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 AAFP.org. 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