ADA Blueprint Care Management Process
Implementing Clinical Reminders at Visit
A guide for practice facilitators helping primary care practices (PCPs) implement Guideline-Based Clinical Reminders at Visit (CRs).
Quick Start Guide
This CMP Quick Start guide can be used to "quicks start" implementation of this CMP in a practice. It provides a list of the essential steps for planning and implementing CRaVs for diabetes care.
Purpose of this Guide
This guide is designed to help practice facilitators (PFs) guide primary care practices in implementing an evidence-based diabetes care management process (CMP), “clinical reminders at visit.”
How to Use This Guide
This Guide provides a list of key tasks that a PF can use to help guide their work with PCPs interested in implementing or enhancing this CMP for patients living with diabetes at their practice.
CMP Description: Clinical Reminders of Preventive Services at Visit
Guideline-based clinical reminders (CR) at visit are a category of Clinical Decision Support (CDS) that alert healthcare providers to specific preventive or chronic care actions that a patient may need, such as vaccinations, screenings, labs or management steps for chronic conditions.
They can help practices improve implementation of evidence-based clinical guidelines, improve quality of care and close care gaps.
They are required functionality of Office of the National Coordinator for Health Information Technology (ONC) certified EHRs and can be delivered in a variety of active or passive formats including:
- pop-ups
- banners
- decision support prompts
- best practice advisories
- required acknowledgement messages
- smart sets
- flags
- hard stop alerts
- health maintenance tabs
- summary lists and dashboards
Clinical reminders (CRs) are part of a broader suit of Clinical Decision Support (CDS) tools set within an EHR that can also include:
- Drug-Drug Interaction Alerts
- Order Sets and Protocols
- Condition-Specific Guidelines
- Data Summaries and Dashboards
- Diagnostic Support
- Documentation Templates
- Patient-Specific Recommendations
- Clinical Calculators and Risk Scores
- Information Buttons
- Public Health Reporting and Safety Alerts
The primary goal of CRs is to improve patient outcomes by reducing missed opportunities for preventive and ongoing care. CR is useful also in addressing population health goals, like increasing screening rates for cancer or managing conditions such as diabetes or hypertension.
Effective clinical reminders are designed with the Five Rights in mind:
- The right information – providing accurate, evidence-based information.
- To the right person – ensuring the reminder reaches the appropriate clinician or staff member.
- In the right intervention format – delivering the reminder in a clear and actionable way.
- Through the right channel – integrating the reminder seamlessly into the clinician’s system.
- At the right time in the workflow – prompting the clinician at the point when the reminder can best inform the decision-making process.
From: Osheroff, J. A., Teich, J. M., Levick, D., Saldana, L., Velasco, F. T., Sittig, D. F., Rogers, K. M., & Jenders, R. A. (2012). Improving outcomes with clinical decision support: An implementer's guide (2nd ed.). Taylor & Francis.
For more resources on CRs and how to help a practice implement and use them click here.
If this is your first time helping a practice implement CRs and you would like to see some examples in EHRs click here.
Rationale for Selection of "Guideline-Based Clinical Reminders at Visit" as a Blueprint CMP
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.
Peterson KA, Carlin CS, Solberg LI, Normington J, Lock EF. Care Management Processes Important for High-Quality Diabetes Care. Diabetes Care. 2023 Oct 1;46(10):1762-1769. doi: 10.2337/dc22-2372. PMID: 37257083; PMCID: PMC10624652.
Read the study here: https://pubmed.ncbi.nlm.nih.gov/37257083/
Benefits of "Clinical Reminders at Visit"
The benefits of implementing guideline-based clinical reminders for preventive services during patient visits include:
- Improved clinician adherence to best practices for preventive services.
- Increased rates of service delivery, such as vaccinations, screenings, and patient counseling.
- Better patient outcomes and a reduction in avoidable hospitalizations and emergency room visits.
- Closure of care gaps and improved performance on national and local quality metrics, ultimately improving practice reimbursement and standing with payers.
By ensuring that the right preventive services are provided at the right time, practices can enhance the quality of care, improve patient satisfaction, and meet key quality benchmarks.
