Guideline-Based Clinical Reminders at Visit
ADA Blueprint Implementation Guide
Quick Start Guide
The Quick Start Guide provides a list of the essential steps for setting up clinical reminders (CR) during diabetes care visits.
Practice Facilitation Guide
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) for clinical reminders for preventive services during a patient’s visit.
How to Use This Guide
This guide provides a list of tasks to integrate guideline-based reminders into the practice workflow that a PF can use with a practice.
CMP Description: Clinical Reminders of Preventive Services During Visits
Guideline-based clinical reminders (CR) at visit are a category of clinical decision support (CDS) that alerts clinicians to specific preventive or chronic care actions that a patient may need, such as vaccinations, screenings, labs or management steps for chronic conditions.
CRs can help practices increase implementation of evidence-based clinical guidelines, improve quality of care and close care gaps.
Office of the National Coordinator for Health Information Technology (ONC) requires CR functionality for an EHR to be certified.
Automated Clinical Reminders can be delivered in active or passive formats including:
  • banners
  • decision support prompts
  • required acknowledgement messages
  • smart sets w/ individualized flags
  • flags
  • hard stop alerts
  • health maintenance tabs
  • summary lists and dashboards
Clinical reminders are part of a broader suit of clinical decision support (CDS) tools 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 goal of CRs is to improve patient outcomes by reducing missed opportunities for preventive and ongoing care. CRs are useful for addressing population health goals such as increasing screening rates for cancer, or improving management of conditions such as diabetes or hypertension.
Effective clinical reminders align with the "5 rights":
  1. The right information: Providing accurate, evidence-based information.
  1. To the right person: Ensuring the reminder reaches the appropriate clinician or staff member.
  1. In the right intervention format: Delivering the reminder in a clear and actionable way.
  1. Through the right channel: Integrating the reminder seamlessly into the clinician’s system.
  1. At the right time in the workflow: Prompting the clinician at the point when the reminder can best inform the decision-making process.
For more information read on the 5 rights read: 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.
If this is your first time helping a practice implement CRs and you would like to see an example in an EHR, click here.
For more background on CRs and their quality context, click here.​
For more resources on CRs and how to help a practice implement and use them click here.
Rationale for Selection of "Guideline-Based Clinical Reminders at Visit" as a Blueprint CMP
Guideline-based CRs during visits were identified in the UNITED study (Peterson et al., 2019) as one of three 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.
Benefits of this CMP
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.
  • Improved 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 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 CRs at a practice, knowing what “good” looks like can help you implement CRs more effectively and efficiently.
Case Examples
Case examples are contributed by PFs and PCPs 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
Before starting work on this and other CMPs, meet with practice leadership to confirm alignment with their goals and their buy-in. As with any quality improvement (QI) work, it is important for you to confirm that the proposed work aligns with the practice’s goals and priorities, otherwise the work you undertake is likely to meet resistance.
Task 1. Establish a governance committee for CR selection and management
Well-designed CRs can increase clinician and staff efficiency and effectiveness, wherease 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:
  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?
  1. Who in our practice has experience with CDS and specifically CRs?
  1. Who has been involved in prior work or current work at this or another practice that can inform this effort?
  1. Which disciplines and roles will be needed to help design and set-up the CRs?
  1. 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). Use the charter worksheet below or create your own.
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
Task 2. Assess the current state of CRs at the practice
Next, help practice conduct a brief assessment of the current state of its CRs during visits.
Some questions you can ask:
  • Which CRs are currently active?
  • How are they being generated and delivered?
  • How well do they align with the “5 Rights?” Check out the assessment​​ ​here.
  1. The right information
  1. To the right person
  1. In the right intervention format
  1. Through the right channel
  1. At the right time in the workflow
  • 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?
You can use an informal ​the Sample 5 Rights Assessment of CRs to conduct an initial assessment.
Task 3. Determine practice goals for CRs during visits
Work with the governance committee or CMP implementation team to define their goals for CRs during visits based on results of the assessment conducted for Task 2, and their goals for CRs (and CDS) at the practice.
Some questions to ask the practice:
  • 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 Practiceto help the practice define their goals for CRs during visits.
Task 4. Evaluate the CR capacity of the practice's EHR 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:
  • What CRs are available?
  • To what degree can the cohorts, triggers, satisfiers, and workflows for CRs be customized?
  • Is there a cost associated with this functionality?
  • 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 health information technology (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 place reminders on patient records in the EHR.
Third-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 during visits through a dashboard and EHR overlay functions.
Hybrid processes.
Care gap reports from health plans, ACOs, and IPAs can be accessed through the entities’ provider portal. The practice may also 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., U.S. Preventive Services Task Force 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 artificial intelligence (AI) and machine learning: Machine learning can facilitate more dynamic personalization of reminders by 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 CRs should be based on:
  • Evidence-based guidelines
  • National quality metrics or
  • Specific local needs.

