Health One Chronic Disease Management · Chronic Obstructive Pulmonary Disease (COPD) ... Some...

Chronic Disease Management Version 8.7.1 March 2020

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Health One

Chronic Disease

Management Version 8.7.1


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Contents

Health one Version ................................................................................................................................. 3

Chronic Disease Management Protocol ................................................................................................ 4

Registration ............................................................................................................................................ 4

Add Review ............................................................................................................................................. 8

Ordering Bloods .................................................................................................................................... 20

Tracking Submissions-CDM Dashboard ............................................................................................... 22

Message Responses .............................................................................................................................. 24


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Health one Version This document will help you become familiar with the new features in Health one version

8.7.1 To ensure you are using the correct version, go to Help > About and check the version

from here. If you are having any problems upgrading, please contact support on 01 4633000.


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Chronic Disease Management Protocol The Chronic Disease Management menu is available for all patients in Health One but at present, it is only applicable for patients who are 75 or over and who have a valid GMS / DVC card.

1. CDM Patients Once you have signed and submitted the contract the CDM reviews will be required as outlined in the Contract for GMS or DVC patients over 75 with any of the following chronic diseases:

Diabetes Type 2 Asthma Chronic Obstructive Pulmonary Disease (COPD) Cardiovascular Disease

o Heart Failure o Ischaemic Heart Disease  o Cerebrovascular Disease (Stroke)  o Cerebrovascular Disease (Transient Ischaemic Attack - TIA)  o Atrial Fibrillation 

2. CDM Review As per the CDM contract there are a maximum of 2 Reviews required in a rolling twelve-month period. The twelve-month period is considered to be a rolling twelve months from the date of the first review.   Each review will consist of two visits (One with Nurse / Phlebotomist and one with the doctor). There must be at least 4 months between all reviews. The CDM Registration screen is part of every review as the patient may need to be registered for new diseases at any of their Interim or Annual reviews.

Registration To begin, we will open a patient in Health One who has a valid GMS card and is over 75 years. In the

example below, this patient has in her problem list, ‘Diabetes Mellitus type 2’.


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We will first register this patient using the Chronic Disease Management Mediform by clicking on the

Mediform button in the patient file.

Search for the Mediform by typing CDM into the search bar.


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If this is not immediately available in the ‘My Forms’ tab, try search under ‘All Forms’. Tick the box to

make it available in ‘My Forms’ by default.

Highlight the form, and click ‘ok’. This will open the Chronic Disease Management Mediform. The

first part of the form will display the ‘registration’ part of the Mediform. In this example, Health One

has registered the fact that this patient has a condition in their problems list of ‘Diabetes Type 2’ and

it has automatically ticked this in the registration form with the date diagnosed.


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In this example, you can see from the patient’s problem list that they had coronary artery stenting

and an ‘endarterectomy’. This indicates that the patient also has ‘Ischemic Heart Disease.

We will therefore tick the box on the CDM (Chronic Disease Management) form and enter the date

diagnosed in the column on the right. We will also for demonstration purposes give her a new

diagnosis of COPD and enter the year diagnosed as 1999. Please note, you can put a full date or a

month and a year.


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Add Review

Once you click ‘ok’, Health One will bring up the review form and will register those conditions

locally in Health One in the patient file. Please note, this can take a couple of seconds while it

registers the conditions and brings the review form up.

As you can see in the example below, Health One has brought up the review form, and has

registered the conditions on the left in the patient’s problems list (Blue Arrow). The top of the form

shows you it’s this patient’s first review (red arrow). It also displays his conditions, (green arrow) and

it tells you here that they have all been registered in Health One.

You can register a disease or go back and edit anything on the registration form by clicking the

‘Diseases’ button at the top. (Grey Arrow).

At the top of the form you will see the responsible doctor, the doctors GMS number, and the IMC

number. (Yellow arrow).

