Chronic Conditions - Key Activity 7


Create and Use Clinician Reminders


This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; implement condition-specific registries; proactive patient outreach and engagement; pre-visit planning and care gap reduction; care coordination; behavioral health integration; address social needs.


This activity provides guidance on how to develop, configure and use reminders in the Electronic Health Record (EHR) so that clinicians are aware of which patients are eligible for and due for wellness care measures regarding diabetes and hypertension. This activity calls for clinician reminders that flag patients at higher risk as well as patients with likely barriers to accessing care (e.g., mobility issues, speaking a language other than English, etc.).

Clinician reminders are one of several tools that clinicians, Medical Assistants (MAs) and other members of the care team can use to help ensure they are aware of their patients’ need for the various diagnostics required to effectively manage diabetes and hypertension. These reminders reduce the amount of time a clinician spends identifying the preventive services recommended for the patient. They also prompt the clinician to inform and educate the patient.

Focus on equity by using data to identify which populations, subpopulations or groups the current outreach and education efforts do not reach. See the PHMI Data Quality and Reporting Guide for more information.

Co-designing outreach strategies with community partners and current patients promotes cultural humility and sensitivity. Tailored outreach with personalized reminders addresses diverse needs and reduces inequities in access to care for chronic conditions.

This activity relies on similar capabilities as care gap management, utilizing population views and registries to create patient-specific reminders within each patient’s chart. For EHRs that have the capacity to display care gaps, that information can be leveraged to create clinician reminders for patients who might have an upcoming appointment. When that technology is not well developed, information from registries/care gap reports can be utilized to generate lists that enable care team members or other clinical staff to create those reminders. Many EHRs are capable of storing next appointment data that can also be used to differentiate patients who need a clinical reminder versus those who would benefit from outreach.

Other relevant HIT capabilities to support this activity include care guidelines; clinical decision support, including patient-facing clinical decision support; and care dashboards and reports.

Action steps and roles

1. Create a flag or alert in the patient record.

Suggested team member(s) responsible: panel manager or data analyst and practice staff responsible for the EHR.

At the patient level, ensure that the practice’s EHR or population health management tool creates a flag or alert to notify the care team of gaps in necessary care for effective diabetes and hypertension management using the latest USPSTF recommendations in accordance with your practice’s clinical practice guidelines. These alerts enable the care team to maximize the identification of necessary chronic disease management services related to patient visits.

This step may involve people from the practice who work on the EHR if it is not clear if or how the EHR can produce the care gap reports.

An example of what a patient-level care gap alert may look like is included in Figure 11.



Figure 11 Example Of A Patient Level Care Gap Alert


2. Configure the EHR alerts.

Suggested team member(s) responsible: practice staff responsible for the EHR.

Collaborate with the person/team responsible for your EHR to set up automated alerts within the EHR system for patients due for chronic disease management care needs.

Determine the timing and frequency of reminders (e.g., annually, biennially) based on clinical guidelines and patient risk factors.

Work with the care team and the person/team responsible for your EHR to help ensure that the automated alerts are not overlooked when there is an overabundance of alerts. The alerts should be provided at the appropriate time and in a format that is intuitive to the care team.

If possible, the alert should flag those at greater risk (see the USPSTF guidelines).

3. Make clinician reminders a part of the pre-visit planning (PVP) process.

Suggested team member(s) responsible: panel manager.

Work with the clinician and care team to develop ways to ensure these reminders are part of the PVP process (see Key Activity 10: Develop or Refine and Implement a Pre-Visit Planning Process).


4. Ensure reminders are updated continuously.

Suggested team member(s) responsible: panel manager, QI lead, and/or their designee.

Practices should have a process for updating EHR records so that the clinician reminders remain accurate (e.g., do not show a patient needing a lab work that they just had). At a minimum, this process should include:

  • The person(s) responsible for doing this.
  • Whether the needed exams/lab work was discussed with the patient (yes/no).
  • If an exam/lab work was discussed, the patient’s response (yes/maybe/no/not at this time).
  • The follow-up based on this conversation, including the results of any exams/lab work and the follow-up needed. Utilize EHR technology to facilitate the follow-up process.


5. Provide ongoing training on creating and using clinician reminders.

Suggested team member(s) responsible: panel manager and practice staff responsible for the EHR

Ensure that all members of the care team receive ongoing training on each of the four steps above. This training can be incorporated into huddles and should be part of the orientation for new staff. At a minimum, it should include ensuring that care team members:

  • Know of the reminders and what they mean.
  • Understand where, how and when they will receive the reminders. This should include showing each clinician where to locate the reminders and ensuring that the flag or alert is turned on. Any visual reminders should be easily accessible to clinicians.
  • Understand the process for updating the EHR to ensure that the reminders are accurate.


6. Monitor clinician reminders for accuracy and completeness.

Suggested team member(s) responsible: panel manager, QI lead, and/or their designee.

It is critical to have a feedback loop with the practice’s care team about any real or potential errors in clinician reminders. Some examples of errors that may occur are:

  • Patients who are eligible for and due for screening for whom a reminder or flag does not appear.
  • Patients who have recently been screened for whom the reminder or flag continues to appear.

The reminders process should be modified as needed whenever errors are discovered.



Figure 12 Example Of A Clinician Reminder

Implementation tips

  • If the practice has successfully implemented clinician reminders in other clinical areas, this can be used as the basis for clinician reminders for chronic conditions.