CDMP Patient Management Help

CDMP Patient Management Help

Overall Objectives Overview Using CDMP Support Process Questions
Find a Patient Alerts/Reminders Patient Management Data Entry Support Process Questions

Overview – CDMP  Care Team driven  Patient centered
 All-in-one solution  Customizable at site  Built on available technologies and tools  Uses familiar red, yellow, green risk signals  Sits on EMR or other clinical DB Weighs behavioral info with clinical info for a “whole patient” picture

Login Username and password are case-sensitive.
Independent from other systems System will timeout automatically after 30 minutes

Timeout The system times out automatically.

CDMP - General Layout Header – menu – always there
Footer – contact support – always there Tabs and command options Patient Menu

Header Menu Home – Care Team Home Page
Status Center – Identify New Data Search – Search for patients Help – This file JVN – Joslin Vision Network Reporting Studies – Study Manager Add Patient – Manually add a patient Should not have to do this. User Pref – Change password & Alert Filtering Admin – only certain people Logout – Logout… User’s home page is configurable. Options presently include the following: Care Team Home Page (default) Search Page Study Manager Study Manager Search JVN

CDMP - Sorting Default sort not displayed – usually based on first column Move mouse pointer over column headers Pointer / Cursor will change to hand Column name will be underlined Click on column headers to sort Subsequent clicks of same column header will reverse the sort order Sorting may take some time on large lists

CDMP Security & Auditing
Full Role-based embedded security system – ability to integrate with LDAP Full Audit Trail Who changed what and when Stores old value and new value Usage Tracking

Page Changes If you try leaving a page after making changes to it, this message displays to warn you that you have not saved it. Click Ok to continue and not save your changes Click Cancel to stay on current page You can then save your changes. This doesn’t happen automatically.

Finding Patients Quick Search Patient Appointments
On the home page Selected by default Just type last name (or partial) Patient Appointments Search page – header menu REMEMBER: Clicking a patient name always takes you to that patient’s home page.

Care Team Home Page Side Bar
Quickly search on Last Name + Last 4 SSN Cursor defaults to this field Always lists today’s appointments Assuming they were in AHLTA the previous night Remember: Click on patient name to access patient record

Patient Search To view a list of all Patients, click Find Patient with no criteria entered. To look for a specific patient, enter the specific criteria and click Find Patient. Patient Search Id (Last Name) is really Last Name plus Last 4 SSN. Search strategy: All search fields will do a partial search on the beginning of the field If you don’t find the patient you are looking for, broaden the search by removing criteria from the search To clear the search criteria, click the Clear Criteria button

Patient Search Assign functionality is only available to users with Management or Admin rights. Only certain people have permission to see unassigned patients. This can be changed on the User Admin page. After clicking Find Patient, your search results will be displayed on the page On the right side the number of results displayed and total results are displayed. Click Next>> or << Previous to navigate between the pages. If available, you can click Assign to assign or change the Care Team a patient is assigned to

Alerts Overview 3 Kinds  Measurement, Timing, & Behavioral
2 Levels  Red & Yellow Automatically created on a nightly basis Alert level is automatically adjusted or closed as new data arrives Alerts will only be created once every 90 days after being closed. Alert thresholds are adjustable for individual patients Measurement Alerts Look at lab values. Is the value above or below a certain value. Ex. If A1c is between 6.5 and 7, generate yellow Alert. If A1c is over 7, generate Red Alert Timing Alerts Based on whether or not a specific event has occurred. Ex. Annual Eye Exam or Foot Exam, A1c test every 6 months Behavioral Alerts Based on patient responses to survey

Care Team Alerts View New – View Alerts < 24 hours old or over weekend All Open – View all open alerts – red and yellow All Red – View only red alerts Close – Select Alerts to close by selecting the checkboxes on the left Select the checkbox in the header to select all alerts currently displayed Print – Prints the list of alerts in a popup Filter On/Off – Apply your personal filter – controlled through User Preferences More on the Filter If the Filter is on A message will be displayed “Warning Alert Filtering is On: All Alerts May Not be Displayed On This Page” The On Radio Button will be selected If the Filter is Off No warning message will be displayed The Off Radio Button will be selected

Care Team Alerts Status – always open here (can be closed at patient level) Level – Yellow or Red – click to view Alert specifics and to close individual alert Patient Name – name of patient – click to access patient record Alert – Name of Alert Origin Date and Days Old – How old is the alert? Count – Number of times the alert has been created – higher number indicates more serious issue

Care Team Alerts Paging – see top right
Displays range of Alerts currently being displayed Displays total number of Alerts Links to view previous or next pages Sorting Click column header to sort list within the page See above: clicking the Origin Date will sort the 50 records currently displayed, not the whole list.

