CDC - Centers for Disease Control and Prevention  NIDDK - National Institute of Diabetes and Digestive and Kidney Diseases

NDEP is a partnership of the National Institutes of Health, the Centers for Disease Control and Prevention, and more than 200 public and private organizations.

Manage Population Health

Population health management is an approach to healthcare that aims to improve the health of everyone in a clinical practice. For diabetes care providers, the aim is to satisfy the needs of every patient with diabetes under their care, even if the person has not made an appointment or been seen in the office for up to two years. Closely linked to the concept of a ‘patient centered medical home’, population health management techniques focus on providing proactive support to a defined and prepared patient population. Driven by increasing use of population based process and performance improvement measures, population health management relies on the ability to provide patient support between clinical visits, and to enhance clinical decision support for more comprehensive care delivery during a clinical visit. The ability for these techniques to improve both quality of care delivery and patient safety helps to explain why diabetes is the most commonly adopted focus of new patient centered medical homes.

“Successful practices know who their patients with diabetes are, and regularly mine the data to ensure they receive the care they need.” [5]

The ability to identify and track patients during the care process is an important advance provided by the creation of a diabetes registry. The advantages of an electronic format to track and recall patients makes following patients with paper registries obsolete by comparison. Two basic types of electronic registries exist: registries that are built into an electronic medical record (EMR), and those that stand-alone outside of an EMR. Figure 1 provides examples of typical advantages and disadvantage of each.

Types of Registries
Figure 1

What a Registry Can Do for Your Practice

A patient registry enables a practice to track its diabetes population and proactively organize and plan care. Successful registries drive change in practice and work flows. Successful registries function at several levels providing support for population management, individual care management, and point of care management.

Population management

Process and performance reporting provides compliance with a specific measure across all patients under the care of a practice or provider. For example, a common diabetes measure is the number of patients in the defined population with an A1C less than 7%. The definition of the specific population that forms the ‘denominator’ can vary widely. For a payer organization or a closed health care system, the population may be defined as all patients with continuous health care coverage provided by the payer. For independent practices, all patients who have visited the practice twice over the last 24 months are generally included. Population based reports provide reports on quality and patient safety. They may also provide insight into practice patterns and a comparison between peer groups.

Care Management

Lists of patients generated by the registry can be used to remind both patients and providers of services that are needed. By reminding patients of recommended lab tests and visits, registries support active care coordination between practice visits and encourage patients to return for necessary care. Patient-specific physician reminders can then be used during pre-visit planning to ensure that, when a patient does return to the practice, that opportunities to receive recommended care are not missed.

Point of Care

The ability to support clinical decision making at the point of care can be very effective in improving care. This includes interventions that are provided at the time of the patient visit, such as the development of patient specific alerts that notify the provider during the patient visit of specific recommended care processes. For example, an alert can notify the provider during a visit that a patient is overdue for an A1C or a foot exam. Point of care interventions are technically challenging since they must be integrated into existing work flows and may require modification or interaction with the existing electronic health record.

Effective registries change the existing work flow in a practice. They require accurate and granular data, and need to organize data so that patterns in care delivery are apparent. A good registry should provide staff with actionable information and perform reliably. Barriers include cost, the disruption of process and workflow changes, and challenges of interoperability between systems. Current limitations of existing systems are common, and reimbursement for the work of coordination is often limited.

Evaluating Registries

All EMRs do not support a good registry. The Health and Human Services (HHS) criteria for certification from the Certification Commission for Health Information Technology (CCHIT) requires that all certified EMRs provide:

  1. A list of patients by condition
  2. Generate reports per Centers for Medicare and Medicaid Services (CMS) measures
  3. Generate reports for public health and surveillance

These requirements focus on population measurement, but do not ensure that EMRs provide for effective care management or point of care support.

The National Committee for Quality Assurance (NCQA) Physician Practice Connections-Patient Centered Medical Home (PPC-PCMH) scoring standards describe recommended population health management functions to include generating lists of patients and reminding patients and clinicians of services needed.

Registry functions are graded with the following criteria:

  1. Uses data system for basic patient information (mostly non-clinical data)
  2. Uses clinical data system with clinical data in searchable data fields
  3. Uses the clinical data system
  4. Uses paper for electronic-based charting tools to organize clinical information
  5. Uses data to identify important diagnoses and conditions in practices

The health care team can identify patients at risk and obtain reports based on projected plans for follow-up and feedback. For example, the system can identify high risk patients such as those with A1C> 9%, those not seen in the practice over the last six months, or those at high-risk for vision complications.

The system also can create a report on aspects of a defined patient population and provide graphical summaries that help the team project needs, analyze possible cause-effect relationships, and plan interventions. Registry population management can help physicians, clinic managers, and regional service organization administrators manage their patient population appropriately. Printed progress notes, patient lists, and summary reports can be generated from the registry database.

