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Anatomy and Physiology of Reminder Dialogs

Anatomy and Physiology of Reminder Dialogs. What is a Dialog?. Look, feel, and act like a note template BUT they are not note templates. List of statements and associated findings that appear in a dialog box in the EHR used to resolve a reminder.

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Anatomy and Physiology of Reminder Dialogs

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  1. Anatomy and Physiology of Reminder Dialogs

  2. What is a Dialog? • Look, feel, and act like a note template BUT they are not note templates. • List of statements and associated findings that appear in a dialog box in the EHR used to resolve a reminder. • Generated from a reminder definition or created manually. • Must be defined and linked to reminders before clinicians can resolve reminders through the EHR. • Dialog boxes appear when specific reminders are selected, with a list of checkbox items that have been defined as potential actions to satisfy the reminder.

  3. How do Dialogs get Created? • Auto-generated once Reminder has been established • Auto generates elements • Does NOT auto generate groups • Once created user will need to confirm that all elements meet user needs & group them if they prefer dialog groups • Manually Created • Create your own dialog elements • Create your own dialog groups • Create your additional prompts • Create your own dialogs to support guidelines

  4. Pro’s/Con’s of Auto-Generated Dialogs • Pro’s: • Automatically linked to a reminder • Includes all elements for the reminder findings • Auto creates the appropriate prompts • Con’s • Includes all the elements for the findings • Requires you to review them to ensure they are all appropriate • Does not generate groups, only elements

  5. Pro’s/Con’s of Manually Generated Dialogs • Pro’s: • Don’t have a lot of unwanted auto generated prompts to clean up • Con’s: • Requires you to link the dialog to the reminder in separate step • Must have naming convention • Must know what dialog prompts to associate the finding item

  6. Basic Building Blocks for Dialog • Resolution: • Where was it done? • In clinic vs historical • How was it done? • Ordered vs Other • Did it get done? • Refused • Finding Item: • What was done? • Immunization, Orderable Item, Health Factor, Exam, etc • Additional Prompts: • Allows you to completely document the finding item • Document lot #, injection site, comments, etc.

  7. Resolution Types • Done at encounter • Capture items such as exams and health factors in the note without having to jump from the note tab to the health factor/exam tab • Done elsewhere • Historical entries such as colonoscopy, mammograms, paps, HIV screening, exams, immunizations, etc • Ordered • Order a consult, lab, med, radiology, nurse order, etc as soon as you complete the note • Contraindicated • This resolution type does not work for IHS • Other • Use for health factors • Patient Refused • Only works for Immunizations currently

  8. Types of Finding Items ED.EntryName to select a EDUCATION TOPICS IM.EntryName to select a IMMUNIZATION ST.EntryName to select a SKIN TEST EX.EntryName to select a EXAM HF.EntryName to select a HEALTH FACTOR CPT.EntryName to select a PROCEDURE ICD9.EntryName to select a ICD9 DIAGNOSIS VM.EntryName to select a VITAL TYPE don’t use, VA TX.EntryName to select a TAXONOMY Q.EntryName to select a ORDER DIALOG MT.EntryName to select a MEASUREMENT TYPE

  9. Adding Additional Finding within an Element • Adding additional findings automatically “stuffs” the code (Pt Ed, ICD, CPT, etc) into PCC. • As with superbill associations, use judiciously and only when it is true every time it is done. • Remember codes don’t update themselves. If you stuff a code and new ICD9 codes come out, you have to update these manually • ONLY use unique codes as additional findings – don’t use the same additional finding in multiple dialogs (so don’t use ED.CA-TESTS for Pap, Mamm and Colon Cancer – use education unique to the element) • Look at the EHR to get an idea what prompts you will need (if any) to enter appropriate information for your findings and addl findings • Pt Ed needs Level of Understanding, Length, etc • Exams need result • Imms need lot #, dose, route, vis, etc • Comments are generally a good thing to offer the user

  10. Dialog Element Definitions

  11. Dialog Group Prompt Definitions

  12. Opens up to the reminders View Use CV to see the other items DI- Reminder Dialogs

  13. Choose from: D Reminder Dialogs E dialog element F forced value G dialog group P prompts R reminders RG* result group (MH) RE* result element (MH) *MH not used in IHS These are the building blocks of the dialog Prompts are the smallest piece Prompts go on elements Elements go into dialogs or they can go into groups Groups go in dialogs Dialog Pieces