Patient Alerts Only Alerts for the Specific Patient – see header
Current – Open Alerts History – Open and Closed Alerts Edit Alert Threshold – Allows modification of alert thresholds for the specific patient

View & Close Alert To View Alerts – click on Alert Level Thresholds
Displays the rules used to generate the Alert – the system level or the custom patient level Allows user to adjust Alert threshold for the specific patient Results Displays the specific results used to generate the Alert

View & Close Alert Follow-Up Actions Required to Close Alert
Multiple Actions can be entered These Actions do not generate any further activity – only a record of what was done. When closing Alerts in any fashion, the user closing the Alerts and the date/time are recorded. This information can be viewed on the Alert History tab for a specific Patient.

Add Follow-Up Action Enter notes if desired
Click Save to just add Action Item Click Save and Close Alert to add Action Item and Close Alert

Close Multiple Alerts When closing Alerts in any fashion, the user closing the Alerts and the date/time are recorded. This information can be viewed on the Alert History tab for a specific Patient. Allows user to apply an Action Item to multiple Alerts and Close more easily Select Action from drop down. Add Notes if desired Add – just adds Action Item to Alerts displayed at bottom Add and Close Alert – Adds Action Items and Closes Alerts Close Alerts (bottom right) – Close all Alerts after an Action Item has been added. Click + to expand the alert and see explanation, threshold, and details

Reminders Reminders can be generated in a number of ways:
Automatically based on Alerts As part of Care Planning process Manually Can be assigned to any provider in the system or the patient If Due Date is past due, displays Red On Care Team Home Page – user sees all reminders for all patients assigned to Care Team the user belongs to On Patient Home Page – user sees all reminders for patient Number of Days: Select how far out to view Reminders Close – select reminders on left with checkbox and click Close Print – prints list of reminders

Patient Reminders Only displays Reminders for specific patient
History – displays all open and closed Reminders Add New – allows user to add a new reminder To close Reminders Select specific Reminders with checkbox on left Or select all Reminders with checkbox in header Click Close Name of person closing the Reminders and the date/time are recorded and displayed on the History Tab.

Patient Management Snapshot - view Clinical Data
Risk Profile Clinical Data Care Plan –create, edit, view, take home Data Entry Reports

Snapshot Header Print View – Display a printer-friendly popup of the Snapshot for printing Demographics – displays Gender Age Ethnicity Taking Aspirin – as determined by medications from ICDB Diabetes Onset – not available Diabetes Type – not available Allergies

Snapshot Status Data from CDMP
Clicking on any blue field shows details - Foot and Eye Exam Report date of exam if documented Self-Reported through BAT Survey JVN – Joslin Vision Network Eye Exam NAT – Nutrition Assessment Survey Risk Profile Automatically generated based on clinical data - Red, Yellow, Green Levels - Click View to see details BAT Score – Survey scoring details Date last taken Summary – See high-level details Detail – See actual Q&A Scoring – used to give provider an idea of where patient needs help BAT Score is based on replies to patient taking the Behavioral Assessment Survey Scoring Details Smoking – Red if patient smokes, Yellow if patient used to smoke, Green if patient does smoke Psycho-Social and Physical Wellness – Each survey question assigned a value from 1 – 3, totals are added and divided by three to assign Low (green), Medium (yellow) or High (red) Risk in the category. Special Note: As of August 1, 2007 – studies are currently underway at Boston VA, WRAMC, and University of Hawaii Community Health Clinics to validate the survey and scoring.

Snapshot Displays most recent Education Evaluation
To see more details and history From Patient Menu select Education, then Evaluation History - Simple alphabetical listing of patient diagnoses

Snapshot Labs and Vital Signs
Displays most recent labs and vitals signs Displays date and value of lab Displays simple trending indicator Has the value moved up/down/not changed Click on lab or vitals in blue to see in graph Graph only displays last 24 months of data To view more lab values, select Clinical and then Labs from the Patient Menu. To view more vitals, select Clinical and then Vitals from the Patient Menu.

Snapshot Medications Displays Medications for last 365 days
Displays the following fields Name Prescription Date or Last Fill Date Number of Refills Left

Patient Demographics Edit Information extracted from ICDB
ICDB is system of record Changes in ICDB will overwrite data here Data extracted includes: Name Search Id Gender SSN Hospital Patient Id – for syncing purposes only Date of Birth Allergies Address Home Phone Number Ethnicity If user wants to change patient demographics it should be done in AHLTA. Other data fields can be modified here

Labs Edit Delete Graph All Lab Results are displayed in chronological order Click Column Header Names to Sort Notes Field: Will contain lab abnormal indicator Lab Names will be the same as in ICDB Can only edit or delete results entered in CDMP. Cannot alter data imported from ICDB.

