2 Overall Objectives Overview Using CDMP Support Process Questions Find a PatientAlerts/RemindersPatient ManagementData EntrySupport ProcessQuestions
3 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 DBWeighs behavioral info with clinical info for a“whole patient” picture
4 Login Username and password are case-sensitive. Independent from other systemsSystem will timeout automatically after 30 minutes
6 CDMP - General Layout Header – menu – always there Footer – contact support – always thereTabs and command optionsPatient Menu
7 Header Menu Home – Care Team Home Page Status Center – Identify New DataSearch – Search for patientsHelp – This fileJVN – Joslin Vision Network ReportingStudies – Study ManagerAdd Patient – Manually add a patientShould not have to do this.User Pref – Change password & Alert FilteringAdmin – only certain peopleLogout – Logout…User’s home page is configurable. Options presently include the following:Care Team Home Page (default)Search PageStudy ManagerStudy Manager SearchJVN
8 CDMP - SortingDefault sort not displayed – usually based on first columnMove mouse pointer over column headersPointer / Cursor will change to handColumn name will be underlinedClick on column headers to sortSubsequent clicks of same column header will reverse the sort orderSorting may take some time on large lists
9 CDMP Security & Auditing Full Role-based embedded security system – ability to integrate with LDAPFull Audit TrailWho changed what and whenStores old value and new valueUsage Tracking
10 Page ChangesIf 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 changesClick Cancel to stay on current pageYou can then save your changes. This doesn’t happen automatically.
11 Finding Patients Quick Search Patient Appointments On the home pageSelected by defaultJust type last name (or partial)Patient AppointmentsSearch page – header menuREMEMBER: Clicking a patient name alwaystakes you to that patient’s home page.
12 Care Team Home Page Side Bar Quickly search onLast Name + Last 4 SSNCursor defaults to this fieldAlways lists today’s appointmentsAssuming they were in AHLTA the previous nightRemember: Click on patient name to access patient record
13 Patient SearchTo 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 fieldIf you don’t find the patient you are looking for, broaden the search byremoving criteria from the searchTo clear the search criteria, click the Clear Criteria button
14 Patient SearchAssign 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 pageOn 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
15 Alerts Overview 3 Kinds Measurement, Timing, & Behavioral 2 Levels Red & YellowAutomatically created on a nightly basisAlert level is automatically adjusted or closed as new data arrivesAlerts will only be created once every 90 days after being closed.Alert thresholds are adjustable for individual patientsMeasurement AlertsLook 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 AlertTiming AlertsBased on whether or not a specific event has occurred. Ex. Annual Eye Exam or Foot Exam, A1c test every 6 monthsBehavioral AlertsBased on patient responses to survey
16 Care Team AlertsView New – View Alerts < 24 hours old or over weekendAll Open – View all open alerts – red and yellowAll Red – View only red alertsClose – Select Alerts to close by selecting the checkboxes on the leftSelect the checkbox in the header to select all alerts currently displayedPrint – Prints the list of alerts in a popupFilter On/Off – Apply your personal filter – controlled through User PreferencesMore on the FilterIf the Filter is onA message will be displayed “Warning Alert Filtering is On: All Alerts May Not be Displayed On This Page”The On Radio Button will be selectedIf the Filter is OffNo warning message will be displayedThe Off Radio Button will be selected
17 Care Team AlertsStatus – always open here (can be closed at patient level)Level – Yellow or Red – click to view Alert specifics and to close individual alertPatient Name – name of patient – click to access patient recordAlert – Name of AlertOrigin Date and Days Old – How old is the alert?Count – Number of times the alert has been created – higher number indicates more serious issue
18 Care Team Alerts Paging – see top right Displays range of Alerts currently being displayedDisplays total number of AlertsLinks to view previous or next pagesSortingClick column header to sort list within the pageSee above: clicking the Origin Date will sort the 50 records currently displayed, not the whole list.
19 Patient Alerts Only Alerts for the Specific Patient – see header Current – Open AlertsHistory – Open and Closed AlertsEdit Alert Threshold – Allows modification of alert thresholds for the specific patient
20 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 levelAllows user to adjust Alert threshold for the specific patientResultsDisplays the specific results used to generate the Alert
21 View & Close Alert Follow-Up Actions Required to Close Alert Multiple Actions can be enteredThese 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.
22 Add Follow-Up Action Enter notes if desired Click Save to just add Action ItemClick Save and Close Alert to add Action Item and Close Alert
23 Close Multiple AlertsWhen 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 easilySelect Action from drop down. Add Notes if desiredAdd – just adds Action Item to Alerts displayed at bottomAdd and Close Alert – Adds Action Items and Closes AlertsClose Alerts (bottom right) – Close all Alerts after an Action Item has been added.Click + to expand the alert and see explanation, threshold, and details
24 Reminders Reminders can be generated in a number of ways: Automatically based on AlertsAs part of Care Planning processManuallyCan be assigned to any provider in the system or the patientIf Due Date is past due, displays RedOn Care Team Home Page – user sees all reminders for all patients assigned to Care Team the user belongs toOn Patient Home Page – user sees all reminders for patientNumber of Days: Select how far out to view RemindersClose – select reminders on left with checkbox and click ClosePrint – prints list of reminders
25 Patient Reminders Only displays Reminders for specific patient History – displays all open and closed RemindersAdd New – allows user to add a new reminderTo close RemindersSelect specific Reminders with checkbox on leftOr select all Reminders with checkbox in headerClick CloseName of person closing the Reminders and the date/time are recorded and displayed on the History Tab.