Health One sends the patients GMS number to the PCRS and the PCRS will send back the doctor’s

GMS number. Health One will look in the UserDB to see which Doctor this GMS number is assigned

to. If it finds a doctor, it will populate the Responsible field with that doctor’s name. If it finds a

number of doctors with this number it will give you a drop down list to choose a doctor from.

If the number is not in the UserDB, Health One will give you a drop down list beside the responsible

Doctor Field to allow you to populate that field with a doctor from the list.

So we will begin populating the mediform with the information required. At the top of the form is

the Physical Examination, and underneath is the Physical Examination (Diabetes). This is only


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displayed because the patient has a condition in the registration form of Diabetes Type 2. So the

form changes based on the criteria and conditions in the registration form.

You can see the grey scroll bar on the right, (yellow arrow) and you can scroll through the form and

fill in the required fields or you can use the images on the left (orange arrow) to jump to a particular

section of the form. This brings that section to the top and makes it easy for you to fill in. If they are

in red, it means some of the mandatory fields are incomplete, if they show in blue, it means the

mandatory fields have been completed.

There’s also a message at the bottom informing you how many mandatory fields are required to

complete the form. (Blue arrow)

So we will begin to fill in the required fields on the mediform and will start with the Physical

Examination. As you can see from the example below, the red exclamation mark at the beginning of

the field is removed and replaced with the blue circle icon indicating the field is complete. (Blue

arrow). In this example, when the blood pressure was entered, Health One has given a hint that the

patient may have mild hypertension. (Red Arrow).


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We will continue through the mediform, populating the required fields. You can see the Physical

Examination has turned blue, indicating that all the mandatory fields in this section have been

populated.


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Next we move to the ‘Risk Factors’ section and fill in the required fields. When you get to the ‘Audit

C Score’ you will see a button that gives you the option to open up another mediform within this

form.

In this example, you can fill in the information to and can use this mediform to get the patients Audit

C score. If you wish you can fill in all the fields here, but these are not mandatory, the only

information you require is the Audit C score.

Click ‘Ok’ to save this.


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Continue to fill in the required fields on the form. Some answers will trigger additional questions.

Under Vaccines, if there has been an Influenza Vaccine given in the past ten months, this will be

automatically populated with the date the vaccine was given. If the patient has ever had a

Pneumococcal Vaccine this will also be auto populated with the date the vaccine was given. You can

also view the vaccine history by clicking the ‘Vaccine History’ Button. (Blue arrow)

The risk factors button will turn blue (Red Arrow) indicating all these fields have been populated and

we will move on to Disease Management.

The Disease Management section of the form begins with the ‘CVD Score’ which is the Q-Risk Score.

To calculate the Q-Risk Score, you will click the little search icon beside the ‘CVD Score button’. This

will bring up the Q=Risk mediform. Please note, when you click this search button (Blue Arrow

below) it may take a couple of seconds for this form to appear.


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The Q-Risk Form opens and will be pre-populated with any information it can from the chart. Fill in

any other required fields and click the ‘calculate’ button at the bottom to calculate the Risk Score

and then press ‘Ok’ to save the value to the CVD Risk Score.


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In this example, as this patient also has COPD, we are asked for the COPD score. This question has a

drop down list to choose from.

That completes the disease assessment in this particular example. The Disease Management button

at the side will turn blue as before, and we will move on to the Investigations section. The first two

questions, have an icon (Blue Arrow) beside them. The first one asks if the patient has ever had an

ECG and the second if they have had Spirometry. To check this in the file, I can click the icon to see if

they have had them.


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Health One will for the first question, check to see if there is any mention in the patient’s file of an

ECG. In this example she had one in 2003. As before, if you say yes, an additional field will appear

where you can enter the result.

When you click the icon beside the second question, it will do the same for Spirometry.

In regards to the laboratory investigations, they will be empty by default, unless the patient has had

bloods done in the past three months. If they have been done, then they will be auto populated.