Vitals Displays graph of Blood Pressure and Weight underneath actual numbers

Medications Prescription Date, Medication Name, Dosage, Frequency and Last Filled information imported from ICDB. Future functionality allows for marking medications as Current

Other Clinical Data Procedures Diagnoses Admissions Name, Date
Admission Date, Discharge Date, Reason Code

Risk Profile Risk Profile currently reports risk levels on five physical measures and 3 behavioral measures. Note: vital signs data is above the risk table to help the care provider correlate risk and current vitals. (Care provider can also take a look at the Snapshot for comprehensive information) Both no information and overdue events trigger higher risk levels. For instance, absence of any eye exam or overdue A1c code will code red, based on guidelines.

Education - Assigned Displays in a Popup
Lists Education Resources assigned through Care Planning. Displays Name of Material, Type, Description, if it is part of a Learning Plan, and whether or not a patient has received the material Click on the Globe Icon to view the material Click Print to print the display Click Close to close the popup

Education Evaluation Evaluate the current level of patient’s knowledge in the 10 ADA self-management categories Select Type of Evaluation: Pre-Evaluation, Post Evaluation or N/A Select the Evaluation Date – defaults to today If complete, mark as Complete – once it is complete it cannot be edited. Mark each area in terms of Proficient, Adequate, Inadequate, No Ed or N/A. ADA Self-Management Topics Disease Process: Diabetes disease process and treatment options test Can describe diabetes as a disease process and treatment options Nutrition: Incorporating appropriate nutrition management Knows about and uses nutrition management ideas Physical: Incorporating physical activity into lifestyle Knows how to work physical activity into lifestyle Medications: Using medications effectively Understands why medication(s) should be taken consistently Monitoring: Monitoring blood glucose and urine ketones and using the results to improve control Knows how to monitor blood glucose and how to use the results to adjust insulin or other medications Acute Complications: Preventing, detecting, and treating acute complications Knows how to prevent detect and treat hypoglycemia and treat hypoglycemia and hyperglycemia Chronic Complications: Preventing (through risk reduction behavior), detecting, and treating chronic complications Understands good self-management now can prevent chronic complications later Goal Setting: Goal setting to promote health and problem solving for daily living Knows about setting physical and lifestyle goals to control diabetes PsychoSocial: Integrating psychosocial adjustments into daily life Understands how attitude and willingness to try new things helps daily health Pregnancy: Promoting preconception care, pregnancy, and gestational diabetes management Understands the need for pre-pregnancy care and close management during pregnancy and after delivery

Education Evaluation Optionally, select Areas to Improve from the drop or click Edit Areas to select multiple from a popup

Education Evaluation History
Click Date to view Details View History of patient’s Education Evaluation to see progress Click on Date in header to view details

Survey History Lists all Surveys taken by the patient
Specific surveys are broken out to display scoring PAID  Problem Areas in Diabetes Behavioral Assessment Survey DSCP  Diabetes Self-Care Profile Display custom report All Surveys Click on Date Taken to view Questions and Answers

Care Plan Print button only displays after the Care Plan has been saved. Set Start Date and Planned End Date – manageable time period a few months at most  NOT a life long care plan To Close the Care Plan and start a new one, click Close Care Plan and Save Click Print to print the Care Plan Take Home Risk Profile displayed here for convenience – Click Hide to regain screen real estate 3 tabs: Self-Management, Education, and Reminders

Care Plan Self-Management
Nothing is required. Enter Patient’s Readiness to Change Select Self-Management Assessments from drop down. These are generic. Once selected add notes to make them more specific Multiple Assessments can be selected If an Assessment is added accidentally click Remove associated with the correct one. If an asterisk (*) displays next to a selected Assessment, it means a Reminder will be automatically created on the Reminder tab. Print button only displays after the Care Plan has been saved.

Barriers Add Barriers by selecting them from the drop down Add Notes to make them more specific Click Remove to delete item from Care Plan Instructed In Add items that you instructed the patient in Add Notes to make more specific Add Completed date Each item here displays on the Care Plan Take Home.

Each item here displays on the Care Plan Take Home. Care Provider Goals Your goals for the patient. Short Term Goals In the patient’s own words (not yours), what are their goals? Long Term Goals In the patient’s own words (not yours), what are their goals Each item here displays on the Care Plan Take Home.