  14. D for Dialogs Always check for where you are Check Status Is it linked? AD for adding

  15. Auto-Generate a Dialog Select Item: Quit// ad Add Reminder Dialog GENERATE DIALOG AUTOMATICALLY: Y// SELECT REMINDER TO GENERATE DIALOG FROM: IHS-ALCOHOL SCREEN NATIONAL ENTER A UNIQUE DIALOG NAME: IHS-ALCOHOL SCREEN// OVERWRITE EXISTING REMINDER DIALOG ? YES// LINK DIALOG TO REMINDER: YES// ENABLE DIALOG: NO//  May want this to be a yes REPLACE ANY EXISTING DIALOG ELEMENTS? NO// • Be very careful if you ever set this to YES

  16. Look at the dialog

  17. Look at the Progress Note Text

  18. It’s very messy….

  19. Clean it up • Delete items not needed • Edit what it says in the progress note • Add new elements if desired • Auto-generate does NOT make any groups. It does make the elements • You can choose to re-make the dialog and put the elements into groups if desired

  20. Display text and Progress Note Text • These two can be different • The display text is what the person entering the note sees • Example: DIALOG/PROGRESS NOTE TEXT: Alcohol Screening - Enter results of the CAGE test ALTERNATE PROGRESS NOTE TEXT: CAGE test scores

  21. After a lot of editing, and grouping it can look like this… Groups Elements Text Only

  22. Here’s an example immunization dialog with prompts. Text only Element Group Element Prompts All the words in the grey box are “Dialog Text.” This is Progress note text. Usually the same as Dialog text. Can use Alternate text. This is what goes into RPMS… the “Finding Item” and “Additional Findings”

  23. Reminder Dialog Script

  24. Naming conventions • Use consistent prefix • Make sure you know its yours – consider appending with site names if you make significant changes and for groups HD text CPT ICD9 ED EX IMM (national uses IM, consider using IMM for locally created ones) HF TX taxonomy GP groups (national uses GRP, consider GP for locally created ones) PR prompts

  25. Recommended Process • Write out what you want to create • Then answer these questions: Resolution: • Where was it done? • In clinic vs historical • How was it done? • Ordered vs Other • Did it get done? • Refused Finding Item: • What was done? • Immunization, Orderable Item, Health Factor, Exam, etc • Is there any other additional findings? • “stuffing” of CPT code, and patient education when giving an immunization Additional Prompts: • Allows you to completely document the finding item • Document lot #, injection site, comments, etc.

  26. Hands on Practice Alcohol – Cage Script Cage Questions: • Have you ever felt you should cut down on your drinking? Yes/no • Have people annoyed you by criticizing your drinking? Yes/no • Have you ever felt bad or guilty about your drinking? Yes/no • Have you ever had a drinking 1st thing on the morning to steady your nerves or to get rid of a handover? Yes/no

  27. Alcohol Script – PCC elements • Record CAGE Score • Cage Score 0/4 • Cage Score 1/4 • Cage Score 2/4 • Cage Score 4/4

  28. Alcohol Script – Quick order • Scoring two or more affirmative should create a high index of suspicion. Four affirmative answers indicates alcoholism. Click below to order a social consult

  29. EHR Reminders Customizing National Dialogs

  30. Recommended Process COPY the existing IM DTAP DONE element into a local name. If you do not, you run the risk of this being overwritten by a released element of the same name on installation at a later date. Once you have this done, you can either: • Edit the National Dialog • Create your own dialog and link this to the National Reminder

  31. Navigating the Dialog screens BEH-REM-DLG-DLG will get you here

  32. AR All reminders LR Linked Reminders QU QuitCV Change View RN Name/Print NameSelect Item: Next Screen//CV TYPE OF VIEW: R// E D dialog, P prompts, R reminder viewAlways look to upper left corner to see where you are (in this case elements)

