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CDMP: Innovative Care Management Software for Federal TeleHealth Partners and Beyond

What is CDMP?

CDMP is diabetes management software with a "whole person" focus that provides tools for continuous care and contact between patients and their providers. Two issues informed its development:

  • Wagner’s chronic care model – components that involve community, self-management, decision support, and technology
  • The knowledge that the traditional physician-centered, acute-care model was not designed for the huge numbers of (largely underserved) people with diabetes.
  • CDMP provides a "technology assist" to the care team with clinical, lifestyle and psycho-social health information at their finger tips.

We used readily available technologies to develop a one-stop, site customizable application.
Using CDMP, patients and care providers may foster active, creative, and positive, continuing relationships that keep patients healthier.

Why this application?

We know successful self-management is a team effort between patient and providers. We also know that most care providers are not diabetes specialists.

CDMP provides the lynch pin between patient and care team. It is a single source for:

  • Clinical decision support.
  • Treatment guidelines with customizable alerts and reminders.
  • Imbedded clinical and behavioral quick surveys.
  • A patient snapshot – single screen reference tool.
  • CarePlanning – a focus for patient-provider conversation.
  • Imbedded patient education tools.
  • A data warehouse for measurement of effectiveness.
  • The CDMP development process found its roots years ago with the Joslin Vision NetworkTM , where we observed that:
    • Looking at a patient’s eyes produces some information.
    • Looking at the clinical record yields some more.


  • Adding a psycho-social or behavioral health dimension makes for better health outcomes, openness and patient participation.

Who uses CDMP?

Primary CDMP users are care managers who facilitate interactions between patients and the diabetes care team or direct providers. They are most often:

  • Nurses 
  • Nurse practitioners 
  • PAs 
  • Educators 
  • Exercise physiologists 
  • Nutritionists 
  • Behavioral clinicians 
  • Some MDs

CDMP may be used in a large urban clinic or a medium–to-large suburban physician practice where a nurse or nurse practitioner sees chronic care patients for the majority of their routine appointments.

We work to complement onsite workflow and train providers in most efficient uses of CDMP for them, specifically.

CDMP Components

  • Clinical Snapshot – for patient review and reference. 
  • Patient Portal – secure uploads of data and patient-provider messaging. 
  • Survey Tools – assessing self-management, nutrition, depression. 
  • CarePlanning – flexible team approach, clinical and self management issues. 
  • Risk Profile – at-a-glance indicator helps drive CarePlanning.
  • Alerts and Reminders – customizable to a site, with treatment guidelines. 
  • Image Catalog – JVN eye images, uploaded patient pictures, EMR imports. 
  • Clinical Studies Management – oversight of study detail, subject pool, etc.

Research Activities

  • CDMP
  • Federal programs and private sources fund most of our work. 
  • Research into filling broad care gaps and exploration of co-morbid conditions are ongoing. 
  • Development continues – even as we begin to roll out new components, we continue to deepen the existing ones, and look again at the technologies we employ. 

In the past year we have begun:

  • Clinical studies in usability for the core CDMP application, the behavior assessment tool, and the patient portal. 
  • A digital camera-nutrition study – Participants photograph their meals, upload them to a central email address, and gather to talk about them in a nutritionist-led discussion group every other week.

Page last updated: November 07, 2019