1. Using A Diabetes Registry: Lessons from Our Office Merced Faculty Associates Atwater, CA Family Medicine Summit Creating the Patient-Centered Medical Home San Francisco Nov. 15, 2008 Isaac Kim, MD Merced Family Medicine Residency

2. Our Office One of 13-14 offices of Merced Faculty Associates Medical Group, Inc. In the “evaluation” phase of EMR/EHR’s Core providers: –One half-time family physician (equivalent) –One full-time physician assistant –One full-time nurse practitioner

3. Our Office Total DM patients: 216 (active, not pre-DM) Medi-Cal: 7/216 (3.2%) Medicare:67/216 (31%) 2007 no-show rate: 7%(of 10,700 visits)

4. What is a registry? “a computer application used to capture, manage, and provide information on specific conditions to support organized care management of patients” 1.Aggregate reports: population tracking. “How do my/our patients measure up?” - may be used for P4P 2.Patient report: reminder system, safety net, visit planner “How do I remind myself to help my patient improve core measures?” - replaces the DM flow sheet 3.Outreach reports: proactive management, case management. “How do I identify patients who are poorly-controlled on a regular basis?”

5. Why did we start a DM registry? Outcomes will improve… or will they? –DM a top chronic medical condition which causes morbidity & mortality Dr. Adubofour’s challenge: how do you know -- how your patients measure up – without collecting data from your own patients’ charts? CAFP* New Directions in Diabetes Care collaborative: free DocSite ® registry (2-year subscription), timeline to implement P4P Bridge / transition / rehearsal towards EMR/EHR Overall burden/commitment: low –Data entry work: 0.5 hours/wk, 10-15 charts/wk *California Academy of Family Physicians

6. Steps of Implementation April 2007: baseline data entry –DM flow sheets continue to be used as before –Data entry specialist went through A-Z in records room and entered into registry if: Master Problem List indicates DM (not pre-DM) Seen < 1 year in our office

8. Steps of Implementation July 2007: Visit Planner system –Replaced the DM flow sheet –Printed from registry and placed in charts the day before office visit, for any reason in front of the Master Problem List –Provider sees patient then checks Visit Planner to see if any Care Opportunities exist: make some changes right away, or arrange follow-up appt (with labs beforehand if needed) –Provider makes corrections, updates the Visit Planner –Records pulls and places on data entry specialist’s desk –Updated Visit Planner is printed the day before next visit

10. Steps of Implementation March 2008: First outreach report 1.Last visit >6 months 2.Most recent SBP >150 3.A1c >9.0% (21 patients) Oct 2008: Second outreach report

11. Setbacks “R” Us Trained: 1st MA/data entry person -- moved unexpectedly Trained: 2nd MA/data entry specialist – unable to adapt FNP: illness – long absence PA-C: illness – long absence Personal time constraints

12. What have we learned… so far? Physician champion is the key to success. Enlist support of all office staff. Data entry specialist is important. The Visit Planner and the Outreach reports have “sold us” on the value a DM registry.

13. In closing… “…those with diabetes received only 45% of care known to reduce costly and debilitating complications…” (McGlynn, E. et al, “The Quality of Health Care Delivered to Adults in the United States,” NEJM, 348;26, 2635-2645, June 26, 2003) “…diabetes often is poorly controlled despite adequate access to health care resources. Over 58% of patients with diabetes have an A1C >7.0% and over 15% have levels >10.0%...” (Thomas KG et al, “Use of a registry-generated audit, feedback, and patient reminder intervention in an internal medicine resident clinic--a randomized trial,” J Gen Intern Med. 2007 Dec;22(12):1740-4. Epub 2007 Nov 1)

14. Helpful Resources 1.“Using Computerized Registries in Chronic Disease Care” http://www.chcf.org/topics/chronicdisease/index.cfm?itemID=21718 http://www.chcf.org/topics/chronicdisease/index.cfm?itemID=21718 2.“Patient registries: a key step to quality improvement” http://www.acponline.org/clinical_information/journals_publications/acp_internist/sep05/patient.htm http://www.acponline.org/clinical_information/journals_publications/acp_internist/sep05/patient.htm 3.“Using a Simple Patient Registry to Improve Your Chronic Disease Care” Free MS Excel spreadsheet DM registry. http://www.aafp.org/fpm/20060400/47usin.html 4.“From Paper to Propietary: Patient Registries” Offers the nuts and bolts of implementing a patient registry. http://www.familydocs.org/new-directions-in-diabetes-care/conversations-in-diabetes-and-re- design.php 5.“Benefits of information technology-enabled diabetes management,” (Bu D et al. Diabetes Care. 2007 May;30(5):1137-42. Epub 2007 Feb 23) 6.“Use of a registry-generated audit, feedback, and patient reminder intervention in an internal medicine resident clinic--a randomized trial,” (Thomas KG et al. J Gen Intern Med. 2007 Dec;22(12):1740-4. Epub 2007 Nov 1) Isaac.Kim@chw.edu Point of contact: Isaac.Kim@chw.edu (209) 385-7995