  33. Script for IM EXAMPLE DTAP DIALOG VIEW (DIALOG ELEMENTS) +Item Dialog Name Dialog type Status 65 HF CAGE 2/4 Dialog Element 66 HF CAGE 3/4 Dialog Element 67 HF CAGE 4/4 Dialog Element 68 HS ASTHMA PLAN Dialog Element 69 IHS-EXAM Dialog Element 70 IM DTAP DONE Dialog Element 71 IM DTAP DONE ELSEWHERE Dialog Element 72 IM DTAP REFUSED Dialog Element 73 IM EXAMPLE DTAP Dialog Element 74 IM HEP A ADLT DONE Dialog Element 75 IM HEP A ADLT DONE ELSEWHERE Dialog Element 76 IM HEP A ADLT REFUSED Dialog Element 77 IM HEP A PED DONE Dialog Element 78 IM HEP A PED DONE ELSEWHERE Dialog Element 79 IM HEP A PED REFUSED Dialog Element 80 IM HEP B ADLT DONE Dialog Element Next Screen - Prev Screen ?? More Actions >>> AD Add CV Change View INQ Inquiry/Print CO Copy Dialog PT List/Print All QU Quit[J Select Item: Next Screen// 73 Dialog Name: IM EXAMPLE DTAP Not used by any other dialog

  34. NAME: IM EXAMPLE DTAP// DISABLE: CLASS: LOCAL// this will always be local SPONSOR: leave blank REVIEW DATE: leave blank RESOLUTION TYPE: DONE AT ENCOUNTER// ORDERABLE ITEM: FINDING ITEM: DTAP// since you copied the existing one, no change needed DIALOG/PROGRESS NOTE TEXT: Patient received dtap immunization at this encounter you can change if you like Edit? NO// ALTERNATE PROGRESS NOTE TEXT: No existing text you can put text here if you want the text in the progress note to be different from what is displayed in the dialog Edit? NO// EXCLUDE FROM PROGRESS NOTE: put yes only if you want the text to display only and not be in the note or saved to PCC, otherwise leave blank. SUPPRESS CHECKBOX: if you have a display item and don’t want a check box to confuse your user, put a “1” here, for this - leave blank

  35. Select ADDITIONAL FINDINGS: ??This is where you can add additional findings. ?? Will give you an idea what is available and how to search '^' TO STOP: You may enter a new ADDITIONAL FINDINGS, if you wish If additional finding items should be posted if the dialog is checked then they should be entered in this field. The field is relevant to both dialog element and dialog group type records. Enter one of the following: USE CAPS, the prefix is case sensitive ED.EntryName to select a EDUCATION TOPICS ED.WH-PAP SMEAR*** only enter pt ed if unique (that is, do not use ED.IMM-PT LIT for multiple immunization elements) IM.EntryName to select a IMMUNIZATIONS IM.TDAP ST.EntryName to select a SKIN TEST ST.PPD EX.EntryName to select a EXAM EX.DEPRESS HF.EntryName to select a HEALTH FACTORS HF.ALC CPT.EntryName to select a PROCEDURE CPT.90700 ICD9.EntryName to select a ICD9 DIAGNOSIS ICD9.V06.1 VM.EntryName to select a VITAL TYPE don’t use – use measurement MT Q.EntryName to select a ORDER DIALOG Q.LROQO HGBA1C, Q.ORZM MENU NAME MT.EntryName to select a MEASUREMENT MT.BP To see the entries in any particular file type <Prefix.?> If you simply enter a name then the system will search each of the above files for the name you have entered. If a match is found the system will ask you if it is the entry that you desire. '^' TO STOP: However, if you know the file the entry should be in, then you can speed processing by using the following syntax to select an entry: <Prefix>.<entry name> or <Message>.<entry name> or <File Name>.<entry name> Also, you do NOT need to enter the entire file name or message to direct the look up. Using the first few characters will suffice.

