Download Disease Management Registry Cat 1 narrative Master

Project Option 1.3.1: A proposal to establish an enterprise wide Chronic Disease Management
Registry
Unique Project ID: 84597603.1.2
Performing Provider / TPI: TEXAS TECH HS CTR FAMILY MED / TPI
Project Description:
The intent of this project is to develop the resources and infrastructure to design, build, and maintain
patient registries as an enterprise priority available as a resource to support any Department that
identifies a need. By developing these resources centrally, we can be assured that disease conditions
treated by multiple departments are recorded in a uniform manner for comparison and reporting
The Texas Tech Physicians of El Paso is a 225 member provider group serving the PLFSOM. We are the
largest multi-specialty care provider group in the region, and provide approximately 250,000 outpatient
visits per year in eight locations. The School is in the process of implementing an EMR and all primary
care Departments are currently utilizing this integrated enterprise system, with the enterprise
completely on-line by the end of DY2. Paul L. Foster School of Medicine is the largest provider of
ambulatory care to the uninsured and Medicaid populations in the region. Approximately 35% of our
outpatients have no 3rd party coverage, and an additional 35% have Medicaid.
Relationship to Regional Goals: This project addresses the Region’s goal to better manage patients with
chronic diseases, such as Diabetes, CHF, Asthma, COPD, and Renal disease to help prevent unnecessary
readmission. The first condition we propose to enroll in the registry is diabetes, one of reflecting the
disproportionate burden this disease places on our Region’s patients as indicated by its specific inclusion
among our regional goals.
Challenges: Like other under-resourced public institutions, PLFSOM has poorly developed internal
communication structures within its clinical care delivery system. Divisions between the silos of
administration, nursing, support services, and medical staff have resulted in a multiplicity of parallel and
typically under-resourced or under-utilized responses to the need to gather registry level information.
Historically, these efforts were led by single providers with a passion for the program, and were either
unsustainable or collapsed when the founder moved on.
Project Goals:
 To establish, at an enterprise level, the resources to develop, implement and maintain disease
management registry programs, to support primary and specialty care clinics.

To establish active patient registries in at least two conditions which reflect its use in primary versus
specialty care, and across departments in the organization.
Expected 5-year outcome for providers and patients: By the end of DY5, PLFSOM will have
implemented disease management registries in Internal Medicine and Family Medicine for diabetes and
breast cancer. These conditions were chosen based on 1) high prevalence and impact in our population
2) the desire to implement this functionality in multiple clinics and departments encompassing primary
and specialty care 3) the need to provide a means to link the patient in both primary and specialty care,
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and 4) because these conditions represent well documented opportunities to improve access and reflect
organizational priorities for other 1115 wavier projects
Baseline: We have no formal registry functionality on campus at this point. There are several small
databases of patients with specific conditions, but these are essentially just lists of patients; they do not
include any of the functionality commonly associated with robust registry programs.
Rationale: Our population caries a disproportionate burden of chronic diseases. The BRFSS 2010 selfreported rate of overweight and obesity, risk factors for diabetes, in PHA Region 9/10 is 67.5 %, while
the nationwide rate is 64.3. Over 70% of El Paso residents are of Hispanic ethnicity, an additional risk
factor for diabetes. Therefore, most of the population is at risk for diabetes. Indeed, the self-reported
rate of diabetes in El Paso is 12.8%, compared to a nationwide self-reported rate of 9.3%. This becomes
even more significant as the population ages. The self-reported rate of diabetes in El Paso increases
from 6.4 % when less than 45 years of age to 19.1 % for ages 45 to 64 and to 28.5% for ages 65 and
older. The overall impact of this particular chronic disease is huge, and 37.1% of BRFSS respondents
from El Paso report no health insurance, compared to a nationwide rate of 15.1%.
Diabetes is the third leading cause of death in the border region of US-Mexico (Healthy Borders 2010,
The United States-Mexico Border Health Commission). In addition to mortality, diabetes morbidity is a
significant problem. In the border region, the incidence rate for diabetes was 310.9 per 100,000
inhabitants in 1995, and by the year 2000 this rate had grown by 35.5 percent. The hospitalization rate
(discharges per 100,000 population) in 2000 for diabetes was 14.9 for the region leading to significant
health costs.
