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User Manual for General Practitioners and other Health Care

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1. GP Assessment approved 15 Jul 2015 View Unseen Notes Figure 87 Approve TCA from Overview Page If you are a Care Plan Creator you are approving the TCA on behalf of the Primary Care Provider Copyright 2015 Precedence Health Care Pty Ltd 83 cdmNet User Manual Version 3 80 If you are a Primary Care Provider and nominated as a Care Plan Creator for the patient s Primary Care Provider as well as a member of the same organisation you are approving the TCA in your own right Team Care Arrangement Approval Are you sure you want to approve this Team Care Arrangement Referrals for Individual Allied Health Services Please enter the number of services provided by each Allied Health provider on this care plan Year 2015 Allied Health Provider Individual Services Dietitian Brian Butterfield 1 Exercise Physiologist Activity Place 4 Podiatrist Heal Toe pia 0 Electronically sign the Allied Health Referral forms Cancel Approve Figure 88 TCA Approval As a PCP or CPC you need to determine how many services the Allied Health Providers can provide the patient per year As per Medicare rules up to 5 services may be provided in total You may select the following year to which the services may be applied Allied Health Referral Forms are only generated if you allocate services to the Allied Health Providers If the patient is of Aboriginal or Torres Strait Islander descent cdmNet p
2. Preventive Health and Infectious Diseases Elizabeth LOCHLEY Born 24 Nov 1995 19 years Gender Female Medicare 4291 68686 1 IHI None Recorded 5 Babylon Street Melbourne University Victoria 3052 Turn Off Patient Notifications Overview Contacts Health Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education Care Plan Conditions Asthma Hepatitis C Valid from 15 Jul 2015 Change Next review 15 Jan 2016 Change GPMP 721 Awaiting your approval Approve GPMP Rebuild Care Plan Show tasks assigned to everyone Main Objective Add Goal Task Responsible How Often Last Next Comment Determine Patient main objective Achieve optimal health Ongoing Ongoing Target Identified goals achieved General Add Goal Goal Responsible How Often Last Next Comment Clear understanding of Comprehensive 7 fil Every year Due Jul 2015 Add Task education and review conditions Target Patient has received education Add Task Minimise asthma symptoms Target Condition optimally managed Figure 24 Planning Page Using the filter at the top you can change the Planning page fo display Copyright 2015 Precedence Health Care Pty Ltd 33 cdmNet User Manual Version 3 80 e Tasks assigned to you e Tasks assigned to your organisations e Tasks assigned to the Primary Care Provider e Tasks assigned to
3. 2015 Precedence Health Care Pty Ltd 64 cdmNet User Manual Version 3 80 e Edit the Contact Details e Add members to the organisation see Chapter 7 5 1 Adding Members e Remove members from the organisation e Accept or reject pending organisation members see Chapter 7 5 1 Adding Members e View the Practice Principals of the organisation this is only relevant for providers participating in the Diabetes Care Project if the information shown is incorrect you should contact Support e View addresses of members on a Google Map by clicking the address e Add Preferred Providers to an organisation Preferred Providers are only available in organisations containing a Primary Care Provider e Remove Preferred Providers where applicable e Add Care Plan Creators to an organisation and e Remove Care Plan Creators 7 5 1 Adding Members to an Organisation To add a member to an organisation click Add Member to the right of the Organisation Members section heading Display providers whose speciality is Any Speciality Display providers from Western Australia in city suburb postcode Search Register a New Provider Name Speciality Location E M Aitch GP Omega Health Perth 1 Generation Street Gaius Baltar GP Perth 1 Generation Street Mr Emmett Brown Nurse Practice Registered Enrolled Perth 1 Generation Street Dr John Zoidberg GP Perth 1 Future Avenue Close Figure 61 Adding a Member
4. Please select from the following resources e Quick Start Guide for General Practice Setup e Frequently Asked Questions e Setup and User Guides e Training Videos e Downloads e Privacy Terms of Use and Agreements Copyright 2011 2014 Precedence Health Care Pty Ltd Privacy Contact Us Patients Partners Research News Training Support Q For support please use one of the following options Email Use our web form to send us an email request Phone 1300 CDMNET 1300 236 638 from Monday to Friday 8 30 am 7 00 pm AEST EDST Fax 03 9614 2650 Should cdmNet Support need to access your machine remotely you may be asked to download our secure remote support software When instructed you can download either e Windows cdmNet remote support software e Mac cdmNet remote support software cdmNet phone support will talk you through using this software when required insafehands Figure 64 Help Page On this page you can e View other manuals guides e View the Frequently Asked Questions e View Training videos e Download cdmNet Desktop Software and Installation Guides and e View the Privacy Terms of Use and Agreements pages Copyright 2015 Precedence Health Care Pty Ltd 69 cdmNet User Manual Version 3 80 9 Creating Care Plans As a Primary Care Provider or a Care Plan Creator you can create care plans for patients Creating a care plan for a patient is a two step process Yo
5. As a PCP or CPC it is up to you to review the GPMP when the review date approaches On the patient list you can select the filter patients awaiting action from you to see patients who may be due for a GPMP Review Copyright 2015 Precedence Health Care Pty Ltd 85 cdmNet User Manual Version 3 80 yi et Precedence Health Care Patients Reports Surveys Resources Preferences Help Log Out Chronic Disease Management Network Logged in as E M Aitch GP Patients You are currently involved in the care of the following patients A indicates that you are the primary care provider Show all patients where you are the primary care provider Include hidden patients N Search Status Clinical Metrics Self Monitoring Metrics Create Health Record Download Patient List Patient Demographics Name Date of Birth Referring GP Last Care Plan Next Review Lynda Day 26 Feb 1970 E M Aitch Health record creation awaiting your action e Ellen Ripley 19 Jul 1979 E M Aitch Care team incomplete 15 Jul 2015 15 Jan 2016 Hide Patient Ms Liz Asher 22 Jan 1979 E M Aitch GPMP Review overdue 15 Jul 2015 Hide Patient e Dean Learner 17 Nov 1981 E M Aitch GPMP Review overdue 15 Jul 2015 Hide Patient Lucien Sanchez 8 Feb 1960 E M Aitch GPMP Review overdue 15 Jul 2015 Hide Patient e Mr Andy Dufresne 3 Feb 1994 E M Aitch 15 Jul 2015 1 Aug 2015 Hide Patient e Miss Maria Kurenai 22 Nov 1989 E M Aitch
6. Documents Assessments Reports Progress Notes Education GPMP awaiting your approval ESSO aa No due or overdue tasks No unsigned documents No unseen notes Figure 74 Approve GPMP action on Overview Page Copyright 2015 Precedence Health Care Pty Ltd 75 cdmNet User Manual Version 3 80 re you sure you want to approve this GP Management Plan Create and distribute a Team Care Arrangement The next annual cycle of care is planned to occur on E 15 Apr 2016 The next review is planned to occur on E 15 Jan 2016 Cancel Continue Figure 75 GP Management Plan Approval Before approving your GPMP you can set the dates for the next review and annual cycle of care if the patient has Diabetess You may get a yellow warning box indicating tasks on the care that do not have providers If is recommended but not required that all tasks have assigned providers You should ensure that the dates of any GPMPs TCAs reviews and ACoCs you conduct using cdmNet are in accordance with Medicare rules for frequency of the relevant MBS items In some cases cdmNet warns you if it notices that you have set two of these items to occur closer together than Medicare guidelines suggest but you are responsible for making the ultimate clinical decision as to what is most appropriate for the care of your patients When you approve a care plan or a review of a care plan cdmNet gives you the option to notify the care team of the
7. Limit to times As required Ongoing Reminders Active Reminder to book an appointment 30 day s before appointment due Delete Task Cancel Update Task Figure 28 Editing a Task If you only want to change the display name of a goal or task clicking the name of the goal or task on the Planning section allows you to begin editing the goal or task inline rather than in a separate screen Press the Return key or click outside the box to save your changes To cancel editing and discard your changes press the Escape key Clear understandingc 7 bi Target Patient has received education Figure 29 Editing a Goal Inline Task Figure 30 Editing a Task Inline To delete a goal or task click the rubbish bin icon in the appropriate goal or task cell or click the pencil icon to display the Edit screen and then click the Delete button Tasks require responsible parties assigned to them To select a responsible party for a task click the downward triangle in the Responsible column for the appropriate task Copyright 2015 Precedence Health Care Pty Ltd 37 cdmNet User Manual Version 3 80 Here cdmNet displays a menu to allow you to select a responsible party The options displayed in the menu depend on who is already assigned for the particular task Where appropriate from this menu you can directly assign the task to the patient or the Primary Care Provider Usually the GP From this menu you can also assign a ta
8. e Are available for the desired date and time and e Ideally have already downloaded and installed the WebEx Meeting Centre client Where participants do not have a microphone you will need to organise a separate phone call with the participant s Schedule Telehealth Conference You are about to schedule a telehealth conference session between selected members of the patient s care team These telehealth services are provided at no cost to cdmNet users courtesy of Cisco Australia Please read the instructions for scheduling and conducting a telehealth conference Prior to proceeding make sure the participants e are available to attend at the scheduled time and e have the appropriate equipment webcam microphone and reliable Internet Fill in the details in the box below to schedule the teleconference indicates a required field Date E 15 Jul 2015 11 00 AM Invitees Dr Julia Heller GP Gabriel Celeste Patient Diane Beeaties Diabetes Educator Brian Butterfield Dietitian Arthur Dent Dentist Dental Practitioner Dental Surgeon Archie Foote Podiatrist Notes i Cancel Schedule Conference Figure 81 Scheduling a Telehealth Conference By default all care team members are listed for invitation to the conference and you must untick any invitee who you do not wish to receive the emailed notice of the conference Click the calendar icon to change the time and date of the conference Once you are happy w
9. members TCA Review agreements appear as a thumbs up with a green tick above it A Primary Care Provider or Care Plan Creator can click the Update Services action to edit the number of Allied Health Services provisionally allocated while a TCA Is in progress Copyright 2015 Precedence Health Care Pty Ltd 45 cCdmNet User Manual Version 3 80 4 2 7 Documents Page The Documents page has the following sections e Drafts e Current Care Plan e Approved Care Plans e Annual Cycles of Care e Supporting Documents and e Uploaded Documents Depending on the status of the patient s record not all of these sections are shown all the time If the patient does not have a care plan only the Uploaded Documents section appears If you wish to upload a document that you feel is relevant to a patient clicking Upload Document allows you to select a document to upload onto a patient s health record Note that all other providers associated with a patient can also view any document you upload You can also control who can see an uploaded document When uploading a document cdmNet pre selects for the document to be visible to Everyone Select Specific people and untick anybody who should not see the uploaded document You can edit this list later if you want by clicking the Edit action next to the document name in the Uploaded Documents section Upload Document Precedence Health Care provides this document upload ser
10. 15 Jul 2015 5 Aug 2018 Hide Patient e Ms Flora Spread 12 Nov 1981 E M Aitch 15 Jul 2015 21 Jul 2015 Hide Patient Figure 91 Patient List Showing GPMP Review Overdue The Commence GPMP Review link becomes available on a patient s record one month before the review date that was set when the GPMP was approved Edward ELRIC Born 12 Jan 1989 26 years Gender Male Medicare None Recorded IHi None Recorded 2 Metal Street Melbourne Victoria 3056 Turn Off Patient Notifications Overview Contacts Health Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education Care Plan Conditions Chronic Kidney Disease Diabetes Mellitus Type Diabetes Mellitus Type II Valid from 29 Jul 2015 Change Next review 21 Aug 2015 Change Hepatitis B Next ACoC 29 Apr 2016 Change GPMP 721 Review approaching _Commence GPMP Review Create New GPMP Annual Cycle of Care Rebuild Care Plan Figure 92 GPMP Review Approaching This is a good point to review the patient s progress while making modifications to the care plan if appropriate by entering new tasks and goals onto the Planning page or clicking Rebuild Care Plan to get cdmNet to generate any proposed changes to the care plan for you Clicking Commence GPMP Review initiates the review process displaying a screen where you can quickly review whether all tasks in the care plan were completed as well as recording any measurements that are
11. About how often did you feel that everything is an effort 9 About how often did you feel so sad that nothing could cheer you up 10 About how often did you feel worthless Total Score 0 Cancel Save Assessment Figure 49 Creating Assessment Fill in the assessment accordingly ideally making sure you answer all questions You can save an incomplete assessment by clicking Save Assessment and come back to it later When you save the assessment it goes into the In Progress Assessments section Click Edit next to the assessment name in the In Progress Assessments section if you want to continue it change or add to your previous answers YOU can view a PDF version of an assessment whether it is in progress or approved by clicking the assessment name Some components of assessments may already be pre filled with data from the patient s health record which depending on the assessment you can edit at your discretion When you are happy with the assessment click Approve Copyright 2015 Precedence Health Care Pty Ltd 5 cdmNet User Manual Version 3 80 in the Actions column of the In Progress Assessments section You cannot approve incomplete assessments Certain assessments can be associated with specific MBS item numbers When this applies cdmNet prompts you to select an appropriate MBS item Alternatively you can choose Not claiming through Medicare Approve Assessment You may be able to claim a rebate f
12. Documents Assessments Reports Progress Notes Education Show Detailed Timeline 15 July 2015 at 9 11 AM Brian Butterfield Dietitian wrote Delete Note shall speak to Manuel about my diet plan with any luck it will be successful 15 July 2015 at 9 09 AM Diane Beeaties Diabetes Educator wrote Delete Note My appointment with Manuel had to be rescheduled to next week 15 July 2015 at 9 06 AM Archie Foote Podiatrist wrote Delete Note Manuel s feet are generally in good condition 15 July 2015 Dr Julia Heller approved the GPMP entered by Dr Beverly Crusher Figure 51 Progress Notes Page Clicking Show Detailed Timeline displays the full list of notes and notifications including GPMP approvals the details of TCA agreements from care team members and so on When someone adds new progress notes including as a result of Uploading a document or scheduling a telehealth conference the green navigation bar indicates that new notes have been added 2 Overview Contacts Health Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education Figure 52 Navigation Bar with Progress Notes Notification Copyright 2015 Precedence Health Care Pty Ltd 54 cdmNet User Manual Version 3 80 You will also find a notification mark next to the name of the patient on your patient list when new progress notes have been added On the patient list select th
13. Julian Bashir GP Gamma Health Brisbane 2 Odyssey Avenue Gamma Health GP z Brisbane 2 Odyssey Avenue Dr Owen Harper GP Gamma Health Brisbane 2 Odyssey Avenue Other Cancel Update Responsible Party Figure 35 Edit Task Select the Provider radio button to assign a provider or click the Other radio button to assign a service provider Tasks also require a set frequency You can set the frequency when you add tasks and then alter them by clicking their frequency in the How Often column You can also set a fixed frequency days weeks months and years and limit the repetitions by ticking the tick box cdmNet calculates the number of times the repetitions occur when you set the fixed frequency and tick the box Change Frequency Goal Manage body weight Task Counselling and review Fixed repeat every 6 Months Limit to 4 times As required Ongoing Cancel Change Figure 36 Edit Frequency of Task 4 2 5 2 Creating and Editing Appointments You can change the next date without setting a specific appointment for when a task needs to be undertaken Under the Next column click the downward triangle beside the due date and the options of changing the next date and adding Copyright 2015 Precedence Health Care Pty Ltd 4 cdmNet User Manual Version 3 80 appointments or adding measurements for measurement related tasks in the Biomedical section are displayed Biomedical Add Goal Res
14. Monitoring and e Risk Calculations ealth Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education Observations All Available Measurements Add Measurements Recent Measurements meeen ze ure 4 Jan 2014 6 Jan 2014 8 Jan 2014 11 Feb 2014 5 Jan 2015 ee Blood Pressure mmHg 123 45 104 72 123 45 History Hip Circumference cm 80 80 History Waist Circumference cm 70 70 History Weight kg 96 68 96 History Height cm 162 History BMI kg m 37 26 37 History Test Results Add Measurements Measurement Latest Target te ee Actions 9 Nov 2013 1 Dec 2013 4 Jan 2014 1 Jul 2014 5 Jul 2014 Serum Creatinine umol L 1 62 1 62 History HbA1c mmol mol 49 7 82 5 49 7 History Microalbumin Spot Albumin Creatinine Ratio 2 2 History mg mmol Proteinuria mg 24 hours 15 15 History Blood Glucose Level mmol L 6 2 6 2 History Estimated GFR eGFR 90 90 History Lipids Add Measurements Measurement Latest Target SE yscnomtaalns Actions 1 Oct 2013 14 Nov 2013 28 Nov 2013 2 Dec 2013 HDL mmol L 5 5 History LDL mmol L 1 37 1 37 History Total Cholesterol mmol L 1 1 History Triglycerides mmol L 1 4 History Self Monitoring These measurements are not monitored by the care team Add Measurements Recent Measurements Measurement Latest Target Actions Blood P
15. Plan and making the appropriate changes 9 2 Modifying Care Plans The Planning and Care Team Pages become available once you have created a care plan for the patient Copyright 2015 Precedence Health Care Pty Ltd 73 cdmNet User Manual Version 3 80 General Add Goal Goal Responsible How Often Comment Clear understanding of conditions Comprehensive Every year Due Jul 2015 Add Task education and review Add Task Target Patient has received education Minimise asthma symptoms Target Condition optimally managed Develop asthma action plan Target Patient is able to detect any deterioration in asthma and respond appropriately Add Task Use asthma Patient Ongoing Ongoing action plan Figure 71 Planning Page Care Plan Modification You should review the care plan that cdmNet has generated to ensure that it meets the level of care that you believe is appropriate for the patient It is up to your discretion to modify the care plan according to the patient s needs see Chapter 4 2 5 1 Adding Editing and Deleting Goals and Tasks In addition to generating a proposed care plan cdmNet automatically assigns providers to tasks and adds them to the patient s care team based on your Preferred Providers preferences see Chapter 7 6 Preferred Providers You can review the care team members by visiting the Care Team page see Figure 41 You can remove particular care team members if you see fit to do so but note that
