Patient Care RegistriesProactively Manage Chronic Conditions

Learning Objectives

1. Describes a patient care registry and the benefits of implementing a registry in your practice

2. Summarizes steps to select the criteria for your registry and build a registry framework

3. Explains how to design practice workflows and train your team to use the registry

Quiz Ref IDA patient care registry is a system to identify and care for patients with chronic conditions and a means of tracking preventive care in your practice. It can be integrated into your practice's electronic health record (EHR), a separate database program, or even a simple spreadsheet that is manually updated.* Patient care registries can be useful at the population level for managing common chronic illnesses like diabetes or hypertension.

A patient care registry can help your practice track high-risk or complex patients to ensure that services are delivered to all patients in a timely manner according to evidence-based guidelines. When optimized, you can use your practice's patient care registry system to create customized planned visit protocols for each patient visit and outreach between visits.

*All patient data is subject to HIPAA regardless of the format of your patient care registry.

1. Select the Criteria for Your Registry

2. Build the Registry Framework

3. Develop Workflows and Train the Team to Use the Registry

4. Put Your Registry Into Action

5. Evaluate and Apply Registry Findings

Including your entire care team is important when planning and creating your registry. Nonclinical and support team members may regularly use and create reports once your registry is active; therefore, they must be familiar with its design. Take the opportunity to engage your entire practice during the brainstorming session to determine what an effective registry will look like. As you discuss, consider metrics or values relevant or tied to payment, such as the date of the most recent Medicare Annual Wellness Visit (AWV).

Fulfilling these 5 criteria yields an effective patient care registry:

1. Include a list of all the patients with the target condition(s) (eg, diabetes, asthma, hypertension)

2. Show a snapshot of the EHR to detail important clinical parameters and identify the gaps in evidence-based care

3. Aggregate the results from all patients in the practice with the specific condition(s) to assess the overall quality of care provided (eg, the percentage of patients with diabetes who have controlled blood pressure)

4. Provide support for outreach and follow-up (eg, for all patients with diabetes who have not had an HbA_1c in 6 months, an eye exam in the past year, or a diabetes education referral placed in the past, the system can suggest these items)

5. Integrate clinical quality reporting into the care process rather than as a separate endeavor (avoid creating new workflows by identifying your current workflows for electronic clinical quality measures (eCQMs) that already align with the target conditions that will be included in the patient care registry)

For any registry system, it is crucial to address patient confidentiality, data privacy, and security requirements.

Figure 1 shows an example of a chronic care registry. The mock data in this sample patient registry can help you learn how to identify care gaps based on the chronic care guidelines you've implemented in your practice. Within the registry, you could flag overdue labs (red boxes in the example), incomplete labs, or labs that are high or out of range for follow-up (red font in the example). You might also highlight diagnoses such as type 2 diabetes or other factors like smoking status to help you monitor specific groups more closely.

Figure 2 illustrates how a patient registry can help you learn how to identify care gaps based on the preventive care guidelines you've implemented in your practice. Within the registry, you could choose to flag outdated or missed preventive screenings or missed Medicare Annual Wellness Visits (AWVs). Yellow indicates a screening or visit that is close to being outdated, red indicates a need to follow-up with the patient. From the registry, you may notice that your practice has some work to do to keep up to date on colonoscopy screenings but that your team is doing an excellent job keeping patients on top of their mammograms and AWVs. This method can help you identify patients who could benefit from more frequent follow-ups.

Quiz Ref IDReview and select a patient care registry system that fits your current EHR, target patient populations, and practice workflows. The chosen registry should include all the clinical parameters you rely on to make informed medical decisions. The parameters need to be presented in an organized and complete format, allowing you to focus on those aspects of care that require the most attention. You may consider using a generic registry template within your EHR or developing a custom version with a programmer. Working with your EHR vendor to create the registry, instead of developing or buying a separate system, may help avoid workflow problems and requirements for separate logins while meeting security and privacy requirements.

Involve the entire care team to keep the patient care registry current and complete. Establish how the team's clinical and nonclinical members should use the registry to follow up on gaps in care and plan for visits to close these identified gaps and provide timely care. Your practice may need to develop new workflows or adapt existing workflows to ensure that the data is correctly and reliably entered and that access is limited to only those who need it, as required by HIPAA.

Everyone on the care team should have access to the registry and be able to use protocols and standing orders to identify and address patient care needs. Designated team members, such as physicians, nurses, medical assistants, care managers, or panel managers, should be well-trained in executing their role in managing the registry to improve data reliability, consistency of care, and patient outcomes.

