Diabetes Registry
The Care Model
Community
Health System
Health Care Organization
Resources and
Policies
SelfManagement
Support
Delivery
System
Design
Informed,
Productive
Empowered Interactions
Patient
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Improved Outcomes
You are
here
Clinical Information Systems
Organize patient and population data to facilitate
efficient and effective care.
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Provide timely reminders for providers and patients.
Identify relevant subpopulations for proactive care.
Facilitate individual patient care planning.
Share information with patients and providers to
coordinate care.
Monitor performance of practice team and care
system.
Diabetes Registry
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Web-based disease-management tool
accessible anywhere within HHC
Supports HHC's Chronic Disease Collaborative
Simplifies point-of-care and quality improvement
Displays clinical measures and quality indicators
Provides “at-a-glance” view of care team
performance and immediate access to individual
patients requiring additional interventions.
Registry Components
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Patient Specific Profile
 Highlights
need for routine interventions
 Provide feedback to caregiver and patient
about progress and goals
 Integrate dynamically with decision support*
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Population Care Planning
 Identify
all patients in need of routine services
 Provide lists of patients not reaching goals
 Be able to stratify/view sub-populations
Registry Components
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Care Team Specific Feedback
 How
is the population doing?
 Are we improving?
 Are there best practices out there?
Diabetes Measures
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Outcomes
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HbA1c levels
 Self management documentation
 Fasting LDL
 Blood pressure
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Processes
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Annual foot exam
 Annual retinal eye exam
 Annual screening for nephropathy
 Screening for depression (PHQ2 – PHQ9)
Fears and Facts
about Registries
Fear: Why do we have to have a registry?
Fact: Planned population-based care cannot be
done without knowing your patient
population and its key clinical data
Fact: Primary care teams that implement
registries are more likely to improve
processes of care for all chronic conditions
Fact: Teams with registries are less likely to lose
patients to follow-up, and more likely to
improve patient satisfaction as care
improves
Fear: I don’t need anyone telling me how to
practice! I’m doing just fine with my patients!
Fact: Surveys show that providers consistently
under estimate the numbers of patients with
chronic disease in their practice
Fact: Surveys show that provider consistently
over estimate their performance measures
on process and clinical outcomes for
chronically ill patients.
Fact: The two are interdependent.
Fact: Knowing you population of patients will help
rectify this disparity.
Fear: It’s just more work during our already hectic
day!
Fact: Using a patient summary form from a
Registry will actually reduce charting time
and make the visit run more smoothly
Fact: The form gives a snapshot of past care,
reminders of needed care and planning for
future care all at the time of the visit
Fact: Teams with registries feel better prepared for
visits since they have the patient information
when and where they need it.
How to use the
Registry
How to Access the
Diabetes Registry
1. At NBHN –
HOME, double
click “Intranet”
2. On the
side bar
double click
“Patient
Registry”
3. Enter Username and Password. (If you do not
know your username contact Maria Mendoza @
36009) Click on “Login”
4. You will see this screen.
If it is not your registry, click the “v” to open the window
5. Click on your name to open your registry.
6. Once you are in your registry, to find a list
of all your patients double click on “Patients”
7. This screen will appear.
8. To see individual patient record click on the
box on the first column and double click on the
patient’s name.
9. You will see this screen.
There’s a wealth of
information you will find. If
you want to create a letter
double click on “Create
Letter”. If you call this patient
double click on “Log Call”
and document your call.
“Contact Hx” – shows you all
the outreach letters and calls
the patient received.
Click on Indicators,
Measures, Visits, Problems,
etc to find out more
information about your
patient.
For other features of the Registry, check on
“How to Use the Diabetes Registry” in the
Intranet
How Should We Use the Registry?
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We would like you to open up your registry at the start of every
session in outpatient practice.
See if the patient who you are seeing with DM is on your registry?
Does this patient have another primary provider?
If not, this patient should be on your registry and you should see this
patient in continuity. Let the supervising attending know that you
need to add this patient to your registry
The goal is for each patient to have a regular provider for continuity
of care.
Using the registry will help you manage your patients and also help
us assure continuity of care
Using the registry….
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We expect you to review your registry regularly and often
If you see patients on your registry whom you have not seen – please let
Maria Mendoza, Dr Weinstein or any of the supervising attendings know –
we will remove them from your registry and place them with the correct
provider.
We will be monitoring your use of the registry---YES, big brother is
watching! We want to see that you are using the registry and also that your
patients are improving and getting the care that they need.
Use the registry to see who needs an appointment to see you – who needs
more intensive care, who needs an appointment to see the ophthalmologist
Be creative and proactive with your patients. If you know you will be on
ambulatory and have more time to see patients – look at your registry and
ask to have particular patients in need scheduled with you
Use the registry to do advanced searches - or even send letters to your
patients about their successes!