1. 1.01 E LECTRONIC M EDICAL R ECORD S YSTEMS AND D ISEASE R EGISTRIES : S ELECTION A LONG THE S PECTRUM Wayne T. Pan, MD Medical Director Choosing a Chronic Disease Registry

2. adapted from Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4. Chronic Care Model (CCM)

3. Community Health System Self-Management Support Delivery System Design Decision Support Clinical Information Systems from Improving Chronic Illness Care (ICIC) website (http://www.improvingchroniccare.org/change/model/components.html). ICIC is a national program supported by The Robert Wood Johnson Foundation with direction and technical assistance provided by Group Health Cooperative's MacColl Institute for Healthcare Innovation Chronic Care Model (CCM)

4. Clinical Information Systems organize patient and population data to facilitate efficient and effective care How a Chronic Disease Registry (CDR) fits into the CCM Health System create a culture, organization and mechanisms that promote safe, high quality care

5. Self-Management Support empower and prepare patients to manage their health and health care How a Chronic Disease Registry (CDR) fits into the CCM Delivery System Design assure the delivery of effective, efficient clinical care & self-management support

6. Decision Support promote clinical care that is consistent with scientific evidence and patient preferences How a Chronic Disease Registry (CDR) fits into the CCM

7. Health Plan of San Mateo County-organized Health System 55,000 covered lives including ABD ~300 participating PCPs with 1/3rd in county hospital clinics

8. 8 Why a Health Plan? Chronic Care Model: Help providers help patients manage their chronic conditions UM can only go so far in managing costs

9. 9 Data rich resources: claims, pharmacy, labs Why a Health Plan? Value-added program: attract other providers to our network

10. 10 Why a Health Plan? HEDIS studies: assist with capturing capitated services Pay for performance

11. What are we looking for in a CDR? Electronic connectivity Ability to work with multiple chronic diseases

12. What are we looking for in a CDR? Integrated clinical practice guidelines Practice management assistance

13. What are we looking for in a CDR? Affordable Configurable, customizable

14. What are we looking for in a CDR? Patient centered”ness” Web-based, HIPAA compliant

15. What are we looking for in a CDR? Technologically appropriate Multi-plan capable

16. California HealthCare Foundation publications

17. Using Computerized Registries in Chronic Disease Care (CDC): How a registry supports CDC Ensure regular follow-up by the care team Embed evidence-based guidelines into daily clinical practice

18. Using Computerized Registries in Chronic Disease Care (CDC): How a registry supports CDC Integrate specialist expertise and primary care Provide timely reminders for providers and patients

19. Using Computerized Registries in Chronic Disease Care (CDC): How a registry supports CDC Identify relevant subpopulations for care Facilitate individual patient care planning

20. Using Computerized Registries in Chronic Disease Care (CDC): How a registry supports CDC Share information with patients and providers to coordinate care Monitor performance of practice team and care system

21. Using Computerized Registries in Chronic Disease Care: Differentiating Patient Registries Source of Registry Application Sponsorship

22. Using Computerized Registries in Chronic Disease Care: Differentiating Patient Registries Technology Hosting Single or Multiple Condition

23. Using Computerized Registries in Chronic Disease Care: Differentiating Patient Registries Stand-alone/Integrated into an EMR Source(s) of Patient Information

24. Using Computerized Registries in Chronic Disease Care: Differentiating Patient Registries Configurability Affordability

25. California HealthCare Foundation publications

26. Chronic Disease Registries: A Product Review Considerations in Registry Selection Overall disease management strategy Direct vs. indirect costs Data management Return on investment (ROI)

27. Chronic Disease Registries: A Product Review Registry Types Build your own Public domain software Commercial registry software

28. Web-based patient-centered CDR Electronic integration of laboratory, pharmacy, encounter, claims and patient-entered data Supporting Evidenced-based Medicine

29. PatientPlanner attributes Web-based Configurable Patient-centered

30. Ensure regular follow-up by the care team Embed evidence-based guidelines into daily clinical practice Provide timely reminders for providers and patients Identify relevant subpopulations for proactive care Facilitate individual patient care planning Share information with patients and providers to coordinate care Monitor performance of practice team and care system PatientPlanner by

31. Visit Planner

32. Patient Planner: Provider Detail

33. Patient Planner: Provider Summary

34. Patient Planner: Site Summary

35. Patient Planner: Outreach

36. Barriers to implementation Physician adoption Upload of laboratory data from: Unilab/Quest LabCorp of America Local laboratories Member recruitment

37. Resources Data analyst with programming skills Pilot physician offices Private practice Free-standing FQHC County hospital clinics

38. Future directions E-prescribing E-appointments E-messaging Multiple insurance plans working together

39. Thank you