• Jeanne Harmon of the WA Diabetes Prevention & Control Program presented draft cardiovascular measures for the next WA State Collaborative scheduled to begin at the end of June. The "Setup Wizard" was used to demonstrate creation of the cardiovascular track in CDEMS. Much of the discussion centered around terminology distinctions and CDEMS coding for cardiovascular, CVD, coronary & peripheral vasuclar, artherosclerosis, vasuclar disease, heart disease...
  
  
• Callie Gard and Betty Mafnas discussed the asthma and HIV CDEMS setup developed at Community Health Care in Tacoma. The "Copy/Paste Append" method was used to demonstrate copying an existing asthma setup from an Excel spreadsheet into CDEMS. The group discussed at length the pros and cons of creating special forms by health condition. Two schools of thought (philosophies) influence the CDEMS setup and the choice to use special forms: a DISEASE-SPECIFIC approach or FULL PATIENT CARE.
  
  A hepatitis tickler was requested for HIV. The CDEMS tickler currently works on a single variable, but Dusty noted interest and will consider revising CDEMS to accomodate this need.
  
  In setting up new conditions, Dusty suggests defining an education track for each type of condition (e.g., diabetes educ, heart educ, asthma educ, etc.). Also, create a "PHQ" (Patient Health Querstionnaire) service for depression screening and record the PHQ score as the result.

• Database Backup. Think about it -- how much data would you be comfortable losing? Back up the cdem_dta.mdb file often. Verify that your cdem_dta.mdb file is part of the server backup if your CDEMS is installed on a network. Never assume that the CDEMS files are included in the network backup!
  
  Follow the steps below for backing up your CDEMS files:
  
  1. Label & date backup medium (floppy, CD or Zip) before inserting into the appropriate drive
  2. Navigate to the cdem_dta.mdb file in the CDEMS folder on your computer
  3. Right click on the file cdem_dta.mdb
  4. Click Send to and select your backup medium - floppy, zip drive, CD
  5. Make back up copies of CDEMS Data Entry (cdem_8-8-03.mdb) and Report (rpt_5-04-03.mdb) programs if you've made customizations worth protecting.
     
     User Tip: Rename your backup file on the floppy, CD or Zip drive to include the date the copy was made (for example: copy_cdem_dta_030404.mdb). This helps identify the most recent backup file in the unfortunate event your data must be recovered. It also prevents writing over previous backup files you may have made.
  
  If your database becomes too large to fit on a floppy, it will have to first be zipped or condensed before copying to the floppy. Compacting and repairing the database, described below, will also help to reduce the size of the database.
  
  
• Compact & Repair the cdem_dta.mdb file to improve performance and conserve disk space. The more activity that occurs in the database, the more frequently this operation should be performed. Also periodically compact & repair CDEMS Data Entry and Reports program files if changes/customizations are made. It's recommended to backup the cdem_dta.mdb file before compacting & repairing, particularly if you think the database may be damaged.
  
  Instructions for compacting & repairing the CDEMS database:
  
  1. Open cdem_dta.mdb file directly
     
  2. Click Tools in menu bar > Click Database Utilities
     
  3. If using Access 2k version, click Compact & Repair Database.
     If using Access 97 version, compact and repair database are separate operations -- compact first, then repair.
     
  4. Close cdem_dta.mdb file
     
  
  User Tip: "Compact on Close" - It's possible to set your database to automatically compact on closing (if the size will be reduced by at least 256KB). Here's how:
  
  1. Open the cdem_dta.mdb file > Click Tools > Options
     
  2. Click the General tab of the Options box
     
  3. Click the Compact on Close check box
  
  
• PCP list/data cleanup - Click Clean up PCP list for instructions in a related CDEMS User Forum discussion.
  
  
• Ethnicity list/data cleanup - Click Clean up Ethnicity data for instructions in a related Forum discussion. Though this discussion refers to cleanup in DEMS, the instructions are the same for CDEMS -- just make the changes in the cdem_dta.mdb file.
  
  
• Telephone format cleanup - Click Clean up Telephone formatting for detailed instructions in a Forum discussion on this topic.
  
  

Q & A

Below are responses to key questions addressed at the meeting with links to additional information:

• Q #1 - When setting up a new health condition, is it possible to customize the data collection page for the new condition? For example, we have set up asthma tracking where the referral and decline options are not needed though they still appear on our blank data collection form.
  
  The code to generate a new abstraction form in CDEMS is very similar to that which creates a visit note and is pretty hard to modify in the wild. I'd generate a master paper form and alter it manually with Xerox art techniques, white-out, rubber glue, and scissors... This makes sense to me because you only need one master and can then make copies thereafter (Dusty Knobel).
  
  
• Q #2 - We have an EMR coming soon. Will the system talk to CDEMS?
  
  CDEMS is already talking to EMR's at clinics in Spokane and Moses Lake. PAML, Labcorp, Quest and Dynacare lab downloads to CDEMS are also good examples of this sharing of data between systems. If there is a way to get data out of an EMR, CDEMS can work with available data in a variety of formats: HL7, comma delimited, Excel, Access, txt files... Many EMR's need a way to manipulate data and generate the types of queries and reports available in CDEMS. So, the ability to export data is an important feature to consider in choosing an EMR system. Some EMR's are proprietary and charge extra $ for an export module. The group also discussed EMR constraints for storing data about labs and services not billed by the clinic, recording declines, and automatic referral updates.
  
