1. 1 Chronic Disease Management Dr David Doolan Director, Clinical IT Support and Development Information Technology and Telecommunications November 2010

2. Chronic Disease Management System  CDM to run within CAP similar to that used in New Zealand, Canada and US (HNEH LICENCE)  Workflow –Establish program and parameters –Enrol Patients –Manage patients –Notify clinicians –Report outcomes and variances  GP secure clinical messaging

3. Plan  Commenced Diabetes, COPD and SHS working groups in July  Documenting workflow and establishing scope  Need to design around different service models in different locations  CDM System (including Shared Health Summary) –Program 1 live Mar - Jun 2011 (Diabetes) –Program 2 live May – Jul 2011 (COPD)

4. How to ‘operationalise’ this model

5. CDM Task List

6. CDM Screening Program

7. CDM Diabetes Program

8. CDM – Foot Assessment

9. Shared Health Summary – Health Profile

10. Shared Health Summary – Progress Note

11. CDM Summary

12. Summary view of Diabetes Data

13. Notifications

14. Population Reporting

15. CDM Issues  Program development and maintenance –Diabetes –COPD  Patient enrolment (scope)  Overlap with existing systems especially CHIME  Interaction with GPs and other external providers –Direct access/integration –Secure Messaging (Medical Objects)

16. Questions and Discussion