16. any member that you remove may leave tasks unassigned so you should return to the Planning page and review the changes after you have done so If you created a non MBS HMR Only or Team Referral care plan that you would like to convert into a GPMP GPMP Review you can do so after the care plan has been approved Simply click Convert Care Plan to GPMP GPMP Review at the right Select the appropriate care plan option you wish to convert to when prompted For a Team Referral or HMR Only care plan you may also want to click Rebuild Care Plan and select one or more medical conditions for the care plan to cover prior to converting to a GPMP GPMP Review Reimi SAIONJI Born 16 Nov 1970 44 years Gender Female Medicare None Recorded IHI None Recorded 2 Calnus Street Melbourne Victoria 3000 Turn Off Patient Notifications Schedule Telehealth Conference Overview Contacts Health Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education Care Plan Conditions Chronic Kidney Disease Coronary Heart Disease Hepatitis B Valid from 15 Jul 2015 Change Next review 15 Jan 2016 Change Care Plan Care plan approved on 15 Jul 2015 Create New Care Plan Convert Care Plan to GPMP GPMP Review Rebuild Care Plan Figure 72 Convert Care Plan to GPMP GPMP Review Copyright 2015 Precedence Health Care Pty Ltd 74 cdmNet User Manual Version 3 80 Please note that converting a non MBS car
17. approval If you tick Create and distribute a Team Care Arrangement you may be prompted to allocate the number of Allied Health Services for the patient s care plan The numbers you enter are not final and you can edit them prior to approving the TCA on the Care Team page by clicking Update Services see Chapter 4 2 6 Care Team Page While Annual Cycles of Care apply for other conditions cdmNet only supports Annual Cycles of Care for Diabetes See Chapter 9 8 Annual Cycles of Care Copyright 2015 Precedence Health Care Pty Ltd 76 cdmNet User Manual Version 3 80 GP Management Plan Approval Along with approving this GP Management Plan you are creating and distributing a Team Care Arrangement Referrals for Individual Allied Health Services Please enter the number of services provided by each Allied Health provider on this care plan Year 2015 gt Allied Health Provider Individual Services Dietitian Brian Butterfield o Podiatrist Heal Toe pia 0 Back Approve Figure 76 Allocating Allied Health Services While Distributing TCA 9 3 1 What Happens Next If you ticked Create and distribute a Team Care Arrangement or subsequently click Create and Distribute TCA cdmNet notifies the care team members that you have proposed a TCA for the patient f you are the Primary Care Provider or a Care Plan Creator the patient then appears as below on your patient list On your patient list you
18. between different systems Account No linked accounts exist Figure 59 Preferences Page The Preferences shows eight sections e Your Account Details Copyright 2015 Precedence Health Care Pty Ltd 6 cdmNet User Manual Version 3 80 e Your Provider Details e Your Payment Details e Your Contact Details e The Organisations to which you belong e Pending Organisations this appears when you have requested to join an organisation but not yet been accepted e Your Preferred Providers for PCPs only e Your Care Plan Creators for PCPs only and e Your Linked Accounts for PCPs only 7 1 Account Details Your Account Details relate to you as a user of cdmNet You can e Change your password e Enable or disable notifications from cdmNeft e Change your Time Zone Time Zones within Australia only e Edit the Automatic Assignment of providers to care plans and e Allow or not allow Test Patients see Chapter 4 1 1 Test Patients 7 2 Provider Details Your Provider Details relate to you as a provider Clicking Edit Provider Details enables you to e Change your Provider Number e Change your HPI l and e Change whether you as a provider work privately 7 3 Payment Details These details are used to provide automated payments to care team members participating in the Diabetes Care Project program You need only fill in your details if you are participating in this program 7 4 Contact Details Your
19. indicates a required field cdmNet Account e Username scottle Password Confirm Password Registration e Terms of Use agree to the Terms of Use Back Finish Figure 4 Username and Password Set Up Copyright 2015 Precedence Health Care Pty Ltd 12 cdmNet User Manual Version 3 80 You must agree to the Terms of Use before continuing You can view these terms in a new window by clicking Terms of Use After you click Continue cdmNet sends you a welcome message Copyright 2015 Precedence Health Care Pty Ltd 13 cdmNet User Manual Version 3 80 3 Logging In Once you have logged in at the top right corner of the page there are seven links They are e Patients e Reports Only available if you are a PCP or CPC e Surveys e Resources e Preferences e Help and e Log Out Met Precedence Health Care Patients Reports Surveys Resources Preferences Help Log Out Chronic Disease Management Network Logged in as Julian Bashir GP Figure 5 Seven Links in the Top Right Corner When you log in for the first time cdmNet directs you to the Preferences section It is recommended that you set up your Preferences at this point see Chapter 7 Preferences Each section and its extending functions will be explained in the order listed Surveys may appear here from time to time depending on various factors such as your geographical location speciality and participation in res
20. list all of the Medicare Benefits Scheme MBS items you completed in cdmNet during July 2015 Show report for This month July 201 5 MM Include items completed by you l M GP Management Plan 721 Total number of items 2 Patient Date of Birth Medicare Number Valid From Approval Date Primary Care Provider Actions Michael Bodger 9 Mar 1985 3334 32342 2 15 Jul 2015 15 Jul 2015 Dr Beverly Crusher View Document Yuki Nagato 11 Nov 2011 None Recorded 15 Jul 2015 15 Jul 2015 Dr Beverly Crusher View Document GP Management Plan Review 732 Total number of items 0 Patient Date of Birth Medicare Number Approval Date Primary Care Provider There are no documents for the selected month Team Care Arrangement 723 Total number of items 1 Patient Date of Birth Medicare Number Approval Date Primary Care Provider Actions Michael Bodger 9 Mar 1985 3334 32342 2 15 Jul 2015 Dr Beverly Crusher View Document Team Care Arrangement Review 732 Total number of items 0 Patient Date of Birth Medicare Number Approval Date Primary Care Provider Actions There are no documents for the selected month Annual Cycle of Care Total number of items 0 Patient Date of Birth Medicare Number Approval Date Primary Care Provider Actions There are no documents for the selected month Referral form for Home Medicines Review 900 Total number of items 1 Patient Date of Birth Medicare Number Approval Date Primary Care Provider A
21. needed Copyright 2015 Precedence Health Care Pty Ltd 86 cdmNet User Manual Version 3 80 Commence Review re you sure you want to commence a GP Management Plan Review The following tasks and measurements are due but have not yet been recorded Please record any information you have in the tables below You can make further changes and review the care plan before final approval Other Care Provider Due Tasks All Completed Goal and Task Responsible Due Completed Avoid foot complications Comprehensive foot Podiatrist E Jul 2015 f examination Clear understanding of conditions Comprehensive Diabetes Educator Jul 2015 education and review Manage alcohol consumption Education Diabetes Educator Dietitian Nurse Practice Registered Enrolled Health E Jul 2015 Promotion Officer or Health Educator Due Measurements Measurement Target Due Value HbA1c lt 7 E Jul 2015 Cancel J Proceed with Review Figure 93 Commence GPMP Review Once the GPMP review has been initiated it is up to the PCP or CPC to approve if When approving a document if you are a Care Plan Creator then you are approving it on behalf of the Primary Care Provider However if you are another Primary Care Provider nominated as a Care Plan Creator for the patient s Primary Care Provider as well as being a member of the same organisation then you are approving the document in your own right You m
22. same time for all entries zj gt Australia West Measurement BELG Time Value Note HDL mmol e g 29 8 1983 M f mmol L Australia West LDL mmol E e g 29 8 1983 M mmol L Australia West Total Cholesterol mmol L e g 29 8 1983 a mmovL Australia West ET e g 29 8 1983 A gt mmol L Triglycerides mmol L C o Australia West Cancel Add Measurements Figure 20 An Example of an Adding New Measurements to Categories Page 4 2 4 2 History The History screen contains more history of measurement values than is displayed on the main Measurements Page Clicking History in the Actions column of a measurement category also allows you to enter measurement values of the particular measurement type you selected Edwina PEPELU Miss Born 4 Mar 1986 29 years Gender Female Medicare 3334 32342 2 IHI None Recorded 1 Helova Street Essendon Victoria 3040 Turn Off Patient Notifications History Observations From 2 Nov 2013 To 5 Jan 2015 Filter Matching measurements from 2 Nov 2013 to 5 Jan 2015 Recent Measurements Measurement Actions 2 Nov 2013 8 Jan 2014 11 Nov 2014 5 Jan 2015 120 70 fil 123 45 Add ee 120 70 mmHg Return to Measurements Summary 11 Nov 2014 12 00 AM AEDT Standing Entered by Dr Beverly Crusher Blood Pressure mmHg Figure 21 Add New History Measurement In the above example of weight history you can see three historical measurem
23. your speciality you will have an opportunity to add more organisations on a later screen The following screen is displayed if cdmNet finds a matching organisation However for security and privacy reasons cdmNet only adds you as a pending member of the organisation you will need to ask someone within the organisation to accept your request to join the organisation see Chapter 7 5 1 Adding Members to an Organisation Provider Registration Potential Organisation Matches The following organisations who are already listed with cdmNet have details similar to your organisation Please review the list below and should you find your organisation listed select the corresponding entry If none of the entries in the list matches your organisation click Organisation not listed Beta Health 1 Original Street Sydney New South Wales 2000 Organisation not listed Back Continue Figure 3 Organisation Match The next screen confirms the details you have entered so far Depending on your speciality you can click Add Another Organisation to enter details of any additional organisations you belong to Once you are happy with the confirmed details and click Continue cdmNet prompts you to set up a username and password By default cdmNet generates a username for you based on your details You can of course change your username if desired Remember your username and password for future reference Provider Registration Account Details
24. 5 None Recorded 15 Jul 2015 Dr Beverly Crusher GP Dr Beverly Crusher View Assessment Health Assessment Standard 703 Total number of items 0 Patient Date of Birth Medicare Number Approval Date Approved By Primary Care Provider Actions There are no assessments for the selected month Health Assessment Long 705 Total number of items 0 Patient Date of Birth Medicare Number Approval Date Approved By Primary Care Provider There are no assessments for the selected month Health Assessment Prolonged 707 Total number of items 1 Patient Date of Birth Medicare Number Approval Date Approved By Primary Care Provider Actions Edith Rubble 4 Apr 1934 None Recorded 15 Jul 2015 Dr Beverly Crusher GP Dr Beverly Crusher View Assessment Return to Reports Page Figure 57 Reports Page for Assessments All providers can click the MBS Items Report Assessments link The reports collated on this page relate to the various MBS items generated upon approval of assessments with associated MBS item You can see the assessments that pertain to a particular month by selecting a month in the Show report for menu If you are a Primary Care Provider you can select to view assessments with associated MBS items approved by you or for any of your patients Note that some assessments can be created and approved with an associated MBS item by a provider on your patient s care team or even by the patient If you are a Care Plan Creato
25. A box cdmNet still notifies your care team that a GPMP exists and prompts them to log in and review it You can create and distribute a Team Care Arrangement at any later time by clicking Create and Distribute TCA when you see fit Once you have approved a GP Management Plan you can view and download a PDF file corresponding to MBS Item 721 from the Documents page You can also view and download the current Care Plan and Patient Summary Copyright 2015 Precedence Health Care Pty Ltd 78 cdmNet User Manual Version 3 80 Overview Contacts Health Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education Show Current and Uploaded Documents Only M Uploaded Documents Upload Document File Description Uploaded By Upload Date Actions There are no uploaded documents Patient Documents Document Actions Patient Summary View Download Current Care Plan Document Actions Care Plan View Download Drafts Document Approval Agreement Date Actions Team Care Arrangement 723 View Download Approved Care Plans Document Approval Agreement Date Actions GP Management Plan 721 15 Jul 2015 View Download Annual Cycles of Care Document Approval Agreement Date Actions There are no current annual cycle of care documents Supporting Documents Document Approval Agreement Date Actions There are no supporting documents Figure 79 Documents Pa
26. BEARS eo Pena rn te net en ree eee ee eT 19 Health Record C 1 Il Oth aaetcoe ve tneunpatserresaiseu ste resena ne ieuanaenuemenemsteschueaouescbieduneaarnenet 2 FEER PS ANE MOR C0 EEN E S 22 FORE AEN ENE SR B FLE AE ES 22 New Patient Health Record Overview PAGE ccccesccesecesccesecesecesceeeces 23 New Patient Health Record Contacts Page essessesssessreesrrerrrerreserereseees 24 A Patient s cdmNet Number and CONG sasisendesssscosavsedcnsiauncderseucdedanasewsevectnens 25 Change a Patient s Primary Care Provider PAG eC ccccscscesconscesseesenes 25 Patient Health Summary PAGE cccccceccccsseccceeccceeecceeneceeeecceasecccauecesaeceeaeess 27 Mmedsure ments Summary OS oases sistein Enr ENEN EEE 29 A Tooltip Displaying Measurement Value Information ccceecceeceeeeeeees 30 An Example of an Adding New Measurements to Categories Page 31 Add New History Measurement ccccccescceccusccesceccusccuseusccuseeessusceuseeseeacss 31 PCO TS SUF VIS See ops acer scnen E E 32 All Available Measurements isicensnacancwasarsnusecoaenasasuecunmedencresuusiesbsedenatatcdeamucencyds 32 Planning PAQE os ccssacasecnssasmonnesseeinensscssannesensatsienneseeeunsussuasaneesensatearenyseoouetsscasas 33 PONG Gi ING ON ERE nesta dee des na ec tenant ed cco eaters cde Sean enncesnasadeatenteesd 35 AR WG EN EET ES E E E A A AA A 36 EAG TO OO e E A E E EE AE A ES DEERE 36 EAO T a E E A AA 37 POROA SOTT e E N E A E N EE 37 EIRG G T
27. Contact Details relate to your methods of contact You can e Edit or change your Name e Edit or change your Preferred Method of Contact e Add edit or delete Phone Numbers Copyright 2015 Precedence Health Care Pty Ltd 62 cdmNet User Manual Version 3 80 e Add edit or delete addresses and e Add edit or delete Email addresses A contact detail with a green dot next to it means that it is the primary instance of that type of contact detail Please note that cdmNet only sends some notifications by fax If you select fax as your preferred method of contact other notifications will be sent by email or SMS if you have these details recorded 7 5 Organisations The list of organisations shows those you belong to as a provider You can register a new organisation fo which you will automatically belong once you have completed the registration process by clicking Register a New Organisation and filling in the appropriate details in the boxes provided You can view the details of an organisation in your list by clicking its name or clicking Edit The Preferences page of an organisation is very similar to your own Preferences page Copyright 2015 Precedence Health Care Pty Ltd 63 cdmNet User Manual Version 3 80 You are viewing the details of Omega Health Specialities GP Nurse Practice Registered Enrolled Address 1 Generation Street Perth Western Australia 6000 General Status Active Notifications Enable
28. Contacts e Health Summary e Measurements e Documents e Assessments e Reports e Progress Notes and e Education Overview Contacts Health Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education Figure 12 Patient Navigation Bar When viewing the health record for a patient who does have a care plan there are two additional sections in the navigation bar They are e Planning and e Care Team Clicking a patient s name in your patient list to view their health record automatically opens the Contacts section If a patient does not yet have a care plan Primary Care Providers and Care Plan Creators can click Create Care Plan fo initiate one see Chapter 9 Creating Care Plans Copyright 2015 Precedence Health Care Pty Ltd 22 cdmNet User Manual Version 3 80 4 2 1 Overview Page Met Precedence Health Care Patients Reports Surveys Resources Preferences Help Log Out Chronic Disease Management Network Logged in as Dr Beverly Crusher GP Elizabeth LOCHLEY Born 24 Nov 1995 19 years Gender Female Medicare 4291 686 1 IHI None Recorded 5 Babylon Street Melbourne University Victoria 3052 Turn Off Patient Notifications Overview Contacts Health Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education Create Care Plan or Referral No due or overdue tasks No unsig
29. Net Desktop Guide available at cdm net au help guides 3 Set up your cdmNet username and password on your desktop to allow automatic login see cdmNet Desktop Guide available at cdm net au help guides 4 Setup your provider preferences in cdmNet see Chapter 7 Preferences and 5 Accept the Service Agreements for GPs to agree to pay any cdmNet fees see cdm net au serviceagreementterms 2 1 Register with cdmNet To register with cdmNet go to cdm net au register You first need to provide your general details as a provider Fill in your details in the boxes provided A red dot indicates that some fields are mandatory A valid method of contact must be provided so that cdmNet can send you notifications when necessary Copyright 2015 Precedence Health Care Pty Ltd 10 cdmNet User Manual Version 3 80 et Precedence Health Care Chronic Disease Management Network Provider Registration To register for a provider account in cdmNet fill in the form below Please provide as many details as possible Note that this is for health care provider registration only The Precedence Health Care site includes information on patient use of cdmNet You can find out more about cdmNet by visiting the Precedence Health Care site All information you enter will be collected and used in accordance with our Terms of Use amp Privacy policies indicates a required field Provider Name Title First Name She