  
• Q #3 - Is it possible to display labs and services in a different order on the progress note? And, I would like to have the numbering order explained more thoroughly for the set up of the page. I understand that groups of numbered things appear together like 90, 100, and 110. Are there assigned blocks of the page in the coding for these particular numbers? Why not use numbers like 1, 2, 3 or 10, 20, 30?
  
  Labs and services can be displayed in any sequence you'd like by re-numbering items in tlkpSetup. Dusty recommends designating a block of numbers for each condition being tracked so that items for that condition appear together on the form. So, diabetes may use 90-99 order numbers and cardiovascular 100-109, etc. For detailed instructions and an expanded answer to part 2 of this question, click Re-order Labs & Services to link to a User Forum discussion on this topic.
  
  
• Q #4 - Please discuss the linking/re-linking process when the data file is copied or relocated. I want to be sure the master data file is safeguarded when files get reorganized or when I'm working with a copy of the data file in test mode.
  
  The CDEMS Data Entry and Reports Programs link to the SAME data file (cdem_dta.mdb). The programs automatically look for the data file in the CDEMS folder, but it can reside anywhere on your computer or on a network server. If the path to your data file is not C:/CDEMS, if you change the name, or if you move the location of the data file, you'll want to know what the current path is and how to re-point the programs to the appropriate file.
  
  Many users set up a testing area to test new queries or setup changes before implementing using the Master data file. Copies of the Data Entry and Reports program are placed in the "Test" folder along with a copy of the cdem_dta.mdb file. In setting up a test environment, it's very important to understand that the Data Entry or Reports program copies retain the original link back to the Master data file . The "Test" Data Entry program must be re-linked to the copy of the data file in the "Test" folder.
  
  Use the following procedure to view or refresh links when changing the location of the linked data file:
  1. Open the program (Data Entry or Reports) that links to the cdem_dta.mdb file.
     
  2. Press F11 function key to work in database view > click on Tables.
     
  3. Follow instructions that match the version of Microsoft Access you're using to reach the Linked Table Manager:
     
     Access 2000/02: Click Tools > Database Utilities > Linked Table Manager to display the path to the data file.
     
     Access 97: Click Tools > Add-ins > Linked Table Manager. The path to the source file will display.
     
     
  To re-link the tables to a data file in a new location, continue on with the next steps:
  
  
  4. Click the "Always prompt for new location" box (lower left corner)
     
  5. Click Select All > OK
     
  6. Navigate to the location of the desired data file > double-click on the cdem_dta.mdb file. You'll see a message "All selected linked tables were successfully refreshed", indicating the tables are now linked to the data file in the new location.
  
  
• Q #5 - How can collaborative and non-collaborative patients be managed in CDEMS without setting up a separate clinic or inventing a new condition for them?
  
  Evaluate the overlap between establishing separate clinic registries for collaborative & non-collaborative patients. What does each accomplish? Consider redundant data and keeping lists synchronized. There's no motivation for separate clinics for separate conditions if there's no overlap (for example, little overlap between asthma and diabetes). Recalls are easier with separate clinics. If one program meets your needs, then use one program. Dusty suggests a simple solution -- assign a field in the health section to track whether the patient is in the collaborative or not. These are "yes/no" fields. All queries but the summary reports can select on the diagnoses the patient has.
  
  
• Q #6 - Can you incorporate Framingham CHD risk assessment into CDEMS calculations like BMI (as part of the visit note)?
  
  Yes, could be done. There's interesting documentation on the Framingham index at http://www.nhlbi.nih.gov/about/framingham/riskabs.htm. Age, sex, diabetes status, lipid panel and BP seem to be the main elements. These are all captured in C/DEMS.
  
  
• Q #7 - What are the differences in report changes from DEMS to CDEMS?
  
  The DEMS summary report did not count non-numeric lab results and used the numeric result population as the denominator instead of the total population who had the test. CDEMS lab counts include numeric and non-numeric results. CDEMS Reports has more age splits, BP now goes back to most recent not just the BP recorded (if any) at last visit. DEMS required a smoke cessation class; CDEMS smoke cessation counts include patients who have completed, declined or been referred to a cessation class.
  
  
• Q #8 - Can the diabetes summary report be modified to add depression screening?
  
  Not easily.
  
  
• Q #9 - Is there a way to delete a health condition once it's entered it in setup wizard?
  
  There is no reverse setup wizard to remove a disease once created in CDEMS. A condition cannot be deleted if currently used in patient records in the registry. Removing a disease is a three-step operation starting with the removal of data stored for the condition from the appropriate tables.
  
  
  1. Use either a delete query or manually remove disease-related data from tblHealth, tblMed, tblServices, and tblLabs.
     
  2. Next, open tlkpSetup and sort the table by health_status to group like conditions together. Select the entire row for all entries (Dx, Meds, Labs, Services, Graphs and Lists) relating to the condition that will be deleted > click Edit > Delete Record. Close tlkpSetup.
     
  3. Double-click tlkpCrosswalk. Select the Dx row of the condition to delete > click Edit > Delete Record. Carefully select the Rx, Labs and Services that relate ONLY to this health condition > click Edit > Delete Record. > Close tlkpCrosswalk
     
     
     

Next User Support Meeting: to be announced...