How Will This Toolkit Help Me?
Learning Objectives
Describe a patient care registry and the benefits of implementing a registry in your practice
Summarize steps to select the criteria for your registry and build a registry framework
Explain 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, as well as 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 extremely useful at the population level for managing common chronic illnesses, such as diabetes or coronary artery disease.
A patient care registry can help your practice track high-risk or high-need patients to ensure that services are delivered to all patients in a timely manner according to evidence-based medicine (EBM) guidelines. When optimized, you can use your practice's patient care registry system to create customized planned visit protocols for each patient visit and for outreach between visits.
Five STEPS to Create a Patient Care Registry for Your Practice:
Develop the Criteria for Your Registry
Build the Registry Framework
Develop Workflows and Train the Team to Use the Registry
Put Your Registry Into Action
Evaluate and Apply Registry Findings
STEP 1 Develop the Criteria for Your Registry
Registries take resources, both human and technical, especially during the launch and pilot phases. It is critical to have the entire care team (including non-clinical and support team members) on board to develop and maintain the registry. Take the opportunity to engage your entire practice during the brainstorming session to determine what an effective registry will look like. The entire team can be an integral part of developing the infrastructure of the actual registry. It is important that non-clinical and support team members are familiar with your patient care registry design, as they may be the ones regularly using reports once your registry is up and active.
To be effective, patient care registries must fulfill 5 criteria:
Include a list of all the patients in the practice with the target condition(s) (eg, diabetes, asthma, hypertension).
Show a “snapshot” of the EHR to detail important clinical parameters and identify the gaps in EBM-recommended care.
Aggregate the results from all patients in the practice with the specific condition to assess the overall quality of care provided (eg, the percentage of patients with diabetes who have controlled blood pressure).
Produce support for outreach and follow-up (eg, for all patients with diabetes who have not had an A1c in 6 months, the registry system suggests an eye exam or diabetes education referral).
Integrate clinical quality reporting into the process of care rather than as a separate endeavor.
Ensure you have sufficient support of team members (eg, medical assistant or nurse) to return phone calls, make appointments, update medication lists, and so forth. Ideally, patients should be able to see their own data in the patient care registry, either provided via an online portal, mailed to them before their visit, or given to them at the visit. For any registry system, it is crucial to ensure that patient confidentiality as well as data privacy and security requirements are adequately addressed.
Registry Brainstorming Guide (52 KB)Use this tool to help you and your team develop your registry criteria.
STEP 2 Build the Registry Framework
Quiz Ref IDSurvey, assess, and select a patient care registry system that best fits with your current EHR, target patient populations, and practice workflows. Your program should include all the clinical parameters that you rely on to make informed medical decisions. These parameters need to be presented in an organized and complete format, allowing you to focus on those aspects of care that need the most attention. You may consider using a generic registry template within your EHR or developing a custom version with a programmer. Note that working with your EHR vendor to create the registry, as opposed to developing or buying a separate system, may help avoid workflow problems and the need for separate log-ins.
STEP 3 Develop Workflows and Train the Team to Use the Registry
Involve the entire care team to keep the patient care registry up to date and complete by developing new workflows or adapting existing workflows to ensure that the data is properly and reliably entered. Establish how the team's clinical and clerical 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.
The entire 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.
STEP 4 Put Your Registry Into Action
When implementing your new patient care registry, your practice may want to start by focusing on just one patient population, such as your patients with diabetes, and limit it even further by identifying an age range (ie, between 40 and 65 years old). Use a phased approach to allow the team to adapt to the patient care registry and the new workflows to manage care between visits.
Although 2 people should be responsible for making sure the registry is working properly 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 information, the better it works.
Consider starting by assembling a list of patients with a specific condition. All patients who have the specific condition should be added to the patient care registry; as patients come in or as new diagnoses are made, make sure the patients are added or that their profiles are updated. As the registry grows, it will become more useful for monitoring EBM care and facilitating outreach.
You may choose to collect information in a spreadsheet until you have selected a software package or if you do not have an EHR system in your practice, being mindful of data privacy and security legal requirements. Your team may find that it is more comfortable starting with a spreadsheet and then moving to the registry function in the EHR.
Diabetes Tracking Worksheet (18 KB)If your practice is starting out with a spreadsheet as a patient care registry, you can customize this template to suit your practice's unique needs.
Figure 1 shows a typical dashboard to visualize hypertension control for a single physician compared to their practice as a whole.
STEP 5 Evaluate and Apply Registry Findings
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 make changes in 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
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. PMID: 21842803. https://www.aafp.org/fpm/2011/0500/p11.html
Metzger J. Using computerized registries in chronic disease care. California HealthCare Foundation. Updated February 19, 2004. Accessed February 15, 2021. http://www.chcf.org/wp-content/uploads/2017/12/PDF-ComputerizedRegistriesInChronicDisease.pdf
Registries: powerful tools to track, manage chronic disease. Medical Economics. May 10, 2013. Accessed February 15, 2021. https://www.medicaleconomics.com/health-care-information-technology/registries-powerful-tools-track-manage-chronic-disease
Ortiz DD. Using a simple patient registry to improve your chronic disease care. Fam Pract Manag. 2006;13(4):47-52. https://www.aafp.org/fpm/2006/0400/p47.html
Centers for Medicare & Medicaid Services. The Physician Quality Reporting System Maintenance of Certification Program Incentive Requirements for 2013. Accessed February 15, 2021. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2013-MOC_Qualification_Requirements.pdf
Centers for Medicare & Medicaid Services. Registry reporting. Updated December 17, 2015. Accessed February 1, 2016. https://wayback.archive-it.org/2744/20160824144659/https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Registry-Reporting.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]. Improving Chronic Care. Accessed February 15, 2021. http://www.improvingchroniccare.org/downloads/astregis.doc
Websites
evidence-based medicine (EBM)evidence-based medicine (EBM):
Clinical research and expert opinion to make recommendations about the best treatment for patients with a specific condition.