30. OE M ene ere ene E E E E 37 Edit Responsible Party MENU cccceecceeceesceessceceesccesseeceusccnseeeceusseuseeeeeucss 38 RES INTO ONS CO IY oars ES eee ere EE 38 Assign to a CdmNet Provider u u u dsssseeeseveeeveeeeeeve ene eee nens een seven seen e ens en sener 39 Assign to an Other Provider Service Provider 1 1 1 1 W W M W ssseeeeeveeereeee seere ereeer 40 Copyright 2015 Precedence Health Care Pty Ltd 4 Figure 35 Figure 36 Figure 37 Figure 38 Figure 39 Figure 40 Figure 41 Figure 42 Figure 43 Figure 44 Figure 45 Figure 46 Figure 47 Figure 48 Figure 49 Figure 50 Figure 51 Figure 52 Figure 53 Figure 54 Figure 55 Figure 56 Figure 57 Figure 58 Figure 59 Figure 60 Figure 61 Figure 62 Figure 63 Figure 64 Figure 65 Figure 66 Figure 67 Figure 68 Figure 69 cdmNet User Manual Version 3 80 GIN NOS E S P SE SEE suetaa testis idl E E REE SENDE REE RERESEE 4 Edir FFEGUCTICY Ol TOSK arisen iie nE E O E elser 4 CAaGnge Nex Dale MOR Ui ic xscdi tiers adic tilissabetun Masdicew eae T RA 42 cERGONJE NEX DOO mene meee tenner T ere ee ences Pe 42 RSS OOO ME MER seara ts tebe ere dadler SR he be el are hr rar esse here 42 Responsible Party Modified G Gu uvssseeeensereereenvere ennen een senere enn ennen ener een ennen nens 43 CORE SC aa SE Ea EE EE aces 44 Care Team Page with Care Team Agreements cccccccscsessccsscensceseees 45 Documents Page o
31. Patient Notifications Overview Contacts Health Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education In Progress Assessments Create Assessment Assessment Created By Date Created There are no assessments in progress Completed Assessments Assessment Approved By Date Approved MBS Item There are no completed assessments Uploaded Assessments Upload Assessment File Description Uploaded By Date Uploaded There are no uploaded assessments Figure 48 Assessments Page Click Create Assessment to begin an assessment Jonathan CREEK Born 1 May 1986 29 years Gender Male Medicare 3362 06541 1 IHI None Recorded 1 Windamere Close SOUTH MELBOURNE Victoria 3205 Turn Off Patient Notifications Create Assessment Kessler Psychological Distress Scale K10 This simple checklist aims to measure how the patient has been affected by depression and anxiety in the past four weeks None ofthe A little of the Some of the Most of the All of the time time time time time 1 About how often did you feel tired out for no good reason 2 About how often did you feel nervous 3 About how often did you feel so nervous that nothing could calm you down 4 About how often did you feel hopeless 5 About how often did you feel restless or fidgety 6 About how often did you feel so restless you could not sit still 7 About how often did you feel depressed 8
32. Stroke It is also possible to create customised care plans for any chronic disease or complex condition An additional option to Generate a standard cdmNet care plan for the selected conditions may appear if a patient is participating in certain programs Copyright 2015 Precedence Health Care Pty Ltd 8 cdmNet User Manual Version 3 80 1 1 Your Role As a registered provider you could have one or more of the following three roles depending on your association with a particular patient 1 A Primary Care Provider or PCP this is usually GPs and Nurse Practitioners 2 A Care Plan Creator or CPC this can be any speciality and 3 Care Team Member this can be any speciality If you are a Primary Care Provider or a Care Plan Creator you have more ability to modify patient information and care plans If you are a Care Team Member you may only be able to view information about patients and edit limited information about a patient s care plan Copyright 2015 Precedence Health Care Pty Ltd 9 cdmNet User Manual Version 3 80 2 How to Get Started To get started with cdmNet there are just a few simple steps to follow 1 Register with cdmNet see Chapter 2 1 Register with cdmNe t If you are a GP Practice Nurse Practice Manager or otherwise working in a Primary Care Practice there are four additional steps 2 Install cdmNet Desktop onto your computer desktop if not already installed see cdm
33. Version 3 80 cdmfet User Manual How to register install and use cdmNet recedence ealthcaLce AUSTRALIA Australian Government cdmNet Help Desk Precedence Health Care Pty Ltd 1300 cdmNet Level 6 520 Collins Street 1300 236638 Melbourne Vic 3000 T 61 3 9023 0800 info precedencehealthcare com www porecedencehealthcare com Copyright 2015 Precedence Health Care Pty Ltd cdmNet User Manual Version 3 80 Table of Contents 1 An MNNOdUCTON rr ker EiS 7 IOUR G e E E T E E ERE ERE ee 9 PONG E aA E A E A 10 2 1 Register with CAOIMNE 1 ccccecccsscccsscccnsccenscseescecesceeeccescecesceesecseuecseescseeseeeseeenss 10 e ae 9 EEE EAE E EE E EAEE en AA EENE E EE AE ee 14 T PED e A esac sananeranccteas 15 4 1 Creating a Patient s Health ReECOor d essescsesseseresecrsrrsesrerersseesereseessreserssersseeseess 20 aIr TEP N aa E E E E E E 21 ARNE AF OROCO aaae E A ER re 22 AT Overview Pagese idene aee a a aaen 23 Aa COACE a A E E EAE EEN 24 A E ORM Yo SE a E ere 27 4 2 4 Measurements PAQE esesessssressesrserresseserserressessesresssressesresessessesressserserereseseess 29 Aroa PONNE eiae E E E E E EEA 33 ALO Ge LS T OS a E E AE AT O OE BEER 44 Ad DO OM A gg amp 9 a A E E E ene eee eee 46 4 2 8 Assessments Page c0ccovsscscsssccnsscscsssconsscsccuscoussasccuscosssasccatsosssesccarcosrsescoesces 5l ALF RODO POGO Serseri EENE EN E EE E A A EE 53 Be PrO eS NOIS FOGO aaner E E E s
34. aim Host Role from the Participant menu in the WebEx menu bar and enter the host key when prompted This starts the conference To start sharing your video click the camera icon it turns green To start a voice conference click the headphones icon or select Integrated Voice Conference from the Audio menu and click Start Conference The microphone icon to the right of the window should be grey not red When you have finished the telehealth conference click End Meeting at the bottom of the window or from the File menu For more information about WebEx including tips for troubleshooting connection problems or audio video difficulties visit http webex com au howto 9 5 Care Team TCA Agreements Once a Team Care Arrangement has been created and cdmNet has notified the care team members it is up to them fo agree fo it A minimum of two agreements Is required in order to continue to the next stage Edward ELRIC Born 15 Jul 1935 80 years Gender Male Medicare None Recorded IHI None Recorded 1 Full Street Perth Western Australia 4000 Turn Off Patient Notifications Schedule Telehealth Conference Overview Contacts Health Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education A indicates that care plan editing is allowed Update Services Name Location Contacts Agreement Actions Brian Butterfield Dietitian Butterfield Enterprises Melbourne 1 Care Way Wo
35. atient has received education Comprehensive A Ogawa AS required AS required Reading material Add Task education and Nurse provided review Practice Registered Enrolled Figure 40 Responsible Party Modified Any modifications made to a care plan will also be indicated by a red Modified mark on the top right of the page The PCP or CPC can accept the modifications by clicking Accept All Changes at their discretion Copyright 2015 Precedence Health Care Pty Ltd 43 cdmNet User Manual Version 3 80 4 2 6 Care Team Page The Care Team page only appears in a patient s navigation bar if a care plan has been created see Chapter 9 Creating Care Plans This page contains the list of the Care Team members individual providers and organisations that are involved in a particular patient s care plan Amy WONG Born 4 Apr 2004 11 years Gender Female Medicare 7165 11463 1 IHI None Recorded 9 New Way Melbourne Victoria 3000 Turn Off Patient Notifications Overview Contacts Health Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education A indicates that care plan editing is allowed Name Location Contacts Agreement Actions Brian Butterfield Dietitian Butterfield Enterprises Melbourne 1 Care Way Work provider example com Remove from Care Team Mobile 03 4999 999 999 Allow Plan Editing Hazel Glass Optometrist iKansee Melbourne 2 Vi
36. ay need to adjust the review date and ACOoC in order to comply with the Medicare rules GP Management Plan Review Approval Are you sure you want to approve this review of the GP Management Plan as currently updated Create and distribute a review of the Team Care Arrangement The next review is planned to occur on 29 Jan 2016 The next annual cycle of care is planned to occur on 15 Apr 2016 Cancel Approve Figure 94 GPMP Review Approval When the GPMP Review has been approved the GP Management Plan Review form 732 becomes available in the Approved Care Plans section of the patient s Documents Page If you have previously prepared a Team Care Arrangement for the patient and you tick Create and distribute a review of the Team Care Arrangement when Copyright 2015 Precedence Health Care Pty Ltd 87 cdmNet User Manual Version 3 80 approving the GPMP review cdmNet notifies the care team that a TCA Review has commenced and needs their agreement 9 7 Reviewing TCAs As with TCAs the TCA Review also needs a minimum of two agreements from care team members in order to continue This time however cdmNet shows the agreements with another grey hand with thumbs up and a green tick Ellen RIPLEY Born 19 Jul 1979 35 years Gender Unknown Medicare None Recorded IHI None Recorded 1 Weyland Close Melbourne Victoria 8069 Turn Off Patient Notifications Schedule Telehealth Conference Overview C
37. c Dr Katherine Pulaski Blood Pressure Cholesterol A Selvaria Bles Hide Patient A Michael Bodger 9 Mar 1985 No Dr Beverly Crusher 7916065 Hide Patient A Manuel Calavera 16 Nov 1960 No Dr Julia Heller Hide Patient Gabriel Celeste 1 Jan 2001 No Dr Julia Heller Sign Documents 4 Hide Patient hd Sheldon Cooper 1 May 1986 No Dr Beverly Crusher Hide Patient e Yuki Nagato 11 Nov 2011 No Dr Beverly Crusher Sign Documents 4 Hide Patient e A Eleanor Rigby 12 Sep 2005 Yes Dr Beverly Crusher Hide Patient e Amy Wong 4 Apr 2004 No Dr Beverly Crusher Hide Patient e Eric Banks 26 Nov 1981 No Dr Beverly Crusher 7 120 80 Jet Black 31 Mar 1974 No Dr Katherine Pulaski Hide Patient e Charlie Brown 1 Nov 2001 No Dr Beverly Crusher e Edward Elric 15 Jul 1935 No Dr Beverly Crusher Hide Patient e Elizabeth Lochley 24 Nov 1995 No Dr Beverly Crusher Hide Patient e Edith Rubble 4 Apr 1934 No Dr Beverly Crusher Hide Patient e Reimi Saionji 16 Nov 1970 No Dr Beverly Crusher 1 Sign Documents Hide Patient e Faye Valentine 4 Mar 1986 No Dr Beverly Crusher 9 130 100 9 Hide Patient Figure 7 Clinical Metrics View of Patient List The columns in the Clinical Metrics view include Attention the attention symbol appears if any new complications have developed within the last 6 months or if any of the clinical metrics have worsened since the patient s care plan was created Smoker whether the patient is known
38. carvonie snantaae ous depateaeuaeienceu sone EEE EE EER 85 Dh FOV AG IGAG r a A E E TE 88 Po AE CIS OO a E E E E E E 88 1O ROSS ash aca a EE A A 90 T PG PONET cet ccc EA EO O 91 Copyright 2015 Precedence Health Care Pty Ltd 3 cdmNet User Manual Version 3 80 Table of Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Figure 14 Figure 15 Figure 16 Figure 17 Figure 18 Figure 19 Figure 20 Figure 21 Figure 22 Figure 23 Figure 24 Figure 25 Figure 26 Figure 27 Figure 28 Figure 29 Figure 30 Figure 31 Figure 32 Figure 33 Figure 34 Registering Provider Details dacassscnsannddcntasnesiog sac dasasensianddae since cieasncdedeuwsaaasnedtucds 1 Register Organisation or Practice M dssseeeeeeerereveee eee eee sene ene ene es eee ee sene en sense nse se 1 FOS OI secretes roca cdenietiencivins o0 eanse peasboainesaneSenscisndsies aneatesunsesoordaeierctnaceess 12 Username and Password Set UP 2 eee ceccceccseccscceeceseceseceeccseceeceeeceeeeeceeeceees 12 Seven LINKS IN TNE Top Right COMNel cccceesseesccnscesscccscccessenscousceuseeescseesss 14 PCH Sal LIST Tay CUS VIS ereire E E E 15 Clinical Metrics View of Patient List scccascxsssntesnssansdavsnonsubcosavencawbadvenacusaveseatwbaoss 17 Self Monitoring Metrics View of Patient LIST cc ccsseccsosscccnesccenesccesescnonece 18 re TE
39. cation and review Assign To Recommended Specialities sf Cancel Assign Figure 32 Assign to a Speciality Selecting Provider allows you to search for a provider within cdmNet to assign to the task Copyright 2015 Precedence Health Care Pty Ltd 38 cdmNet User Manual Version 3 80 Assign to a cdmNet Provider Select a provider to assign to this task Task Maintain healthy diet Comprehensive education and review Speciality Recommended Specialities Provider name or Organisation City Suburb Postcode State Victoria T Display preferred providers only Search Register a New Provider Name Speciality Location Brian Butterfield Dietitian Butterfield Enterprises Melbourne 1 Care Way Marjorie Dawes Dietitian Fat Fighters Melbourne 1 Dust Close Cancel Assign Figure 33 Assign to a cdmNet Provider Ticking the Display preferred providers only box restricts the search results to display the PCP s preferred providers only From here you can also register a new provider on their behalf if you cannot find them in cdmNet To do this click Register a New Provider and fill in the appropriate details in the boxes provided see Figure 62 As long as you are able to provide accurate contact information the new provider should receive a notification with a username and temporary password with which they can use to log into cdmNet in future If there is a menu in the Speciality col
40. ccept Reject Preferred Providers Add Preferred Provider Add Preferred Providers from Postcode Remove All Preferred Providers Name Speciality Location Contacts Actions Mr Emmett Brown Nurse Practice Registered Enrolled 1 Generation Street Perth Western Australia 6000 Work ebrown example com Remove Mobile 0481 512 3456 Work 12 3456 Fax 1234 56 789 Marjorie Dawes Dietitian Fat Fighters Work provider example com Remove 1 Dust Close Melbourne Victoria 3000 Mobile 03 4999 999 999 Care Plan Creators Add Care Plan Creator Name Speciality Location Contacts Actions Alyssa Ogawa Nurse Practice Registered Enrolled Omega Health Mobile 08 4815 162 342 Remove 1 Generation Street Perth Western Australia 6000 Fax 08 4815 162 342 Dr John Zoidberg GP 1 Future Avenue Perth Western Australia 6000 Home zoidy example com Remove Figure 60 Organisation Preferences Page From an organisation s preferences page you can e Edit the General details including whether tasks are assigned only to the organisation individual providers within the organisation or to the organisation or to individual providers within the organisation e Edit the Organisation Details including whether the organisation is a private practice e Edit the Payment Details you need only fill these in if the organisation is involved in the care of a patient who is participating in the Diabetes Care Project Copyright
41. ccept it This could happen when two practice nurses from the same practice independently upload health records for the same patient for example 4 1 1 Test Patients By default the Is the patient a test patient box is ticked Leaving this box ticked means that the patient is marked as a Test Patient This means that notifications will not be sent to the care team linked to the patient Marking patients as test patients is recommended for testing and training purposes particularly if you are new to cdmNeft Once you have marked a patient as a test patient you cannot turn them back into a normal patient However you can always delete that test patient and upload the patient record onto cdmNet again if you created a test patient in error for a real patient You can turn off the test patient option in your Preferences see Chapter 7 1 Account Details If you marked a patient as a Test Patient cdmNet indicates this on the patient s health record with the following red bar with the option of deleting the patient Copyright 2015 Precedence Health Care Pty Ltd 21 cdmNet User Manual Version 3 80 This is a test patient Notifications will not be sent to care team members Delete Test Patient Figure 11 Test Patient Marker 4 2 Patient Health Record When viewing the health record for a patient who does not have a care plan the main green navigation bar contains nine sections to choose from They are e Overview e
42. ccsscsessscssccesccsscssscsessseceeessenss 88 Appfove Annal Cycle O C O Onee iE E serbere dende 89 cdmNet User Manual Version 3 80 1 An Introduction The aim of this document is to help GPs and practice nurses effectively use Precedence Health Care s Chronic Disease Management Network cdmNet to maximise the benefits to patients and to the practice cdmNet provides the following benefits to healthcare providers and patients e Evidence shows that properly personalised and well managed care plans can significantly improve health outcomes for patients with chronic disease e Individual accounts that provide faster and easier creation of best practice GP Management Plans GPMPs Team Care Arrangements TCAs and GPMP and TCA Reviews e Automation and streamlining of documentation and MBS CDM compliance processes e Higher quality care plans using best practice guidelines and personalised to patient needs e Improved health outcomes for patients resulting from use of best practice personalised care plans and tracking of patient actions to ensure compliance with management goals e Improved sharing of information and continuity of care across the care team and with the patient through the cdmNet web portal e Improved communication and coordination between the GP and other care team members facilitated through the use of email SMS and the cdmNet web portal e Increased practice revenues through increased throughput of MBS to C
43. could select the filter oatients awaiting action from others to view patients whose health record requires action from members of the care team MW t Precedence Health Care Patients Reports Surveys Resources Preferences Help Log Out Chronic Disease Management Network Logged in as Dr Beverly Crusher GP Patients You are currently involved in the care of the following patients A indicates that you are the primary care provider Show patients awaiting action from others z from any organisation M 7 Include hidden patients S _ Search Status Clinical Metrics Self Monitoring Metrics Create Health Record Download Patient List I Patient Demographics a aa ee Name Date of Birth Referring GP v Last Care Plan Next Review Actions Jet Black 31 Mar 1974 Dr Katherine Pulaski 15 Jul 2015 15 Jan 2016 Hide Patient Edward Elric 15 Jul 1935 Dr Beverly Crusher 15 Jul 2015 15 Jan 2016 Hide Patient Figure 77 Primary Care Provider TCA Awaiting Care Team Agreement To care team members the same patient appears as below on the patient list For care team members selecting the filfer patients awaiting action from you displays patients whose care plans require your action Copyright 2015 Precedence Health Care Pty Ltd 77 e t Precedence Health Care Chronic Disease Management Network cdmNet User Manual Version 3 80 Patients Reports Surveys Resources Preferences Help L
44. ctions Michael Bodger 9 Mar 1985 3334 32342 2 15 Jul 2015 Dr Beverly Crusher View Document Figure 56 Reports Page for Documents The reports collated on this page relate to the various types of documents generated at particular stages of patients chronic disease management plan You can select the documents that pertain to a particular month by selecting a month in the Show report for menu If you are a Care Plan Creator you can select to view the MBS items completed by your Primary Care Provider s Click a patient s name to view their health record Click View Document to the right of a patient s name under the Actions column to view a particular document under the desired section Note if you are a PCP you can view all documents that you approved or that were approved on your behalf If you are a CPC you can see all documents that were approved by or on behalf of your Primary Care Providers Copyright 2015 Precedence Health Care Pty Ltd 58 cdmNet User Manual Version 3 80 MBS Items Report Assessments The sections below list all of the Medicare Benefits Scheme MBS assessment items completed for your patients in cdmNet during July 2015 Show report for This month July 2015 z Include assessments approved for any of your patients M Health Assessment Brief 701 Total number of items 1 Patient Date of Birth Medicare Number Approval Date Approved By Primary Care Provider Actions Edward Elric 15 Jul 193