What Good Looks Like for This CMP
As a practice facilitator (PF) or a primary care provider (PCP) implementing or enhancing CMPs in a practice, knowing what “good” looks like can help you implement CMPs more effectively and efficiently.
Case Examples
As a practice facilitator (PF) or a primary care provider (PCP) implementing or enhancing CMPs in a practice, knowing what “good” looks like can help you implement CMPs more effectively and efficiently.
Case examples are contributed by PFs like you and practices that have developed exemplary processes and protocols for this CMP
PEARLS
PEARLS are contributed by PFs and their practices. This is a dynamic list of “lessons learned” you can use to enhance your CMP process and avoid common pitfalls and refine your and your practice’s processes.
Click here to read or submit case examples or PEARLS for CRs click here.
Help promote PF knowledge and skills in this area: Submit your case examples and "pearls" here: (placeholder for submission link)
Key Tasks
Start with Practice Leadership
As with any quality improvement work, it is essential to confirm that the proposed work aligns with the practice’s current goals and priorities, otherwise any work you undertake is likely to meet resistance. Before starting work on this and other CMPs, meet with practice leadership to confirm alignment with their goals and their buy-in
Task 1. Establish a governance committee for Clinical Reminder (CR) selection and implementation
Implementing Guideline-Based Clinical Reminders at Visit (CRs) and other forms of Clinical Decision Support (CDS) requires careful thought and planning. While 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 CRs 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 Care Management Process champion and practice leadership to create a project team for this Care Management Process that can also serve as its first governance group.
The team should include representatives from all relevant roles in the practice, including:
Some questions to ask the practice as they decide on the team are:
- 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?
- Who in our practice has experience with CDS and specifically CRs?
- Who has been involved in prior work or current work at this or another practice that can inform this effort?
- Which disciplines and roles will be needed to help design and set-up the CRs?
- Which disciplines and roles will be impacted by the clinical reminders once they are live?
Create a CDS Governance Committee Charter
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).
Worksheets
Use this CDS and CR Governance Charter Worksheet to guide a practice through the formation of a Clinical Decision Support Governance Committee or work with the practice to create their own
You can use an informal Clinical Reminder Assessment Worksheet.pdf as a starting point.
Task 2. Assess current state 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:
- Which CRs are currently active?
- How are they being generated and delivered?
- How satisfied are clinicians and staff with the reminders?
- How many CRs does a clinician or staff person receive during a typical day?
- What percent are dismissed?
- Is alert or reminder fatigue a concern?
- How effective have the CRs been for closing care gaps? Improving QI performance? Improving patient outcomes and safety?
- 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
- Which preventive and health maintenance performance measures does the practice want to improve?
- What role do they see CR playing in these improvements?
- Why do they believe CR will be successful for this?
- What are their performance targets for these measures?
Use the Goal-Sheet for the Practice to document the practice’s goals
Task 4. Assess capabilities of practice HIT for delivering CRaVs and select method
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:
- What CRs are available?
- To what degree can the cohorts, triggers, satisfiers, and workflows for CRs be customized?
- Is there a cost?
- What training is available to help us get started?
- Does the vendor monitor and update the CR when there are changes to the guidelines/metrics?
- 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.
3rd party platforms.
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 CRaVs to Implement
From a best practices perspective reminders should be based on:
- Evidence-based guidelines
- National quality metrics or
- Specific local needs.
A. Guideline-based CRs for Diabetes
View more
B. Quality Metric Based CRaVs
View more
C. Local Needs-Based CRaVs
View more
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.
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:
- The cohort of patients
- Exclusion rules
- The “finding” or event that will trigger the reminder
- Type of CR notification used
- Who on the care team or staff will receive the reminder
- The specific actions that will satisfy the reminder (resolution logic that turns the reminder off)
- How these actions are documented
- What follow-up reminders are needed to confirm preventive services delivered outside of practice
- 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.
Logic map template
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:
Click here for AHRQ's PDSA Worksheet
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
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:
- How will the practice monitor for changes to key guidelines and quality metrics the CRs are based on?
- Who will do this?
- How will modifications to CRs decided upon ?
- 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
Task 12. Celebrate practice progress!
