Patient Care RegistriesProactively Manage Chronic Conditions

What can I monitor with a patient care registry?

Your practice should start with one or more chronic conditions commonly seen in your patient panel that have well-developed EBM guidelines and established clinical performance measures.

Examples include:

• Diabetes

• Hypertension

• Asthma

• Coronary artery disease

• Chronic obstructive pulmonary disease (COPD)

• Attention deficit hyperactivity disorder (ADHD)

• Depression

You could also use a patient care registry to monitor preventive services, such as age-appropriate screenings and immunizations, and track social determinants of health.

Can I use a patient care registry for following high-risk or high-need patients?

You can use a single patient care registry system to track and follow up with patients identified as high-risk or high-need. This approach is more patient-centered than a disease-specific registry and can be especially useful to support care managers, care coordinators, and a care transitions team as they follow those particular patients in your practice. It is important to collaborate with the care managers of patients who are already receiving other care coordination services in order to integrate the care into your registry. For example, a registry of patients on opioids for non-cancer pain will aid in ensuring that the patients have current documented goals of care and (if appropriate) updated opioid registry reviews have been completed.

How can I include multiple conditions in my patient care registry?

We recommend you use a system that will enable your practice to have an all-condition, or patient-centered, registry. However, you may want to expand to include multiple conditions in your patient care registry after your practice has had some experience with its systems and workflow when it includes one condition. Once your practice feels more comfortable with these processes, you can then expand the effort over time to other chronic conditions and preventive services, such as patients with diabetes and hypertension on appropriate blood pressure medicines like ACEi (angiotensin-converting enzyme inhibitors).

This system should also display all the parameters for a patient with multiple chronic conditions, which helps to identify gaps in EBM-recommended care. Almost all patients in the practice need age-appropriate screenings and immunizations as part of your preventive medicine strategy. Registries within EHR systems will eventually help track and measure the rates of these services for all patients. Many registries are built outside of EHR systems, so you are not limited to those within EHRs, but you then need to be sure your EHR data is compatible with the outside registry and that all necessary data privacy and security requirements for legal compliance will be in place with any such integration.

How is a patient care registry different from a national database registry?

Patient care registries differ from national database registries in three fundamental ways:

• Patient care registries are available to the physician and care team during any type of patient encounter to show the current status and highlight gaps in EBM care parameters.

• The patient care registry information is part of the regular office workflow.

• Patient care registries can be designed to feed data into national databases, but the current constructs used by most national database registries limit their ability to feed data in real time.

Most national database registries are designed to collect data, establish useful comparisons, and provide reports back to practices at some regular interval. Comparison data is helpful to evaluate how your practice is doing relative to other practices with similar patient demographics and risk profiles.

What are some examples of patient care registry systems I could use or purchase?

Many EHRs have modules for a registry function that are either not installed or not turned on. Be sure to check with your EHR vendor and evaluate the registry functionality against the 5 criteria listed in STEP 1. Working with the EHR vendor is generally preferable to building a separate registry, as it will be built into the existing workflow of the EHR that your practice is already familiar with. If a module is not available through your EHR, then stand-alone registries are available for a fee.

The 3 essential components of stand-alone registries include:

• A database—complete with a server, database management software, and management tools—to store patient information

• A data model to organize and integrate information

• Software tools that allow users to sort, manipulate, and create reports from the information

You may purchase each of these components individually to create a stand-alone registry, purchase them as a package, or choose to use a simple spreadsheet. No matter what approach you choose, you should make sure that your patient care registry is fully integrated into your practice workflow.

What searchable fields do I need to include in the patient care registry program?

Keep it simple. In addition to the usual demographic data to identify and contact the patient, you need to include the clinical parameters you and other care team members would want to know to make an informed decision about care, including social determinants of health.

For example, if you are setting up a diabetes registry that would be compatible with the Diabetes Collaborative Registry, you will want searchable fields for:

• Body mass index (BMI)

• HbA1c

• Lipid levels

• Blood pressure

• Blood pressure control (angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker [ACE/ARB] use)

• Kidney function (albumin/creatinine ratio, eGFR, or creatinine)

• Smoking status

• Dates and results of dilated eye exams

• Dates and results of foot exams

• Influenza, pneumococcal, and hepatitis vaccines

• Housing status

• Employment status

• Access to nutritious food and safe exercise

Most are the same searchable fields required to calculate most of the clinical performance measures that may need to be reported to payers, CMS, and for maintenance of certification (MOC) part IV activities. Keep in mind that the fields must conform to electronic Clinical Quality Measures (eCQMs) to satisfy federal value-based payment reporting.

Who sets up the patient care registry?

Designate a small work group to investigate the available options, the costs, and the functionality. While the entire care team will contribute to the registry, these specific team members will spend the most time working with the system or software. This group may also help design a workflow and formalize the procedures, roles, and responsibilities for using the registry. Data entry should be automated wherever possible, so integration with your EHR is essential to reduce duplication of work. For example, lab test results or blood pressure readings from the EHR should automatically populate on the patient summary page in the registry with a visual cue identifying the result as in or out of range. Some tasks or set-up, such as entering a new patient into the registry, may need manual input.

What kind of training does the team need to make sure patient care registry data is accurate and reliable?

Ideally, the practice should train 2 individuals in registry implementation, maintenance, and daily integration into the workflow. If you are using an EHR-based registry, your vendor should offer training. You may find additional registry training as part of population health and care coordination curriculums. These two “registry specialists” should be responsible for sharing their knowledge with everyone on the practice team. Much of the training will involve educating the care team about where information from the EHR flows into the registry, so that the data is as accurate and complete as possible. There may be some manual tasks in the initial set-up process or when entering a new patient into the registry. For more information about using a registry to improve care, see the AMA STEPS Forward™ toolkit on panel management.

How can I incorporate the patient care registry into my existing workflows to maximize impact?

Implementing a patient care registry is just one of many systematic changes you can make to improve practice efficiency and effectiveness. As you consider the design and implementation of your registry, there may be some overlap and synergies in workflows. Other AMA STEPS Forward™ toolkits can help guide how your patient care registry might integrate with or facilitate pre-visit planning, expanded rooming and discharge, panel management, and risk-stratified care management. The combination of these approaches with the registry should yield efficient, comprehensive, and effective care for patients with chronic conditions.

How do I make sure our patient care registry is adaptable and sustainable to meet ever-changing practice and payer standards?

As your practice starts to feel comfortable with the existing registry, let your patient population and practice priorities guide expansion to include another chronic condition. The registry function is basically the same regardless of the sub-population, so adding another common chronic condition (or two) should be easier. If clinical performance measures change or more measures are added by regulators or payers, you will need to actively manage the modifications in the parameters you track or the acceptable ranges that you set in the system.

Doesn't the patient care registry just add more work for everyone? What is the advantage?

Initially, yes, but your practice may soon see a return on the investment. A well-functioning registry can reduce the amount of digging you have to do to identify what EBM care your patients need.

Some of the advantages of a properly implemented system that meets all 5 criteria may include:

• Less chaotic care for patients and an improved patient experience

• A more even distribution of work across the care team

• A better practice workflow

• Engagement of the entire team because everyone can update and view the registry

• Active participation in patient care by the entire team through the use of standing orders and established protocols

• Elimination of data-gathering activities by the physician during the patient visit

• Clear presentation of clinical parameters that are out of range so that the physician and team can focus on the areas that need the most attention

• Potential revenue capture for pay-for-performance or other value-based payment models