Chronic Care Management Platform
User Guide
Index
Table of Contents
1.Overview……………………………………………………………………………………………………………………………………………………………………3
2. Keywords............................................................................................................................................................3
3. Benefits/ Use case………………………………………………………………………………………………………………………………………………..3
4. Installation..........................................................................................................................................................3
4.1 Minimum System Requirements .................................................................................................................................. 3
4.2 Getting started with the solution.................................................................................................................................. 3
4.3 Access ............................................................................................................................................................................ 4
5. Admin Features ...................................................................................................................................................4
5.1 Admin Login .................................................................................................................................................................. 4
5.2 Change Password .......................................................................................................................................................... 4
5.3 Role Management .............................................................................................................................................4
6. Provider/Staff Module .........................................................................................................................................6
6.1 Add Provider/Staff (Individually) .................................................................................................................................. 7
7. CCM Care Provider - Registration and Log-In .........................................................................................................8
7.1 Dashboard Module ............................................................................................................................................8
7.2 Patients Module .............................................................................................................................................. 10
7.3 CCM Module ................................................................................................................................................... 11
7.3.1 CCM Enrollment ....................................................................................................................................................... 12
7.3.2 CCM Detailed Page................................................................................................................................................... 13
7.3.3 Create Survey ........................................................................................................................................................... 14
7.3.4 CCM Service Log ....................................................................................................................................................... 15
7.3.5 ICD Code Mapping ................................................................................................................................................... 16
7.3.6 Follow-Up Date ........................................................................................................................................................ 17
8. Admin Report ................................................................................................................................................... 18
8.1 CCM Individual Report ................................................................................................................................................ 18
8.2 Generating Default Report.......................................................................................................................................... 20
8.3 Creating Custom Report Templates ............................................................................................................................ 21
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1. Overview
The objective of this document is to explain the steps to be followed by new users who are on-boarded to the HealthViewX
Chronic Care Management web portal. CCM Application workflow would explain the below steps in detail with sample
screens
Practice Administrator logs into the web portal, on-boards a new CCM provider to whom an automated email with
the credentials are triggered
CCM provider logs in with his/her respective credentials, adds a new patient and enrolls them for CCM service
CCM Provider creates logs for the services provided for the patient against the CCM cycle within the portal and
generates detailed report with the logs for the patient
Practice Administrator generates a consolidated report with the list of patients and the minutes of CCM service
provided and submits it for CMS billing
2. Keywords
HVX – HealthViewX
CCM - Chronic Care Management
User - Platform registered user
SaaS - Software as a Service
3. Benefits/ Use case
HVX CCM is designed to help CCM providers deliver Chronic care services as approved by CMS. The platform will allow
users to
On-board Patients enrolled for CCM Service
Record CCM Service Logs
Generate CCM Detailed or Consolidated Report
4. Installation
4.1 Minimum System Requirements
HVX CCM solution requires no additional software or hardware installation as it is a SaaS platform. Furthermore, the
solution is best compatible with the latest versions of Mozilla, Firefox and Google Chrome.
(Application is best viewed in Google Chrome (Version 30.x and above) and Mozilla Firefox (Version 25.x and above))
4.2 Getting started with the solution
The SaaS nature of the product allows the solution to be used without any installation. During on-boarding HVX will
register an employee of the client as the ‘Super Administrator’ and provide credentials, who will then access the cloud
platform and register other employees as users.
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4.3 Access
Access to the platform’s functionality will be regulated on the basis of the registered role, with Super Administrator having
complete access to all information and functionality. Super Administrator in turn will regulate, review and modify other
user’s access to the platform.
5. Admin Features
5.1 Administrator Login
HVX will create a profile for a “Super Administrator” and share the credentials with the client. Super Administrator is in
charge of organizing and managing the HVX CCM solution on behalf of the client
5.2 Change Password
First time login requires the user to set up a password using the code sent to their respective registered email address.
The user can enter his email address/ username in the login screen and when prompted enter the registration code and
then set his/ her password.
