Creating a registry for patients with chronic disease


Fam Pract Manag. 2006 Sep;13(8):16-24.

As a third-year family medicine resident in an academic program, I wondered why many patients with chronic diseases didn’t make regular clinic appointments. Instead, many were treated in the university hospital or ER for acute exacerbations. I wanted a way to monitor these patients and remind them to make regularly scheduled appointments without having to create a registry from scratch.

At our large academic medical center with numerous satellite health centers, I discovered that the infrastructure for improved patient communication and monitoring was already in place. I just needed to use the systems more fully.

One solution was to use the centralized university-wide computer database to build registries for patients with various chronic diseases. We asked our information systems department to search for particular patient information stored in the large university database and then transfer it to Excel. The database contained all the information we needed: when the patients were last seen for chronic disease visits; when they last had important blood work and screening tests; and when they were last seen by other specialists or in the hospital. It also contained updated addresses and contact information for every patient at the health center. For example, for our diabetes registry, we obtained a complete list of patients who had an A1C or urine albumin/creatinine ratio drawn within the last 18 months and their corresponding lab values. If Mr. Smith needed to have his A1C and cholesterol checked and also needed a follow-up visit for diabetes maintenance, I would mail him an appointment reminder along with a lab slip and ask him to get his test done a few days before his visit. A few days later I would check our electronic schedule to make sure Mr. Smith had scheduled an appointment.

Another solution was to open a free e-mail account and send myself reminder e-mails about important follow-up testing and appointments. For example, if Mrs. Smith needed a repeat Pap smear in six months, I could generate an e-mail reminder to be sent automatically to my account in six months. I would then follow up with her and the e-mail could be deleted or saved in my account depending on whether a reminder would be needed for a future date.

After six months of using the system, patient visits for chronic disease maintenance rose 40 percent. Our patients’ health improved as well. For example, LDL for patients with hypercholesterolemia dropped 20 percent during the first six-month period.

Many providers have a favorite reminder system they use for keeping patients with chronic diseases as healthy as possible. Telephone reminder systems, largely available through companies that supply electronic health records (EHRs), have advantages such as speedy message delivery to patients. EHRs are popular, but the high cost of adapting and maintaining them in a large clinic may prohibit some from using them. Other physicians describe using Excel spreadsheets for tracking visits and test results for patients with chronic diseases (see “Using a Simple Patient Registry to Improve Your Chronic Disease Care,” FPM, April 2006). For those providers affiliated with academic centers with a central computer tracking system, fundamental components of a chronic disease registry are already in place and ready for use.


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Copyright © 2006 by the American Academy of Family Physicians.
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