  36. Now add your Additional Findings Select ADDITIONAL FINDINGS: CPT.90700 Searching for a PROCEDURE, (pointed-to by ADDITIONAL FINDINGS) Searching for a PROCEDURE 90700 DTAP VACCINE, < 7 YRS, IM DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VACCINE (DTAP), FOR USE IN INDIVIDUALS YOUNGER THAN 7 YEARS, FOR INTRAMUSCULAR USE ...OK? Yes// y (Yes) DO NOT ADD THE VACCINE ADMINISTRATION CPT CODE or Generic IMM PT ED CODES AS ADDITIONAL FINDINGS ON IMMUNIZATION ELEMENTS!!!!!!!!!!!!!!!!!!!!!!!!! Have users select Pt Ed separately (Pt Ed is already included in the national dialog) OR choose Pt Ed for the specific ICD9 for the imm (example shown) Select ADDITIONAL FINDINGS: ICD9.V06.1 Searching for a ICD9 DIAGNOSIS, (pointed-to by ADDITIONAL FINDINGS) Attempting FILEMAN lookup...V06.1 V06.1 DIPHTHERIA-TETANUS-PERTUSSIS ...OK? Yes// y (Yes) ADDITIONAL FINDINGS: V06.1// ED.V06.1 1 V06.1-L DIPHTHERIA-TETANUS-PERTUSSIS-PATIENT INFORMATION LITERATURE V06.1-L 2 V06.1-L DIPHTHERIA-TETANUS-PERTUSSIS-PATIENT INFORMATION LITERATURE V06.1-L 3 V06.1-L DIPHTHERIA-TETANUS-PERTUSSIS-PATIENT INFORMATION LITERATURE V06.1-L 4 V06.1-L DIPHTHERIA-TETANUS-PERTUSSIS-PATIENT INFORMATION LITERATURE V06.1-L 5 V06.1-L DIPHTHERIA-TETANUS-PERTUSSIS-PATIENT INFORMATION LITERATURE V06.1-L Press <RETURN> to see more, '^' to exit this list, OR CHOOSE 1-5: 1 DIPHTHERIA-TETANUS-PERTUSSIS-PATIENT INFORMATION LITERATURE V 06.1-L Select ADDITIONAL FINDINGS:

  37. To check your work, when you return to “additional findings” prompt, put in ? – it will show you what you have entered Select ADDITIONAL FINDINGS: CPT.90700// ? Choose from: V06.1 90700 DIPTHERIA-TETANUS-PERTUSIS-PATIENT INFORMATION LITERATURE Now, you copied the national element, so you know that the prompts for Immunization entry are included in the element. Now you need to figure out if you need additional prompts. You don’t need more prompts for CPT or ICD9 codes, but you DO need some prompts for Patient Ed (minimum Level of Understanding and Length). Any comment written will enter text in all v file entries.

  38. Now add any more prompts. In this case, we’ll replace #5 with Level of Understanding, add #6 with Length and add back #7 Comment RESULT GROUP/ELEMENT: Select SEQUENCE: 5// ?? PXRM prompts are national prompts. When I build my own dialogs, I usually number 5,10,15 etc to allow for future additions Choose from: 1 PXRM LOT NUMBER 2 PXRM IMM SITE 3 PXRM VOLUME 4 PXRM IMM VIS DATE 5 PXRM COMMENT You may enter a new COMPONENTS, if you wish This field specifies the order in which this item will be displayed or processed.

  39. National Prompts Not all delivered prompts are functioning yet, blue are functioning as designed currently CIAV REFUSAL TYPE prompt LOCAL PXRM ADD TO PROBLEM LIST prompt NATIONAL PXRM COMMENT prompt NATIONAL PXRM CONTRAINDICATED prompt NATIONAL PXRM IMM REFUSED prompt NATIONAL PXRM IMM SITE prompt NATIONAL PXRM IMM VIS DATE prompt NATIONAL PXRM LEVEL OF SEVERITY prompt NATIONAL PXRM LEVEL OF UNDERSTANDING prompt NATIONAL PXRM LOT NUMBER prompt NATIONAL PXRM OUTSIDE LOCATION prompt NATIONAL PXRM PED GOALS prompt NATIONAL PXRM PED LENGTH prompt NATIONAL PXRM PED OUTCOME prompt NATIONAL PXRM PED REFUSED prompt NATIONAL PXRM PED SETTING prompt NATIONAL PXRM PRIMARY DIAGNOSIS prompt NATIONAL PXRM QUANTITY prompt NATIONAL PXRM REACTION prompt NATIONAL PXRM READING prompt NATIONAL PXRM REFUSED forced value NATIONAL PXRM REPEAT CONTRAINDICATED forced value NATIONAL PXRM RESULT (EXAM) prompt NATIONAL PXRM RESULT (SKIN TEST) prompt NATIONAL PXRM SERIES prompt NATIONAL PXRM SKIN GIVEN prompt NATIONAL PXRM SKIN READ DATE prompt NATIONAL PXRM SKIN READER prompt NATIONAL PXRM VISIT DATE prompt NATIONAL PXRM VOLUME prompt NATIONAL