Password should contain min: 6 and max: 30 characters. Password should contain alphabets, digits and special characters
Password
Confirm Password
Once the password is set, user can login to the application with the same. CCM Dashboard will be displayed
5.3 Role Management
Administrator can create custom roles to define each user’s level of access to patient information and features.
To create a role, Admin users can navigate to Administrator Settings
Click on the dropdown next to the User Icon and select option “Admin Settings”
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The User can click on ‘Create Role’ in the Roles and Permissions page
In the resulting pop-up enter
- Role Name
- Data Access: Patient level for access to only ‘created or assigned patients’ (or) Facility level access for access
to data of all patients in a facility
- Description
- Clone From: If the role is similar to another existing role then this can be Cloned
‘Save’ to continue
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User can now define role access by checking the checkboxes against each module
To give complete module access select the “Select All” checkbox next to each module
Define access by selecting permissions (Create/ Read/ Update/ Delete)
Once completed, select ‘Update’ to save the choices
After creating a new role, the same can be mapped against Providers/ Staff during creation
6. Provider/Staff Module
Administrator can on-board other users into the platform by using the ‘Provider/Staff’ feature. Providers and staff can be
on-boarded in two ways
Individual Upload
Bulk Upload
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6.1 Add Provider/Staff (Individual Upload)
Administrator can add providers and staff individually using the Add Provider link. Every provider need to be mapped to
a facility and have a defined access/role
All providers can be mapped to either of the two ‘Provider Types
Provider – PCP/Billing Practitioners
Staff – Tele-nurse/ Care Navigators/ Facility Administrators
The Administrator can on-board users by clicking on the ‘Provider’ tab on the left navigation menu which will
navigate the user to the “Create Provider” screen
Administrator can click on ‘Add Provider’ option. The following information needs to be entered to create a
provider account. Fields will vary for different provider types
Once the above details are entered Click ‘Submit’, which will display a success message. An account will be created
for the respective provider and also an invitation email will be triggered automatically to the given email address
with the login credentials using which the CCM provider can login to the application
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7. CCM Care Provider - Registration and Log-In
Registered users will receive the link to the platform along with credentials to log into the HVX CCM platform
Users have to login to https://imbs.healthviewx.com/ and can input their User Name and Password and click on ‘Sign In’
to continue.
7.1 Dashboard
Dashboard will display charts and graphs based on the user(s) activity in the platform
Components in this page is designed as configurable widgets based on a profile but the standard version will have the
following widgets
(1) CCM Follow-up (2) CCM Minutes Completed (3) CCM Service Summary
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In addition to the standard widgets, users can custom create widgets as required. To add new widgets user can click on
the Icon in the bottom of the Dashboard page.
Users can then configure the widget by:
Clicking add Widget
Choosing a name and graph type
Selecting X-axis and Y-axis, labels and use filters/ additional filter if needed and save the graph
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7.2 Patients Module
Patient’s page will list all patient information uploaded to the platform. Patient information can be added to My Patients
list using the below three methods
Add Patient from Header
Add Patient from List Page
Bulk Upload
Add Patient from Header
Users can add patients individually by selecting the “Add Patient” option from the header bar
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Add Patient from List Page
Users can add patients individually by selecting the ‘Create’ option from the Patient List
Bulk Upload
Multiple Patients data can be entered in the HealthViewX application using the sample template provided (comma
separated value file) and loaded into the system on one-click using the “Bulk Upload” feature
7.3 CCM Module
CCM page will list the patients who are eligible for CCM services, where users can enroll patients and log CCM service time
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The CCM patients list can be filtered using either the simple or advanced filter options. Users can filter on basis of
providers, CCM status, patient type and eligibility status among others. The user can also download the list of patients
into the following formats
.csv
.xls
.pdf
7.3.1 CCM Enrollment
To log time for CCM services, the patients need to be enrolled. Changing the status of a patient from ‘Not Enrolled’ to
‘Enrolled’ indicates that the patient has accepted to receive CCM services. To enroll please follow the below steps
Users can navigate CCM page and click on a ‘Not Enrolled’ patient
This will open the consent form where patient’s verbal consent can record the date and hit ‘Agree’
Navigate to the details page of the patient and the user can change the status from ‘Not Enrolled’ to “Enrolled’
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Status can be changed into ‘Declined’ to indicate the patient has declined to receive CCM services
Alternatively, CCM status can be changed ‘In-Active’ to indicate that the patient is enrolled but does not wish to
get CCM services currently
7.3.2 CCM Detailed Page
After the enrollment is completed the User will be automatically redirected to the CCM tab inside the respective patient’s
file. Alternatively users can get to the CCM Detailed page by clicking on the patients status in the CCM list page like shown
below.