26 Patient Management Snapshot - view Clinical Data Risk ProfileClinical DataCare Plan –create, edit, view, take homeData EntryReports
27 Snapshot HeaderPrint View – Display a printer-friendly popup of the Snapshot for printingDemographics – displaysGenderAgeEthnicityTaking Aspirin – as determined by medications from ICDBDiabetes Onset – not availableDiabetes Type – not availableAllergies
28 Snapshot Status Data from CDMP Clicking on any blue field shows details- Foot and Eye ExamReport date of exam if documentedSelf-Reported through BAT SurveyJVN – Joslin Vision Network Eye ExamNAT – Nutrition Assessment SurveyRisk ProfileAutomatically generated basedon clinical data- Red, Yellow, Green Levels- Click View to see detailsBAT Score – Survey scoring detailsDate last takenSummary – See high-level detailsDetail – See actual Q&AScoring – used to give provider an idea ofwhere patient needs helpBAT Score is based on replies to patient taking the Behavioral Assessment SurveyScoring DetailsSmoking – Red if patient smokes, Yellow if patient used to smoke, Green if patient does smokePsycho-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.
29 Snapshot Displays most recent Education Evaluation To see more details and historyFrom Patient Menu select Education,then Evaluation History- Simple alphabetical listing of patient diagnoses
30 Snapshot Labs and Vital Signs Displays most recent labs and vitals signsDisplays date and value of labDisplays simple trending indicatorHas the value moved up/down/not changedClick on lab or vitals in blue to see in graphGraph only displays last 24 months of dataTo 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.
31 Snapshot Medications Displays Medications for last 365 days Displays the following fieldsNamePrescription Date or Last Fill DateNumber of Refills Left
32 Patient Demographics Edit Information extracted from ICDB ICDB is system of recordChanges in ICDB will overwrite data hereData extracted includes:NameSearch IdGenderSSNHospital Patient Id – for syncing purposes onlyDate of BirthAllergiesAddressHome Phone NumberEthnicityIf user wants to change patient demographics it should be done in AHLTA.Other data fields can be modified here
33 LabsEditDeleteGraphAll Lab Results are displayed in chronological orderClick Column Header Names to SortNotes Field: Will contain lab abnormal indicatorLab Names will be the same as in ICDBCan only edit or delete results entered in CDMP. Cannot alter data imported from ICDB.
34 VitalsDisplays graph of Blood Pressure and Weight underneath actual numbers
35 MedicationsPrescription Date, Medication Name, Dosage, Frequency and Last Filled information imported from ICDB.Future functionality allows for marking medications as Current
36 Other Clinical Data Procedures Diagnoses Admissions Name, Date Admission Date, Discharge Date, Reason Code
37 Risk ProfileRisk 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.
38 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 materialClick on the Globe Icon to view the materialClick Print to print the displayClick Close to close the popup
39 Education EvaluationEvaluate the current level of patient’s knowledge in the 10 ADA self-management categoriesSelect Type of Evaluation: Pre-Evaluation, Post Evaluation or N/ASelect the Evaluation Date – defaults to todayIf 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 TopicsDisease Process: Diabetes disease process and treatment options test Can describe diabetes as a disease process and treatment optionsNutrition: Incorporating appropriate nutrition management Knows about and uses nutrition management ideasPhysical: Incorporating physical activity into lifestyle Knows how to work physical activity into lifestyleMedications: Using medications effectively Understands why medication(s) should be taken consistentlyMonitoring: 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 medicationsAcute Complications: Preventing, detecting, and treating acute complications Knows how to prevent detect and treat hypoglycemia and treat hypoglycemia and hyperglycemiaChronic Complications: Preventing (through risk reduction behavior), detecting, and treating chronic complications Understands good self-management now can prevent chronic complications laterGoal Setting: Goal setting to promote health and problem solving for daily living Knows about setting physical and lifestyle goals to control diabetesPsychoSocial: Integrating psychosocial adjustments into daily life Understands how attitude and willingness to try new things helps daily healthPregnancy: Promoting preconception care, pregnancy, and gestational diabetes management Understands the need for pre-pregnancy care and close management during pregnancy and after delivery
40 Education EvaluationOptionally, select Areas to Improve from the drop or click Edit Areas to select multiple from a popup
41 Education Evaluation History Click Date to view DetailsView History of patient’s Education Evaluation to see progressClick on Date in header to view details
42 Survey History Lists all Surveys taken by the patient Specific surveys are broken out to display scoringPAID Problem Areas in DiabetesBehavioral Assessment SurveyDSCP Diabetes Self-Care ProfileDisplay custom reportAll SurveysClick on Date Taken to view Questions and Answers
43 Care PlanPrint 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 planTo Close the Care Plan and start a new one, click Close Care Plan and SaveClick Print to print the Care Plan Take HomeRisk Profile displayed here for convenience – Click Hide to regain screen real estate3 tabs: Self-Management, Education, and Reminders
44 Care Plan Self-Management Nothing is required.Enter Patient’s Readiness to ChangeSelect Self-Management Assessments from drop down.These are generic. Once selected add notes to make them more specificMultiple Assessments can be selectedIf 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.