45. d Yes Change Notifications will be sent by Email Service Announcements Enabled Yes Change Messages will be sent by Email Responsibility Organisation or Individual Providers Edit Time Zone Australia West Edit Organisation Details Verification Status Unverified HPI O None Recorded 2 Edit cdmNet Number 1948040743 Private Practice Yes Change Payment Details Add Payment Details These details are for participants in the Diabetes Care Project program and are used in order to provide automated payments to care team members You do not need to complete these details unless your organisation is involved in the care of a patient who is participating in the program No payment details available Contact Details Organisation Name Omega Health 4 Edit Preferred Contact Method Email Edit Add Phone Number Phone Number Type Actions e 0481 512 3456 Mobile Edit Delete Add Address Address Type Actions e 1 Generation Street Perth Western Australia 6000 Work Edit Add Email Address Email Address Type Actions omegahealth example com Work Edit Delete Organisation Members Add Member Name Speciality Contacts Actions Dr Beverly Crusher GP Work beverly example com Mobile 0481 516 2342 Alyssa Ogawa Nurse Practice Registered Enrolled Mobile 08 4815 162 342 Remove Fax 08 4815 162 342 Pending Organisation Members Name Speciality Contacts Actions E M Aitch GP Work emh example com A
46. e creators developers and operators of cdmNet Someone with a speciality in the medical field who is associated with Patients Organisations and Care Plans for example they might be a GP Podiatrist Diabetes Educator Someone with a non medical speciality for example they might be Laundry Shopping Respite Team Care Arrangement An arrangement of Care Team Members assigned to a patient to see to tasks on a care plan An online portal where scheduled conferences are held Health Care Pty Ltd 90 11 PHC Partners Clever Networks Afafe CISCO DIABETES ANN AUSTRALIA VICTORIA GL S BAL HEALTH MONASH University Departmerits of Innovation Industry and Regional Development cdmNet Help Desk 1300 cdmNet 1300 236638 Copyright 2015 Precedence Health Care Pty Ltd cdmNet User Manual Version 3 80 De Health THE AUSTRALIAN E HEALTH 6 RESEARCH CENTRE ASSOCIATION of GEELONG intel recedence ealthcare VICTORIA UNIVERSITY Precedence Health Care Pty Ltd Level 6 520 Collins Street Melbourne Vic 3000 T 61 3 9023 0800 info precedencehealthcare com www precedencehealthcare com 91
47. e filfer patients with unseen notes to view only those patients for whom you have not read new Progress Notes Patients You are currently involved in the care of the following patients A indicates that you are the primary care provider Show patients with unseen notes 4 from any organisation Include hidden patients N Search Status Clinical Metrics Self Monitoring Metrics Create Health Record Download Patient List Patient Demographics EELT a Fa Name Date of Birth Referring GP Last Care Plan Next Review e Manuel Calavera 16 Nov 1960 Dr Julia Heller TCA awaiting your approval 15 Jul 2015 15 Jan 2016 Hide Patient 11 Nov 2011 Dr Beverly Crusher TCA awaiting primary care provider approval 15 Jul 2015 15 Jan 2016 Leave Care Team Yuki Nagato Hide Patient Figure 53 Patient List With Notification of New Progress Notes Copyright 2015 Precedence Health Care Pty Ltd 35 cdmNet User Manual Version 3 80 4 2 11 Education Page The Education page displays links and information that may be relevant to a patient s health record Yuki NAGATO Born 11 Nov 2011 3 years Gender Female Medicare None Recorded IHI None Recorded 505 Brigade Street Melbourne Victoria 8061 Turn Off Patient Notifications Schedule Telehealth Conference Overview Contacts Health Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education Chron
48. e plan into a GPMP GPMP Review is an operation that cannot be undone and you will be charged the fees as explained in the cdmNet Terms and Conditions After converting the non MBS care plan into a GPMP GPMP Review the new care plan commences at the approved GPMP or GPMP Review stage also distributing a TCA to the care team if you ticked the corresponding box when converting the care plan 9 3 Approving the GPMP Once you are happy with the care plan and the care team members associated with if click Approve GPMP If you are a Care Plan Creator preparing the care plan on behalf of the Primary Care Provider click Release to Primary Care Provider Upon doing this cdmNet presents the option of approving the GPMP on behalf of the PCP If you are a Primary Care Provider and nominated as a Care Plan Creator for the patient s Primary Care Provider as well as being a member of the same organisation clicking Approve GPMP means that you approved the GPMP in your own right rather than approving on behalf of the patient s usual Primary Care Provider You can click the Approve GPMP action from the Overview or Planning page Care Plan Conditions Asthma Hepatitis C Created by Dr Beverly Crusher Next review 15 Jan 2016 Change Valid from 15 Jul 2015 Change GPMP 721 Awaiting your approval Approve GPMP Rebuild Care Plan Figure 73 Approve a GPMP Overview Contacts Health Summary Measurements Planning Care Team
49. e you have selected the conditions you want the care plan to cover cdmNet generates a proposed care plan for you based on the patient s information If you chose the GPMP TCA option a newly created care plan looks like this Eleanor RIGBY Born 12 Sep 2005 9 years Gender Female Medicare 273083922 IHI None Recorded 4 Rice Terrace Pennyville Victoria 3999 Turn Off Patient Notifications Overview Contacts Health Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education Care Plan Conditions Chronic Obstructive Pulmonary Disease Depression as a comorbidity Valid from 15 Jul 2015 Change Next review 15 Jan 2016 Change Diabetes Mellitus Type Il Next ACoC 15 Apr 2016 Change GPMP 721 Awaiting your approval Approve GPMP Rebuild Care Plan Figure 68 Care Plan Ready For Modification If you chose the GPMP TCA Review option a newly created care plan looks like this Copyright 2015 Precedence Health Care Pty Ltd 72 cdmNet User Manual Version 3 80 Sheldon COOPER Born 1 May 1986 29 years Gender Male Medicare 6843 37832 1 IHI None Recorded 816 Bang Street EAST MELBOURNE Victoria 3002 Turn Off Patient Notifications Overview Contacts Health Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education Care Plan Conditions Chronic Kidney Disease Osteoarthritis Valid from 15 Jul 2015 Cha
50. eam Members on their behalf provided that you have consulted with them on the matter To do this click Add Agreement and tick the box that confirms it Copyright 2015 Precedence Health Care Pty Ltd 44 cdmNet User Manual Version 3 80 Edward ELRIC Born 15 Jul 1935 80 years Gender Male Medicare None Recorded IHi None Recorded 1 Full Street Perth Western Australia 4000 Turn Off Patient Notifications Schedule Telehealth Conference Overview Contacts Health Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education A indicates that care plan editing is allowed Update Services Name Location Contacts Agreement Actions Brian Butterfield Dietitian Butterfield Enterprises Melbourne 1 Care Way Work provider example com Remove Agreement Mobile 03 4999 999 999 Remove from Care Team Allow Plan Editing Justin Case Pharmacist Blue Bottle Melbourne 49 High Street Work provider example com Remove Agreement Mobile 03 4999 999 999 Remove from Care Team Allow Plan Editing Alyssa Ogawa Nurse Practice Registered Enrolled Omega Health Perth 1 Generation Street Fax 08 4815 162 342 Add Agreement Remove from Care Team Allow Plan Editing Figure 42 Care Team Page with Care Team Agreements Similarly when a TCA Review Is in progress the Care Team members need to agree to it and as the PCP or CPC you can add agreements on behalf of Care Team
51. earch programs Copyright 2015 Precedence Health Care Pty Ltd 14 4 Patients cdmNet User Manual Version 3 80 When you log in cdmNet displays your patient list pet Patients You are currently involved in the care of the following patients A indicates that you are the primary care provider Show all patients Precedence Health Care Chronic Disease Management Network M from any organisation z Include hidden patients Status Clinical Metrics Self Monitoring Metrics Patients Reports Surveys Resources Preferences Help Log Out Logged in as Dr Beverly Crusher GP Search Create Health Record Download Patient List OSE Name Date of Birth ReferingGP FStats fr Last Care Plan Next Review Actions Eric Banks 26 Nov 1981 Dr Beverly Crusher Health record creation awaiting your action e Charlie Brown 1 Nov 2001 Dr Beverly Crusher Health record creation awaiting your action Selvaria Bles 11 Nov 1978 Dr Katherine Pulaski Awaiting care plan approval 15 Jan 2016 Hide Patient Manuel Calavera 16 Nov 1960 Dr Julia Heller TCA awaiting primary care provider approval 15 Jul 2015 15 Jan 2016 Hide Patient Edward Elric 15 Jul 1935 Dr Beverly Crusher TCA awaiting your approval 15 Jul 2015 15 Jan 2016 Hide Patient e Elizabeth Lochley 24 Nov 1995 Dr Beverly Crusher GPMP awaiting your approval 15 Jan 2016 Hide Patient Eleanor Rigby 12 Sep 2005 Dr Beverly Cr
52. ebes 67 FSO Oe ERE E E E E E E E A EE E O E E E E 69 TAS CNE Sofa PM P beroren E E EN OTE T ENE tial 70 credie COre PIR MEM SSlSC OU N enses iage a RE N 7 Creqgie C ore PION COMGINOM SSIS CTO Nersen n uc cedyean nishedanseleete 72 Care Plan Ready For Modification W sssseesereereereerv ennen ennen ennen nerver serne seee 72 Pre existing Care Plan Ready For MO IPICOTION cceccesscceescceesceenseeencs 73 Non MBS Care Plan Ready For Modification esssssesessessessesreseererserrsrrereses 73 Copyright 2015 Precedence Health Care Pty Ltd 5 Figure 70 Figure 71 Figure 72 Figure 73 Figure 74 Figure 75 Figure 76 Figure 77 Figure 78 Figure 79 Figure 80 Figure 81 Figure 82 Figure 83 Figure 84 Figure 85 Figure 86 Figure 87 Figure 88 Figure 89 Figure 90 Figure 91 Figure 92 Figure 93 Figure 94 Figure 95 Copyright 2015 Precedence Health Care Pty Ltd cdmNet User Manual Version 3 80 Planning Page Care Plan Modification cisitiatstcieenss Me tiaite ded ener ene never ere teens 74 Convert Care Plan to GPMP GPMP Review sissticicesatetiais dest danurantlickeauiades 74 PODIOVEO GE IMP am ore nere E eeio eee 79 Approve GPMP action on Overview PAQE cc csssesscessccesccsscsesssceseeessense 75 GP Management Plan APpprovadl sessssesesssrsesrssesesrrsseserssserssesersesresersreseseese 76 Allocating Allied Health Services While Distributing TCA cece ceecceeeeeee ee 7 7 Pri
53. elects the review option When you click Continue cdmNet displays the following Copyright 2015 Precedence Health Care Pty Ltd 7 cdmNet User Manual Version 3 80 Create Care Plan or Referral Which conditions do you want the care plan to cover Asthma Chronic Heart Failure Chronic Kidney Disease Chronic Low Back Pain Chronic Obstructive Pulmonary Disease _ Coronary Heart Disease Depression as a comorbidity Diabetes Mellitus Type Diabetes Mellitus Type II Hepatitis B Hepatitis C _ Mental Health _ Osteoarthritis Post Surgery Breast Cancer Preventive Health Refugee Immigrant Health Stroke Add Custom Condition Back Create Care Plan Figure 67 Create Care Plan Condition Selection If you selected HMR Only or Team Referral in the previous step cdmNet does not prompt you to select conditions Some conditions are initially ticked if they are matched against the Current History section of the Health Summary You can tick or untick any conditions you want to include or exclude from the care plan You can also add a custom condition to the care plan by clicking Add Custom Condition and selecting or entering the condition accordingly Note that if you add a custom condition cdmNet will not generate any goals or tasks specific to that condition automatically so you may need to add custom goals and tasks on the Planning page if you see fit see Chapter 4 2 5 1 Adding Editing and Deleting Goals and Tasks Onc
54. ents for the Date Range selected Hover your mouse over a measurement to view the pencil icon to edit it or the rubbish bin icon to delete it Figure 21 shows the middle measurement with a tooltip displaying more information about the measurement value To add a new measurement value on the same page click Add New under the Actions column cdmNet then displays the following Copyright 2015 Precedence Health Care Pty Ltd 3 cdmNet User Manual Version 3 80 Add Blood Pressure Measurement indicates a required field Date 12 Aug 2015 11 25 AM e Value mmHg Notes Cancel Add Measurement Figure 22 Add Measurement Value You can add the appropriate Value and any Notes in the boxes provided Any notes you enter in this page will only be displayed in the tooltip on the Measurements page when you hover your mouse over that particular measurement value they will not appear on the patient s Progress Notes page 4 2 4 3 All Available Measurements Click the All Available Measurements link at the top right to see all available measurement information in cdmNet for a patient including those not handled in cdmNet By default the page displays the past year s worth of measurements for a patient Edwina PEPELU Miss Born 4 Mar 1986 29 years Gender Female Medicare 3334 32342 2 IHI None Recorded 1 Helova Street Essendon Victoria 3040 Turn Off Patient Notifications All Available Measure
55. erred providers to your own Preferred Provider list manually by clicking one of the Add Preferred Providers actions and following the prompts 7 7 Care Plan Creators Care Plan Creators are providers whom you permit to create or modify care plans for your patients You can select a provider from any speciality to be a care plan creator as long as they are already registered in cdmNet Usually care plan creators would be other members of your practice or organisation such as Practice Nurses It is good to add care plan creators to your organisation s because that care plan creator list acts as a master list and the providers on that list become care plan creators for the organisation and are available as care plan creators for other GPs within the organisation s To add a care plan creator to your organisation click Add Care Plan Creator Enter your search criteria when cdmNet displays the following Add Care Plan Creator Franklin Display providers whose speciality is Any Speciality Display providers from South Australia in city suburb postcode Search Name Speciality Location Dr Stephen Franklin GP Delta Health Adelaide 2 Voyager Way Close Figure 63 Add Care Plan Creator Once there are care plan creators in the organisation s Care Plan Creators list on your own Preferences page next to the Care Plan Creators heading is a tick box labelled Include Care Plan Creators from Organisation By default thi
56. es that you are the primary care provider Show patients with unsigned documents from any organisation x O include hidden patients q Search Status Clinical Metrics Self Monitoring Metrics Create Health Record Download Patient List EN Patient Demographics Date of Birth Referring GP BETE Next Review Gabriel Celeste 1 Jan 2001 Dr Julia Heller 15 Jul 2015 15 Jan 2016 Sign Documents Hide Patient e Yuki Nagato 11 Nov 2011 Dr Beverly Crusher 15 Jul 2015 15 Jan 2016 Sign Documents Hide Patient e Reimi Saionji 16 Nov 1970 Dr Beverly Crusher 15 Jul 2015 15 Jan 2016 Sign Documents Hide Patient Figure 89 Patient List Filtered by Patients with Unsigned Documents Sign Documents Please confirm that you have read the selected documents for Gabriel Celeste and wish to sign them electronically Referral forms for Allied Health Services 2015 Individual Services Diane Beeaties Diabetes Educator 2015 Individual Services Brian Butterfield Dietitian 2015 Individual Services Archie Foote Podiatrist Cancel Sign Figure 90 Sign Documents 9 5 2 Leaving the Care Team If you are assigned to a patient but do not wish to participate in their care for whatever reason find the patient in your patient list and click the Leave Care Team action in the Actions column When you use the Leave Care Team action a note appears on the Progress Notes page indicating that you have left the care team 9 6 Reviewing GPMPs
57. f a Patient with No Care Plan u s sseeeeeeereesee ere ereeer 47 Patient With Care Plan Documents Page ii cenesttvsaoranadsndissiai evne ennen nens ener eneste 48 Create or Modify Supporting Documents cccceccecsccesscccnsccesscsensceeesees 49 Create or Modify Supporting Documents Including Indigenous Services50 ASSOS MENS F COC seie a a aa 5l Ceding ASS SSSI Slit annara a T uence meaaenaaneene 51 Approving an Assessment with MBS item numbers cece eeeceeecceeceeeeeenes 52 Progress NOTES PAGG setena re laane caitlin R E EO T de eal 54 Navigation Bar with Progress Notes Notification sesesesssserssereseessseresrrsses 54 Patient List With Notification of New Progress Notes u Gu u d dssssseeeeeeeereeereereeer 55 EJE SAP O arer n Ea Re deat eet En br ER TE 56 MB Hene RODOS erasana lee 57 REDOMS Fage Tor DOCUMEN deri E ene ot dibavetuihe babe Ene ka 58 Reports Page for ASSESSMENTS 1 V W VW M sssseseseveseveese even eee nens eee seven sene ere vener 59 RESOUlCES POGO aeie a a T ene ea eee 60 Prelec F AGS ninan N T TE 6 Organisation Preferences PAJe esssesrsssresressesresrrsseseresresresseseesreseeseeeeessees 64 Adding a Member to an Organisation cccescsessscsscensccnscssscsesssecceessenss 65 Registering a New Provider esssessesressrerssseesreseesseseeserssessresresseseesressessereress 66 AGO Care Pan GrEOT OL secettashs testeneditebtieeshilocettaedsdasheediiehietedilecstaedidesheneddi
58. ge with Item 721 Available If at any time you feel that it is necessary to start a new GPMP for the patient you can click Create New GPMP Please note that if you are a Primary Care Provider and nominated as a Care Plan Creator for the patient s Primary Care Provider as well as being a member of the same organisation clicking Create New GPMP automatically makes you the patient s Primary Care Provider The previous care plan is superseded and a new care plan can be implemented The Valid trom date changes to the current date and the next review and ACoC dates change accordingly 9 4 Scheduling Telehealth Conferences A care team member can schedule a telehealth conference with other members of the care team and optionally the patient once a patient s GPMP has been approved The Schedule Telehealth Conference action becomes available in the patient s demographics area Copyright 2015 Precedence Health Care Pty Ltd 79 cdmNet User Manual Version 3 80 Gabriel CELESTE Born 1 Jan 2001 14 years Gender Male Medicare None Recorded IHI None Recorded 7 Stars Close Melbourne Victoria 3000 Turn Off Patient Notifications Schedule Telehealth Conference Figure 80 Schedule Telehealth Conference Action Before scheduling a Telehealth Conference ensure that all participants e Are registered with cdmNet and are part of the patient s care team e Have the necessary equipment a webcam microphone and reliable Internet
59. has been approved if any changes have been made to the care plan for example assigning a different provider to a task or changing a task s frequency a pink change bar appears next to the modified area Hover the Mouse over the pink change bar to view information on a fooltip as to what the change was Yuki NAGATO Born 11 Nov 2011 3 years Gender Female Medicare None Recorded IHI None Recorded 505 Brigade Street Melbourne Victoria 8061 Turn Off Patient Notifications Schedule Telehealth Conference Overview Contacts Health Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education Care Plan Conditions Chronic Low Back Pain Diabetes Mellitus Type I Valid from 15 Jul 2015 Change Next review 15 Jan 2016 Change Next ACoC 15 Apr 2016 Change GPMP 721 As approved on 15 Jul 2015 Create New GPMP TCA 723 As approved on 15 Jul 2015 Modified Accept All Changes Annual Cycle of Care Rebuild Care Plan Show tasks assigned to everyone MM Main Objective Add Goal Task Responsible How Often Last Next Comment Achieve optimal health Patient to Patient Ongoing Ongoing adhere to care Add Task General Add Goal Responsible How Often Last Clear understanding of Educationand fil DrdJ Heller Every year 15 Jul 2015 Due Jul 2016 conditions review Replaced Dr Beverly Crusher GP with Dr Julia Heller GP Target P
