Diabetes Registry at OU Family Medicine Presenters: Dr. James H. Beebe Dr. L. Oberst-Walsh.

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Presentation transcript:

Diabetes Registry at OU Family Medicine Presenters: Dr. James H. Beebe Dr. L. Oberst-Walsh

Objectives 1. What is a Registry? 2. Describe Diabetes Master Clinician Program 3. Discuss the pro’s and con’s of a registry 4. OU- Tulsa experience 5. Group visits 6. Using a registry in practices without EHR’s

What is a diabetic registry? A spreadsheet or program with patient demographics and care measures for monitoring and tracking, e.g. OU FM Master Clinician Program is an example of one

Screen Shot of OU-TFM Portal

Data Entry Sample

Report Card

Uses Patient Terminology and Shows Progress

Currently OU-TFM has 851 patients in the DMCP Registry

ClinicianClinician HbA1cLDLBP HbA1c & LDL & BP B2B2 Percent38%58%71%14% Met Goals Patients Compare Clinicians and Monitor Results Clinician B2 Improvements

What is the Diabetes Master Clinician Program? Started in 2003 Created by Florida Academy of Family Practice Funded by grants Currently 90 offices, 250 clinicians, 350 nurses and trained MA’s 17,500 patients in the registry Internet based: all data & reports on the web

DMCP value for diabetic patients: Increased quality of care Decreased complications and suffering Entry into Medical Home Concept Increased patient engagement and improved self management skills

DMCP advantages: For patients: Measures progress Patients are engaged Can be used for other chronic diseases For practice: Incentives w/ PQRI NCQA certification More team-based provision of care

Potential disadvantages: No EMR interface with registry… double entry EMR interface with registry… critical data entry in obs terms (meaningful use)

Results from OU-TFM Registry Data

Group Visits: 30 randomly selected patients Initial group visit, and then after 2, 4 and 6 months 3-1/2 hours long Led by: 2 of 6 residents attending faculty exercise physiologist pharmacists Patients given copy of their MDCP report card at start of each group visit

Results: More visits = more success

Group visits empower patients. They enjoy the process and learn more.

No EMR? Use form used in the DMCP Spreadsheet with patient list If electronic, select system with registry interface AAFP Excel Sheet Diabetic Registry: copy and go OHCA contracted with IFMC to provide incentivized practice facilitation and chronic disease registry services for Sooner Care patients

ID numberProviderA1c Date of last A1c Date of last DFE Date of last foot exam Date of last BMPLDL Date of last lipids testSystolic BPDiastolic BP Date of last BP Ortiz6.51-Mar-061-Apr-051-Mar Nov Nov Ortiz5.724-Feb-0612-Dec-0524-Feb Feb Dec Ortiz6.323-Jan-0624-Jul-0523-Jan Jan Jan Ortiz7.816-Feb-0620-Mar-0516-Feb-0612-Nov Nov Feb Ortiz6.824-Oct-0521-Jul-0524-Oct Oct Oct Ortiz7.56-Aug-052-Feb-059-Jan Jan Jan Ortiz6.219-Dec-0516-May-0519-Dec Dec Dec Ortiz6.431-Jan Jan Jan Ortiz617-Dec Dec Dec Ortiz729-Dec-0518-May-0529-Dec Dec Dec-05 AAFP diabetes registry

Other uses for a Registry? Chronic diseases, including… Hypertension Dyslipidemia Depression

Recap How OU-TFM uses DMCP diabetes registry to improve care. How group visits improve patient self management. How YOU can access and use a diabetes registry in your own practice (with or w/o an EMR).

Our Recommendation? Just jump in and DO it! Conclusion/ Final Thoughts