Clinical (EHR) Reminders
Physiology of a Reminder
Session Objectives
At the end of this session, participants should beable 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 usingBoolean 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 CAGErecorded
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 NOThysterectomy
What expressions look like…
Findings are expressed as Finding 1, Finding 2and 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… AND
AND 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 =1
Patient has DM. Patient does not have HTN
FI(1) =1 and FI(2) =0 Statement = 0
Patient does not DM. Patient has HTN
FI(1) =0 so Statement =0
HTN
DM
AND
Physiology… OR
OR 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 = 0
51yo and no colon cancer.
AGE =1, FI(1) =1 NOT FI(1) = 1, Statement =1
49yo and no colon cancer.
Age = 0, Statement = 0.
49yo and colon cancer.
Age = 0, Statement = 0.
Physiology… NOT
NOT placed before a finding makes a false true and true false… it is used to exclude
NOT (’)
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 hysterectomyare excluded
Abn 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
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 halftrue
•You can change the logic by changing the order of the findings, OR byadding 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 toevaluate in the way you want
Sample cohort logic
Age over 2 AND high risk diseases
AGE&FI(1)
Age over 50 AND NOT Colon Cancer
AGE&’FI(1)
Female AND age 21-65 AND NOT hysterectomy
SEX&AGE&’FI(1)
Diabetes AND NOT end stage renal disease
FI(1)&’FI(2)
Sample Resolution Logic
HGBA1C lab test
FI(1)
Alcohol exam or CAGE or pt ed code or Alcoholdx
FI(1)!FI(2)!FI(3)!FI(4)
Mammo in Rad file or Mammo CPT or Mammorecorded in WH package or Refusal
FI(1)!FI(2)!FI(3)!FI(4)
Basic Reminder Logic
Does patient meet cohort criteria?
No
Yes
Any Exclusions?
Yes
Fulfills resolution criteria?
No
Yes
No
Reminder Resolved
Applicable (blue clock)
Reminder Due
Due (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, bothsexes
•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 orcholesterol
•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 ReminderExchange
•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 cancopy the national reminder, edit it and then use
National Reminders
•Many national reminders need to have sitesmap their own local terms to the reminderterms, especially those reminders with lab testresults
•TEST, TEST, TEST before the general public usesthe reminders. Be sure they are workingproperly
Questions & Discussion