4/13/2015
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CareManager User Training
version 3.5_072209
Introduction to CareManager & Diabetes
Module
Class Agenda
What is CareManager?
CareManager Control Panel
Diabetes Dashboard
CareManager Application
Diabetes Identification Tab
Diabetes Treatment Tab
Diabetes Drug Safety Tab
Diabetes Performance Tab
Diabetes Services Due Tab
Patient Communications
Resources & Help
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What is CareManager?
Disease Management software for:
Asthma
Cervical Cancer Screening
Coronary Heart Disease
Diabetes
Drug Safety
Heart Failure
Osteoporosis
Stroke Prevention
Tobacco Cessation
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CareManager has two main components - one
is accessed within the EHR and one via Web
The CareManager Control Panel and Dashboards are
Encounter Forms in the EHR where you can:
View individual patient status
Easily enter data that will flow to the CareManager application
The Web based CareManager application:
Allows you to track a single patient or your entire population of
patients by disease state
Generally you do NOT make entries directly in the CareManager
application. Most data entry is done in the EHR.
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CareManager Control Panel
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CareManager Control Panel – access by
starting Chart Update in EHR
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1.
Care management
summary for the
patient, showing key
treatment indicators
for each module
2.
Color Coded for
triage
3.
Detailed Dashboards
available for all
modules
4.
Screening module
dashboards available
as well
What do the colors mean?
Green = in compliance with recommended care ( i.e.
test is not overdue or the test result is within target)
Yellow = test due shortly or test result is slightly
above target
Red = overdue or a result significantly above target
White = guideline or evidence does not apply, or
insufficient information available
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Diabetes Dashboard
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Using a Dashboard - Diabetes
Start at Control Panel
then select Diabetes
Dashboard
Opens to first of three
tabs
First tab is used to:
Review
history/reminders
Enter historical data
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Using the Diabetes Dashboard – First Tab
Top half for:
• Review
• Reminders
• Status of Stops/Waits
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Using the Diabetes Dashboard – First Tab
Bottom half for entering historical data
1. “Push to record”
2. “Click to include review of parameters in note”
3. Print or Remove Diabetes Management Handout
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Using the Diabetes Dashboard – Intervention (second)
Tab for Labs/Meds
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1.
Used to tell CareManager
to temporarily stop
tracking a specific
parameter such as LDL
for weeks or months
2.
Select Stop (good for up
to 12 months) or Wait for
a specific parameter
3.
Use the drop down menus
to choose a reason or
type in a reason
4.
To stop all interventions
for ALL CareManager
modules, use STOP ALL
on the same form
Using the Diabetes Dashboard – Intervention (Third)
Tab for Exams/Injections
1. Select Stop (good for
up to 12 months) for a
specific exam
2. Use the drop down
menus to choose
reason or type in
reason
3. Close, end update
and sign
Note: If patient
declines due to
allergy, note allergy in
chart. CM will then
display “allergy” in
dashboard
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CareManager Application (Web)
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CareManager Application (Web)
1. Modules purchased
2. Can view by provider,
one or more Locations
of Care or entire
organization
depending on setup
Staff users can be
associated with
specific clinicians if
desired
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Getting More Information, Sorting and Printing
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Diabetes Module - Identification Tab
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Diabetes Identification Tab
This tab is used to review and classify patients five ways:
General cleanup of inactive and deceased patients
Add DX of Diabetes where appropriate
Indicate where DX of diabetes is not appropriate
Indicate care is being monitored elsewhere
Monitoring patients for changes
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Diabetes Identification Tab
TOP SECTION
Patients who may need to be classified as Diabetics and monitored appropriately
Over Age 18 and missing a 250.xx Diagnosis AND one or more of these:
Their highest-ever level of hemoglobin A1c greater than or equal to 6.1 percent.
Their highest-ever level of random serum glucose greater than or equal to 200 mg/dL.
Prescription for a hypoglycemic agent on the medication list.
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Using the Diabetes Identification Tab
First Step: General clean up of inactive, deceased, etc
1.
Open CareManager application
2.
From main menu click and select your provider name
3.
Click the Diabetes button
4.
Click the Identification tab
5.
Print patients that you want to review by selecting the box next their name and then using the PRINT
icon
6.
Make notations on the document of deceased, inactive, and transferred patients
7.
If the patient status is ambiguous - make notation for staff to contact the patient
8.
Flag or give document to staff to correct the status of these patients
9.