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In the CCM tab, a user can
Create a condition specific care plan
Log CCM service time
Add Progress Notes
Set follow up date
View various details pertaining to CCM
7.3.3 Create Care Plan
A user can create a custom condition specific care plan for each patient using the “Create Care Plan” button. The link will
navigate the user to the “CCM Care Plan Assessment” page which is a step by step questionnaire
Note: CCM Care Plan Assessment page will take the user through step by step questions based on chronic condition
selected for each patient. The user can select one or more options as answer to each questions and select ‘Submit’ to
complete the assessment.
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The first question will be to list the chronic conditions
The remaining questions will change in relation to the selection of choices
Completing the questionnaire will populate the care plan in the ‘CCM Detailed’ page
The care plan can be downloaded
Progress notes section will be available to the right of each section
Users can click in the text box to type and click outside of the box to save the notes added
7.3.4 CCM Service Log
User can log CCM service time using the “Service Log” component found above the CCM Care Plan
Service log will have a timer which will also function as a stop watch
Date and Time section (pre-populated with the present day’s date and time)
CCM Service Provider (logged in user)
CCM Service Type to record the type of service the patient is given, e.g. Creating a Care Plan
CCM Progress Update changes against the created Care Plan
The platform will auto populate entries for some standard actions like Creating a Care Plan etc.
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Users can also use the Timer on the top of the screen which can be used to accurately record the time spent on an
activity. To engage the Timer Users can hit the play and stop button
7.3.5 ICD Code Mapping
Users can map ICD codes for each chronic condition
User can click on ‘Add’ link next to Medical Problems tab as shown in the screenshot below
Search and select the relevant ICD 10 Codes
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7.3.6 Follow-Up Date
A Follow-up date is used to track next scheduled engagement with a patient
Users can set reminders to follow up with a patient using ‘Add’ button’ next to Follow-ups tab as highlighted
The system will display the reminder in the Dashboard and the Follow-up pop-up will let users pick a follow-up
date and save notes
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8. Reports
Users can generate the following reports
CCM Individual Report – PDF report on service to each patient
CCM Summary Report - Consolidated reports on CCM activities
8.1 CCM Individual Report
To generate this report select ‘Download’ in the patient’s CCM page and then select the data needed in the report and
select ‘OK’
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Users also have an option to select the required components that need to be a part of the report by just checking or
unchecking the check boxes. On clicking ‘OK’ the reports are downloaded which is indicated by a download icon. On
completion user can click this report to download this as a .pdf
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8.2 CCM Summary Report
Users can generate consolidated reports on CCM activities to be sent to for billing. Admin users can select ‘Reports’ from
left navigation ribbon to be directed to the reports module. Using this module Users can create custom reports or
generate default reports available.
To generate the report select ‘Download’ in the patient’s CCM page.
Users can
Select the report by clicking on the reports name
Preview the report and apply additional filters if needed
Export reports by clicking the ‘Export’ dropdown and selecting the report format
- .csv
- .xls
- .pdf
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Note: Sample report
8.3 Creating Custom Report Templates
To create custom report template, follow the below steps,
Open report creation page by clicking on the ‘Create’ button as highlighted below
Start by selecting the Module for which report needs to be created
Select Report Type (Tabular/Summary/Matrix)
Select and arrange reports fields using the ‘Field Selection’ tool
Input a unique name for the report with a brief description
Select ‘Save’ complete the process
The platform will now take Users to the report preview page and the report will also be listed in the listing page
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