Guideline Based Clinical Reminders at Visit
ADA Blueprint CMP
Rationale for Inclusion
Guideline-based clinical reminders at visit was identified in the UNITED study (Peterson et al., 2019) as one of three care management processes (CMPs) out of 64 that were most associated with improvements in care quality and health outcomes for patients with diabetes.
Read the study here: https://pubmed.ncbi.nlm.nih.gov/31882407/
Quick Start Guide for Blueprint CMP:
Guideline-Based Clinical Reminders
Task 1. Establish governance for CR selection and implementation
Implementing CRs at visit and other forms of CDS can be a contentious process for a practice. Well-designed reminders and other forms of CDS can increase clinician and staff efficiency and effectiveness, too many or poorly designed ones can increase workplace stress, harm quality and negatively impact patient flow.
Because of this, design of CR and other CDS requires careful planning and serious buy-in by clinicians and staff who will be impacted by them.
Find out if the practice already has a CDS governance process in place. If not, work with the CMP champion and practice leadership to create a project team for this CMP that can also serve as its first governance group.
The team should include representatives from all relevant roles in the practice, including:
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Front desk or scheduling staff: They will be involved in patient intake and verifying patient information, which can influence which reminders are triggered.
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Medical assistants (MAs): MAs may be responsible for educating patients about reminders and acting on them in preparation for the clinician's visit.
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Clinicians: Ultimately, clinicians will make the decision to act on the reminders, so their input is crucial.
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IT or EHR specialists: They will help configure the system and ensure the alerts are functioning as intended.
Some questions to ask the practice as they decide on the team are:
1. Who in our practice is interested in or passionate about CDS and/or improving diabetes care who could serve as the CMP champion and the lead of the Governance Group?
2. Who in our practice has experience with CDS and specifically CRs?
3. Who has been involved in prior work or current work at this or another practice that can inform this effort?
4. Which disciplines and roles will be needed to help design and set-up the CRs?
5. Which disciplines and roles will be impacted by the clinical reminders once they are live?
If the practice is establishing a CDS Governance for the first time, suggest they create an initial charter that they can use to guide their decision making around the CRs they will be implementing (or improving).
Task 2: Assess the current status of CRs at the practice
Next, help practice conduct a brief assessment of the current state of its guideline based CRs at visit.
Some questions you can ask:
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Which CRs are currently active?
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How are they being generated and delivered?
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How well do they align with the “5 Rights?”
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The right information
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To the right person
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In the right intervention format
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Through the right channel
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At the right time in the workflow
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How satisfied are clinicians and staff with the reminders?
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How many CRs does a clinician or staff person receive during a typical day?
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What percent are dismissed?
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Is alert or reminder fatigue a concern?
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How effective have the CRs been for closing care gaps? Improving QI performance? Improving patient outcomes and safety?
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Are there reminders the practice would like to add/retire?
Task 3: Determine practice goals for CRs at visit
Work with the governance committee or CMP implementation team to define their goals for CRs at visit based on results of the assessment or their aims for the practice.
Some questions to consider discussing with the practices
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Which preventive and health maintenance performance measures does the practice want to improve?
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What role do they see CR playing in these improvements?
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Why do they believe CR will be successful for this?
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What are their performance targets for these measures?
Goal Sheet template
Task 4: Evaluate EHR CR capabilities and select approach
Begin your design and planning work with a practice for this CMP by reviewing the capacity of their EHR, and its Clinical Decision Support modules and resources.
Arrange for a meeting with the vendor and a demonstration of the EHR’s CDS and CR functions.
Some questions to consider asking the vendor:
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What CRs are available?
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To what degree can the cohorts, triggers, satisfiers, and workflows for CRs be customized?
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Is there a cost?
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What training is available to help us get started?
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Does the vendor monitor and update the CR when there are changes to the guidelines/metrics?
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Does the vendor have case examples of other customers’ CRs and workflows that we can learn from so we can avoid “reinventing the wheel?”
If the EHR is does not provide the needed CR functionalities, work with the practice to explore other HIT resources and approaches:
Population health management tools. Many practices have access to a population health management platform or HIE that can deliver care gap reports that can be used to generate CRs within patient records in the practice’s EHR or used to place manual reminders on patient records in the EHR during pre-visit prep.
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External systems such as DartNet’s In4medCare or Holon Ribbon can integrate with a practice’s EHR or population health system and provide CR at visit through dashboard and EHR overlay functions.
Hybrid processes. Care gap reports from Health Plans, ACOs and IPAs can be accessed through the entities’ provider portal, or the practice may receive them via fax or secure email and can be used to generate manual CRs through flagging patient records or similar methods.
Manual chart reviews. In smaller practices or settings with limited health IT infrastructure, PCPs and staff may manually review patient charts to identify overdue preventive services. This process involves using predefined checklists based on clinical guidelines (e.g., USPSTF recommendations) to track which services are due. Although labor intensive, manual chart reviews ensure that preventive services are addressed, even without automated systems.