Implementing team-based care fundamentals will teach your team the skills to share tasks, including managing the patient care registry. An exercise in creating a process map can help your team visualize the registry use workflow or pinpoint how the workflow might help you address gaps in care identified by the registry.

When implementing your new registry, your practice may start by focusing on one specific condition, such as diabetes. Using a phased approach allows the team to adapt to the patient care registry and new workflows. Begin by assembling a list of patients with that condition, then add the list of patients to your patient care registry. If the number of patients in the registry is too large to manage at first, narrow the list by adding additional criteria. For example, you may want only a registry tracking patients with diabetes between 40 and 65 years old. Update the registry consistently as patients are added to the practice, or you make new diagnoses. These updates could be automated if your registry is integrated with your EHR. Other formats may require manual updates. As the registry grows, it will become more useful for monitoring EBM care and facilitating outreach.

You could collect pertinent information in a spreadsheet until you select a software package. Be mindful of data privacy, security, and any legal requirements for collecting patient data. Your team may find that it is more comfortable starting with a spreadsheet and then moving to the registry function in the EHR.

Ideally, 2 people should be responsible for ensuring the registry is working correctly and used by all. Every care team member should contribute to its maintenance by entering information when missing fields are identified—the more complete the data, the more effective the registry.

In addition to providing more efficient and effective care for your patients with chronic conditions, registries can help with quality improvement efforts. For example, if you learn from the registry that only 50% of your diabetic patients have their blood pressure under control, you could adapt your treatment approach, initiate a health coaching program, or pursue a more active follow-up approach with these patients. You can then use the registry to track whether these process changes improve the percentage of patients whose blood pressure is under control. Depending on the sophistication of your patient care registry, you could generate the following types of reports to improve your practice:

• Patient reports at the time of the visit

• Exception reports to flag patients not meeting management targets

• Progress reports for care team members to measure care delivery

• Population reports to monitor and stratify at-risk patients

Properly using a patient care registry improves practice efficiency, enhances patient care, and reduces liability risks. Additionally, patient care registries provide valuable data for value-based care reporting and metrics.

A patient care registry can allow you to be proactive—rather than reactive—in your approach to providing care to patients with chronic conditions, including preventive care. This organized approach to tracking and reporting specific disease measures and management will help you and your practice team reveal opportunities for improvement and the delivery of better and more efficient care to your patients.

Journal Articles and Other Publications

• Bagley BA, Mitchell J. Registries made simple. Fam Pract Manag. 2011;18(3):11-14. https://www.aafp.org/fpm/2011/0500/p11.html

• Yang M, Loeb DF, Sprowell AJ, Trinkley KE. Design and implementation of a depression registry for primary care. Am J Med Qual. 2019;34(1):59-66. doi:10.1177/1062860618787056

• Constructing an asthma registry [download]. American Academy of Pediatrics, Improving Chronic Care. Accessed March 19, 2023. https://downloads.aap.org/MedHome/doc/astregis.doc

• Surbhi S, Brooks IM, Shuvo SA, et al. A mid-South chronic disease registry and practice-based research network to address disparities. Am J Manag Care. 2020;26(7):e211-e218. doi:10.37765/ajmc.2020.43764

• Improving clinical processes and effectiveness of care through creation of a disease-specific registry. Health Catalyst. September 26, 2017. Accessed March 19, 2023. https://www.healthcatalyst.com/success_stories/chronic-disease-registry-provides-data-to-improve-care

• Registries and information systems for diabetes care in the WHO European Region: preliminary findings for consultation. World Health Organization Regional Office for Europe. 2021. Accessed March 19, 2023. https://cdn.who.int/media/docs/librariesprovider2/euro-health-topics/diabetes/registries-information-systems-diabetes-consultation-eng.pdf?sfvrsn=d9f3551f_2&download=true

Websites

• Computerized disease registries. Agency for Healthcare Research and Quality. Digital Healthcare Research Archive. February 2015. Accessed March 19, 2023. https://digital.ahrq.gov/key-topics/computerized-disease-registries

• What is a disease/immunization registry? HealthIT.gov. Reviewed January 15, 2013. Accessed March 19, 2023. https://www.healthit.gov/faq/what-diseaseimmunization-registry

Toolkits

• Panel Management

• Prediabetes and Type 2 Diabetes

• Team-Based Care

• Medical Assistant Professional Development

• Medicare Annual Wellness Visit (AWV)

Podcasts

• Team-Based Care Model

• One Practice's Success in Implementing Advanced Team-Based Care

• Improve Patient Care With Collaborative Care Team Models

• Medicare Annual Wellness Visit

Webinars and Videos

• Advanced Team-based Care