The national Chronic Disease Management (CDM) dashboards provide data to inform your decision-making and to help you track complex disease patient compliance.

These dashboards allow you to monitor and manage patients that are overdue for labs, appointments, injections, medication, etc. associated with specific chronic conditions, all in one convenient place.

The following table provides an overview of the chronic disease management analytics dashboards available in the Collaborative Health Record.

📌 Note: If you don’t see these dashboards in your CHR, contact the CHR support team (Contact us).

Dashboard name

Description

CDM Asthma

Tracks patients with an asthma diagnosis. Provides information on their asthma action plan and asthma medication.

CDM CAD

Tracks patients with a coronary artery disease (CAD) diagnosis. Provides information on their lipids level, blood pressure, body mass index and CAD medication.

CDM COPD

Tracks patients with a chronic obstructive pulmonary disease diagnosis. Provides information on their smoking status and immunisation.

CDM Diabetes

Tracks patients with a diabetes diagnosis. Provides information on their blood sugar levels, nephropathy, lipids, blood pressure, body mass index, and foot and eye exams.

CDM Heart failure

Tracks patients with a heart failure diagnosis. Provides information on their lipids test, blood pressure, body mass index and heart failure medication.

CDM Hypertension

Tracks patients with a hypertension diagnosis. Provides information on their creatinine, lipids, blood pressure, body mass index and hypertension medication.

Medications Due

Tracks patients with one of the chronic conditions, and who have been prescribed a continuous medication that needs to be renewed.

Filters available across all CDM dashboards

By default, the Primary Provider filter is set to is not blank, the appropriate diagnosis is selected in the Diagnosis Description and the Diagnosis status is Active.

In other words, the dashboard displays patients who have an active provider and an active diagnosis in their patient chart (the selected diagnosis depends on the dashboard, e.g. Asthma, COPD).

Here is a list of filters available across all CDM dashboards.

📌 Note: The CDM Medications Due dashboard has other specific filters. For more information, see CDM Medications Due dashboard.

Filter

Description

Primary Provider

Defaults to is not blank to show all patients with an active primary practitioner.

To limit results, select the is or contains condition, then select one or more providers from the list.

Family Physician

To see only patients of a specific family physician or group of family physicians, select the is or contains condition, then select physicians or groups for the list.

Appointment Date

Use this filter to see only patients that had an appointment within a set period of time. You could for example limit the results to patients who had an appointment in the last 3 years.

Gender

To see only patients of a specific gender, select Female, Male or Other.

Age

To see only patients of a specific age or age group, select a condition and enter the age in the field. For example, to only see patients 50 or older, select the is >= condition and enter 50 in the field.

📌 Note: Click More to see the following three filters.

Filter

Description

Diagnosis Description

This filter allows you to see only patients who have a certain diagnosis in their patient chart.

By default, the name of the condition (e.g. Asthma, COPD, Heart Failure) is selected. The reports include all patients who have a diagnosis that contains the selected value. You can change this value or add another value if you use a different description for a diagnosis.

Diagnosis Code

This filter allows you to see only patients with a specific diagnosis code in their patient chart. You can add one or more diagnosis codes by selecting them from the list. By default, no diagnosis code is selected.

Diagnosis Status

This filter allows you to filter based on the status of the diagnosis in a patient health profile. By default, Active is selected, which means only patients for whom the diagnosis is active appear in the dashboard. To include patients for whom the diagnosis is no longer active, deselect Active or select Resolved.

For more information on how to use filters, see Filtering analytics dashboards.

Colour coding

All CDM reports follow the same colour code to identify patient compliance.

  • Green: Compliant patients

  • Red: Non-compliant patients

  • Orange: Patients missing a certain item, but it may be optional (e.g. not having a specific condition or medication). You should take a closer look at these patients to determine if they are compliant or not.

For example, in the report on the left, 44 % of hypertension patients are treated with blood pressure (BP) medications, and 56 % are not (but may not require medication). In the report on the left, however, 44 % of patients have not had their required blood pressure reading done in the last year (and are therefore not compliant).

Updated October 28, 2022

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