Electronic Health Records (EHRs) and Meaningful Use

The technology for electronic health records is rapidly expanding. With a properly structured database, reports can be run as desired and patients can receive appropriate interventions – whether a phone call, post card reminder, or scheduling of an exam or visit. Providing patients with reminders and ongoing support is an important facet of patient-centered care. It has been shown that high performance is associated with use of provider alerts. [2] In addition, population-based reports can be generated.

Meaningful use

“Meaningful use” describes ways in which EHRs can be used to measure, report, and exchange health information. Medicare and Medicaid incentive payments are offered to those who use certified EHR technology to achieve meaningful use objectives that are set in three distinct stages:

  • Stage 1 primarily requires standardization of the electronic capture and use of health information.
  • Stage 2 criteria further underscore the concept of using standardized formats and fields for exchange of data.
  • Stage 3 criteria include more population-based health objectives that require practices to generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach.

Reporting specific metrics with the EHR/registry

To assess your system’s capacity to report on the measures you have selected, consider the source of the data, types of information you will need to produce and how often you will need this information. List the capabilities needed to support reporting then align these components with the functional requirements for reporting. For example you may want to be able to:

  • Identify a subpopulation of patients
  • View and manipulate data
  • Export data
  • Create notifications for patients and providers
  • Track quality measures

Networked and Interactive Systems

Secure, networked systems can help different team members access information, such as test results or the long-term management plan. This sharing of information can make team decision-making and communication more effective and efficient. Interactive systems into which patients input daily blood glucose values, blood pressure readings, or food selections allow the team to monitor a patient's progress electronically from a remote location, provide education, answer questions, renew prescriptions, send reminders, and provide other interactions. Patient education materials and behavioral assessment tools can be integrated into the system.

Resources for Information Systems and Population Health Management

Please note: Some links on this page take you outside the NDEP website. The NDEP does not endorse or otherwise guarantee the accuracy of links that take you out of this website.

  1. Agency for Healthcare Research and Quality (AHRQ)

    Diabetes Care Resource Guide and Workbook
    Diabetes Care Quality Improvement: A Resource Guide for State Action and its companion workbook, Diabetes Care Quality Improvement: A Workbook for State Action.

    Databases and Related Tools from the Healthcare Cost and Utilization Project (HCUP)
    Fact sheet about a multiState health data system for health care research and decision making.

    National Quality Measures Clearinghouse™ – provides a large database of information

    Measuring Healthcare Quality
    This website covers topics such as: National Healthcare Quality Report, National Healthcare Disparities Report, CAHPS®; Health Care Innovations Exchange; Measuring Healthcare Quality; Patient Safety & Medical Errors; Patient Safety Network; WebM&M; Quality Indicators; Quality Information & Improvement; and TalkingQuality

  2. American Health Quality Association (AHQA)
    AHQA represents Quality Improvement Organizations (QIOs) and professionals working to improve health care quality and patient safety, Medicare, Medicaid, and private payers and purchasers.
  3. Chronic Disease Electronic Management System (CDEMS)
    The CDEMS is a public domain registry program for management of chronic health conditions. It is pre-coded to track diabetes and adult preventive health but is customizable to track other chronic conditions.
  4. California Health Care Foundation (CHCF).
    Electronic Health Records versus Chronic Disease Management Systems: A Quick Comparison & a Video on Disease Registry Tools
  5. Centers for Medicare and Medicaid Services: Resources for Quality Improvement
    The Medicare Quality Improvement Community (MedQIC) is a national knowledge forum for health care and quality improvement professionals.
  6. Physician Quality Reporting Initiative
    This CMS initiative provides financial incentive for eligible professionals who successfully report a designated set of quality measures.
  7. Health Insurance Portability and Accountability Act (HIPAA)
    HIPPA health information privacy rule to safeguard privacy and confidentiality. HIPAA regulations need to be met and access should always be limited to providers of care who have been trained in the expected standards of confidentiality. For all providers, signed statements protecting the rights of the individual patient regarding data (both in print as well as electronic format) should be on file.
  8. Open Source Electronic Health Records
    1. OpenEMR:
      An electronic health records and medical practice management application
    2. OSCAR
      A suite of electronic health applications
    3. WorldVistA
      An electronic health record and health information system based on and compatible with the U.S. Department of Veterans Affairs VistA®
  9. QualityNet
    Established by the Centers for Medicare & Medicaid Services (CMS) to provide healthcare quality improvement news, resources and data reporting tools and applications used by healthcare providers and others
  10. Resource and Patient Management System (RPMS) from the Indian Health Service
    RPMS integrates the management of clinical and administrative information in health care facilities of various sizes and orientations using hardware configurations, software applications, and network communication components.