Point-of-Care Registries

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Presentation transcript:

Point-of-Care Registries Alan Glaseroff MD Chief Medical Officer Humboldt Del Norte IPA alang@hdnfmc.com

Chronic Care Model

Point-Of-Care Administrative data vs. point-of-care Registry as a planned visit protocol Availability of clinical data: BMI, blood pressure, foot exam, aspirin, tobacco, self-management goals Lab, pharmacy, services billed (>30 day delay) available administratively only in managed care Offices need a single system for all patients

Humboldt Diabetes Project IPA with >95% of clinicians (MDs, advanced practitioners, behavioral health professionals, podiatrists) Managed care <10% of patients Point-of-care as primary source of data Functionality key to sustaining programs CLG: “Invite implementers into the planning process…” Pilot systems before wide implementation Office managers, medical assistants critical to design

Information/Decision Support Build vs. buy (public domain vs. proprietary) C-DEMS: public domain, open source, customizable, control data and reporting 2770 total (803 study, 1967 registry only) Progress Note: best practice tool actualized Patient summary: focus group Prompts and reminders: keep it simple (HbA1c>9, no HbA1c in past 6 months)

Going Forward Co-morbidities the rule, not the exception Plan all care, not just chronic care Patient activation - overcoming barriers Informed consent checklist Shared decision-making tools Links to credible information Instantaneous QI – statistical process control