A note about AI and machine learning. Machine learning can facilitate more dynamic personalization of reminders – tailoring messages for individual patients based on a variety of variables and patient behaviors, and to individual clinician and staff responses to and preferences around receipt of clinical reminders. Go to AHRQ, ONC, HIMSS and websites like AI in Healthcare to keep up to date on developments of AI in CDS systems.
Task 5: Select CRs to implement
Next, work with the practice to select which CRs to implement.
From a best practices perspective reminders should be based on:
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evidence-based guidelines,
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national quality metrics or
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specific local needs.
Guideline-based CRs for Diabetes
For diabetes related-CRs, a suggested starter list from the American Diabetes Association is:
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Comprehensive annual eye exam
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CKD screening w/ eGFR and UACR
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A1C
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Lipids
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Foot exam
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Flu vaccine
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Covid vaccine
Use the American Diabetes Association’s Standards of Care in Diabetes as a reference for developing the CR rules: https://professional.diabetes.org/standards-of-care
Use the US Preventive Services Task Force Guidelines as an additional resource for CR selection and design: https://www.uspreventiveservicestaskforce.org
Quality Metric Based CR
The NCQA and the HEDIS (Healthcare Effectiveness Data and Information Set) is a good place to start: https://www.ncqa.org/hedis/measures/
Local Needs-Based CR
The unique context or needs of the practice or patients can be another reason for selecting specific CR to implement. Some questions for the practice to consider related to selection of CR based on local need include:
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Do we have specific patient groups that are unable to or fail to access specific preventive services as recommended?
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Are there preventive service metrics where our practice is performing particularly poorly or below local and national benchmarks?
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Are there specific patient groups who are experiencing health equity issues that clinical reminders could be a tool to help correct?
Task 6. Confirm availability of structured data for generating CRs
Structured data is required in order to generate automated clinical reminders at visit, as well as a consistent location for the documentation.
As a next step, work with the practice to evaluate how and where the practice documents the services that will be used to trigger the CRs such as comprehensive annual eye exams and foot exams.
If any of these are captured in free text, or in inconsistent locations in the record, work with the practice to explore adding or changing to the use of structured data fields for these elements.
The completeness and consistency in documentation of key variables used to generate CRs is key to their accuracy and ultimate usefulness.
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Task 7. Define rules for the CRs
For this task, work with the practice to determine the rules for each CR that align with the guidelines or relevant quality metrics.
For each reminder, the practice will need to decide:
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The cohort of patients
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Exclusion rules
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The “finding” or event that will trigger the reminder
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Type of CR notification used
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Who on the care team or staff will receive the reminder
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The specific actions that will satisfy the reminder (resolution logic that turns the reminder off)
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How these actions are documented
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What follow-up reminders are needed to confirm preventive services delivered outside of practice
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Escalation protocols if the reminder is not resolved
Use a logic map that tracks exclusions, at visit satisfiers, post-visit satisfiers and the follow-up process.
Task 8. Determine best place to insert in the workflow
The practice will also need to decide here in the workflow the CR will be provided. Poor timing can undo any positive benefit from CRs at visit.
If the CR occurs too late or too early in the care process, it will not be ineffective.
To do this, work with the practice to map out the entire patient visit for the , from check-in to check-out. Place the reminders at moments where they will be most useful and actionable, such as during patient intake, in consultation, or before completing orders.
Involve the care team member that will be receiving or acting on the CR in mapping their specific workflow and identifying the best timing for the reminder.
You may need to use swim lane maps to document the involvement of different members of the care team and staff in the reminder process.
Task 9: Test the CRs and refine
Before the practice goes live with a new CR, help them test the CRs to evaluate their accuracy, impact on clinician and staff workflow, and patient flow.
Background testing. A first preferred option is to run them in the background and assess their accuracy, timing, and volume for a day or week. The technology the practice is using may or may not allow for background testing of reminders.
Plan-Do-Study-Act Cycles. If not, a second step for assessing reminders is to test them on a single day or week depending on eligible patient volume. You can use a last 10 or 20 patient audits to do an initial test of the effectiveness of the reminders.
Some areas to include in the testing include:
Task 10: Create job aids and train clinicians and staff
Work with the practice to develop supportive materials for the staff who will be carrying out the new tasks including creating process maps and job aids to support training of current and future staff.
Click here for a sample job aid for back-office staff for a manual CR generation process
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Task 11: Monitor guidelines and update CRs as needed
Monitor and update CRs as guidelines and quality metrics change. Guidelines and quality metrics change over time. Once deployed, keeping CR content up to date is critical both for their adoption by clinicians and staff, and to their effectiveness to helping the practice attain the desired outcomes and improvement in patient care.
Work with the practice to determine how it will monitor changes in guidelines or metrics and update its CR to align with these changes.
Some questions to ask:
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How will the practice monitor for changes to key guidelines and quality metrics the CRs are based on?
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Who will do this?
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How will modifications to CRs decided upon ?
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Who will implement the changes?
As with any improvement you are working with a practice to implement (or enhance), before you complete your work with the practice on CRs, work with the practice to select a few key metrics that align with their QI objectives and can be tracked as part of their routine QI activities.
