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

2. 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

3. 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

4. Screen Shot of OU-TFM Portal

5. Data Entry Sample

6. Report Card

7. Uses Patient Terminology and Shows Progress

8. Currently OU-TFM has 851 patients in the DMCP Registry

9. ClinicianClinician HbA1cLDLBP HbA1c & LDL & BP B2B2 Percent38%58%71%14% Met Goals 48 64 94 16 Patients 127 111 133 111 Compare Clinicians and Monitor Results Clinician B2 Improvements

10. 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

11. 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

12. 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

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

14. Results from OU-TFM Registry Data

18. 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

19. Results: More visits = more success

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

22. 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

23. www.aafp.org/fpm/20060400/diabetesregistry.xls 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 111-11-1111Ortiz6.51-Mar-061-Apr-051-Mar-06 7523-Nov-051409023-Nov-05 222-22-2222Ortiz5.724-Feb-0612-Dec-0524-Feb-06 9024-Feb-061107512-Dec-05 333-33-3333Ortiz6.323-Jan-0624-Jul-0523-Jan-06 10323-Jan-061058523-Jan-06 444-44-4444Ortiz7.816-Feb-0620-Mar-0516-Feb-0612-Nov-059812-Nov-051317516-Feb-06 555-55-5555Ortiz6.824-Oct-0521-Jul-0524-Oct-05 8824-Oct-051208024-Oct-05 666-66-6666Ortiz7.56-Aug-052-Feb-059-Jan-06 879-Jan-06130809-Jan-06 777-77-7777Ortiz6.219-Dec-0516-May-0519-Dec-05 9919-Dec-051287719-Dec-05 888-88-8888Ortiz6.431-Jan-06 6731-Jan-061158031-Jan-06 999-99-9999Ortiz617-Dec-05 10017-Dec-051308017-Dec-05 000-00-0000Ortiz729-Dec-0518-May-0529-Dec-05 7629-Dec-051207529-Dec-05 AAFP diabetes registry

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

25. 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).

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