Chronic Disease Management Registry

Management of chronic health problems like high blood pressure, diabetes, hypothyroidism, and heart disease is a major part of most primary care physician's work. In the traditional model the physician sees a patient for an episode of care, assesses the status of the conditions, makes suggestions, adjusts medications, and orders any indicated testing. The patient is advised of the time when they are asked to return for followup care.

For years the best practices have been using a means of monitoring some or all of their patients with certain chronic medical problems by means of a disease registry. In this model of care all of the patients with a problem, for example diabetes, are listed in a data base, either a paper filing cabinet, or a digital data base. In the data base certain details of the patients status are recorded. For example in a diabetes data base the information might be the last Hemoglobin A1C value and date, the last blood pressure, the last LDL cholesterol, the date of the last dilated eye exam, the last diabetic foot exam, the last test for kidney damage, and their smoking status.

Keeping the data base required entry of this data into the registry every time a new piece of data was obtained, and having a means of periodically looking for patients who were past due for certain services.

Use of an electronic medical record which stores granular pieces of information in a way that can be retrieved electronically, intentionally entering the information into the EMR in a way that it can be retrieved, and developing a report or system for creating a virtual disease management registry has allowed progressive physicians and practices to much more efficiently and effectively manage groups of patients with selected chronic medical problems proactively.

In these offices if a patient is due a visit for followup care, or is past due for any type of testing or service, they can be more easily and efficiently discovered, contacted, and encouraged to receive the optimal care. Ask your physician if they have a disease management registry to help them provide optimal care for your medical condition.

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