Read these FPM articles to learn more about patient registry systems and how they can help improve patient care: "Using a Simple Patient Registry to Improve Your Chronic Disease Care"; "Building a Patient Registry from the Ground Up."
The AAFP video "Improve Care with Patient Registries" is another helpful resource.
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Set up a Patient Registry
Time to Complete: 1 to 2 months to design system and start implementation
Difficulty: Moderate; requires multiple steps
Outcome: A database to manage patients who have chronic disease and to measure improvement
Steps
Install patient registry system
- Select the patient registry system you want to use. Some EMR systems include a registry function. In some cases, set-up time may be required for registry functions that come with EMR systems. If you don't have an EMR in your practice, you may choose to use an online patient registry system. You can also use a database program, such as Access, or even Microsoft Excel to set up a patient registry (see Tool section).
- If necessary, get training to learn how to use the registry system.
Input data
- Enter information on all patients who have the conditions you chose to measure. If using a more simple registry system, enter the data manually. If your patient registry is a function of your EMR system, information will probably come from an electronic feed.
- Set your registry system to track the core measures you selected for each condition.
Integrate data collection into care process
- Have patients' status reports from the registry at hand at every visit.
- Have a nurse or medical assistant input the clinical parameters you want measured for each patient in the status report at the beginning of the visit.
- At each visit, review the status report and update the care plan.
- At the end of each visit, give patients a copy of their status report, including updated care plan.
Identify needed care
- Set up a reminder system to alert you and your staff of labs or preventive services your patients may need.
- Develop a system to notify patients when a certain service is due.
What You Will Need
- A patient registry function, available in certain EMR systems; a database program, such as Access; or Microsoft Excel
- Time to input data
- Training to learn how to use the registry system
Tools
- The following FPM tools can help you and your staff keep track of core measures for patients who have diabetes or asthma: Diabetes Tracking Worksheet (1-page Excel file. About downloading files); Asthma Management Flow Sheet (2-page PDF file. About PDFs)
- Send patients this sample Reminder Letter from FPM to remind them of services that are due. This will help keep your treatment plans on track. (1-page PDF file. About PDFs)
Where to Go for Help
Join a free collaborative online network committed to practice transformation. Learn more about Delta-Exchange.
This Patient-Centered Medical Home section of the AAFP web site was supported in part by a grant from Merck & Co.
This Patient-Centered Medical Home section of the AAFP web site was supported in part by a grant from Merck & Co.
Install a System to Collect Data