Information will update in CareManager application overnight
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Using the Diabetes Identification Tab
Second Step: Review remaining patients to either add DX of
Diabetes or Indicate NO DX appropriate
1. Open CareManager application
2. From main menu, click and select your name (provider)
3. Click the Diabetes button
4. Click the Identification tab
5. Print patient list for review
6. Toggle to the EMR and open each chart for review
7. Decide whether you will add a DX or note a reason for no DX.
Use CareManager Encounter Form – Control Panel for data entry
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To ADD Diagnosis of Diabetes using
EHR
1. Start Chart Update –
use CareManager
Encounter Type.
2. From the
CareManager
Control Panel,
select the DeIdentify tab.
3. Select Patient HAS
a diagnosis of
Diabetes – click
Enroll patient and
add the diagnosis
to the problem list.
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To ADD Diagnosis of Diabetes
4. Select the correct
DX code using the
two choices provided
or add other types
by selecting one of
the blue buttons.
5. Close the
CareManager
Control Panel.
6. End and sign the
update. This
information will
update in
CareManager
overnight.
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To note NO DX of Diabetes
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1.
Start Chart Update – use
CareManager Encounter
Type.
2.
From the CareManager
Control Panel, select the DeIdentify tab.
3.
Select Patient does NOT
have diagnosis of Diabetes
- not the comment that
appears in upper right hand
side of box
4.
Close the CareManager
Control Panel.
5.
End and sign the update. This
information will update in
CareManager overnight and
patient will be moved to the
de-identified lower table in the
CareManager application.
If Patient’s status is inactive, deceased
or in hospice
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1.
Begin a chart update.
2.
Open the CareManager
Control Panel.
3.
Click Gen DeID.
4.
Complete the form by
selecting the Patient is not
mine or Patient in Hospice
reason and close and sign
update.
5.
For inactive or deceased
patients, you also must
ensure patient is inactivated
or deceased or assigned to
another clinician in EMR so
CareManager will update
overnight. ONLY hospice
patients are moved to the deidentified table.
Ongoing Monitoring of Patients
Monitoring:
1. Open CareManager application
2. From main menu, click and select your name (provider)
3. Click the Diabetes button
4. Click the Identification tab
5. Check the top table for new entries or changes to existing
patients
6. Check the lower table for patients at high risk for developing
diabetes
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Treatment Tab – CareManager Application
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Color Review
Green = in compliance with
recommended care (i.e. test
is not overdue or the test
result is within target)
Yellow = test due shortly or
test result is slightly above
target
Red = overdue or a result
significantly above target
White = guideline or
evidence does not apply, or
insufficient information
available
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What do the symbols mean?
Active Stop = Do not pursue treatment at this time
.
Expired Stop = Expiration date for stop is over. Pursue.
Active Wait = Waiting for patient action, result or treatment.
Expired Wait = Expiration date for wait is over. Pursue.
Multiple Provider Support = Multiple Providers involved.
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Using the Treatment Tab
This tab is used by physicians to monitor compliance
After monitoring, user may add interventions or update
information using the CareManager Control Panel in the EMR
Users may also generate Patient Communications from this tab –
covered later in this class
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Drug Safety Tab
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Using the Drug Safety Tab
This tab is used by physicians to monitor drug therapy
and possible contraindications for diabetic patients
being managed by CareManager
Two areas: Metformin & TZDs and relevant lab values
for each
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Using the Drug Safety Tab
1. Open CareManager application.
2. From main menu, click and select your name (provider).
3. Click the Diabetes button.
4. Click the Drug Safety tab.
5. For all patients with elevated or overdue parameters – Select
ALL and Print.
6. Using the list, open the chart in EHR and review.
7. Determine if the patient is still on the medication. If no, remove
the drug from the Medication List using the EMR.
8. Identify patients needing follow up based on monitoring criteria.
Goal is to help you quickly identify patients who need intervention
of some kind.
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Performance Feedback Tab
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Performance Feedback Tab
- At target for LDL
- At target for blood pressure
- At target for A1c
- With poor control of A1c
- On an antiplatelet agent
- With renal protection
- With current monofilament exam
- With current dilated retinal exam
- Who have received pneumovax
- Whose BMI is >30 or unknown
- Whose tobacco status is current or unknown.
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Using the Performance Tab
This tab is used by physicians to track performance monthly
Updated monthly only
1.
Open CareManager
2.
From main menu, click and select provider being reviewed
3.
Click the Diabetes button
4.
Ensure you are on Performance Feedback tab
5.
Review Information and print if desired
Print by using Press CTRL + P.
