Patient registry for population health management

Use a Patient registry for population health management, chronic disease management, organized care management. EHRs are not suitable for this.

Categorized as Operations
What is a patient registry 

Forget the buzzwords. It’s simply an organized list of your patients that have a particular condition. That’s it. The conditions could include diabetes, hypertension (HTN), asthma, coronary artery disease, depression etc. There’s no limit to which conditions that a registry can be created for.

A patient registry ensures that you get a summary / bird’s eye view of a patient’s health in a single pane. It’s very much like an executive summary. It helps highlight gaps in care, and manage care of high-risk or high-need patients.

What does a patient registry do

It makes your job of providing recommend care for a particular condition as easy as managing a TODO list.

EMRs are great to have. But, what you need is to cut through the “noise” of an EMR, and get to a summarized view of your patient’s health score. A patient registry helps you keep on top of clinical guidelines for a specific condition.

A patient registry helps you track patient appointments, tests they had vs tests they’re recommended to have, other doctors they’ve been referred to vs they’ve actually been to, etc. Your registry can even flag “out of range” situations(e.g, A1C > 7 %). Such alerts prompt even lay people take notice.

Who needs a patient registry 

Anyone that’s interested in population health management, in general. Anyone that gets compensated for management of patients’ health conditions. Anyone that gets capitated payments. Anyone interested in value based care – for clinical interests or even for financial reasons. Anyone that is negatively impacted by diminishing health of the patient population under their management.

You could have 20 COPD patients or 200 diabetic patients or 2000 retina patients. A registry is what you need to improve patient outcomes.

Tangible benefits of a patient registry 

– Get away from the tyranny of “acute care”. 
– Streamline workflow for chronic illness care. You don’t have to hire as many staff.
– Improve patient outcomes, get higher reimbursements next year
– Easily provide data for quality improvement – registries can also report quality measures for health plans + Centers for Medicare & Medicaid Services (CMS)
– Outsource operational work to practice staff automatically
– Set management goals for your practice with well defined metrics
– Monitor metrics easily by simply comparing against the TODO lists
– It can actually create TODO lists for your patients as well, to keep them more engaged in their own health!

How to start with a patient registry 

Do you use an EMR? In all likelihood , your EMR already has a patient registry. Just ask. Even if your EMR doesn’t have a patient registry, it’s super easy to create and maintain one. You can also buy a registry system.

Next step is to select the conditions you want to manage. Note the ICD codes for those.

After finalizing the list of ICD codes, decide the number of years, months (period of time) you want to “look back”.

Decide what parameters you want to monitor and manage. For example, to manage type-2 diabetes, you might chose to monitor blood pressure, lipids, foot exam, eye exam, immunizations and A1C.

Ask your staff to pull all patients that have these DX codes or have been billed for the related CPT codes over the period of time.

Populate your patient registry spreadsheet or database. Ask the staff to enter target values – eg last eye exam, last A1C, etc.

Get started by adding data to the patient registry as you keep seeing patients. You don’t have to finish the whole list before you can get started.

How to organize patient care using a registry 

You don’t even need to spend a lot of time or brain cells to establish care plans for that specific patient population. Nor do you have to spend any time in figuring out the interventions for non adherence of patients. All of these clinical guidelines are already established by your peers, and mostly are available from CMS and NCQA.

All you have to do is explain the guidelines and the necessary intervention procedures to your supporting staff. This way you can use the registry to optimize care for patients who need your services.

Why not use an EHR for population health management 

EHRs collect large amounts of data, but using that volume of data to make informed decisions might be challenging. Typically, EMRs are not well suited nor designed to address population health management, preventive care management, task management, disease management etc. Registries in their simplicity, help achieve those goals.

How to use patient registry for care management 

Think about the triple aim – improve the patient experience and health of populations while decreasing the cost of care. In a primary care practice, you can use the care management strategy to manage patient populations. 

Basically, you identify, monitor, intervene and provide chronic care support to high risk populations. It will reduce hospitalizations and emergency department (ED) visits. 

You can move away from disease management to population management.

Hire a registered nurse or train your medical assistant to work with these patients. 

Give them access to the patient registry, the care plans for that patient population,  the interventions needed for non adherent patients. Create standing orders (order sets in your EMR). 

Standardize and automate care delivery. This will most definitely reduce your own workload
You’ll notice more care coordination with the patient’s care team that could include LTF or HH agencies as well. This auto-pilot, template based care coordination will greatly increase patient loyalty, retention rates as well.

What’s care management

It’s simply coordinating and managing transitions of care. This could be managing transition of care from acute to post-acute care settings. It could involve transitioning care from acute to home. It could include assessing and closing care gaps.

Care management is about addressing patient needs, coordinating care among the patient’s health care team

Care management is important to identify care gaps and to mitigate the risk of readmission. 

Using patient registries for care gaps

Generally, for a patient population of high risk, you’ll find gaps in their care plan. I don’t have to teach you that. These care gaps can be social or preventive in nature.

Social care gaps can include food or housing insecurity. It can be a matter of lack of access to health care as well.
Meanwhile, preventive care gaps can include immunizations or screenings.

Your patient registry will be able to alert you about care gaps your patient has. It will be able to align your support staff towards closing gaps in care. It helps your support staff identify the areas where patients lack sufficient education that might help them self-manage their chronic conditions or the symptoms and functional changes associated with them. 

Your care managers don’t always need to be clinically certified. That’s the biggest value a registry provides – templates that a layman can understand, follow.

Your patient registry makes it easy for care managers to help in disease management, case management, care coordination, care navigation, and social work.