DEVELOP DIABETES MANAGEMENT REGISTRY

Identifying Project and Provider Information: Category 1: Implement a Chronic
Disease Management Registry; Project Option 1.3.1: Implement/enhance and use
chronic disease management registry functionalities; 094109802.1.3; HCA Las
Palmas Del Sol (094109802).
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Project Description: HCA Las Palmas Del Sol will establish a chronic disease
registry for patients with diabetes, so that their care can be tracked and managed
within the local community. A disease registry requires technology and adequate
staffing to support it. Entering this data can be time intensive, but ultimately
enhances patient care. To establish the diabetes patient registry, HCA Las Palmas
Del Sol will identify patients for inclusion and assist patients through the registry to
track and manage their disease. We also want to investigate the need to track and
manage the large population with pre-diabetes. Currently it is unclear whether or not
these patients can be tracked within the diabetes registry. The model will include a
Clinical Information System (registry) to structure, organize, and trend patient data
for registries, clinical outcomes, and prevention services. The registry we are
considering is called CDEMS and is used by community health centers, primary care
practices, rural clinics, hospitals, and quality improvement projects across the United
States and in Canada, India, Haiti, and South Africa. This program was developed
and is shared by the Washington Diabetes Prevention and Control Program.
o Goals: Diabetes registries will be fully implemented by DY 5; staff reference and
maintenance of the registry will be part of the standard provision of care by DY 5.
This registry can serve as a pilot project for the Health Information Exchange
(HIE) initiative through the Paso Del Norte Health Foundation.
o Challenges: Identifying all patients with diabetes and pre-diabetes; hiring staff
and training them on use of the registry; maintaining an up-to-date registry on a
consistent basis; use of same database registry across the community. There are
some databases that could fit our needs, but further research on these
databases needs to be conducted.

Starting Point/Baseline: Currently, there is not a hospital-wide registry of patients
with diabetes.

Rationale: Over 16 million Americans have diabetes. Type-2 diabetes is the most
common form, accounting for 90 to 95 percent of cases. In El Paso, the weighted
estimate of the prevalence of self-reported diabetes mellitus was 7.3 percent
(95%CI=5.5%, 9.0%), or nearly 34,000 adult diabetics (1996 PDNHF BRFSS). We
believe, based on results of the 1996 PDNHF Survey and estimates from other
studies that the number of people 18 years and older in El Paso with glucose
intolerance is actually closer to 94,000. Diabetes is the ninth leading cause of death
in El Paso County and the death rate from diabetes in El Paso County is nearly 10
percent higher than the statewide average (Texas Department of Health/Texas
Diabetes Council). Findings from the 1996 PDNHF BRFSS indicate that obesity,
education, income, and access to healthcare are factors affecting El Paso County’s
high diabetes morbidity and mortality rates.
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
The economic impact of diabetes and its complications is extremely high.
According to the 1999 Border Diabetes Report, the annual direct medical cost of
diabetes averages approximately $400 million in El Paso and $9 billion in the
state of Texas.
If neglected, diabetes can lead to serious complications that may cause loss of
quality of life or premature death. Complications of diabetes include:
 Blindness due to diabetic retinopathy - diabetes is the leading cause of new
blindness in people 20 to 70 years of age.
 Kidney disease due to diabetic nephropathy – 21 percent of diabetics develop
kidney disease.
 Heart disease and stroke - people with diabetes are 2 to 4 times more likely to
have heart disease and to suffer stroke.
 Nerve damage – 60 to 70 percent of the people with diabetes have mild to
severe forms of diabetic nerve damage.
 Amputation - diabetes is the most frequent cause of non-traumatic lower limb
amputation; each year 56,200 people lose a foot or leg to diabetes.
In 1983 the Texas Legislature established the Texas Diabetes Council (TDC).
This council operates to prevent diabetes through health promotion, and to assist
diabetic patients with quality information and advocacy. It is the primary agency
dealing with diabetes in the state.
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In summary, utilization of registry functionalities helps care teams to actively manage
patients with targeted chronic conditions, because the disease management registry
will include clinician prompts and reminders, which should improve rates of
preventive care.

