Diabetes Registry Diabetes Registry at OU Family Medicineat OU Family Medicine

Presenters: Dr. James H. Beebe Dr. L. Oberst-Walsh

ObjectivesObjectives

1. What is a Registry?2. Describe Diabetes Master Clinician Program3. Discuss the pro’s and con’s of a registry 4. OU- Tulsa experience5. Group visits6. Using a registry in practices without EHR’s

What is a What is a diabetic registry?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

Screen Shotof OU-TFM

Portal

Data Entry Sample

Report Card

UsesPatient

Terminology and

ShowsProgress

Currently OU-TFM has 851

patients in the DMCP

Registry

Clinician  HbA1c LDL BP

HbA1c & LDL & BP

B2Percent 38% 58% 71% 14%

Met Goals   48   64   94   16

Patients   127   111   133   111

Compare Clinicians and

Monitor Results

Clinician B2 Improvements

What is theWhat is theDiabetes Master Diabetes Master Clinician Program?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

DMCP value for DMCP value for diabetic patients:diabetic patients:

• Increased quality of care

• Decreased complications and suffering

• Entry into Medical Home Concept•

• Increased patient engagement and improved self management skills

DMCP advantages: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

Potential Potential disadvantages:disadvantages:

• No EMR interface with registry… double entry

• EMR interface with registry… critical data entry in obs terms (meaningful use)

Results from OU-TFM Registry Data

Results from OU-TFM Registry Data

Results from OU-TFM Registry Data

Results from OU-TFM Registry Data

Group Visits: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

Results: More visits = more success

-2

-1

0

1

2

n=1 n=1 n=7Po

un

ds

Average A1C Change

Visit 1 to 2

-2

-1

0

1

2

n=0 n=0 n=3

Average A1C Change

Visit 1 to 3

Results: More visits = more success

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

No EMR?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

www.aafp.org/fpm/20060400/diabetesregistry.xls

ID number Provider A1cDate of last A1c

Date of last DFE

Date of last foot exam

Date of last BMP LDL

Date of last lipids test Systolic BP Diastolic BP

Date of last BP

111-11-1111 Ortiz 6.5 1-Mar-06 1-Apr-05 1-Mar-06 1-Mar-0675 23-Nov-05140 90 23-Nov-05

222-22-2222 Ortiz 5.7 24-Feb-06 12-Dec-05 24-Feb-06 24-Feb-0690 24-Feb-06110 75 12-Dec-05

333-33-3333 Ortiz 6.3 23-Jan-06 24-Jul-05 23-Jan-06 23-Jan-06103 23-Jan-06105 85 23-Jan-06

444-44-4444 Ortiz 7.8 16-Feb-06 20-Mar-05 16-Feb-06 12-Nov-0598 12-Nov-05131 75 16-Feb-06

555-55-5555 Ortiz 6.8 24-Oct-05 21-Jul-05 24-Oct-05 24-Oct-0588 24-Oct-05120 80 24-Oct-05

666-66-6666 Ortiz 7.5 6-Aug-05 2-Feb-05 9-Jan-06 9-Jan-0687 9-Jan-06130 80 9-Jan-06

777-77-7777 Ortiz 6.2 19-Dec-05 16-May-05 19-Dec-05 19-Dec-0599 19-Dec-05128 77 19-Dec-05

888-88-8888 Ortiz 6.4 31-Jan-06 31-Jan-06 31-Jan-06 31-Jan-0667 31-Jan-06115 80 31-Jan-06

999-99-9999 Ortiz 6 17-Dec-05 17-Dec-05 17-Dec-05 17-Dec-05100 17-Dec-05130 80 17-Dec-05

000-00-0000 Ortiz 7 29-Dec-05 18-May-05 29-Dec-05 29-Dec-0576 29-Dec-05120 75 29-Dec-05

AAFP diabetes registryAAFP diabetes registry

Other uses Other uses for a Registry?for a Registry?

Chronic diseases, including…HypertensionDyslipidemiaDepression

RecapRecap 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).

Our Recommendation?

Just jump in and DO it!

Conclusion/Conclusion/Final ThoughtsFinal Thoughts