60. hronic Disease Management CDM items and Practice Incentive Payments PIP e Further incentives for Home Medication Reviews which are recommended for many patients with chronic disease and complex conditions e Duty of care and compliance support for GPs and other providers through automated reminders and alerts to patients and the care team e Greater visibility of the care planning process through the provision of reports and summaries detailing current care plan status and health outcomes for all patients e All patients on a care plan are regularly reviewed and the results of reviews are shared with the care team e cdmNet can be used either directly by a GP or in collaboration with a practice nurse e cdmNet also allows the patient to track their own care plan and provides reminder and alert services to help the patient adhere fo this plan Copyright 2015 Precedence Health Care Pty Ltd 7 cdmNet User Manual Version 3 80 cdmNet is available for people with the following chronic diseases either singularly or as comorbidities e Asthma e Chronic Heart Failure e Chronic Kidney Disease e Chronic Low Back Pain e Chronic Obstructive Pulmonary Disease e Coronary Heart Disease e Depression as a comorbidity e Diabetes Mellitus Type e Diabetes Mellitus Type Il e Hepatitis B e Hepatitis C e Mental Health e Osteoarthritis e Post Surgery Breast Cancer e Preventive Health e Refugee Immigrant Health e
61. ic Lower Back Pain Resource Description Australian Pain Management Association Information focused on living with pain and managing pain effectively Diabetes Mellitus Type I Diabetes Australia Guidelines for understanding and managing Diabetes Type 1 Diabetes Australia myD Guidelines for understanding and managing Diabetes Type 1 Figure 54 Education Page Copyright 2015 Precedence Health Care Pty Ltd 56 cdmNet User Manual Version 3 80 5 Reports pet Precedence Health Care Patients Reports Surveys Resources Preferences Help Log Out Chronic Disease Management Network Logged in as Dr Beverly Crusher GP Reports The following reports are available to view Medicare e MBS Items Report Documents e MBS Items Report Assessments Figure 55 MBS Items Reports The reports shown in this section vary depending on your speciality how you have used cdmNet and whether you are participating in any research programs If you are a PCP or a CPC click the MBS Items Report Documents link to display a page containing six categories of your completed MBS Items e GP Management Plan 721 e GP Management Plan Review 732 e Team Care Arrangement 723 e Team Care Arrangement Review 732 e Annual Cycle of Care and e Referral forms for Home Medicines Review HMR 900 Copyright 2015 Precedence Health Care Pty Ltd 57 cdmNet User Manual Version 3 80 MBS Items Report Documents The sections below
62. ice Registered Enrolied Hermes CONRAD Born 15 Jan 1974 41 years Gender Male Medicare None Recorded IHI None Recorded 7 Future Ave Melbourne Victoria 3000 Create Health Record A request has been received to create a health record for this patient in cdmNet Details of this request are as follows From Poppy Pomfrey Date 12 Dec 2012 5 07 PM Australia Queensland You must choose a primary care provider for the patient from the list below Name Speciality Location E M Aitch GP Delta Health Adelaide 2 Voyager Way Julian Bashir GP Gamma Health Brisbane 2 Odyssey Avenue Dr Stephen Franklin GP Delta Health Adelaide 2 Voyager Way Dr Owen Harper GP Gamma Health Brisbane 2 Odyssey Avenue Is the patient a test patient Ignore This Request Figure 10 Health Record Creation If you are a Care Plan Creator uploading a patient record onto cdmNet you are prompted to select a Primary Care Provider You must obtain the patient s consent to share their health record in order to continue unless they are a Test Patient Once you have created the patient s health record the patient receives a notification from cdmNet with a username and temporary password they can use to log in to cdmNet While the health record request is waiting for you to accept it if someone else Uploads the same patient s health record to cdmNet the other person s request overrides the existing request and they are able to a
63. ient e Sheldon Cooper 1 May 1986 Hide Patient Edward Elric 15 Jul 1935 Hide Patient Elizabeth Lochley 24 Nov 1995 Hide Patient e Yuki Nagato 11 Nov 2011 10000 6 6 25 Sign Documents Hide Patient e Eleanor Rigby 12 Sep 2005 Hide Patient Edith Rubble 4 Apr 1934 Hide Patient Reimi Saionji 16 Nov 1970 Sign Documents Hide Patient e Faye Valentine 4 Mar 1986 Hide Patient Amy Wong 4 Apr 2004 Hide Patient Figure 8 Self Monitoring Metrics View of Patient List The columns in the Self Monitoring Metrics view reflect the measurements entered in the Self Monitoring section of the Measurements section of a patient s health record see Chapter 4 2 4 Measurements Page Self Monitoring measurements can be entered by the patient or by a provider on behalf of the patient If you cannot find the patient you are looking for immediately on the list you can search for them using the search box provided To search for patients you can enter a first name last name cdmNet Number or Medicare Number For example if the only information you had about a patient was a surname such as Farnsworth you could type Farnsworth in the search box and among the results returned you would find the patient Hubert Farnsworth Click Search without entering anything in the search box to display all listed patients Click Download Patient List to export a copy of your patient list as a CSV file based on the current filters and sort column You ca
64. ith the arrangement for the telehealth conference click Schedule Conference cdmNet displays a confirmation message cdmNet notifies all invitees who can be contacted electronically that you have Copyright 2015 Precedence Health Care Pty Ltd 80 cdmNet User Manual Version 3 80 scheduled a telehealth conference Any invitee who does not have a form of electronic contact email SMS willneed to be contacted manually Schedule Telehealth Conference The following telehealth conference has been successfully scheduled An automated invitation will be sent to all invitees unless indicated below Date 15 Jul 2015 11 00 AM Invitees Diane Beeaties Diabetes Educator Brian Butterfield Dietitian Dr Beverly Crusher GP Arthur Dent Dentist Dental Practitioner Dental Surgeon Archie Foote Podiatrist Dr Julia Heller GP Notes No notes entered OK Figure 82 Telehealth Schedule Confirmation Message Once the scheduling of the conference is confirmed a new entry appears in the Progress Notes A basic summary of this note also appears on the Overview page Overview Contacts Health Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education Show Detailed Timeline 15 July 2015 at 10 10 AM Dr Beverly Crusher GP scheduled a telehealth conference Telehealth conference on 15 July 2015 at 11 00 AM with Diane Beeaties Diabetes Educator Brian Butterfield Dietitia
65. l the visibility of Uploaded assessments Simply click the Specific people radio button and edit the list of providers accordingly when uploading the assessment or later if required Copyright 2015 Precedence Health Care Pty Ltd 52 cdmNet User Manual Version 3 80 4 2 9 Reports Page At present reports are only available for patients from some practices participating in certain programs Copyright 2015 Precedence Health Care Pty Ltd 33 cdmNet User Manual Version 3 80 4 2 10 Progress Notes Page The Progress Notes page Is where everyone involved in the patient s care including the patient themselves can make notes about the patient s progress The page also displays information about when major milestones such as GPMPs TCAs and reviews related to the patient s care plan occurred You can only delete notes that you have entered When you delete a note cdmNet prompts you to enter a reason for deleting the note Deleted notes are distinguishable by the grey header Any notes that you have not seen are marked with a red circle Basic information about unseen notes is also displayed in the Unseen Notes widget on the Overview page Manuel CALAVERA Born 16 Nov 1960 54 years Gender Male Medicare None Recorded IHI None Recorded 1 Fandango Road Melbourne Victoria 3000 Turn Off Patient Notifications Schedule Telehealth Conference Overview Contacts Health Summary Measurements Planning Care Team
66. low Test Patients Provider Details Provider Number 5097331B 2 Edit HPI l None Recorded 2 Edit cdmNet Number 1816010138 Speciality GP Private Practice Yes Change Payment Details Add Payment Details These details are for participants in the Diabetes Care Project program and are used in order to provide automated payments to care team members You do not not need to complete these details unless you are involved in the care of a patient who is participating in the program No payment details available Contact Details Name Dr Beverly Crusher Edit Preferred Contact Method Email Edit Add Phone Number Phone Number Type Actions e 0481 516 2342 Mobile Edit Delete Add Email Address Email Address Type Actions beverly example com Work Edit Organisations Add Organisation Name Location Contacts Actions Omega Health Perth 1 Generation Street Work omegahealth example com Edit Mobile 0481 512 3456 Work 1234 56 789 Fax 1234 56 789 Pending Organisations Name Location Contacts Actions Zeta Health Adelaide 1 Gyver Street Work sherman example com Cancel Request Work 1234 567 890 Preferred Providers Add Preferred Provider Add Preferred Providers from Postcode Remove All Preferred Providers Include Preferred Providers from Organisation O preferred providers included from organisations Name Speciality Location Contacts Actions Brian Butterfield Dietitian Butterfield Enterprises Work pr
67. m the Primary Care Provider s or Care Plan Creator s clinical desktop software Best Practice or MD3 Faye VALENTINE Born 4 Mar 1986 29 years Gender Female Medicare 3777 75600 1 IHI None Recorded 60 Hills Road Melbourne Victoria 3000 Turn Off Patient Notifications Overview Contacts Health Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education Medical Status Smoking Status Non smoker Edit Drinking Status Non drinker Edit Family History Unknown Current History Date Problem Description Actions 4 1985 Diabetes Mellitus Type Il Delete 4 2012 Ckd chronic Kidney Disease Stage 5 Delete 77 Nov 2013 Dermatitis Delete 77 Nov 2013 Iron deficiency Delete Past History Date Problem Description Actions None Current Medications Medication Strength Dose amp Frequency Last Script Date Eleuphrat 0 05 Lotion 0 05 1 In the evening Topical Delete Iron Sucrose 2 7g Infusion 20mg mL Daily Oral Delete Medication Notes Date Actions No current medication notes Add Adverse Reactions Agent Date Recorded Reaction Actions Parsnips Vomiting Delete Immunisations Immunisation Date Sequence Number Actions Diphtheria 21 May 2012 1 Delete Engerix B Adult 7 Jun 2013 1 Delete Figure 17 Patient Health Summary Page On a patient s Health Summary Page Primary Care Providers and Care Plan Creators only can e Edit a patient s Smoking Status S
68. mary Care Provider TCA Awaiting Care Team Agreement as CGE TE OMNIMEMDSI VIEW t banens ins seated a eae did ibew allie adlede s 78 Documents Page with Item 721 Available ccceccrssccessereesssensecessecenss 79 Schedule Telehealth Conference ACtION ssssessseessserssersssessserssersseessses 80 Scheduling a Telehealth Conference e sssssecssecseererssesrerssesrsreseeseesseseessersee 80 Telehealth Schedule Confirmation MESSAGE ccccceeccesecceseceeseceeecceesceaeecs 81 Telehealth Conference Schedule Note Entry in Progress Notes 81 Team Care Arrangement Awaiting Care Team Agreement e ne 82 TCA Agreed Pending Approval ccccessccsscsessscnsceesccnscssscsesseecseessenss 83 Approve TCA from Flanning Page eair i enaa EA A Gexlas 83 Approve TCA from Overview PAQ ssessssessresressreserserersresresseesereseererersereses 83 ICAAPDIOVOI crana E T E S ET ON 84 Patient List Filtered by Patients with Unsigned DOCUMENTS c ceeceeeees 85 Ste gel Be lei 0 la ale ay ksmeennees cera meme ene trie re mer enn rn O 85 Patient List Showing GPMP Review Overdue ccsecccssccesscsesssseeseserseneese 86 GPMP Review Approaching scdaciataaetincendehindorticancnedocaadeadiadiccssinUarteanatedeteaaeacine 86 COMMENCE GrME REVIEW scssescensutestiewatel nanaveacneatenaiesdbragateansuaysesadeetedabieede 87 CPMF REVIEW ADOLOTEA E a uauetentands 87 TCA Review With Review AGERE MENNS cccss
69. ments From 15 Jul 2014 To 15 Jul 2015 View For Date Range Date Name Value Units 4 May 2015 12 00 AM Blood Glucose Level 2 5 mmol L 4 May 2015 12 00 AM Blood Pressure 123 45 mmHg 4 May 2015 12 00 AM Heart Rate 60 bpm 4 May 2015 12 00 AM Hip Circumference 75 cm 4 May 2015 12 00 AM Lung Function FEV 4 L 4 May 2015 12 00 AM Oxygen Saturation SpOz 5 4 May 2015 12 00 AM Steps Per Day 8000 steps 4 May 2015 12 00 AM Waist Circumference 70 cm 4 May 2015 12 00 AM Weight 68 kg 5 Jan 2015 4 21 PM Blood Pressure 123 45 mmHg 11 Nov 2014 12 00 AM Blood Pressure 120 70 mmHg Return to Measurements Summary Figure 23 All Available Measurements Copyright 2015 Precedence Health Care Pty Ltd 32 cdmNet User Manual Version 3 80 4 2 5 Planning Page The Planning page only appears in a patient s navigation bar if a care plan has been created see Chapter 9 Creating Care Plans The purpose of the Planning page is to set tasks and goals tailoring them to suit the individual patient in order for them to manage their condition s The content and composition of a patient s planning page varies depending on the condition s they have and your association with that patient There is a general template of planning consisting of several main sections They include Main Objective Disease Lifestyle General Lifestyle Condition Management Factors Management e Biomedical Psychosocial Complications Medications
70. moker Ex smoker or Non smoker e Edit a patient s Drinking Status Drinker or Non drinker e Delete items from a patient s Current History e Delete items from a patient s Past History e Delete items from a patient s Current Medications Copyright 2015 Precedence Health Care Pty Ltd 27 cdmNet User Manual Version 3 80 e Edit Medication Notes about a patient s Current Medications e Delete items from a patient s Adverse Reactions and e Delete items from a patient s Immunisations Any data that is relevant to this page is uploaded from your clinical desktop software when the patient data is uploaded for the first time and any subsequent new data is uploaded where appropriate The data on this page affects generation of goals and tasks upon care plan creation Anything you subsequently change here such as deletions will not affect the care plan unless you rebuild it Anything you delete will not affect patient data on your clinical desktop software t Note that Medication Notes are different from the Progress Notes section see Chapter 4 2 10 Progress Notes Page Copyright 2015 Precedence Health Care Pty Ltd 28 4 2 4 Measurements Page cdmNet User Manual Version 3 80 A patient s measurements page contains information about the patient s clinical measurement history and how it relates to their care plan There are five main categories of measurements They are e Observations e Test Results e Lipids e Self
71. n Dr Beverly Crusher GP Arthur Dent Dentist Dental Practitioner Dental Surgeon Archie Foote Podiatrist Dr Julia Heller GP No notes were entered for this telehealth conference request Join Telehealth Conference Host Key 480162 Figure 83 Telehealth Conference Schedule Note Entry in Progress Notes If you need to change the scheduled time of the telehealth conference or add or remove a participant simply reschedule a new ftelehealth conference Upon rescheduling you could add a note indicating the changes If you need to cancel a telehealth conference contact cdmNet Support at cdm net au support At the time of the scheduled telehealth conference you can click the Join Telehealth Conference link from the Progress Notes entry or from the link in the automated confirmation message which takes you directly fo WebEx Note that when using this service for the first time after clicking the blue Join button you may be prompted to download and install the WebEx Meeting Centre client to engage in the telehealth conference You may need to re join the conference after doing this If you are the host join the telehealth conference as above You may need to enter the Host Key which is displayed next to the Join Teleheath Conference link and also provided in the automated confirmation message To reclaim host privileges select Copyright 2015 Precedence Health Care Pty Ltd 81 cdmNet User Manual Version 3 80 Recl
72. n import this file into a soreadsheet or database application such as Excel or Numbers Click Create Health Record to create a patient whose health record does not exist on your clinical desktop software Best Practice Zedmed Monet or MD3 Fill in the patient s details accordingly Copyright 2015 Precedence Health Care Pty Ltd 18 cdmNet User Manual Version 3 80 Create Health Record You are about to create a health record for a new patient Please ensure the patient is not already in your patient list before taking this action Please enter the patient details below indicates a required field Patient Name Title e First Name Middle Name Last Name Patient Details e Date of Birth E click to choose a date e Gender M Indigenous Status M IHI Medicare Number Contact Details You must enter either a phone number or an email address Phone Number Home Work Mobile Email Address Type Home Figure 9 Create Health Record Once you have completed the patient s details you can then proceed to obtain and confirm the patient s consent to share their health record selecting a Primary Care Provider for the Patient if you are a Care Plan Creator See also Chapter 4 1 Creating a Patient s Health Record A green dot to the left of a patient s name indicates that you are that patient s PCP Clicking Show Primary Care Provider Patients Only displays the patients for whom you are
73. ne 3 Handy Way Jim s Gardening Garden Maintenance Melbourne 1 James Street Dean Learner Garden Maintenance Melbourne 1 Dark PI Lucien Sanchez Garden Maintenance Jim s Gardening Melbourne 1 James Street Cancel Assign Figure 34 Assign to an Other Provider Service Provider This functionality works similarly to the Assign to Provider functionality described above Here selecting Service Type and clicking Assign allows you to assign a type of service to the task but not a specific service provider or organisation To select a specific service provider or organisation select the Service Provider radio button and search accordingly Alternatively having clicked the pencil icon next to a task name you can choose to assign a speciality the patient the GP or either type of recommended speciality provider or services provider for a particular task by clicking the Change action next to the current assignee s name see Figure 28 Copyright 2015 Precedence Health Care Pty Ltd 40 cdmNet User Manual Version 3 80 Edit Task Task Manage alcohol consumption Counselling and review Speciality Only Recommended Specialities _ a i HE Patient GP Dr Beverly Crusher Provider ee i Speciality Recommended Specialities M Provider name or Organisation City Suburb Postcode State Queensland z _ Display preferred providers only Search Register a New Provider Name Speciality Location