Related Category 3 Outcome Measure(s): OD-3: Potentially Preventable ReAdmissions—30 day Readmission Rates; IT-3.3: Diabetes 30 day readmission rate;
(094109802.3.3).

Relationship to Other Projects: This project is part of LPDS’s larger plans to
expand and develop primary care and specialty care services, while improving
access to care and containing the costs of care. Specifically, this project will
complement LPDS’s Congestive Heart Failure Clinic project (094109802.2.2); both
of these projects are targeted towards patient populations for whom delivery system
reform could result in great improvements in the cost and quality of care, as well as
improvements in overall patient population health.

Relationship to Other Performing Providers’ Projects in the RHP: TBD

Plan for Learning Collaborative: TBD

Project Valuation: $5,960,701. The valuation of each LPDS project takes into
account the transformational impact of the project, the population served by the
project (both number of people and complexity of patient needs), the alignment of
the project with community needs, and the magnitude of costs avoided or reduced
by the project. In particular, this project has been valued based on the significant
cost savings when diabetes patients are assisted to more effectively self-manage
their care, as well as the logistical difficulties and costs that will need to be borne in
order to effectively coordinate the development of this project’s infrastructure and the
implementation of the project’s procedures.
094109802.1.3
1.3.1.X
HCA Las Palmas Del Sol
094109802.3.3
IT-3.3
Related Category 3
Outcome Measure(s):
Year 2
(10/1/2012 – 9/30/2013)
Milestone 1: Establish baseline for
metrics P-2.1, P-3.1, P-4.1, and I-15.1.
Metric 1: Establish baseline for future
years.
Milestone 1 Estimated Incentive
Payment: $1,457,776
1.3.1
Year 3
(10/1/2013 – 9/30/2014)
DEVELOP DIABETES MANAGEMENT REGISTRY
094109802
Diabetes 30 day readmission rate
Year 4
(10/1/2014 – 9/30/2015)
Milestone 2 [P-2]: Review current
registry capability and assess future
needs.
Milestone 5 [I-15]: Increase the
percentage of patients enrolled in the
registry.
Metric 1 [P-2.1]: Documentation of
review of current registry capability
and assessment of future registry
needs.
Baseline/Goal: n/a
Data Source: EHR systems; other
performing provider
documentation.
Metric 1 [I-15.1]: Percentage of
patients in the registry.
Baseline/Goal: 10% increase over
DY 2 baseline.
Data Source: Registry or EHR.
Milestone 2 Estimated Incentive
Payment: $795,168
Milestone 3 [P-3]: Develop crossfunctional team to evaluate registry
program.
Metric 1 [P-3.1]: Documentation of
personnel (clinical, IT, administrative)
assigned to evaluate registry
program.
Baseline/Goal: n/a
Data Source: Team roster and
minutes from team meetings.
Milestone 3 Estimated Incentive
Payment: $795,167
Milestone 5 Estimated Incentive
Payment: $1,594,979
Year 5
(10/1/2015 – 9/30/2016)
Milestone 8 [I-15]: Increase the percentage of
patients enrolled in the registry.
Metric 1 [I-15.1]: Percentage of patients in
the registry.
Baseline/Goal: 10% increase over DY 2
baseline.
Data Source: Registry or EHR.
Milestone 8 Estimated Incentive Payment:
$1,317,591
094109802.1.3
1.3.1.X
HCA Las Palmas Del Sol
094109802.3.3
IT-3.3
Related Category 3
Outcome Measure(s):
Year 2
(10/1/2012 – 9/30/2013)
Year 2 Estimated Milestone Bundle
Amount: $1,457,776
1.3.1
DEVELOP DIABETES MANAGEMENT REGISTRY
094109802
Diabetes 30 day readmission rate
Year 3
(10/1/2013 – 9/30/2014)
Year 3 Estimated Milestone Bundle
Amount: $1,590,335
Year 4
(10/1/2014 – 9/30/2015)
Year 4 Estimated Milestone Bundle
Amount: $1,594,979
TOTAL ESTIMATED INCENTIVE PAYMENTS FOR 4-YEAR PERIOD: $5,960,701
91320
Year 5
(10/1/2015 – 9/30/2016)
Year 5 Estimated Milestone Bundle Amount:
$1,317,591