Chronic Disease Management:
Quality Improvement Program


The Ministry of Health, the Saskatchewan Medical Association and eHealth Saskatchewan partnered to launch this program focused on the on-going continuous improvement of chronic disease management in Saskatchewan.

An expert group of Saskatchewan clinicians have designed smart flow sheets based on clinical practice guidelines and best practices in chronic disease management. This website contains relevant information related to this initiative. A supplementary payment will be made based on the physician's successful submission of process indicator data. The process indicators are not tied to targets or patient outcomes; they simply reflect actions related to best practice patient care. This payment is in addition to current CDM fee codes included in the Physician Payment Schedule.

Update regarding CDM-QIP Flow Sheets (April 2022)

CDM-QIP Supporting Flow Sheet Resources

CDM-QIP Clinical Flow Sheets

Sask LWCC program contacts

CDM-QIP Payment

CDM-QIP Advance Care Directive

CDM-QIP Frequently Asked Questions

CDM-QIP Privacy

Updated CDM-QIP EMR Flow Sheets (Diabetes and CAD)

You spoke; we listened.  Based on your feedback, the current EMR flow sheets for both diabetes mellitus (DM) and coronary artery disease (CAD) have been revised to make the flow sheets more “user-friendly.”  The paper-based flow sheets have also been updated to include additional information, such as the names of medications, and to align with the updated EMR flow sheets. 

We are pleased to announce several improvements to the flow sheets: 

Length and Ease of Use Improvements:

  • A number of formatting characteristics (text boxes, comment areas, etc.) have been removed or reduced in size to decrease the number of “clicks” and overall length of the flow sheets
  • Observations have been re-ordered to align better with clinic work flow
  • A number of links to handouts and guidelines have been replaced with a single link to the CDM-QIP webpage containing all items, thus reducing the overall length of the flow sheet

Functional Improvements:

  • For CAD, the ICD-9 codes 410-414 are now accepted for flow sheet use and export  
  • You will now receive a prompt to enter the chronic condition in the Med Access Profile or QHR History of Problems, if you missed it prior to starting a CDM-QIP visit
  • Both eGFR tests used in the province (CKD-EPI and MDRD) are now mapped to one lab result field*
  • Height value will now auto-populate if recorded in a previous visit
  • Advanced care directive information will be available from a link within the flow sheet

*only for those currently with Lab Information System and linked to Saskatchewan Lab Results Repository

EMR flow sheets for HF and COPD will be available in the EMRs in January 2016. 

Please note that these new flow sheets, whether paper- or EMR-based, are the official flow sheets of the CDM-QIP.

For more information about the program please contact or call 1-888-316-7446 The eHealth Saskatchewan Peer Program is available as a support for providers and medical office assistants (MOAs) as they incorporate CDM-QIP best practices into their clinical workflows.  You can contact them by emailing  (For more information about the Peer Program, please go to

CDM-QIP Clinicians

If you are a clinician already using CDM-QIP, or would like to review the clinical content of the program, please click here.

How can I gain access?

If you would like more information about the program please contact the eHealth Service Desk at or call 1-888-316-7446. The service desk will connect you with a change and delivery specialist who can answer all of your questions and assist you with program enrolment.

CDM Toolkit

The Chronic Disease Management (CDM) Toolkit was used by physicians, authorized office staff and health care providers as a patient registry and decision support tool to assist in providing quality care for patients with chronic conditions. The Chronic Disease Management Collaborative was a clinical quality improvement project funded by Health Quality Council with funding ending March 31, 2010. The CDM Toolkit was considered an interim solution until Electronic Medical Record (EMR) software was implemented in physician practices. The toolkit is still in use but has not been maintained and is now out of date. As of December 31, 2014, the CDM toolkit will no longer be available.