Chronic Disease Management:
Frequently Asked Questions

The following questions and answers have been collected based upon common questions asked concerning CDM-QIP.

General

What are the benefits of the CDM-QIP to my practice?

What role does the eHR Viewer play in supporting CDM-QIP?

Is participation in the program more work?

Is there additional work for those who manage physician billing?

Program Specifics

What are the CDM-QIP indicators?

The new CDM-QIP flow sheets appear long. Does everything have to be covered at every visit?

What happens if my patient does not achieve target values for tests?

What chronic conditions does the program currently include?

Will the optimal care flow sheets be kept current with best practice guidelines?

Will practices receive training? What kind of training?

I do not have an EMR. Can I still participate in the program?

I have an EMR - why do I still need to sign up for the eHR Viewer?

Will my data be automatically exported from my EMR?

Where can I get brochures and posters?

Is CDM-QIP different than the CDM collaborative?

General

Q. What are the benefits of the CDM-QIP to my practice?

The focus of the CDM-QIP is to improve the health of patients with chronic conditions in Saskatchewan by encouraging the best practice in chronic disease management.  The program includes:

  • standardized, evidence-based optimal care flow sheets and electronic clinic support tools (e.g., clinical practice guidelines, resources for patients, and clinical decision support tools in the EMR) that will be regularly updated to reflect current best practices;

  • standardized reporting to support quality improvement.  Physicians can generate clinical and administrative reports through eHealth's Micro Strategy reporting and through their EMRs to support optimal chronic disease care; for example, the Recommended Care report will help identify patients due or overdue for follow-up; the Patient Profile provides demographic information, the Observation History provides a snapshot of visit process indicators.  Providers can also view graphical reports of historic chronic disease indicators for specific patients or groups of patients within their clinical setting.

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Q. What role does the eHR Viewer play in supporting CDM-QIP?

The eHR Viewer is a secure, online website that allows authorized health care providers access to personal health information about their patients regardless of where the information originated. The eHR Viewer stores the CDM-QIP observation data that has been collected from the CDM flow sheets and allows generation of reports and the entry of indicator data for paper-based health care providers. Many physicians use the eHR Viewer in conjunction with their EMR.

For more information about the eHR Viewer, please visit the eHealth Saskatchewan website, www.ehealthsask.ca/services/ehrviewer.

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Q. Is participation in the program more work?

Physicians may initially invest some additional time and effort, but should experience increased benefit to both the physician and patient.

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Q. Is there additional work for those who manage physician billing?

Payment is processed automatically in the background without any additional work for those who manage physician billings at your office. Payment is based on submission of process indicator data (sent from physicians’ EMRs or submitted through the eHR Viewer).

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Program Specifics

Q. What are the CDM-QIP indicators?

Please go to Chronic Disease Management – Quality Improvement Program:
Indicators of Best Practice
.

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Q. The new CDM-QIP flow sheets appear long. Does everything have to be covered at every visit?

The flow sheets are designed for optimal CDM care for each medical condition. CDM implies management of a patient’s chronic condition over time, so every item on a flow sheet does not have to be completed at every visit. However, what should be done at each visit and the visit frequency may be different for each patient and may be influenced by factors such as the age of the patient, type and stability of medical conditions, and presence of complications.

Some aspects of care in the flow sheets should be covered at every CDM visit (every 3 – 6 months), while some require only annual testing/screening, and others are included as prompts to address items that may otherwise be forgotten during a busy clinic visit.

Examples of items that should be included in every CDM visit include:

  • assessment of glycemic control and BP for diabetes;

  • assessment of any cardiac symptoms and BP, pulse for CAD; and

  • review of medications and discussions about any side effects/adherence issues.

Screening for depression/anxiety may be required at every visit in some people who are struggling to manage their condition or not achieving targets, and only annually in others.

Examples of items that should be included at least annually (or every 1-2 years) include:

  • screening for diabetic complications by ordering urine ACR;

  • peripheral neuropathy testing;

  • dilated eye exam; and

  • ECG for CAD.

