CDMPPatient Management

Help

Overall Objectives

• Overview

• Using CDMP– 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…

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

– 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

• 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 isassigned 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

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

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.

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

- 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

Patient Management

• Snapshot - view– 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

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

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- 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

Other data fields can be modified here

Edit

Labs

• 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.

Edit

Graph

Delete

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– Name, Date

• Diagnoses– Name, Date

• Admissions– Admission Date, Discharge Date, Reason

Code

Risk Profile

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.

Education Evaluation

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

Education Evaluation History

• View History of patient’s Education Evaluation to see progress

• Click on Date in header to view details

Click Date 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

• 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.

Care Plan Self-Management

• 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.

Care Plan Self-Management

• 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.

•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

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

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.

Care Plan Take Home

Adobe Acrobat Document

• 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

Click icon above to view

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

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

Common Data Entry Features

There are three (3) ways to select a value for data entry1. Use the left most field as characters are typed a quick search will

be performed. Select the desired item from the drop down list.2. Select a value from the Quick Select (drop down).3. 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.

Common Data Entry Features

• 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– Name– Date

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.