74. ned documents No unseen notes Figure 13 New Patient Health Record Overview Page The Overview page outlines the context relevant information pertaining to a patient s health record in widgets The Actions widget displays actions you can perform including creating and approving care plans and documents and recording appointments The Tasks widget displays tasks assigned to you on the patient s care plan that are due or overdue The Unsigned Documents widget displays a list of documents related to a patient s cdmNet care plan that have not been signed You can electronically sign documents from this widget when the appropriate button appears in the widget The Unseen Notes widget displays a basic summary of any notes that other care team members or the patient have entered since you last visited the Progress Notes page see Chapter 4 2 10 Progress Notes Page You can rearrange the widget positions into your preferred order by dragging their title bars Copyright 2015 Precedence Health Care Pty Ltd 23 cdmNet User Manual Version 3 80 4 2 2 Contacts Page et Precedence Health Care Patients Reports Surveys Resources Preferences Help Log Out Chronic Disease Management Network Logged in as Dr Beverly Crusher GP Elizabeth LOCHLEY Born 24 Nov 1995 19 years Gender Female Medicare 4291 1 IHI None Recorded 5 Babylon Street Melbourne University Victoria 3052 Turn Off Patient Notifications Ove
75. nge Next review 15 Jul 2015 Change GPMP 721 Review overdue Commence GPMP Review Create New GPMP Rebuild Care Plan Figure 69 Pre existing Care Plan Ready For Modification If you chose this Review option once you have modified the care plan as desired see Chapter 9 2 Modifying Care Plans you should click Commence GPMP Review see Chapter 9 6 Reviewing GPMPs Note that care team members and the patient will only be able to access the care plan once you approve the GPMP Review If you chose the Non MBS Care Plan option a newly created care plan looks like this Selvaria BLES Born 11 Nov 1978 36 years Gender Female Medicare None Recorded IHI None Recorded 1 Valkyria Close Melbourne Victoria 3000 Turn Off Patient Notifications Overview Contacts Health Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education Care Plan Conditions Chronic Kidney Disease Chronic Obstructive Pulmonary Disease Valid from 15 Jul 2015 Change Next review 15 Jan 2016 Change Depression as a comorbidity Care Plan Awaiting care plan approval Approve Care Plan Rebuild Care Plan Figure 70 Non MBS Care Plan Ready For Modification If you made a mistake in creating the care plan or the patient develops a new chronic disease at any stage of the GP Management Plan lifecycle you can modify the care plan and repeat the automatic generation process by clicking Rebuild Care
76. nts the option to include Indigenous Allied Health Services here When the TCA Review has been approved the Team Care Arrangement Review form 732 is available on the patient s Documents Page 9 8 Annual Cycles of Care At the time of writing cdmNet supports the Annual Cycle of Care for Diabetes only You can view the current progress against the ACoC by clicking Annual Cycle of Care in the top section of the Planning page when viewing a patient s health record This opens a new window displaying the information in a PDF file The information presented in the ACOoC is based on the progress of the patient s care plan cdmNet automatically calculates appropriate dates to include in the Copyright 2015 Precedence Health Care Pty Ltd 88 cdmNet User Manual Version 3 80 ACOC corresponding to the history of appointments and measurements shown on the Planning page You can approve an ACOoC within a month of the Next Annual Cycle of Care date by clicking Approve ACOC Are you sure you want to approve the Annual Cycle of Care The next review is planned to occur on E 21 Jul 2015 The next annual cycle of care is planned to occur on 29 Jul 2016 Cancel Approve Figure 96 Approve Annual Cycle of Care A yellow warning box appears if there are areas in the ACoC that may not meet the Medicare minimum frequency requirements Should you have any further questions about using cdmNet or how it works please contact our S
77. oals by clicking the pencil icon in the appropriate cell Clicking the pencil icon displays a separate screen where you can edit the task or goal in its entirety You can change the Display Name of the goal or task which is used everywhere in cdmNet In addition the original goal or task name is shown on these edit screens care team members and patients can see this original name in a tooltip by hovering the mouse pointer over a task or goal name on the Planning section You can also delete tasks and goals from these screens by clicking the Delete Goal or Delete Task button Edit Goal indicates a required field Goal Name Correct use of medications e Display Name Correct use of medications Target General Target No incidents of misuse of medications Delete Goal Cancel Update Goal Figure 27 Editing a Goal Copyright 2015 Precedence Health Care Pty Ltd 36 cdmNet User Manual Version 3 80 Edit Task indicates a required field Goal Name Manage body weight Task Name Body weight assessment and counselling e Display Name Assessment and counselling Comments Responsible Party Brian Butterfield Dietitian Change Butterfield Enterprises 1 Care Way Melbourne Victoria 3999 Work provider example com Mobile 03 4999 999 999 Assign to all tasks unassigned tasks with provider s speciality or tasks previously assigned to Brian Butterfield e Repeat Fixed repeat every 2 Years M
78. odiatrist Archie Foote 1 Cancel Modify Create New Figure 46 Create or Modify Supporting Documents If a patient is of Aboriginal or Torres Strait Islander descent Primary Care Providers and Care Plan Creators can also create new or modify existing supporting documents to include Indigenous Allied Health Services Copyright 2015 Precedence Health Care Pty Ltd 49 cdmNet User Manual Version 3 80 Create Modify Supporting Document Editing Referral forms for Allied Health Services for 2015 last modified on 15 Jul 2015 Referrals for Individual Follow up Allied Health Services Indigenous Please enter the number of services provided by each Allied Health provider on this care plan Year 2015 Health Assessment Completed 701 703 705 707 715 Allied Health Provider Indigenous Services Dietitian Brian Butterfield 1 3 Podiatrist Heal Toe pia 2 1 Electronically sign the Allied Health Referral forms Cancel Modify Create New Figure 47 Create or Modify Supporting Documents Including Indigenous Services Copyright 2015 Precedence Health Care Pty Ltd 50 cdmNet User Manual Version 3 80 4 2 8 Assessments Page You can create an assessment for a patient at any time provided that you have access to their health record Jonathan CREEK Born 1 May 1986 29 years Gender Male Medicare 3362 06541 1 IHI None Recorded 1 Windamere Close SOUTH MELBOURNE Victoria 3205 Turn Off
79. og Out Patients You are currently involved in the care of the following patients Show all patients M from any organisation Status Clinical Metrics Date of Birth Referring GP O include hidden patients Self Monitoring Metrics Care Plan Jet Black Dr Katherine Pulaski ELO Vl Use Beigel ont 31 Mar 1974 Manuel Calavera 16 Nov 1960 Dr Julia Heller TCA awaiting your agreement Edward Eric 15 Jul 1935 Dr Beverly Crusher Ellen Ripley 19 Jul 1979 E M Aitch Michael Bodger 9 Mar 1985 Dr Beverly Crusher Last Care Plan Next Review Actions Logged in as Brian Butterfield Dietitian Search Download Patient List 15 Jan 2016 Leave Care Team Hide Patient Leave Care Team Hide Patient 15 Jan 2016 15 Ju 2015 15 Jan 2016 Leave Care Team Hide Patient 15 Ju 15 Jul 2015 2015 15 Jan 2016 Leave Care Team Hide Patient 15 Jan 2016 Leave Care Team Hide Patient Gabriel Celeste 1 Jan 2001 Dr Julia Heller 15 Jul 2015 15 Jan 2016 Leave Care Team Hide Patient Alfonse Elric 9 Mar 1991 E M Aitch 29 Jul 2015 5 Aug 2015 Leave Care Team Hide Patient Yuki Nagato 11 Nov 2011 Dr Beverly Crusher 15 Jul 2015 15 Jan 2016 Leave Care Team Hide Patient Reimi Saionji 16 Nov 1970 Dr Beverly Crusher 15 Jul 2015 15 Jan 2016 Leave Care Team Hide Patient Figure 78 Care Team Member View If you did not tick the TC
80. ons see e Leave Care Team Chapter 9 5 2 Leaving the Care Team e Sign Documents Chapter 9 5 1 Signing Documents and e Hide Patient see below You can hide patients you no longer wish to see in the list by clicking the Hide Patient action in the Actions column Hidden patients are only hidden for you other providers can continue to access them normally You can choose to unhide patients by clicking Unhide Patient available when the Include hidden patients box is ticked Clicking a patient s name displays the patient s health record see Chapter 4 2 Patient Health Record For Primary Care Providers and Care Plan Creators if you have not yet created a health record for this patient clicking their name displays the create health record page see Chapter 4 1 Creating a Patient s Health Record 4 1 Creating a Patient s Health Record When you want to create a health record for a patient you can upload their medical history and clinical information from your clinical desktop software Best Practice Zedmed Monet or MD3 to cdmNet using cdmNet Desktop see the cdmNet Desktop Guide available at cdm net au help guides cdmNet displays the following page Copyright 2015 Precedence Health Care Pty Ltd 20 cdmNet User Manual Version 3 80 pet Precedence Health Care Patients Reports Surveys Resources Preferences Help Log Out Chronic Disease Management Network Logged in as Poppy Pomfrey Nurse Pract
81. ontacts Health Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education A indicates that care plan editing is allowed Name Location Contacts Agreement Actions Diane Beeaties Diabetes Educator Diabeatles Melbourne Beaties Way Work provider example com vY Remove Review Agreement Mobile 03 4999 999 999 a Remove from Care Team Allow Plan Editing Download Referral For Individual Services Brian Butterfield Dietitian Butterfield Enterprises Melbourne 1 Care Way Work provider example com Add Review Agreement Mobile 03 4999 999 999 Remove from Care Team Allow Plan Editing Download Referral For Individual Services Heal Toe pia Podiatrist Melbourne 24 Inch Lane Work healtoepia example com v Remove Review Agreement H Remove from Care Team Allow Plan Editing Download Referral For Individual Services Figure 95 TCA Review With Review Agreements Once two care team members have agreed to the TCA Review you can approve it as the PCP or CPC from the Planning or Overview page If you have not already generated Allied Health referral forms for the current year you are prompted to do so when approving the TCA Review If is up to your discretion to alocate the number of services that Allied Health members can provide to the patient applicable to the current or following year If the patient is of Aboriginal or Torres Strait Islander descent cdmNet prese
82. other care team members e Tasks assigned to the patient and e Tasks assigned to everyone By default cdmNet displays all tasks in the care plan this is the tasks assigned to everyone option If you change the filter to display another view it applies for the particular patient you are viewing until you move on to another patient or log out cdmNet then changes the filter back to the default selection On this page you can e Edit the Last time a task was undertaken and e Set the Next time a task will be Undertaken See Chapter 4 2 5 2 Creating and Editing Appointments In addition PCPs and CPCs can e Add new goals e Add new tasks e Edit or set the responsible party for particular tasks e Edit or set the frequency of tasks and e Add comments about particular tasks See Chapter 4 2 5 1 Adding Editing and Deleting Goals and Tasks For more information on the context in which you might do these things see Chapter 9 2 Modifying Care Plans Care Plans consist of goals column on the left and tasks to achieve them Task column next to Goal column There are providers responsible for seeing tasks through Responsible column and the frequency of the tasks to be undertaken Tasks Indicates The task is your responsibility Your attention may be required for this area or you may need to check the information cdmNet has generated Copyright 2015 Precedence Health Care Pty Ltd 34 cdmNet User Manual Ver
83. oval Agreement Date Actions There are no current annual cycle of care documents Supporting Documents Create Modify Supporting Document Document Approval Agreement Date Actions Referral form for Individual Allied Health Services 2015 Diane Beeaties Diabetes Educator 15 Jul 2015 View Download Referral form for Individual Allied Health Services 2015 Brian Butterfield Dietitian 15 Jul 2015 View Download Referral form for Individual Allied Health Services 2015 Archie Foote Podiatrist 15 Jul 2015 View Download Figure 45 Patient With Care Plan Documents Page cdmNet automatically generates documents that are relevant to the patient s care plan when appropriate These include e Care Plans e Patient Summary e GP Management Plans MBS item 721 e Team Care Arrangements MBS item 723 e GP Management Plan Reviews MBS item 732 e Team Care Arrangement Reviews MBS item 732 e Annual Cycles of Care e Referral forms for Allied Health services including referral forms for group Allied Health services when the Minimise diabetes lifestyle risk factors goal in the Lifestyle section is added to the care plan of a patient with diabetes type Il See Chapter 4 2 5 1 Adding Editing and Deleting Goals and Tasks and Copyright 2015 Precedence Health Care Pty Ltd 48 cdmNet User Manual Version 3 80 e Referral forms for Home Medicines Review HMR MBS Item 900 When the Domiciliary medication managemen
84. ovider example com Remove 1 Care Way Melbourne Victoria 3999 Mobile 03 4999 999 999 Justin Case Pharmacist Blue Bottle Work provider example com Remove 49 High Street Melbourne Victoria 3000 Mobile 03 4999 999 999 Heal Toe pia Podiatrist 24 Inch Lane Melbourne Victoria 3000 Work healtoepia example com Remove Dr Julia Heller GP Alpha Health Work heller example com Remove 2 Generation Street Melbourne Victoria 3000 Jim s Gardening Garden Maintenance 1 James Street Melbourne Victoria 3000 Work jims example com Remove Alyssa Ogawa Nurse Practice Registered Enrolled Omega Health Mobile 08 4815 162 342 Remove 1 Generation Street Perth Western Australia 6000 Fax 08 4815 162 342 Lucien Sanchez Garden Maintenance Jim s Gardening Mobile 0498 765 4321 Remove 1 James Street Melbourne Victoria 3000 Care Plan Creators Include Care Plan Creators from Organisation 4 care plan creators included from organisations Add Care Plan Creator Name Speciality Location Contacts Actions Gaius Baltar GP Omega Health Work gaius example com Remove 1 Generation Street Perth Western Australia 6000 Mobile 0481 516 2342 Alyssa Ogawa Nurse Practice Registered Enrolled Omega Health Mobile 08 4815 162 342 Remove 1 Generation Street Perth Western Australia 6000 Fax 08 4815 162 342 Linked Accounts Add Linked Account These accounts will be linked to your cdmNet account to automatically share patient information
85. plays the following page Evangeline MCDOWELL Born 18 Apr 1990 25 years Gender Female Medicare None Recorded IHI 8003603443763496 1 Mahora Avenue Melbourne Victoria 3000 Turn Off Patient Notifications Assign Primary Care Provider Select a primary care provider for the patient from the list below Display providers from i New South Wales M in city suburb postcode Search Name Speciality Location Contacts Leonard McCoy GP Beta Health Sydney 1 Original Street Work bones example com Mobile 0481 516 2342 laale Ohanbhaszal AN Nata I lanbi EN lanma 4 Owininal Obenanti Tha Milas lnitingis a M sedlen ma A l ant Oben nt l lanna inalefMaueamsenla anaana Figure 16 Change a Patient s Primary Care Provider Page Copyright 2015 Precedence Health Care Pty Ltd 25 cdmNet User Manual Version 3 80 You can search for the Primary Care Provider by name city and postcode You can view up fo 300 results per page by clicking the drop down menu fo the right of the page If you would like to reassign all tasks on the patient s care plan to the preferred providers of the new Primary Care Provider tick the Replace all care team members on this care plan with the selected provider s preferred providers box before clicking Assign Copyright 2015 Precedence Health Care Pty Ltd 26 cdmNet User Manual Version 3 80 4 2 3 Health Summary Page A patient s health summary page contains the information uploaded fro
86. ponsible How Often Next Change Next Date Add Appointment Monitor renal function Target Albumin Creatinine Ratio lt 2 5 mg mmol GFR gt 60 ml min 1 73 Microalbumin timed overnight collection lt 20 g min Microalbumin spot collection lt 20 mg L Add Task Figure 37 Change Next Date Menu You can change the next date for a task up to five years in the future When there is no specific party assigned to a task you can only change the next date Change Next Date Goal Maintain healthy diet Task Comprehensive education and review Next Due December mf 2015 Cancel Change Figure 38 Change Next Date Record Appointment e indicates a required field Tasks Maintain healthy diet Comprehensive education and review Due Jul 2015 Manage body weight Assessment and counselling Due Jul 2015 Provider Brian Butterfield Dietitian Organisation Butterfield Enterprises Patient Elizabeth Lochley Date E 31 Jul 2015 12 00 AM e Progress Scheduled z Notes Cancel Record Appointment Figure 39 Record Appointment Clicking the calendar icon next to Date displays a date and time calendar where you can set a specific date and time for appointments You can also record appointments from the Overview Page Copyright 2015 Precedence Health Care Pty Ltd 42 cdmNet User Manual Version 3 80 4 2 5 3 Seeing Changes After a GPMP
87. programs The second filter allows you fo filter your patients Copyright 2015 Precedence Health Care Pty Ltd will only appear if you have any patients 15 cdmNet User Manual Version 3 80 e From any organisation e Where you are the primary care providert e Where you have been assigned where you as an individual are assigned to a task on a care plan e Where your speciality has been assigned where you have been assigned to a task directly or where your organisation has been assigned and your speciality has been selected and e From specific organisations organisations you belong to that are assigned to a task on a care plan or where the primary care provider also belongs to the same organisation By default cdmNet filters your patient list to show all patients from any organisation or if you are a Primary Care Provider the list is filtered to all patients where you are the primary care provider You can filter your patient list by one or a combination of the two filfers and your patient list remains filtered until you change it The Include hidden patients box turns on or off the display of hidden patients By default this box is not ticked and remains that way until you change it meaning that hidden patients are not included in the list There are three views of the patient list Status Clinical Metrics and Self Monitoring Metrics You can sort the patient list by any column and it remains sorted by
88. provider you can also enter measurements on their behalf if they are not confident or comfortable with doing it themselves You can see who entered particular measurement value to display such information in a tooltip Self Monitoring These measurements are not monitored by the care team Measurement Blood Pressure mmHg Hip Circumference cm Heart Rate bpm Waist Circumference cm Weight kg Blood Glucose Level mmol L Steps Per Day steps Oxygen Saturation SpO2 Lung Function FEV L Latest 123 45 75 60 70 measurements Target by hovering your Recent Measurements 68 2 5 8000 5 4 mouse pointer Add Measurements Actions 4 May 2015 123 45 History 75 History 75 cm 4 May 2015 Entered by Dr Beverly Crusher on behalf of Miss Edwina Pepelu 2 0 Mmistory 8000 History 5 History 4 History 26 26 History Figure 19 A Tooltip Displaying Measurement Value Information 4 2 4 1 Adding Measurements To add new measurements to a category click the Add Measurements link to the right of the category cdmNet displays a screen like the following where you can add the appropriate information accordingly Copyright 2015 Precedence Health Care Pty Ltd q 30 cdmNet User Manual Version 3 80 Add Measurements Lipids Use same date for all entries 7 7 2015 e g 29 8 1983 Use
