1. How to use a chronic disease management registry: a case report
Diego De la Mora MD FACP
Assistant Professor – PLFSOM
Assistant CMIO
April 2018

2. Disclosure
I have no actual or potential conflict of interest in relation to this presentation

3. Activity
Write down the name of one of your healthcare providers in your organization (you can choose yourself if you take care of patients)
Think of the most common chronic condition that he/she takes care of
Write down how many his/her patients have this condition
Write down how many of these patients have their condition well controlled.
How exact are these numbers? (1-10, 10 being the most exact)
How difficult would it be for you to know the exact number? (1-10, 10 being the most difficult)

4. Agenda Overview of TTUHSC – El Paso Internal Medicine Clinics
Population Health
Empanelment
Pre-visit planning
Point of Care
Empowering Quality Improvement
Results
Reporting
Outreach

5. Overview TTUHSC – El Paso Largest multi-specialty group in the region
One of only 2 Medical Schools in the Texas-Mexico border
Serves primarily a highly populated, low income urban center
Main Campus and Trans-Mountain Campus

6. Overview – our partner hospital
University Medical Center of El Paso
County safety-net hospital
327 beds
Trauma 1 hospital

7. Overview – internal medicine clinic
Internal Medicine Clinic has
Providers:
9 General IM MD
1 General IM NP
45 Residents
40 Specialists
Staff:
3 RNs and 1 LVN
A ratio of about 1:1 MA per MD/NP
About 30 administrative staff.

8. Paradigm
Photo by Jim Zuckerman

9. Shifting the healthcare paradigm
Is this patient’s blood pressure well controlled?
What percentage of my patients has a controlled blood pressure?
The patient
A blood pressure cuff
Define “well-controlled” for this patient
Define percentage
How do you identify “my patients”?
Multiple blood pressure measurements
Define “controlled blood pressure” for the population

10. Shifting the healthcare paradigm
Personal Health
Population Health
Individual pathology
Healthcare provider – centered approach
Prescriptive solutions
Systems-based pathology
Team-based approach
Trial and error

11. Chronic Disease Registry
A database (list) of your patients
Grouped by chronic condition
Contains mostly structured (discrete) clinical information
Commonly done in electronic form
Updated regularly
Name
DOB
A1c
Renal
Eye
Jorge
01/20/1970
6.9
01/08/2018
Due
Elisa
09/15/1945
9.3
12/01/2017
Mike
07/11/1932
Peter
11/18/1950
7.2
01/12/2018
01/12/2006

12. Registry at TTUHSC - EP
Delivery System Reform Incentive Program (DSRIP)
A software was purchased that would obtain the data from our EMR
Panels have been created in various clinics
Internal Medicine
Family Medicine
Endocrinology
Cardiology
Chronic “conditions” include
Cardiovascular Risk Reduction
Diabetes Mellitus
Preventive Services & Adult Immunizations
Asthma
Heart Failure

13. Empanelment
The first step

14. Empanelment Plan your target population
Assign responsibility to create accountability (clinics, teams, individuals)
Address limits of accountability
Incorporate empanelment into day to day practice
When patients present for a follow up or a new patient visit they are assigned to their Provider
Urgent care visits are excluded
Every year, the list of pt’s of graduating residents gets re-assigned
Front desk is tasked with assigning patients, but CMAs and Providers are expected to double check
Providers and MA’s can review panel and remove patients that are deceased or not seen for 2 years.

15. Design
Share only helpful information

16. Design Patient Patient 1 Patient 2 Patient 3 Patient 4 Patient 5

17. Pre-visit planning
Structures team based approach

18. Pre-visit planning It is planned for two days prior to the appointment
A Pre-Visit Planner reviews the schedule for the appointments planned for two days ahead
The Pre-Visit Planner “combs” the chart.
Access the Electronic Medical Record
Updates the EMR in the appropriate structure fields
Initiates ordering for gaps in preventive services
Leaves comments to indicate care-gaps at the Point of Care visit

20. Pre-Visit planning
The registry serves as a play book for the pre-visit team
Allows team members to understand the goal
Empowers the team for action before the patient shows up at the door

21. Point of care
Saving physicians from fatal pop-ups

23. Point of care Huddle Five to ten minutes prior to the first patient
Physician and MA Huddle to discuss prompted orders
Provider signs orders that are appropriate
When patients arrive
Pre-Visit Planning comments are visible in the start page
Providers also have access to a large number of Clinical Decision Support alerts (good bye pop-ups)

25. Empowering quality improvement
Measuring success is critical

26. Empowering residents for QI
Texas Tech University HSC El Paso
Internal Medicine
45 Categorical Residents
10 Groups (4-5 Residents each)
Assigned QI projects based on registry reporting capabilities
Required by ACGME
Previously used paper chart review
More time to focus on Improvement

30. HbA1c CONTROL IN TEXAS TECH EL PASO IM RESIDENTS CLINIC
Lyan Gondin, PGY-3
Mehran Albolbashari. PGY-3
Angie Ariza, PGY- 2
Peter Khalil, PGY-2
Miguel A. Chavez- PGY-1

31. Active Patients Only

32. INCREASE RISK OF AMPUTATON, DYALISIS, STROKE, MI…
HANDOUTS
INCREASE RISK OF AMPUTATON, DYALISIS, STROKE, MI…

33. DIABETES EDUCATION REFERRAL
Medical Nutrition Therapy and Diabetic Education Referral

34. RESULTS

35. Results

36. IM Resident Clinic
IM Faculty Clinic

37. IM Resident Clinic
IM Faculty Clinic

38. Healthcare Effectiveness Data and Information Set (HEDIS)

39. Reporting
Creating a data-driven culture

40. Provider performance reporting
The Performance Reporting tool is updated monthly by an Administrative Assistant
Currently requires a few manual steps
The Administrative Assistant creates the PDFs and send them via
Group reviews are done at the individual clinic level

43. Outreach
Leveraging a registry to close specific gaps

44. Outreach Contact patients outside the walls of the practice
A registry allows physicians/staff to have a ‘bird’s-eye’ view of their patient population
Select the target population from the registry
And prioritize high risk populations for contact
Mail Letter/Postcard
Text
Phone call

45. Outreach example: Group Dietary Education
Milestone:
20% of our Diabetic Population to attend Group Dietary Education
Plan:
Population based “marketing” strategies
Automatic recorded phone calls inviting patients to attend a free Diabetes Dietary Education class
Partnered with the county Hospital’s Diabetes Education Program
Standing-Order Referral

48. Questions?