Monday, August 24, 2009

Disease registry: "Chronic disease tracking system" for those who cannot afford an EMR

For practices that do not plan to purchase an EMR and want to proactively manage the health of population, a registry can be used instead. This registry can be used to track a practice's diabetes patients, including their required labs and preventive services. This information can then be used to manage population health proactively.

A simple MS-Excel based Disease registry can be found here at This file tracks interventions and clinical parameters that are important in diabetes management. In case problems are encountered, an alert is displayed. For instance, if the date of a patient's last A1C was more than 90 days ago, that date cell turns yellow as a warning; and turns red if more than 180 days ago.

Identifying all patients in the practice with a chronic disease such as Diabetes type 2 and initial data entry of this registry excel sheet are identified as major challenges to achieving a complete and functional disease registry. However, once the registry is complete, it provides many advantages:

  • Proactive management of chronic diseases
  • Use for preventive services and screenings such as Pap smears, mammograms, colon cancer screening etc. for general patient population
  • Increased compliance with recommended services
  • Improved patient care
  • Document performance as part of p4p activities

Dr. David Ortiz who created this registry worksheet recommends:
  • Start small, pick a chronic condition that you want to improve
  • Involve your practice staff. Get their buy-in and agreement before operationalizing the plan

1 comment:

  1. I agree with Dr. Ortiz. The patient registry is an important HIT tool that is rapidly gaining momentum. CCHIT will soon certify registries, which speaks to their importance in the HIT landscape.

    Along with thousands of other users across the country, I use WellCentive Registry to help me improve quality at the point of care as well as through better population management and patient outreach.

    WellCentive Registry is a Web-based, all-patient, all-disease preventive care and chronic disease management system, with many major features not seen in other registries:

    1. Point-of-care decision support
    2. Evidenced-based alerts
    3. Patient outreach in the form of automated care reminder letters and VoIP telephone calls using a text-to-voice system
    4. Heavy emphasis on interfacing and integration with outside HIT systems and vendors
    5. Direct reporting to payers for P4P
    6. Comprehensive reporting tools
    7. CMS PQRI Certified
    8. Full support for the PCMH
    9. Many others

    In addition to being one of the co-founders of WellCentive, I also still practice internal medicine part time. I'm a regular user of WellCentive Registry, and it has helped improve the quality of care we deliver here at my site significantly.

    My PHO, like many others, has had steady improvements in its payer incentive payments over the past few years, since the implementation of WellCentive Registry.

    At $650 per provider per year, it is very easy to realize a significant ROI from increased payments for P4P, PCMH certification, PQRI, and other disease management incentive programs.

    Please see for more information, and thank you for letting me tell you about another registry option.

    Paul D. Taylor, M.D.
    CEO & Medical Director