89. r you can select to view the approved assessments with associated MBS items completed by your Primary Care Provider s Copyright 2015 Precedence Health Care Pty Ltd 59 cdmNet User Manual Version 3 80 6 Resources All providers have the following standard list of Resources General Previous 1 2 3 Next Show 20 per page Absolute Cardiovascular Disease CVD risk Australian Heart Foundation CVD information Alcohol Smoking and Substance Involvement Screening Test A WHO developed resource to detect and manage substance use and related problems in primary care Allied Health Group Services under Medicare Diabetes Medicare rebates for Allied Health Group Services for patients with diabetes Allied Health Incentives and Allowances Medicare rebates for Allied Health Chronic Disease Management services Asthma Management Handbook Best practice evidence based guidance on asthma diagnosis and management Australian Centre for the Study of Sexual Assault What works in preventing sexual assault Australian Drug Foundation Australian Drug Foundation Australian Hearing instructions for GPs Australian Hearing instructions for GPs CALD Cancer Resource Directory Culturally and Linguistically Diverse Cancer Resource Directory CALD communities sexually transmissible infections and viral hepatitis A resource manual for health and community services Chronic Kidney Disease Management in General Practice Guidance and clinical tips to help identif
90. ral The following MBS CDM Items appear in your practice records GPMP 11 Feb 2014 TCA 11 Feb 2014 GPMP TCA Review 25 Jan 2012 Which item would you like to create in cdmNet GPMP and or TCA GPMP and or TCA Review Non MBS Care Plan HMR Only Team Referral Cancel Continue Figure 66 Create Care Plan Item Selection If a patient has an existing care plan on paper or in another system you can start the patient s care plan at the GPMP Review phase in cdmNet You can also select to create a non MBS care plan This means that you do not create any MBS items aside from HMR forms as part of the care plan process You can select HMR Only to create a very basic care plan for generating a Home Medicines Review referral Once you create the care plan you should assign a pharmacist to the Domiciliary medication management review task and approve the care plan in order to create the Referral form for Home Medicines Review You can select Team Referral in order to establish a referral connection with one or more providers and share the patient s health record and progress notes When creating a care plan choose the appropriate option GPMP and or TCA GPMP and or TCA Review Non MBS Care Plan HMR Only or Team Referral on the first screen If cdmNet Desktop has detected previous MBS CDM items in your clinical desktop software such as GPMPs TCAs GPMP Reviews and TCA Reviews cdmNet displays their details on this screen and pre s
91. resents the option to include Indigenous Allied Health services here Note that you can only electronically sign the Allied Health Referral Forms if you are the Primary Care Provider or another Primary Care Provider nominated as a Care Plan Creator for the patient s Primary Care Provider as well as a member of the same organisation Once you have approved the TCA PDF files for MBS item 723 and supporting documents Allied Health Forms become available in the Documents page 9 5 1 Signing Documents If you untick the box to Electronically sign the Allied Health Referral Forms or similar for any Home Medicines Review Referral Forms if simply means that the documents created are not electronically authenticated You can sign them electronically from the patient list by finding the patient using the patients with unsigned documents filter if appropriate and clicking the Sign Documents action in the Actions column You can of course sign the documents manually on paper if you wish You can also electronically sign documents from the Overview page in the Unsigned Documents widget Copyright 2015 Precedence Health Care Pty Ltd 84 cdmNet User Manual Version 3 80 Chronic Disease Management Network Logged in as Dr Beverly Crusher GP Met Precedence Health Care Patients Reports Surveys Resources Preferences Help Log Out Patients You are currently involved in the care of the following patients A indicat
92. ressure mmHg History Hip Circumference cm History Heart Rate bpm History Waist Circumference cm History Weight kg History Blood Glucose Level mmol L History Steps Per Day steps History Oxygen Saturation SpO2 History Lung Function FEV L History BMI kg m History Risk Calculations Measurement Latest Target Recent Measurements 2 Dec 2013 8 Jan 2014 5 Jan 2015 Absolute CVD Risk Figure 18 Measurements Summary Page Targets only appear on this page if the patient has a care plan The main point of the measurements page is to keep track of the history of measurements and review how well the patient is progressing to achieve the targets Copyright 2015 Precedence Health Care Pty Ltd 29 On this page all providers can Add Measurements Measurements and to each category cdmNet User Manual Version 3 80 see Chapter 4 2 4 1 Adding Click History in the Actions column to add a new measurement to a particular measurement type see Chapter 4 2 4 2 History If the PCP or CPC had any of the relevant data for a particular measurement type on their clinical desktop software Best Practice or MD3 you should find it that it has been uploaded into the appropriate fields in the Measurements Page The Self Monitoring category is primarily for patients who wish to enter measurements they took themselves for example readings from a home blood sugar level monitor However as a
93. rk provider example com Add Agreement Mobile 03 4999 999 999 Remove from Care Team Allow Plan Editing Justin Case Pharmacist Blue Bottle Melbourne 49 High Street Work provider example com Remove Agreement Mobile 03 4999 999 999 Remove from Care Team Allow Plan Editing Alyssa Ogawa Nurse Practice Registered Enrolled Omega Health Perth 1 Generation Street Fax 08 4815 162 342 Add Agreement Remove from Care Team Allow Plan Editing Figure 84 Team Care Arrangement Awaiting Care Team Agreement While if is recommended that all care team members agree to the TCA independently you can agree to their part in the agreement on their behalf provided that you have consulted with them about it To do this click Add Agreement and tick the box to confirm that you have consulted with the provider Copyright 2015 Precedence Health Care Pty Ltd 82 cdmNet User Manual Version 3 80 Edward ELRIC Born 15 Jul 1935 80 years Gender Male Medicare None Recorded IHI None Recorded 1 Full Street Perth Western Australia 4000 Turn Off Patient Notifications Schedule Telehealth Conference Overview Contacts Health Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education A indicates that care plan editing is allowed Update Services Location Contacts Agreement Actions Brian Butterfield Dietitian Butterfield Enterprises Melbourne 1 Care Way Work pro
94. rman Middie Name e Last Name Cottle Provider Details Speciality Community Health Worker E AHPRA Number MED1234567890 Contact Details You must enter either an email address or a mobile number Email Address sherman example com Mobile Number 04815162432 Phone Number Fax Number Cancel Continue Figure 1 Registering Provider Details After clicking Continue you are prompted to add Practice or Organisation Details Organisation Details If you leave the organisation name blank cdmNet will use your name as the organisation name You must enter an address If you work in multiple organisations you will have the opportunity to add other organisations on the next screen indicates a required field Address Organisation Name e Street Address 84 Stellar Street e City Suburb Melbourne e State Victoria z e Postcode 3000 Contact Details Email Address sherman example com Mobile Number 04815162432 Phone Number 04123456789 Fax Number Back Continue Figure 2 Register Organisation or Practice Copyright 2015 Precedence Health Care Pty Ltd 1 cdmNet User Manual Version 3 80 Note that when you register all registered providers within the same postcode of your organisation are added to your organisation s preferred provider list see Chapter 7 6 Preferred Providers Depending on
95. rom Medicare for completing this assessment Please choose the MBS Item Number you intend to claim for this service Health Assessment Brief 701 Health Assessment Standard 703 Health Assessment Long 705 Health Assessment Prolonged 707 Not claiming through Medicare Please note cdmNet does not automatically claim MBS items for you Are you sure you want to approve the assessment Health Assessment for Female Aged 75 Years and Older created by Dr Positive Impact on 15 Jul 2015 Please note that once approved you will no longer be able to edit the assessment Cancel Approve Figure 50 Approving an Assessment with MBS item numbers After approval the assessment goes into the Completed Assessments section cdmNet adds a Progress Notes entry and makes the assessment available for viewing on the Assessments page for all care team members as well as the patient You can also delete assessments by clicking Delete Please note that approved assessments with associated MBS items cannot be deleted If you approved an assessment and associated it with an MBS item you can see the details of this assessment in the Reports section see Chapter 5 Reports To upload an existing assessment you have completed outside cdmNet click Upload Assessment Note that all care team members including the patient can view or download any assessments you upload Just as with the uploaded documents on the Documents Page you can contro
96. roviders Preferred Providers are the providers that you can assign particular tasks to on patient care plans If is good to add preferred providers to your organisation s because that preferred provider list acts as a master list and the providers on that list become available as preferred providers to the other GPs within the organisation s To add a preferred provider to an organisation click Add Preferred Provider to the right of the Preferred Providers section heading You can add preferred providers by clicking e Add Preferred Provider and e Add Preferred Providers from Postcode Copyright 2015 Precedence Health Care Pty Ltd 66 cdmNet User Manual Version 3 80 Clicking Add Preferred Provider displays a page similar to Figure 61 including the option of registering a new provider on their behalf To search for providers by postcode simply enter the postcode from which you would like to add preferred providers cdmNet then automatically adds all registered providers from that postcode both individuals and organisations Once there are preferred providers in the organisation s Preferred Providers list on your own Preferences page next to the Preferred Providers heading is a tick box labelled Include Preferred Providers from Organisation By default this tick box Is ticked and it means that all of the preferred providers from your organisation s are also your preferred providers You can also add individual pref
97. rview Contacts Health Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education Patient Details Name Elizabeth Lochley Medicare Number 4291 68686 1 IHI None Recorded Edit cdmNet Number 1582101841 Show cdmNet Card Date of Birth 24 Nov 1995 Gender Female Indigenous Status Non indigenous Edit cdmNet Status Active Edit Marital Status Unknown Preferred Contact Method Email Notifications Enabled Yes Notifications will be sent by Email Primary Address 5 Babyion Street Melbourne University Victoria 3052 Contacts Home elizabet example com Health Insurance Details Edit Type Unknown CALD Information None Edit Additional Contacts No additional contact information available Add Additional Contact Primary Care Provider Provider Dr Beverly Crusher 5097331B Address Omega Health 1 Generation Street Perth Western Australia 6000 Contacts Work beverly example com Mobile 0481 516 2342 Change Figure 14 New Patient Health Record Contacts Page On the Contacts page Primary Care Providers and Care Plan Creators only can e Turn On Off Patient Notifications whether the patient displayed receives notifications from cdmNet about their care plan this is available on alll pages e Hide or unhide the patient this action is available to all providers on all pages e Edit the IHI of the patient e View the patient
98. s Notes entry displays this reason Clicking the file name in the File column opens a new window displaying the content of the document You can also click View in the Actions column to view the document in a new window Clicking the description of the file in the Description column allows you to change the description of any document you uploaded You can download a document by clicking Download in the Actions column You can also delete any documents that you have uploaded by clicking Delete in the Actions column Copyright 2015 Precedence Health Care Pty Ltd 47 cdmNet User Manual Version 3 80 Gabriel CELESTE Born 1 Jan 2001 14 years Gender Male Medicare None Recorded IHI None Recorded 7 Stars Close Melbourne Victoria 3000 Turn Off Patient Notifications Schedule Telehealth Conference Overview Contacts Health Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education Show Current and Uploaded Documents Only Uploaded Documents Upload Document File Description Uploaded By Upload Date Actions There are no uploaded documents Patient Documents Document Actions Patient Summary View Download Current Care Plan Care Plan View Download Approved Care Plans Document Approval Agreement Date Actions Team Care Arrangement 723 15 Jul 2015 View Download GP Management Pian 721 15 Jul 2015 View Download Annual Cycles of Care Document Appr
99. s cdmNet Number and Card see Chapter 4 2 2 1 A Patient s cdmNet Number and Card e Edit indigenous status Aboriginal or Torres Strait Islander e Edit the patient s cdmNet status Active Discontinued or Deceased e Edit the patient s health insurance details Copyright 2015 Precedence Health Care Pty Ltd 24 cdmNet User Manual Version 3 80 e Edit the patient s CALD Culturally and Linguistically Diverse information e Add Edit or Remove a patient s Additional Contacts multiple additional contacts are allowed and e Change the patient s Primary Care Provider see Chapter 4 2 2 2 Changing a Patient s Primary Care Provider When viewing the health record for a patient who has a care plan this page also lists the Care Team Details 4 2 2 1 A Patients cdmNet Number and Card The cdmNet Number is a unique number identifying the patient s record within cdmNet Click View cdmNet Card to display a printable card containing this number and a barcode for use in conjunction with third party systems that integrate with cdmNet Evangeline MCDOWELL 1 Mahora Avenue Melbourne Victoria 3000 7 Evangeline McDowell 1 Mahora Avenue C d m e t Melbourne Victoria 3000 1582101914 Return to Health Record Print Figure 15 A Patient s cdmNet Number and Card 4 2 2 2 Changing a Patient s Primary Care Provider To change a patient s Primary Care Provider click Change Primary Care Provider cdmNet dis
100. s tick box is Copyright 2015 Precedence Health Care Pty Ltd 67 cdmNet User Manual Version 3 80 ticked and it means that all of the care plan creators from your organisation s are also your care plan creators You can also add individual care plan creators to your own Care Plan Creators list manually by clicking the Add Care Plan Creator action and following the prompts 7 8 Linked Accounts This is only available to PCPs If you have an account in a third party system that offers integration with cdmNet for example Extensia you can enter the username and password in the Linked Accounts section of your preferences so that cdmNet can communicate with the external system on your behalf Copyright 2015 Precedence Health Care Pty Ltd 68 8 Help cdmNet User Manual Version 3 80 Clicking Help opens a new window with the following page precedence carce Login or register for A t Home About cdmNet General Practice Allied Health cdmNet Help Welcome to cdmNet help cdmNet is an online productivity tool for GPs their practice nurses care providers and patients to assist them to better manage chronic disease cdmNet automates the complex administrative and communication tasks associated with chronic disease management freeing up GP time and improving productivity It facilitates collaboration and sharing of information among the care team and allows patients to understand and better manage their own care
101. sion 3 80 Medications Add Goal Goal Task Responsible How Often Last Next Correct use of medications Domiciliary J Case Every 2 years Due Jul 2015 medication Pharmacist Target No incidents of misuse of management medications review Dr B Crusher Every year Due Jul 2015 GP Review inhaler hal is Every year Due Jul 2015 a sn technique Inhaler technique Patient Ongoing Ongoing Edit Name idei AS required As required Figure 26 Adding a New Task In previous releases of cdmNet adding tasks occurred in a separate screen You can still use this method of adding tasks by holding down the Alt or Option key on your keyboard when you click Add Task When you click Add Task cdmNet adds a new provisional task row into the goal To edit the task name click Edit Name If there are pre defined tasks available for the goal a combo box downward triangle appears from which you can select the pre defined task you want When you choose a pre defined task cdmNet automatically fills in the other information for that task including assigning a provider from the Primary Care Provider s preferred providers if applicable setting the task s frequency and displaying the Next date If you want to add a custom task type in the task s name rather than choosing a pre defined option If there are no pre defined tasks available for the goal the combo box downward triangle does not appear You can also edit tasks and g
102. sion 3 80 There is a problem that needs resolution for example an overdue task Not highlighted The task may be the patient s responsibility Or The task has already been assigned to another provider Note that only Primary Care Providers and Care Plan Creators can assign providers to tasks Care Team Members cannot assign themselves to tasks regardless of their speciality and association with a patient 4 2 5 1 Adding Editing and Deleting Goals and Tasks This functionality is only available to PCPs and CPCs To add a new goal click Add Goal to the right of the section title to which the goal applies Add Goal indicates a required field e Section Lifestyle Goal Pre defined Goal Assess driving capability New Goal Target Safe driving skills Cancel Add Goal Figure 25 Adding a New Goal To view all available pre defined goals select the All option from the section menu You can add pre defined goals that apply to the patient s conditions as well as goals that may apply to other conditions where you see fit You can add a custom goal if you cannot find an appropriate goal in the pre defined goal list To do this click the New Goal radio button and fill in the appropriate details in the boxes provided You can add tasks to particular goals where you see fit by clicking Add Task in the appropriate goal row Copyright 2015 Precedence Health Care Pty Ltd 35 cdmNet User Manual Ver
