Clinical (EHR) Reminders

Physiology of a Reminder

Session Objectives

At the end of this session, participants should be able to:Understand basic "physiology" of a reminder•Cohort logic•Resolution logic•Reminder term conditions

“Physiology…”

Boolean logic is the foundation of reminders… the reminder parts can be combined using

Boolean logic to determine:• Cohort (inclusion and exclusion)• Resolution

Physiology… Boolean Logic

AND• A and B must be true for the statement to be true Example: Patient has diabetes AND hypertension

OR• A or B must be true for the statement to be true

Example: Patient has Alcohol Screen exam OR CAGE recorded

NOT (used mostly for exclusion criteria)• If A is not found, the response is true • If A is found, the response is false

Example: Female patient, 21-65 AND NOT hysterectomy

What expressions look like…

Findings are expressed as Finding 1, Finding 2 and abbreviated in logic statements: FI (1), FI(2)Findings are not found/false = 0 found/true = 1 Logic statements are false = 0 true= 1 AND: FI(1)&FI(2)OR: FI(1)!FI(2)AND NOT: FI(1)&’FI(2)

Physiology… ANDAND FI(1) & FI (2) =

DM HTN Statement Result

T T T

T F F

F T F

F F F

AND (&)FI(1)&FI(2) -both must be true for the statement to be true -if either are false then the statement is false

Example: Cohort = Patients with both DM FI(1) and HTN FI(2) Patient has DM and HTN

FI(1) =1 and FI(2) =1 Statement =1Patient has DM. Patient does not have HTN

FI(1) =1 and FI(2) =0 Statement = 0Patient does not DM. Patient has HTN

FI(1) =0 so Statement =0

HTNDM

AND

Physiology… OROR FI(1) ! FI (2) =

Alcohol Exam CAGE Statement Result

T T T

T F T

F T T

F F F

OR (!)FI(1)!FI(2) -if either is true, then the statement is true -both must be false for the statement to be false

Example: Resolution = Alcohol Exam FI(1) or CAGE FI(2) to resolve

Patient has had Alcohol Exam and CAGE recorded FI(1) =1 or FI(2) =1, Statement =1

Patient has had Alcohol Exam. No CAGE recorded. FI(1) =1 or FI(2) =0 , Statement = 1

Patient has not had Alcohol Exam. CAGE is recorded. FI(1) =0 or FI(2) = 1, Statement =1

Patient has had neither Alcohol Exam or CAGE FI(1) =0 or FI(2) = 0, Statement =0

Alcohol Exam

or CAGE

Physiology… NOT

AND NOT AGE & ‘FI (1) =

AGE result FI(1) Result (result after NOT operator)

Statement Result

T T (F) F

T F (T) T

F T (F) F

F F (T) F

NOT (‘) If found/true then the NOT converts this to false in the logic statement. AND NOT (&’)AGE&’FI(1) Only if the first finding is found, and the second finding is NOT found is the statement true

Example: Cohort= I want patients age over 50 (AGE) and no h/o colon CA FI(1)51yo and colon cancer.

AGE =1, FI(1) =1 NOT FI(1) = 0, Statement = 051yo and no colon cancer.

AGE =1, FI(1) =1 NOT FI(1) = 1, Statement =149yo and no colon cancer.

Age = 0, Statement = 0.49yo and colon cancer.

Age = 0, Statement = 0.

50+ & Not Colon CA

Colon CA

Physiology… NOTNOT placed before a finding makes a false true and true false… it is used to excludeNOT (’) If found/true then the NOT converts this to false (0) in the logic statement.________________________________________

Example: Resolution = I want patients with h/o abnormal PAP with an intact uterus FI(1) &’FI(2) = Abnormal Pap and NOT h/o hysterectomy. Patients with hysterectomy

are excludedAbn Pap and not hysterectomy Patient has Abn Pap and has not had a hysterectomy. FI(1) is true. FI(2) is not found so this is also true . Statement is true.

Patient has Abn Pap and has had a hysterectomy. FI(1) is true. FI(2) is found, so this is false. Statement is false.

Patient has no history of Abnormal Pap FI(1) is false. The statement is false

AbnPap & NOThyst

h/ o hyst

Boolean Logic - precedence• Precedence (), Not, And, Or

If no parenthesis, it evaluates them using the precedence rules

• A and B or C works the same as (A and B) or C Both A and B must be true or C can be true.

• A or B and C works the same as A or (B and C)If A is true then the statement is true

If A is false, then both B and C need to be true to make the second half true

• You can change the logic by changing the order of the findings, OR by adding parenthesis

Boolean Logic - precedence

A or B and C or D Default precedence is: A or (B and C) or D DM or Pre-DM and HTN or Elevated BP DM or (Pre-DM and HTN) or Elevated BP

You really want (A or B) and (C or D) (DM or Pre-DM) and (HTN or Elevated BP)

You can use Custom Logic to force the items to evaluate in the way you want

Sample cohort logic

Age over 2 AND high risk diseasesAGE&FI(1)

Age over 50 AND NOT Colon CancerAGE&’FI(1)

Female AND age 21-65 AND NOT hysterectomySEX&AGE&’FI(1)

Diabetes AND NOT end stage renal diseaseFI(1)&’FI(2)

Sample Resolution Logic

HGBA1C lab testFI(1)

Alcohol exam or CAGE or pt ed code or Alcohol dx

FI(1)!FI(2)!FI(3)!FI(4)Mammo in Rad file or Mammo CPT or Mammo

recorded in WH package or RefusalFI(1)!FI(2)!FI(3)!FI(4)

Basic Reminder Logic

Does patient meet cohort criteria?

No YesAny Exclusions?

Yes

Fulfills resolution criteria?

No

Yes No

Reminder Resolved Applicable (blue clock)

Reminder DueDue (red clock)

Reminder not applicable(white clock)

No

No

No

Yes

Yes

Reminder not applicable(white clock)

Yes

Cohort Logic

• AGE and SEX are built into the system• If you don’t enter anything its all ages, both

sexes• Examples: What is the result?

– Pap Smear: AGE and SEX and not HYST– Pap Smear: AGE and SEX or not HYST– Flu shot: AGE or DIABETES

Resolution Logic

• What turns the reminder off?• Examples:

– Using lab tests:• Lipid Test: LDL or HDL or LDL (Calc) or Lipid Profile or

cholesterol• Lipid Test: LDL or LDL-Calc and HDL

HDL and LDL or LDL-Calc (LDL or LDL-Calc) and HDL

– Reminder Term• Lipid Test: Lipid Tests

National Reminders• Distributed with dialogs in PXRM 1.5 p1005• Updated in PXRM 1.5 p1006, 1007, 1008• The patch loads reminders to the Reminder

Exchange• Reminders will not display in the EHR until:

– Installed from exchange– Reminder system is activated– Reminders are added to the display list

• National Reminders cannot be edited. Sites can copy the national reminder, edit it and then use

National Reminders

• Many national reminders need to have sites map their own local terms to the reminder terms, especially those reminders with lab test results

• TEST, TEST, TEST before the general public uses the reminders. Be sure they are working properly

Questions & Discussion