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Services Due Tab
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Using the Services Due Tab
This tab is used by staff to prioritize patient outreach
Uses the same grid of colors and symbols:
Clock = wait has been applied to the column value
Stop Sign = time-based stop on value or patient
People = multiple providers are managing this patient’s diabetes
File Cabinet = letters or correspondence added to this patient’s chart
Use Patient Communication tools for contact (i.e. letters or phone notes)
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Strategies for Working the Services Due
Tab
This tab is a “safety net” for patients who have not had
recent contact with their PCP and are overdue on labs
or have high out of range values
Focus on patients who do not have appointments
scheduled in the next 30 days
Focus on patients with multiple red boxes
First contact attempt might be letter or secure
message with lab order for overdue labs attached
Second contact – repeat letter and lab order
If no response contact patient by phone
Advise PCP if no response
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Patient Communications
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Patient Communications
This feature can be used to
send templated letters to a
single patient or group of
patients from within many
CareManager modules
Patient messages can be
printed or send by Secure
Messaging based on
products installed and
patient communication
preferences
Can also be used to
document phone calls or
you may do that within the
EHR
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Patient Communications
All documents created are imported to the patient
chart
Use Cases:
Send an individual, personal letter or email to a patient who is due for a
particular lab test.
Document a phone call made to an individual patient to explain a lab
result.
Create a customized message that is designed for a group of people
who need to come in for a particular test, and personalize the message
for each patient in the group by using symbols that CareManager
replaces with patient-specific EHR data.
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Patient Communications Workflow
1. Select one or more patients by clicking one or more
boxes in the Select column.
Note: Only one patient may be selected for Phone Notes
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Patient Communications Workflow
2. Click the Patient Communication
icon to open the
Patient Communication Form. Some letter templates
may have a “blue” status indicating late but not out of
range
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Patient Communications Workflow - Letter
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1.
In the Message Type list, click an
option (such as Custom Message
or Phone Note). The summary
text associated with the selected
Message Type appears in the
Summary field and in summary
line of EHR document.
2.
If you want to print the
intervention, click a printer name
in the Printer list.
3.
If you want to add a predefined
letter head to the letter, click an
option in the Letter Head list.
4.
If you want to change the return
address, click an option in the
Return Address list.
5.
If you want to Preview message –
click Preview.
Patient Communications Workflow - Preview
1. Close after preview
2. Click Send on right
side of screen
3. Document will appear
in patient chart
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Patient Communications Workflow – Phone
Note
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1.
In the Message Type list, click
Phone Note. The summary text
associated with the selected
Message Type appears in the
Summary field and in summary
line of EHR document
2.
If you want to print the
intervention, click a printer name
in the Printer list
3.
For phone notes, use no
letterhead default
4.
“Signed” box should be checked
or left unchecked based on clinic
policy
5.
Enter note in text box
6.
Click Save when complete
Patient Communications Workflow - Audit
Click
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Patient Communications – Intervention
Tracking
1.
2.
3.
4.
5.
6.
7.
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To add intervention tracking
while creating a letter or
message, check the
Intervention Tracking box
Choose the parameter to be
tracked (i.e. LDL)
Choose the type( i.e. Stop or
Wait)
Enter Reason for Stop or Wait
Enter duration of Stop or Wait
Preview
Click Send and letter will be
sent and copied to chart and
intervention will update
overnight in CareManager
Resources and Help
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Resources & Help are actually helpful!
Problem #1: You are in the Treatment tab and
cannot figure out why a patient’s Statin status is
WHITE
Solution: Click on the
at the top right of the page
and the Table of Contents for the HELP will open for
you.
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Resources & Help are actually helpful!
1. Select Treatment
Tab from the
Contents
2. Select White from
the list on right
You will be taken to a
table explaining the
“White” parameters
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Resources & Help are actually helpful!
Problem #2: You are in the Diabetes module and
want to know what ICD codes are used to place a
patient in this module
Solution: Click on the
at the top right of the page and the
Diabetes Table of Contents will open for you
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Resources & Help are actually helpful!
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•
Select Index Tab at
top of Table of
Contents
•
Click on the letter “I”
and then ICD codes
•
You will be taken to a
list of all the ICD and
CPT codes that are
used in the Diabetes
module
Resources & Help are actually helpful!
Problem #3: You are in the Diabetes module and
would like to check the latest ADA guidelines
Solution: Select the Resources Tab in the
CareManager module
1. You will see a list of the latest guidelines
2. Click on the area you would like to review
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CareManager Introduction
& Diabetes Module
Questions?
Thanks for attending!
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