45 Care Plan Self-Management BarriersAdd Barriers by selecting them from the drop downAdd Notes to make them more specificClick Remove to delete item from Care PlanInstructed InAdd items that you instructed the patient inAdd Notes to make more specificAdd Completed dateEach item here displays on the Care Plan Take Home.
46 Care Plan Self-Management Each item here displays on the Care Plan Take Home.Care Provider GoalsYour goals for the patient.Short Term GoalsIn the patient’s own words (not yours), what are their goals?Long Term GoalsIn the patient’s own words (not yours), what are their goalsEach item here displays on the Care Plan Take Home.
47 Care Plan EducationSearch for Education Items to Assign to the PatientKeyword Search search Item name and DescriptionMedia Filter use this if you only want to find certain types of materialEx. Books, Pamphlet, WebsiteClick Search to search for specific itemsClick View All to view list of all education itemsIf available, click the Globe icon to view and print the materialEducation Items can be added, modified, and deleted from the Admin functionality
48 Care Plan Education Status: Open or Closed Action: Select Reminder Notes: Freeform text to make reminder more specificDate Due: Required Assigned To: Can assign to patient or any Care Team memberIf assigned to the patient, it will display on the Take Home PrintoutClick Done to mark the Reminder as being completed.Click Remove to delete the ReminderEducation Items can be added, modified, and deleted from the Admin functionality
49 Care Plan EducationReminders created here are also displayed on the Care Team and Patient Home PagesClosing 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
50 Care Plan Take Home Click icon above to view To Print Care Plan Take Home, save the Care Plan and click PrintPopup 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 ContentsIntroGraphs: A1c, Blood Pressure, Weight, BMI for last 12 monthsRisk ProfilePersonal Health GoalsReminders assigned to patientBarriersEducational Items assigned to patientThe Cover Letter content can be edited in the Admin functionality.
51 Patient MaintenanceTo add a patient, click Add Patient in the CDMP HeaderRequired fields are marked by an asterisk (*). They are:First Name, Last Name, Care Team, Date of Birth, Search Name, and GenderSearch NameUsed in Quick Search on Home PageMost likely Last Name or Last Name + Last 4 SSNHospital Patient Id (not required, if populated do not change!)Used to match CDMP Patient Record with ICDB Patient RecordClick Save to add patient
52 Patient MaintenanceAfter saving basic patient information additional tabs are displayedNo further information is required to add a patientConditionsSpecify chronic condition and specific detailsDiabetes and/or Chronic Kidney Disease at this pointData SourcesAdmin use onlyData SourcesData 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 pharmaciesThe identifying information entered here is used to match CDMP patients with the source patients.
53 Common Data Entry Features Date Fields – use ‘t’ to set today’s dateSave and Add Another – allows you to save the record and quickly add anotherSave and View List – allows you to save and then simply view vitals – use when only entering one valueRecently Added Vital SignsJust for convenience to see what was recently added to help prevent duplicate data
54 Common Data Entry Features There are three (3) ways to select a value for data entryUse 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 itemHint: To add a lab to the quick list (drop down), select it in the free form text box and click the green arrow.
55 Common Data Entry Features Click the edit icon to edit the record associated with itClick the delete icon to delete the record associated with it.No data is ever really deleted.Full audit trail is maintainedWho changed what, when, old and new valuesEditDelete
56 Maintain Vitals Required field Only Date Recorded – use ‘t’ ! Should enter at least one fieldBMI is automatically calculatedIgnore Current Vitals – will be disappearing
60 Change Password To Change your Password Enter your current password Enter your new passwordEnter 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
61 Alert FilteringUse 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.
62 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 daysEnter a new number of daysClick RefreshTo view any data, simply click on the entryWhen 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…
63 Helpful Hints Not sure? Click it! Explore! Make sure popup blocker is offPress ‘t’ in date fields – the current date will be automatically populatedMost drop downs can be modified through the Admin functionality
64 Start Up Strategy Start using the system Manual Data EntryThere will be issues – we will work through those as quickly as possibleWeekly Con Calls on Tuesdays at 2pm CentralRevisit in three weeksWhat can we change / do betterIf new or modified functionality is desired and it cannot be configured, the functionality will be scheduled for the next release.