow for data collection
  • Reports help Drill Down data to provider and
    patient specific levels
  • Enhance patient safety by prompting for clinical
    actions

74
Just to review Building Blocks of Reminders--
  • Cohort the WHO
  • Resolution the WHAT
  • Frequency the WHEN

75
What can we do with these building blocks?
  • Assure quality patient care through timely
    interventions
  • Create patient lists mass mailings, etc., case
    management tools
  • Create reports, charts, graphs (The Joint
    Commission loves these!)
  • Develop report Cards Everyone likes to know how
    well they do their job!
  • YOUR job is to add to this list!!!

76
Wrap - up
  • We will take questions now
  • Any questions not answered today will be
    available on the website
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