  40. SEQUENCE: 5// ADDITIONAL PROMPT/FORCED VALUE: PXRM COMMENT// PXRM LEVEL 1 PXRM LEVEL OF SEVERITY prompt NATIONAL 2 PXRM LEVEL OF UNDERSTANDING prompt NATIONAL CHOOSE 1-2: 2 PXRM LEVEL OF UNDERSTANDING prompt NATIONAL OVERRIDE PROMPT CAPTION: START NEW LINE: YES// EXCLUDE FROM PN TEXT: REQUIRED: y YES Select SEQUENCE: 6 ADDITIONAL PROMPT/FORCED VALUE: PXRM PED LENGTH prompt NATIONAL ...OK? Yes// (Yes) OVERRIDE PROMPT CAPTION: START NEW LINE: y YES EXCLUDE FROM PN TEXT: REQUIRED: n NO Select SEQUENCE: 7 ADDITIONAL PROMPT/FORCED VALUE: PXRM COMMENT prompt NATIONAL ...OK? Yes// (Yes) OVERRIDE PROMPT CAPTION: START NEW LINE: y YES EXCLUDE FROM PN TEXT: REQUIRED: Select SEQUENCE:

  41. Now you have your new prompts Answer with COMPONENTS SEQUENCE, or ITEM Choose from: 1 PXRM LOT NUMBER 2 PXRM IMM SITE 3 PXRM VOLUME 4 PXRM IMM VIS DATE 5 PXRM LEVEL OF UNDERSTANDING 6 PXRM PED LENGTH 7 PXRM COMMENT

  42. Now we’ll edit the National Dialog Using CV option, Change View to “D” for Dialog. You want then select the IHS-PED DTAP IMMUN

  43. Choose to EDIT the dialog We need to replace this with the one You made, and you see it is in a “group” So we need to CV to the Group Menu

  44. Navigate to the Group menu screen, go back 1 menu, select CV and change view to G for GroupThen select “3” for GRP DTAP PED

  45. We’ll simply replace the IM DTAP DONE with the one we made

  46. CURRENT DIALOG ELEMENT/GROUP NAME: GRP DTAP PED Used by: IHS-PED DTAP IMMUN (Reminder Dialog) reminds you where its used NAME: GRP DTAP PED// DISABLE: CLASS: LOCAL// SPONSOR: REVIEW DATE: RESOLUTION TYPE: ORDERABLE ITEM: FINDING ITEM: GROUP CAPTION: PUT A BOX AROUND THE GROUP: YES// SHARE COMMON PROMPTS: NO// MULTIPLE SELECTION: ONE OR MORE SELECTIONS// HIDE/SHOW GROUP: HIDE// GROUP HEADER DIALOG TEXT: Check to document immunization information. Edit? NO// GROUP HEADER ALTERNATE P/N TEXT: Immunization information Edit? NO// EXCLUDE FROM PROGRESS NOTE: SUPPRESS CHECKBOX: NUMBER OF INDENTS: 2// INDENT PROGRESS NOTE TEXT: INDENT// Select ADDITIONAL FINDINGS: Select SEQUENCE: 15// 5 this is the one we want to replace SEQUENCE: 5// DIALOG ELEMENT: IM DTAP DONE// IM EXAMPLE DTAP dialog element LOCAL ...OK? Yes// (Yes)

  47. Hit return until you get back to CV, then CV back to the Dialog menu, then select the IHS-PED DTAP IMMUNE to see if the changes are there.As you can see, the new element is now in the GRP DTAP PED

  48. The New Display with all the additions!Remember to log out/log back in to see the changes Dialog Note Text PCC entry

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