103. sion Lane Work provider example com Remove from Care Team Fax 1591 59 159 Allow Plan Editing Heal Toe pia Podiatrist Melbourne 24 Inch Lane Work healtoepia example com Remove from Care Team Allow Plan Editing Dean Learner Garden Maintenance Melbourne 1 Dark PI Mobile 0432 165 4987 Remove from Care Team Manual contact required Alyssa Ogawa Nurse Practice Registered Enrolled Omega Health Perth 1 Generation Street Fax 08 4815 162 342 Remove from Care Team Allow Plan Editing Figure 41 Care Team Page On this page you can e Click a care team member s email address to send them an email e Click a care team member s contact number fo initiate a Skype call if Skype is installed e Allow or don t allow a care team member to edit care plans and e Remove a care team member from the care team When you click Allow Plan Editing for a care team member a green dot appears next to the care team member s name Enabling a care team member to edit care plans means that they are able to edit a care plan in the same way that a Care Plan Creator can Click Don t Allow Plan Editing if you no longer want that care team member to be able to edit care plans When a TCA has been distributed see Chapter 9 5 Care Team TCA Agreements the Care Team Members need to agree to participate If when they have a grey thumbs up icon appears next to their name As a PCP or CPC you can add agreements from Care T
104. sk to one of the top 5 preferred providers who have the recommended speciality for the task as per the Primary Care Provider s preferred providers Lifestyle Responsible How Often Last f fil Maintain healthy diet Comprehensive Every 2 years Due Jul 2015 education and review Target Patient maintaining healthy d Action to achieve target Patient GP Dr Beverly Crusher Omega Health GP Dr Beverly Crusher Zeta Health Action to Speciality achieve target Maintain physical activity Provider Other Target 30 Minutes per day of selected exercise 5 days per week within patient limitations Target Weight lt 95 of current Weight Brian Butterfield Dietitian Butterfield Enterprises Alyssa Ogawa Nurse Practice Registered Enrolled Omega Health Marjorie Dawes Dietitian Fat Fighters Assessment and counselling Mr Emmett Brown Nurse Practice Registered Enrolled Figure 31 Edit Responsible Party Menu Selecting Speciality allows you to select a speciality for a task without having to select a specific individual or organisation When you choose a single speciality you can also record appointments and generate Allied Health Referral forms for that speciality see Chapter 4 2 7 Documents Page Assign to a Speciality Select a speciality to assign to this task Task Maintain healthy diet Comprehensive edu
105. t review task is added to the Correct use of medications goal of the Medications section of the Planning page you will be warned that this document will be generated automatically when the GPMP is approved See Chapter 4 2 5 1 Adding Editing and Deleting Goals and Tasks When a document has not yet been approved such as GPMP or TCA a Drafts section is displayed containing the related documents The Supporting Documents section contains documents that accompany the care plan including referral forms for Allied Health services or Home Medicines Review HMR Allied Health services documents will only be available when the TCA has been approved as long as you allocate a number of services for the individual Allied Health providers When supporting documents are already available for the current year Primary Care Providers and Care Plan Creators can create new or modify existing supporting documents where available to prepare for the following year and future needs of the patient by clicking Create Modify Supporting Document Create Modify Supporting Document Editing Referral forms for Allied Health Services for 2015 last modified on 15 Jul 2015 Referrals for Individual Allied Health Services Please enter the number of services provided by each Allied Health provider on this care plan Year 2015 gt Allied Health Provider Individual Services Diabetes Educator Diane Beeaties 1 Dietitian Brian Butterfield 2 P
106. the PCP Depending on your role you may be able to change a patient s PCP on the patient s health record if you wish see Chapter 4 2 2 2 Changing a Patient s Primary Care Provider A small number in red next to a patient s name indicates whether any Progress Notes have been added since you last viewed the patient s health record see Chapter 4 2 10 Progress Notes Page If you are assigned to some patients indirectly for example as a member of an organisation or a care plan creator you can click Show Assigned Patients to view only patients to whom you are assigned Copyright 2015 Precedence Health Care Pty Ltd 19 cdmNet User Manual Version 3 80 If you are logging in to cdmNet for the first time you may not have any patients This may be because you have not uploaded any patient information from cdmNet Desktop or you may not yet have been assigned to any patients by a PCP If you cannot find a patient s name this could mean one of two things 1 If you are a PCP or a CPC you need to upload the patient s details from your clinical desktop software using cdmNet Desktop see the cdmNet Desktop Guide available at cdm net au help guides 2 Otherwise the patient s PCP has not added you as a member of the patient s care team Contact the PCP and ask them to assign you to a task on the patient s care plan The actions column appears if there are any actions that you can perform For more information about these acti
107. the view and column you select until you change it When you first view the patient list the Status option is selected The Status view of the patient list initially sorts patient records by the Status column under the Care Plan category The columns included in the Status view include e Referring GP the patient s Primary Care Provider e Status the status of the patient s care plan e Last Care Plan the date when the patient s care plan was approved e Next Review and e Programs this column appears if you have any patients participating in a program The Clinical Metrics view of the patient list initially sorts the patient records by the Attention column t This filter only appears for GPs and providers who have the role of primary care provider Copyright 2015 Precedence Health Care Pty Ltd 16 cdmNet User Manual Version 3 80 Patients Reports Surveys Resources Preferences Help Log Out Logged in as Dr Beverly Crusher GP et Precedence Health Care Chronic Disease Management Network Patients You are currently involved in the care of the following patients A e indicates that you are the primary care provider Show all patients from any organisation Z O include hidden patients S Search Status Clinical Metrics Self Monitoring Metrics Create Health Record Download Patient List Patent Demograprics eet Ciel Metis Date of Birth 11 Nov 1978 No Referring GP HbAi
108. to an Organisation You can enter a first name last name or provider number If you cannot find a provider they may not be registered with cdmNet However you can register a new provider on their behalf by clicking Register a New Provider and filling in the appropriate details in the boxes provided Providers without these details will not be able to participate in the patient s care using cdmNet As long as you are able to provide a correct method of contact that provider should receive a notification with a username and temporary password they can use to log into cdmNet in future Copyright 2015 Precedence Health Care Pty Ltd 65 cdmNet User Manual Version 3 80 indicates a required field Provider Name Title e First Name Middle Name e Last Name Provider Details Speciality GP M e Provider Number Contact Details You must enter an email address a mobile number or a fax number Email Address Mobile Number Phone Number Fax Number Cancel Continue Figure 62 Registering a New Provider During the process of registration other providers may indicate that they belong to an organisation to which you already belong cdmNet records them as pending organisation members The Pending Organisation Members section appears when there are providers who have requested membership of the organisation but not yet been accepted Click Accept or Reject next to the provider s name at your discretion 7 6 Preferred P
109. to be a smoker Referring GP the patient s Primary Care Provider HbAIc in Blood Pressure in mm Hg Cholesterol in mmol L BMI in kg m and Programs this column appears if you have any patients participating in a program If you have an extensive list of patients you can change the number of patients shown per page up to 300 The Self Monitoring Metrics view initially sorts the patient records by name Copyright 2015 Precedence Health Care Pty Ltd 17 cdmNet User Manual Version 3 80 Patients Reports Surveys Resources Preferences Help Log Out Logged in as Dr Beverly Crusher GP et Precedence Health Care Chronic Disease Management Network Patients You are currently involved in the care of the following patients A indicates that you are the primary care provider Show all patients EJ from any organisation M Include hidden patients Search Status Clinical Metrics Self Monitoring Metrics Create Health Record Download Patient List P Patent Demographios Sf Monitoring Metis OOOO OOOO O Date of Birth Blood Pressure Weight Steps Day SpOz2 FEV BMI Actions e Eric Banks 26 Nov 1981 Jet Black 31 Mar 1974 Hide Patient Selvaria Bles 11 Nov 1978 Hide Patient e Michael Bodger 9 Mar 1985 Hide Patient e Charlie Brown 1 Nov 2001 Manuel Calavera 16 Nov 1960 160 90 97 2700 2 3 Hide Patient Gabriel Celeste 1 Jan 2001 Sign Documents Hide Pat
110. u have to e Create the patient s health record then e Create a care plan that is appropriate for the patient For information about creating a health record for a patient see Chapter 4 1 Creating a Patient s Health Record 9 1 Creating a GP Management Plan Start months ceme gt e J TOA Review Review St 3 months 3 months La 3 months TCA Review 6 months TCA Review Figure 65 The Cycle of a GPMP Overall Cycle of Care Two Years Times between GPMPs and Reviews are as recommended by Medicare but may be tailored to patient s needs As recommended by Medicare the duration of the overall cycle of care when implementing GPMPs is two years as illustrated in Figure 65 Of course times between GPMPs and Reviews can be tailored to an individual patient s needs Once a patient has a health record you can create a GP Management Plan To create a Care Plan click Create Care Plan or Referral from either the Overview or Planning page when viewing a patient s health record cdmNet displays the following Please note that if you are a Primary Care Provider and nominated as a Care Plan Creator for the patient s Primary Care Provider as well as being a member of the same organisation you automatically become the patient s Primary Care Provider if you create their care plan Copyright 2015 Precedence Health Care Pty Ltd 70 cdmNet User Manual Version 3 80 Create Care Plan or Refer
111. umn this indicates the organisation has members with different specialities you need to choose one of these specialities to assign If there is a menu in the Location column this indicates that the provider is a member of multiple organisations you need to choose one of these organisations as appropriate to the referral If a provider has the additional text organisation referral in the Location column this indicates that the task would be assigned to the organisation as a whole not the individual provider When you have selected the provider for a task you can assign them fo all tasks that the previous provider was assigned to or assign them to unassigned tasks with that provider s speciality You can do this by ticking the Assign to all tasks box when it becomes available after you select a provider Selecting Other from the menu allows you to search for a service provider a provider whose speciality is not medical Copyright 2015 Precedence Health Care Pty Ltd 39 cdmNet User Manual Version 3 80 Assign to Other Provider Select a provider to assign to this task Task Minimise risk of falls outdoors Keep garden paths clear Service Type Any Speciality xf Service Provider BC Speciality Garden Maintenance Provider name or Organisation City Suburb Postcode State Victoria xj Display preferred providers only Search Name Speciality Location Hans Dee Garden Maintenance Melbour
112. upport team by visiting cdm net au help Copyright 2015 Precedence Health Care Pty Ltd 89 10 Glossary Term ACoC APCP CPC GPMP HPI I HPI O IHI PCP PHC Provider Service Provider TCA WebEx Copyright 2015 Precedence cdmNet User Manual Version 3 80 Annual Cycle of Care A yearly program of care for managing diabetes cdmNet only supports annual cycles of care for diabetes Associated Primary Care Provider A CPC who is also a PCP and a member of the same organisation as a patient s Primary Care Provider APCPs can construct and manage care plans with the ability to approve documents in their own right as well as electronically signing supporting documents such as Allied Health Forms Care Plan Creator A provider who can construct and manage care plans on behalf of a PCP General Practitioner Management Plan A plan devised by the PCP or CPC to manage a patient s chronic disease s Health Provider Identifier for Individuals A unique number that identifies an individual who provides health care services Health Provider Identifier for Organisations A unique number that identifies an organisation that provides health care services Individual Health Identifier A unique number that identifies an individual such as a patient Primary Care Provider The main care provider responsible for a patient who constructs and manages care plans Precedence Health Care Pty Ltd Th
113. useenceeee 54 AAA FAUCO Or r E EE A EE E E OEE 56 S ROPO ea Eee ERE 57 acta ieee ass ae cd screed nie renter meanest 60 T PEEN SS ca SEERE SEE SURE SES pnesaphon T cqenacaadentieatdea a cia E 61 7 1 Account Details ie ose aise rnc cerca rctienernreoue vs voewe te eiaanoaiinbaeasenrencsasertsbusaoumueedntaeemesurouetiecunsens 62 BE EON ED US TE E A re 62 Fo POS DGI I ips EEN ER Se EET 62 TA GORE DOS GE EEN E E E E 62 V SNER ROOMS OT eae A E E A E 63 7 5 1 Adding Members to an Organisation essessssssssssresreserresrrertesrrsereserssreeeeeseee 65 LO PEO TOV G e E E E E E E E E T 66 Tesh Care PIS CON recreates cistrace aeotere grep io EE NEE ELSEN ES 67 Fo Gm S CE HR SEE EET SE E E E ES 68 e PED eee ner RENEE DERES SEERE ERE E 69 7 Caina Care PIONS anise 70 Copyright 2015 Precedence Health Care Pty Ltd 2 cdmNet User Manual Version 3 80 9 1 Creating a GP Management Plan 1 W u sseeeseveeeveeeevene eve venerne ene ne ennen venerne een 70 Pe NOMO CIO LEE E een ere a 73 23 cnt 6 4 612 TAS G7 1 Ree eee ee 75 hoal Wna FIO Delis NOX ES ore re AEA E EA EOAR ies 9 4 Scheduling Telehealth CONFErENCe S cccccccseescceescccscccssccesscceescsensceeesceeeseeencs 79 9 5 Care Team TCA AQGrEG Me N1S ccccecceeccsecescceeccsecenceeccseceeceseceeceeceseceeeeeceneceecees 82 PEEL SIE AA IDO CUS REE ME nce monet eeneanene E E E 84 2092 Leaving Nne Care TEON errno nee ner 85 96 TRE VIS WING SFI APS entisteseranstcm
114. usher GPMP awaiting your approval 15 Jan 2016 Hide Patient e Amy Wong 4 Apr 2004 Dr Beverly Crusher GPMP awaiting your approval 15 Jan 2016 Hide Patient Sheldon Cooper 1 May 1986 Dr Beverly Crusher GPMP Review overdue 15 Jul 2015 Hide Patient Jet Black 31 Mar 1974 Dr Katherine Pulaski 15 Jul 2015 15 Jan 2016 Hide Patient Michael Bodger 9 Mar 1985 Dr Beverly Crusher 15 Jul 2015 15 Jan 2016 Hide Patient Gabriel Celeste 1 Jan 2001 Dr Julia Heller 15 Jul 2015 15 Jan 2016 Sign Documents Hide Patient e Yuki Nagato 11 Nov 2011 Dr Beverly Crusher 15 Jul 2015 15 Jan 2016 Sign Documents Hide Patient e Edith Rubble 4 Apr 1934 Dr Beverly Crusher Hide Patient Reimi Saionji 16 Nov 1970 Dr Beverly Crusher 15 Jul 2015 15 Jan 2016 Sign Documents Hide Patient e Faye Valentine 4 Mar 1986 Dr Beverly Crusher Hide Patient Figure 6 Patient List in Status View To the left of the patient list there are two filters The first filter allows you to see e All patients e Patients with unsigned documents Allied Health Forms and HMR Forms e Patients awaiting action from you e Patients awaiting action from others e Patients with unseen notes e Patients not receiving notifications e Patients with after hours referrals and e Patients participating in programs The patients with after hours referrals choice will only display patients if you are participating in certain programs Choices for patients in programs participating in
115. vice for sharing of important information among the care team and with the patient It is not intended to be a substitute for storage of documents and Precedence Health Care does not guarantee that any uploaded documents will be permanently retained indicates a required field File to upload Browse No file selected Description Visible To Everyone Specific people Amy Wong Patient Brian Butterfield Dietitian Hazel Glass Optometrist Heal Toe pia Podiatrist Cancel Upload Figure 43 Editing Visibility of Uploaded Document Copyright 2015 Precedence Health Care Pty Ltd 46 cdmNet User Manual Version 3 80 Faye VALENTINE Born 4 Mar 1986 29 years Gender Female Medicare 3777 75600 1 IHI None Recorded 60 Hills Road Melbourne Victoria 3000 Turn Off Patient Notifications Overview Contacts Health Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education Uploaded Documents Upload Document File Description Uploaded By Upload Date Actions _MG_5212 jpg Photo of patient Dr Beverly Crusher GP 21 Sep 2015 12 29 PM AWST View Download Edit Delete Figure 44 Documents Page of a Patient with No Care Plan When you upload a document an entry appears in the Progress Notes page detailing the date time and the description if applicable If you delete a document you uploaded cdmNet prompts you for a reason for deleting the document and the Progres
116. vider example com Remove Agreement Mobile 03 4999 999 999 Remove from Care Team Allow Plan Editing Justin Case Pharmacist Blue Bottle Melbourne 49 High Street Work provider example com Remove Agreement Mobile 03 4999 999 999 Remove from Care Team Allow Plan Editing Alyssa Ogawa Nurse Practice Registered Enrolled Omega Health Perth 1 Generation Street Fax 08 4815 162 342 Add Agreement Remove from Care Team Allow Plan Editing Figure 85 TCA Agreed Pending Approval Once you have enough agreements from your Care Team Members you can approve the TCA by clicking Approve TCA from the Planning page or the Overview page Overview Contacts Health Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education Care Plan Conditions Chronic Obstructive Pulmonary Disease Mental Health Created by Dr Beverly Crusher Next review 15 Jan 2016 Change Valid from 15 Jul 2015 Change GPMP 721 As approved on 15 Jul 2015 Restart Care Plan Sequence TCA 723 Awaiting your approval Approve TCA Rebuild Care Plan Figure 86 Approve TCA from Planning Page A 1 Overview Contacts Health Summary Measurements Planning Care Team Documents Assessments Reports Progress Notes Education TCA awaiting primary care provider approval Approve TCA Clear understanding of conditions Comprehensive Due Jul 2015 education and review Go To Care Plan
117. y manage and refer CKD in your practice Chronic Kidney Disease Management in General Practice PDF Guidance and clinical tips to help identify manage and refer CKD in your practice Clinical guidelines The RACGP endorses a wide range of guidelines to assist general practitioners in their work Clinical guidelines for Musculoskeletal Diseases Clinical guidelines for Musculoskeletal Diseases Clinical Guidelines for Stroke Rehabilitation and Recovery Clinical Guidelines for Stroke Rehabilitation and Recovery Clinical Practice Guideline Early Breast Cancer Full Guidelines for management of early breast cancer for health professionals and consumers COPD X guidelines COPD X guidelines Diabetes Australia The Diabetes Australia Website Diabetes Management in General Practice Guidelines for Type 2 Diabetes Diagnosis management and prevention of Infections in recently arrived refugees Clinical Guidelines and resources Figure 58 Resources Page Clicking any of the links under the Resource column opens a new window with information that corresponds with its Description Copyright 2015 Precedence Health Care Pty Ltd 60 cdmNet User Manual Version 3 80 7 Preferences Account Account Name beverly Password eeeeeeee Change Notifications Enabled Yes Change Notifications will be sent by Email Time Zone Australia West Edit Assignment Automatically assign providers to care plan tasks Edit Test Patients Test Patients are not allowed Al

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