In this example, bloods were done in the past three months and most were pre-populated. I

manually populated any results that had not been picked up by default. If a blood has not mapped


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correctly, press CTRL+F to open search for the chart and you can manually search for a particular

blood result this way. If the result is not available, you can click the ‘NA’ which will make the results

field ‘Not Available’. This field will now be seen as completed.

The Thyroid Function and Liver Function buttons act the same as the ECG and Spirometry, you can

click the icon beside them and Health One will search the chart to see if there is any mention of

them in the patient file.

That completes the Investigations part of the form. Just to note, if it is a first visit, you may be taking

the bloods today for the first time and may not have any results to enter. If this is the case, you can

save the form to complete the Lab Investigations at a later date.

In this example, they are completed, the button on the left will turn blue and we will move on to the

Medication Review and Patient Education.

The first question asks us has the patient had a medication review. We can say ‘yes’ or ‘no’ and if we

say yes, additional fields will appear allowing us to record the date and to view the patients current

repeat medications.


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We can click the ‘tablet’ icon to review the patient’s medication. This returns a list of the patient’s

repeat medications.

We will complete the rest of the fields in this section and as before the button and we will move on

to the care plan.


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The Careplan is not mandatory and does not need to be submitted. It can be completed at

any time by the doctor or nurse. You can populate the fields as you did before.

Once you have finished, you can click the print button at the bottom and print out the care plan for

the patient. The document will only be populated with the fields you have completed.


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Once you close out of the careplan document you are back to the mediform and at the bottom of

the form is a ‘Submit’ button. If I try to submit but there are still fields left to populate, Health One

will not allow me to submit, it will prompt and warn me there are fields left to populate. In that case,

we will click the ‘Save’ button to save the information and if it’s blood results for example that the

form is waiting for, we will save until the results come back and will submit the form then.

Health One will save the information in the patient file, we will make an appointment for the patient

to come back and see the doctor where he will review the whole visit and check the results and

complete any missing fields.


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Ordering Bloods

To order the bloods in Health One, you can use the Lab Management button. Click the ‘Insert Lab

Request’ button in the patient file as you would if you were ordering any bloods for the patient.

The lab Request form opens, it is set to ‘default’ by default. To order the bloods from the Chronic

Disease Management group, option from the drop down list.


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This will tick all the required blood results for the condition you have diagnosed. You will take the

bloods, enter the date done, done by, and click ‘ok’ to save.

You would then wait for the bloods to come back from the lab.

Just to Note: If the patient develops one of the Chronic Diseases between the different examinations

and you record it by right clicking on the problems list and adding, this will automatically be part of

your Chronic Disease Management.

At any point you can bring back up the registration form, by going to ‘HCR’ and selecting ‘Chronic

Disease Management’ from the drop down list. This will bring up the registration form and allow you

register the patient for any additional diseases without having to do a new review.


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Tracking Submissions-CDM Dashboard

Next we will look at the dashboard where you can track your Chronic Disease Management

submissions.

To view the dashboard, you will go to Analysis, Chronic Disease Management Dashboard


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Here you will see a list of all patients who have had a CDM review. Here you can filter the patients by

responsible doctor, or for different time periods, by patient name, or by the status of the review.

In the example below, you can see the different stages of the CDM reviews. Some of them have not

yet been submitted as they are awaiting bloods results. Others have been submitted and accepted

(In green). The status changes when you download your bloods from healthlink, and an

acknowledgement is returned.


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In this example, you can also see CDM reviews done for patients under 75. These were not

submitted as it will only submit for patients 75 and above. So if you wish, you can use the CDM

functionality for all your patients but they will not be submitted as part of the Chronic Disease

Management at present.

When you right click on any of the patients on the list, you get some further options. You can submit

the review from here, you can check the GMS number online, you can open the form, or you can

open the patient file. There is also an option to ‘export info’. This is useful if the submission has been

rejected. You can use this option to investigate why it was rejected.

Message Responses

CDM response messages are downloaded during the normal process of downloading HL7 messages

from Healthlink in Health One.


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The updated status can be viewed from the patient’s chart and the Dasboard.

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