In addition, work with them ensure that the new processes are fully incorporated into the practice's policies and procedures manual, as well as into new staff training program. These steps will help embed the CRs into daily operations, support staff consistency, and drive measurable improvements in patient care outcomes.
Possible measures to add to QI plan
Governance Charter Worksheet
CDS and CR Governance Charter
Practice Name: ___________________________
Date: ___________________________
Practice Facilitator (PF) Name: ___________________________
Clinical Reminder Champion: ___________________________
Section 1. Purpose and Objectives for the Clinical Reminder Governance Group
1.1 What is the primary purpose of the Clinical Reminder Governance Group?
(Example: To review, approve, and monitor the use of clinical reminders in the EHR system, ensuring alignment with clinical practice guidelines and patient safety.)
__________________________________________________________
1.2 What are the key objectives of the group?
(Examples: Prevent reminder fatigue, ensure clinical relevance, reduce unnecessary reminders, improve patient care.)
__________________________________________________________
__________________________________________________________
__________________________________________________________
Section 2. Roles and Responsibilities
2.1 Who will be part of the governance group? Identify roles below.
Role
Name
Responsibilities
Physician Lead
______________________
Provide clinical oversight, validate reminders
IT Lead
______________________
Manage technical implementation in the EHR or related system
Practice Manager
______________________
Coordinate meetings and follow-up actions
Quality Improvement Lead
______________________
Track metrics and outcomes
Nursing Representative
______________________
Offer insight into workflow impacts
Office Manager
______________________
Oversee training and implementation among staff
End user member (PCP)
______________________
End user member (MA)
______________________
End user member (Clerk)
______________________
End user member (Care Coordinator)
______________________
End user member (Other)
______________________
2.2 How often will the group meet?
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Weekly
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Biweekly
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Monthly
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Quarterly
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Other: ___________________
Section 3: Clinical Reminder Review and Approval Process
3.1 What types of reminders will be reviewed by the governance group?
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New reminders for chronic disease management
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Medication safety reminders
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Preventive care reminders
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Reminders related to transitions of care
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Other: ___________________
3.2 What criteria will be used to approve or reject clinical reminders?
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Alignment with evidence-based guidelines
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Relevance to the practice's patient population
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Reminder sensitivity and specificity
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Impact on workflow and efficiency
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Reduction of reminder fatigue
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Other: ___________________
Section 4: Decision-making Framework
4.1 What decision-making process will be used for approving or rejecting reminders?
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Consensus
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Majority vote
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PCP-led decision
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Other: ___________________
4.2 Will there be a process for testing new reminders before implementation?
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Yes
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No
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If yes, describe the process for testing: ______________________
Section 5: Monitoring and Evaluation
5.1. What metrics will be used to evaluate the success of the clinical reminder governance process?
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Reduction in reminder fatigue
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Improvement in care outcomes (e.g., chronic disease management)
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Time saved in workflow
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Reduction in unnecessary or duplicate reminders
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Other: ___________________
5.2. How often will these metrics be reviewed?
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Monthly
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Quarterly
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Annually
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Other: ___________________
Section 6: Continuous Improvement
6.1. How will feedback from clinicians and staff be incorporated into the governance process?
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Surveys
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Focus groups
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Direct reporting during governance meetings
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Other: ___________________
6.2. How will the governance group address issues with ineffective or unnecessary reminders?
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Regular review and removal of outdated reminders
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Revisions based on clinician feedback
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Other: ___________________
Sample Assessment of Guideline-Based Clinical Reminders at Visit
Sample Assessment of Guideline-Based Clinical Reminders at Visit
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Does the practice currently use clinical reminders for preventive services at visit?
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Yes
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No
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If yes, how are these reminders generated and delivered?
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Automated reminders through EHR
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Automated 3rd party platform. Name:_______________
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Combination of automated and manual. Describe:_________________
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Manual chart review and checklist
3. If yes, assess provider satisfaction and design of the existing diabetes-related preventive service reminders:
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Goal Sheet
Goal Sheet
Our goals for implementing/improving clinical reminders for our patients with diabetes are:
1.
2.
3.
We will know we have accomplished these when:
1.
2.
3.
New reminders we would like to implement are:
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Comprehensive annual eye exam
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CKD screening w/ eGFR and UACR
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A1C
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Lipids
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Food exam
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Flu vaccine
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Covid vaccine
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Other:________________________________________
Improvements we would like to make to existing reminders are:
Clinical Reminder Logic Map
CR design worksheet
Sample job aid
Job Aid
Front Office Staff
Preventive Services Clinical Reminders at Visit
1. Day before visit
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Print schedule for next day
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Log-into (Pop Health Platform)
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Search and find patient, select “gap report”, add to “print batch”
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Send to printer
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Place in “Check-in” basket for next day
2. At Patient Check-In
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Review the gap report w/ patient
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Green highlight gaps already closed by patient
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Place sheet in provider basket
3. End-of-Day Closed Gap Reconciliation
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Open patient record in EHR
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Compare printed gap report (returned to basket by MA) for care gap closure at visit
Last 10 Patients Chart Audit Form