A. Guideline-based CRs for diabetes

For diabetes related-CRs, the American Diabetes Association® (ADA) suggests starting with: Comprehensive annual eye exam Chronic kidney disease (CKD) screening with eGFR and UACR A1C Lipids Foot exam Flu vaccine COVID-19 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

B. Quality metric-based CRs

The National Committee for Quality Assurance (NCQA) and the HEDIS (Healthcare Effectiveness Data and Information Set)​ ​is a good place to start. Find more information here: https://www.ncqa.org/hedis/measures/https://www.ncqa.org/hedis/measures/

C. Local needs-based CRs

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: Do we have specific patient groups that are unable to or fail to access specific preventive services as recommended? Are there preventive service metrics where our practice is performing particularly poorly or below local and national benchmarks? Are there specific patient groups who are experiencing health equity issues that clinical reminders could be a tool to help correct? “Alert fatigue” is a special consideration when selecting CRs to implement. While more may seem better, it is important to not overdo CR and other CDS reminders and alerts, as this can produce a phenomenon called “alert fatigue” in providers and staff where they begin to ignore CRs and other CDS. To learn more about this click ​​here.

Task 6. Ensure structured data is available to generate CRs
Structured data is required in order to generate automated clinical reminders during visits, as well as a consistent location for the documentation.
As a next step, work with the practice to evaluate how and where it documents the services that will trigger the CRs, such as comprehensive annual eye exams and foot exams.
If information needed to generate the CRs is documented using free text in encounter notes, or entered in inconsistent locations by different providers, you will need to work with the practice to modify their documentation methods to provide the structured data needed to automate and generate the CRs.
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:
  1. The cohort of patients
  1. Exclusion rules
  1. The “finding” or event that will trigger the reminder
  1. Type of CR notification used
  1. Who on the care team or staff will receive the reminder
  1. The specific actions that will satisfy the reminder (resolution logic that turns the reminder off)
  1. How these actions are documented
  1. What follow-up reminders are needed to confirm preventive services delivered outside of practice
  1. Escalation protocols if the reminder is not resolved
Use a logic map that tracks exclusions, at- and post-visit satisfiers, and the follow-up process.
Logic map template
Use the design worksheet below to help the practice design the CRs it will use.
Task 8. Determine the best place for the CR in workflow
The practice will also need to decide where the CR will be provided in the workflow. Poor timing can undo any positive benefit from CRs during visits.
If the CR occurs too late or too early in the care process, it will be ineffective.
Work with the practice to map out the entire patient visit for from check-in to check-out.
Place CRs at moments where they are the most actionable, such as during patient intake, in consultation, or before completing orders.
Include 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.
For a brief training for your practice on workflow mapping go here: https://www.ahrq.gov/downloads/ncepcr/pf-modules/process-mapping/story.html
Task 9: Test the CRs and refine
Before the practice goes live with their new CRs, work with them to test and refine the CRs before implementing them in practice.
Background testing.
If the HIT system being used to deliver the reminders allows for background testing, use this option to test the CRs'accuracy, timing, and volume for a few days.
Plan-Do-Study-Act Cycles.
Use Plan Do Study Act (PDSA) cycles or a similar QI process for conducting small tests of change to test and refine the CRs. Try with a single patient, single provider or single day. You can use a modified "last 10 patient" chart audit to gather data on the on the CRs. Collect feedback from staff and clinicians on their accuracy, timing and actionability. Make refinements to the process, and conduct another PDSA. Repeat this until you and the practice believe the CRs are ready to implement.
Some areas to consider testing include the:
Click ​here​ for a PDSA worksheet the practice can adapt and use to test its new CRs.
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: Add to the practice's QI plan and monitor 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 their effectiveness in helping the practice improve quality and outcomes of 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 be determined?
  • Who will implement the changes?
In addition, 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.
Possible measures to add to QI plan
Task 12. Add the new processes to practice policies and procedures and new staff training
As a final step, work with the practice to add the new processes to the practice's policies and procedures, as well as 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.
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