Diabetes Dashboard

The Diabetes Dashboard gives your practice a clear, central view of all patients with an active diabetes condition. It combines demographic, clinical and billing information to help your team improve care, close gaps, and support accreditation. With flexible filters and detailed patient lists, the dashboard makes it easy for both practice managers and practitioners to track diabetes management and identify where follow-up is needed.

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The Sections included in this article are:

• What is the Diabetes Dashboard
• Coding and Accuracy
• Key feature and filters
• Use cases - How can I use this dashboard?

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What is the Diabetes Dashboard?

The Diabetes Dashboard gives your practice visibility into patients with an active diabetes condition. It supports both whole-of-practice quality improvement and individual practitioner care by bringing together clinical, demographic, and billing information into one place.

This dashboard is designed to:

• Help practices improve care for patients with diabetes

• Enable doctors and nurses to view their own patients with diabetes

• Support audits and accreditation by highlighting gaps in care

• Empower practices to identify where coding corrections are needed in the patient record

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Coding and Accuracy

In Best Practice (Bp), diabetes can be coded in two ways:

• Clinical coding: a hard-coded diagnosis selected from a drop-down list

• Free text entry: a diagnosis written directly into the patient file

Because free text entries may not always match coded terms, the true number of diabetic patients in your practice may be underreported. Cubiko allows you to enable free text terms on your dashboard filters, giving you control to include these free text entries about patients conditions in your lists.

This approach also helps you identify records that need correcting in the PMS — improving both clinical care and your reporting for Quality Improvement (QI) and CPD activities.

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Key feature and filters

The Diabetes Dashboard surfaces metrics such as:

• Total diabetic patients at your practice (e.g. % of RACGP active patients with diabetes)

• Diabetic patients by Practitioner

• Diabetic patients by type (Type 1, Type 2, Type 3c, Unstable, Controlled, Diabetes, Latent autoimmune)

• All diabetic patients 

• Diabetic patients due for a CCMP review. This list of patients are those who would appear on the list who could be eligible to be moved from a CDM plan to a CCMP are would be due for a review of their previously billed CDM item. The patients on this list have;

  • Active diabetes diagnosis

  • Billed item 721 or 723 in the last 2 years

  • No CCMP (item 965) billed

  • No 721, 723, or 732 billed in the last 3 months

• Diabetic patients who may be eligible for a new CCMP (item 965). This list of patients are those who would appear on the list for a new CCMP (item 965) but also have a condition of diabetes on their file. 
  • Their patient record is active
  • Has been billed a 721, 723, or 965 in the past
  • Has not been billed a 721 or 723 in the last 2 years
  • Has not been billed a 965 in the last 18 months
  • Has not been billed a 967 in the last 3 months

 

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Clinical Information Displayed

For each diabetic patient, the dashboard presents:

• Pathology & Observations

  • HbA1c result recorded or not recorded in the previous 12 months, and date recorded
  • Blood pressure recorded or not recorded and the date of their last recorded sitting blood pressure result in the form Systolic / Diastolic
  • BMI - recorded or not recorded and result if recorded 
  • Weight – recorded/not recorded and result if recorded (in kg)
  • Fluvax this season - vaccinated or not vaccinated 
  • Alcohol consumption - not recorded or last recorded date
• Demographics
  
  • Ethnicity - not recorded or recorded ethnicity 
  • Smoking status – recorded/not recorded (# per day if recorded)
  • Allergies - recorded, not recorded, some recorded or nil known ticked 

• Medications

  • Current medications recorded
  • Number of active medications 

• Comorbidities

  • Other active conditions in addition to diabetes

• Appointments & Billings

  • CDM care plan billing in the last 2 years
  • CCMP billing (including review items) in the last 18 months
  • Upcoming appointment with a Doctor or Nurse
  • Future reminders on patient record 
  • Number of appointments in the last 12 months 

• Practitioner Linkages

  • Usual Doctor (from PMS)
  • Last seen Doctor

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How to use filters

You can filter your patient list in two main ways:

Sidebar Filters

Use the filters in the left-hand sidebar to refine by:

• Patient information (e.g. age, gender, ethnicity, MyMedicare, RACF)

• Vaccinations (e.g. flu status)

• Clinical information (e.g. conditions, comorbidities, test results, risk factors)

Column Filters

You can also filter directly in the list view columns:

• For example, in the Diabetes Condition or Active Conditions column, click the filter icon and tick which conditions you’d like to include.

• In columns such as HbA1c record date, use the dropdown options (contains, equals, before/after) and enter keywords or date ranges to refine your search.

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Available Filters

Dates

• Patients with upcoming appointments

• All patients

• Next appt with…

Patients

• Age bracket – e.g. <18, 50–60, 75+

• Usual Doctor

• Last seen Doctor

• Gender

• City / suburb

• Postcode

• Concession card

• Allergy/ADR

• Ethnicity

• Smoking status recorded

• Alcohol status recorded

• RACGP active patients

• Include deceased/inactive patient records

Vaccinations

• Flu vaccination this season

• All patients

Clinical

• Diabetes condition

• Filter patients with clinical condition

• Filter patients with clinical observation

• Filter patients with medications

• Include custom clinical conditions - Enable this filter to allow selection of non-hard coded conditions, from the filters above that reference conditions. Enabling this filter may impact load times. Enabling this filter will allow you to find instances where a condition has not been hard coded.

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Why use this dashboard?

The Diabetes Dashboard helps your practice to:

• Identify all diabetic patients (coded and free text) for more accurate reporting
• Audit care delivery against RACGP and Diabetes Australia guidelines
• Spot gaps in HbA1c, blood pressure, urine, cholesterol, weight, and smoking status
• Track CDM/CCMP activity to ensure patients are managed under the correct plan
• Support practitioners with tailored patient lists linked to their usual Doctor
• Improve coding accuracy by highlighting free text entries that should be recoded

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