Care Plan Education Search for Education Items to Assign to the Patient Keyword Search  search Item name and Description Media Filter  use this if you only want to find certain types of material Ex. Books, Pamphlet, Website Click Search to search for specific items Click View All to view list of all education items If available, click the Globe icon to view and print the material Education Items can be added, modified, and deleted from the Admin functionality

Care Plan Education Status: Open or Closed Action: Select Reminder
Notes: Freeform text to make reminder more specific Date Due: Required  Assigned To: Can assign to patient or any Care Team member If assigned to the patient, it will display on the Take Home Printout Click Done to mark the Reminder as being completed. Click Remove to delete the Reminder Education Items can be added, modified, and deleted from the Admin functionality

Care Plan Education Reminders created here are also displayed on the Care Team and Patient Home Pages Closing Reminders or marking them Done on this page has the same effect. You do not have to do it in both places. Education Items can be added, modified, and deleted from the Admin functionality

Care Plan Take Home Click icon above to view
To Print Care Plan Take Home, save the Care Plan and click Print Popup asks if you want to print a cover letter or not? Print this if patient is not present and you are mailing the document. Take Home Contents Intro Graphs: A1c, Blood Pressure, Weight, BMI for last 12 months Risk Profile Personal Health Goals Reminders assigned to patient Barriers Educational Items assigned to patient The Cover Letter content can be edited in the Admin functionality.

Patient Maintenance To add a patient, click Add Patient in the CDMP Header Required fields are marked by an asterisk (*). They are: First Name, Last Name, Care Team, Date of Birth, Search Name, and Gender Search Name Used in Quick Search on Home Page Most likely Last Name or Last Name + Last 4 SSN Hospital Patient Id (not required, if populated do not change!) Used to match CDMP Patient Record with ICDB Patient Record Click Save to add patient

Patient Maintenance After saving basic patient information additional tabs are displayed No further information is required to add a patient Conditions Specify chronic condition and specific details Diabetes and/or Chronic Kidney Disease at this point Data Sources Admin use only Data Sources Data on this tab is to allow entry for multiple data source ids. Each data source represents an external data source such as ICDB, labs, or pharmacies The identifying information entered here is used to match CDMP patients with the source patients.

Common Data Entry Features
Date Fields – use ‘t’ to set today’s date Save and Add Another – allows you to save the record and quickly add another Save and View List – allows you to save and then simply view vitals – use when only entering one value Recently Added Vital Signs Just for convenience to see what was recently added to help prevent duplicate data

There are three (3) ways to select a value for data entry Use the left most field as characters are typed a quick search will be performed. Select the desired item from the drop down list. Select a value from the Quick Select (drop down). Click Find Labs or Find Medications to perform an advanced search for a specific item Hint: To add a lab to the quick list (drop down), select it in the free form text box and click the green arrow.

Click the edit icon to edit the record associated with it Click the delete icon to delete the record associated with it. No data is ever really deleted. Full audit trail is maintained Who changed what, when, old and new values Edit Delete

Maintain Vitals Required field Only Date Recorded – use ‘t’ !
Should enter at least one field BMI is automatically calculated Ignore Current Vitals – will be disappearing

Maintain Labs Required Fields Lab Lab Date Result Measurement

Maintain Medications Required Fields Medication Prescription Date

Maintain Procedures & Diagnoses
Procedure Required Fields Name Date Diagnosis Required Fields

Change Password To Change your Password Enter your current password
Enter your new password Enter your password a second time to confirm you entered it accurately. New Password must conform to the specifications displayed. Click Save to save your password or Cancel to not change your password

Alert Filtering Use this page to adjust the Alerts that are displayed when Alert Filter is on. This setting is for your personal view and does not affect others. All alerts are always created. This only changes what you see when filter is on. Make the desired changes and click Save to save the changes. Click Cancel to not save your changes.

Status Center Displays new data in the last X days
Where X is entered by the user – this value is retained between uses. To change the number of days Enter a new number of days Click Refresh To view any data, simply click on the entry When to use, returning from vacation and wondering what is new or waiting for a couple patient’s lab results, simply view the data on this page…

Helpful Hints Not sure? Click it! Explore!
Make sure popup blocker is off Press ‘t’ in date fields – the current date will be automatically populated Most drop downs can be modified through the Admin functionality

Start Up Strategy Start using the system
Manual Data Entry There will be issues – we will work through those as quickly as possible Weekly Con Calls on Tuesdays at 2pm Central Revisit in three weeks What can we change / do better If new or modified functionality is desired and it cannot be configured, the functionality will be scheduled for the next release.

CDMP Patient Management Help

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CDMP Patient Management Help

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