Some of these tests should be done more frequently if the patient has diabetic complications.

Examples of items that are included as prompts for optimal CDM care include:

  • contraception or preconception planning in women with diabetes;

  • diet and physical activity in people with DM and/or CAD; and

  • advanced care planning/health care directive.

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Q. What happens if my patient does not achieve target values for tests?

The CDM-QIP indicators are “process” indicators for chronic disease care. They were selected to represent parameters of optimal chronic disease management for each condition. They are not utilized to assess target numbers or specific test results. For some conditions like diabetes, there is evidence that patients who have regular CDM visits with monitoring of BP, glycemic control (A1C) and lipids will have better outcomes even if specific targets (e.g. LDL<2.0) are not achieved (compared to patients with no regular CDM).

For some CDM-QIP indicators, such as A1C and lipids, lab results are collected because that is how it can be ascertained that the specific parameter of care (monitoring glycemic control and lipids) has been followed. These lab values can be utilized by physicians to run reports on their own patients, but assessing these lab values for ‘meeting targets’ is NOT how financial reimbursement occurs in CDM-QIP.

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Q. What chronic conditions does the program currently include?

The program is being introduced in multiple phases. Phase one has been implemented and includes diabetes (DM) and coronary artery disease (CAD). Phase two will be implemented in January 2016 and will include heart failure (HF) and chronic obstructive pulmonary disease (COPD).

The program will continue to add additional chronic conditions in the future.

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Q. Will the optimal care flow sheets be kept current with best practice guidelines?

The Ministry of Health and the Saskatchewan Medical Association in conjunction with clinical experts will be developing a process for the ongoing monitoring of clinical practice guidelines and best practice indicators. CDM-QIP flow sheets and best practice indicators will be periodically updated to reflect current best practices in Canada.

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Q. Will practices receive training? What kind of training?

Yes. There are a number of training options available.

Both EMR vendors provide on-line help, user guides, videos and WebEx clinic or group-based training sessions. These sessions cover EMR set-up for the CDM-QIP, optimal care flow sheet use and export functionality.

For paper-based physicians, eHR Viewer in-person training is available, if required, as well as training videos. eHealth Saskatchewan will assist in organizing and supporting training delivery for your practice.

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Q. I do not have an EMR. Can I still participate in the program?

Yes, participating providers who do not currently have an EMR enter process indicator data into eHealth Saskatchewan’s eHR Viewer (electronic health record viewer).

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Q. I have an EMR - why do I still need to sign up for the eHR Viewer?

Upon completion of the CDM-QIP visit in your EMR and approval to export, a copy of the process indicator data is submitted to eHealth for display in the eHR Viewer. The data itself remains within the EMR system for EMR-based reporting.

Access to the eHR Viewer allows only authorized providers to view patient records regardless of which provider entered the information.

This link, www.ehealthsask.ca/services/ehrViewer, will provide more information and training videos to support CDM-QIP within the eHR Viewer. Training videos are available on the eHR Viewer Training page under chronic disease management.

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Q. Will my data be automatically exported from my EMR?

Both TELUS Med Access and QHR Accuro have established a process to ensure the provider determines if and when process indicators are exported. No data will be transferred without provider awareness and approval.

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Q. Where can I get brochures and posters?

Brochures and posters can be acquired by contacting eHealth Saskatchewan at 1-306-337-0972, or by emailing cdmqip@ehealthsask.ca.

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Q. Is CDM-QIP different than the CDM collaborative?

Yes. Each collaborative was a time-limited clinical quality improvement project funded by the Health Quality Council to support improved care of people living with some chronic conditions, and the collection and reporting of chronic disease patient information. The collaborative ended March 31, 2010, and the flow sheets are no longer updated and the CDM Toolkit application will be decommissioned. Use of the new CDM-QIP flow sheets is recommended for best practice and will now be required for payment.

CDM-QIP is an on-going program, collaboratively developed and supported by the Ministry of Health, the Saskatchewan Medical Association (SMA) and eHealth Saskatchewan.

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