Table 1. Core Principles of Reminders
Design principles
  • Reminders must be simple action items, one line only. Absolutely no background, reference, or persuasive material should ever be included. Educating clinicians about and convincing them of the value of the services to be reminded about must take place off line, not in the time-pressured, information-saturated clinic environment.

  • Multiple response options must be offered. Clinicians should not have to spend time or effort determining how to handle the reminder itself, but focus only on its targeted service. Clinicians must be able to document patient refusal and designate individual patients as not candidates when appropriate.

  • “False alarms” must be aggressively minimized. They damage the system's credibility, and sorting valid from invalid reminders further adds to cognitive burden. Therefore billing diagnoses should not be used to drive reminders; rather, a clinician-verified problem list should be kept for each patient. Data from as many systems as possible should be imported to capture services provided and avoid triggering reminders for services already provided. Patient preference (refusal) and noncandidate status must suppress reminders (eg, do not issue irrelevant reminders for cervical cytology screening for patients who have had hysterectomies for benign disease).

  • The system must fit flexibly into the workflows of diverse physicians and teams. Different clinicians place their “windows of opportunity” for attending to additional information stimuli in different places within the visit structure and must accommodate the variable whereabouts of other team members. Some information may be handled outside of the visit, as well. Disrupting task structuring, such as with a “forcing function”20,21 approach requiring a response at a specific time and preventing other work until a response is made, should be avoided.

Implementation principles
  • Support for the system as a whole, and for each new set of reminders to be added, must be gained before reminders are activated.

  • Reminders must address quality goals determined by clinicians in a group process. Reminders do not address cost-cutting measures or administratively imposed objectives.

  • Physicians and teams must be able to adapt the system to their own uses, which may not be foreseen by the design team.

  • Resources to make responding to reminders feasible in busy clinics must be in place before reminders are activated (eg, clinical support staff should be trained and have time allocated to educate patients with asthma and work out asthma action plans with them before initiating reminding for asthma action plans). Implementation may need to involve team members who are not directly part of visit workflows.