309H Clinical Reminders Treasure Chest

1. 309H Clinical Reminders Treasure Chest (Arrgh � thar be data here!) [Automated Reminder Extracts] Rob Silverman, PharmD Alan Montgomery August 21 and 22, 2007

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3. 3 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

4. 4 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

5. 5 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

6. 6 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?

7. 7 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

8. 8 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.)

9. 9 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

10. 10 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!

11. 11 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

12. 12 Report Automation Steps Create EXTRACT DEFINITION PXRM EXTRACT DEFINITION Instructions come from a RULE SET Output goes to a PATIENT LIST Reminders are run against the list Summary of results is saved Manual extract as a test

13. 13 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

14. 14 Extract Enhancements Anchor Visit Simplify Reminder Definition Add Sub-Cohorts Additional Detail via DSF option

15. 15 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

16. 16 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

17. 17 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

18. 18 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

19. 19 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

20. 20 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?

21. Hands-On Experience

22. 22 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

23. 23 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

24. 24 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

25. 25 Extract Results

26. 26 Reminder Report Comparison

27. 27 Scheduled Option Queued for 8-21@1400, 8-22@0930 Rescheduling Frequency would be �Monthly�

28. 28 FileMan Setting for Auto Extract

29. 29 Auto Extract Appearance

30. 30 [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

31. 31 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)

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