1.01%20ELECTRONIC%20MEDICAL%20RECORD%20SYSTEMS%20AND%20DISEASE%20REGISTRIES:%20SELECTION%20ALONG%20THE%20SPECTRUM

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1.01ELECTRONIC MEDICAL RECORD SYSTEMS AND
DISEASE REGISTRIES SELECTION ALONG THE SPECTRUM
Choosing a Chronic Disease Registry
Wayne T. Pan, MD Medical Director
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Chronic Care Model (CCM)
adapted from Wagner EH. Chronic disease
management What will it take to improve care for
chronic illness? Effective Clinical Practice.
199812-4.
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Chronic Care Model (CCM)
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/chang
e/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
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How a Chronic Disease Registry (CDR) fits into
the CCM
Clinical Information Systems organize patient and
population data to facilitate efficient and
effective care
Health System create a culture, organization and
mechanisms that promote safe, high quality care
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How a Chronic Disease Registry (CDR) fits into
the CCM
Self-Management Support empower and prepare
patients to manage their health and health care
Delivery System Design assure the delivery of
effective, efficient clinical care
self-management support
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How a Chronic Disease Registry (CDR) fits into
the CCM
Decision Support promote clinical care that is
consistent with scientific evidence and patient
preferences
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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
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Why a Health Plan?
Chronic Care Model Help providers help patients
manage their chronic conditions
UM can only go so far in managing costs
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Why a Health Plan?
Data rich resources claims, pharmacy, labs
Value-added program attract other providers to
our network
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Why a Health Plan?
HEDIS studies assist with capturing capitated
services
Pay for performance
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What are we looking for in a CDR?
Ability to work with multiple chronic diseases
Electronic connectivity
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What are we looking for in a CDR?
Integrated clinical practice guidelines
Practice management assistance
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What are we looking for in a CDR?
Affordable
Configurable, customizable
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What are we looking for in a CDR?
Patient centeredness
Web-based, HIPAA compliant
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What are we looking for in a CDR?
Technologically appropriate
Multi-plan capable
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California HealthCare Foundation publications
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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
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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
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Using Computerized Registries in Chronic Disease
Care (CDC) How a registry supports CDC
Identify relevant subpopulations for care
Facilitate individual patient care planning
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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
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Using Computerized Registries in Chronic Disease
Care Differentiating Patient Registries
Source of Registry Application
Sponsorship
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Using Computerized Registries in Chronic Disease
Care Differentiating Patient Registries
Technology Hosting
Single or Multiple Condition
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Using Computerized Registries in Chronic Disease
Care Differentiating Patient Registries
Stand-alone/Integrated into an EMR
Source(s) of Patient Information
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Using Computerized Registries in Chronic Disease
Care Differentiating Patient Registries
Configurability
Affordability
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California HealthCare Foundation publications
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Chronic Disease Registries A Product
Review Considerations in Registry Selection
Overall disease management strategy
Direct vs. indirect costs
Data management
Return on investment (ROI)
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Chronic Disease Registries A Product
Review Registry Types
Build your own
Public domain software
Commercial registry software
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Web-based patient-centered CDR
Supporting Evidenced-based Medicine
Electronic integration of laboratory, pharmacy,
encounter, claims and patient-entered data
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PatientPlanner attributes
Web-based
Configurable
Patient-centered
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PatientPlanner by
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
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Visit Planner
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Patient Planner Provider Detail
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Patient Planner Provider Summary
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Patient Planner Site Summary
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Patient Planner Outreach
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Barriers to implementation
Physician adoption
Member recruitment
Upload of laboratory data from Unilab/Quest
LabCorp of America Local laboratories
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Resources
Data analyst with programming skills
Pilot physician offices Private practice
Free-standing FQHC County hospital clinics
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Future directions
E-prescribing
E-appointments
E-messaging
Multiple insurance plans working together
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Thank you