The population served by PLFSOM is particularly at risk. Approximately 70% of our patient base lack 3rd
party insurance coverage or have only Medicaid. Our region has a profound shortage of adult primary
care physicians, estimated at nearly 370i. Given this profound shortage, it is very difficult for unfunded
or underfunded patients to access primary care for chronic conditions, and absolutely critical that, as an
organization, we have in place the tools to be able to identify, track and proactively manage chronic
diseases on a population level. A registry is essential to accomplish this goal.
If care as currently practiced for the chronic disease conditions were optimized for Medicaid and
unfunded patients, then patients with diabetes, for example, would be identified and treated effectively
reducing both the mortality rate of diabetes and the need for hospitalization. However, we know that a
substantial proportion of high risk patients have suboptimal outcomes for managing and improving
outcomes for chronic disease. This disparity may be addressed, in part, through programs which track
clinically relevant information in a uniform manner and deliver to the provider at the point of care.
Cancer is the second leading cause of death in the border regions of Mexico and the United Statesii.
Each year, more than 13,000 border residents die from cancer, with about 3,000 deaths in Mexico and
more than 10,000 in the United States border area. The 2000 mortality rate for malignant neoplasms in
the Mexico border region was 59.0 per 100,000 inhabitants and 174.4 in the U.S. border region.
The most important cancer sites or types, in terms of cancer mortality, are lung cancer, stomach and
colorectal cancer, breast cancer, and cervical and prostate cancers. Survival rates for most cancers are
significantly improved through early detection and treatment. Improved screening for cancer is essential
to reduce the cancer death rate programs which track clinically relevant information and deliver to the
provider at the point of care would have significant impact. Female breast cancer is one of the most
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important cancers for border women. In the United States, the diagnosis of new cases of breast cancer
is increasing among Hispanics.
We chose Project Option 1.3.1 because we have no organized or functional enterprise or Departmental
level registry program or resources and we will accomplish all required elements in this option set.
a) Enter patient data into unique chronic disease registry. This will accomplished in late DY2 and
DY3 as the registry function is rolled out, and is a formal Improvement target (IT-15) in DY4 and
DY5.
b) Use registry data to proactively contact, educate, and track patients by disease status, risk
status, self-management status, community and family need. This is included in P-5 in DY3.
c) Use registry reports to develop and implement targeted QI plan. P-13 is included in DY3, DY4
and DY5 in the clinical setting and includes review of data and formulating responses including
identifying improvements needed
d) Conduct quality improvement for project. P-13 is included in al l4 DY years and reflects ongoing,
weekly analysis of information from the registry and formulating responses to the data.
We propose to incorporate the continuous quality improvement requirements initially by including
Registry status as a standing item on our EMR steering committee agenda. This committee consists of
senior administration (Associate Deans for finance and clinical affairs, VP of Information Technology,
EMR project manager, Medical Records and Quality Directors), can pull in ad hoc representatives from
the scheduling system group, and reports directly to the Dean of the Medical, the senior most leader of
the Performing Provider. This group meets at least bi-weekly and usually weekly. Once the Registry is in
operation, we will have regular meetings with clinic personnel to review.
This project addresses: CN.1 expansion of Primary care and CN.2 access to specialty / secondary care.
The improvement milestones reflect the adoption of the registry by end users and the expansion of this
functionality to other Departments and providers, reflecting one of the core goals of this project, namely
to establish and maintain this functionality at an enterprise, rather than local level.
As noted above, we have no registry capability at this point. This is a significant, new initiative for us.
The milestones chosen for this project reflect the planning and IT / EMR integration required to fully
optimize the use of the registry, reflecting the current state of readiness of the Kenworthy Family
Medicine Clinic where we will initially role it out. Our improvement targets reflect the goal of expanding
this registry functionality across departments and to specialty as well as primary care conditions.
Improved care of DM patients by utilization of registries will lead to better patient outcomes from
better data available to providers, fewer complications needing secondary and tertiary care from
specialists in both inpatient and outpatient settings and based on data from THE PATIENT CENTERED
PRIMARY CARE COLLABORATIVE, a reduction in hospital admissions. http://www.pcpcc.net/
The utilization of a registry for patients with breast cancer supports long term sequential follow up of
this high risk group, which is essential in managing the two year survivorship program proposed in
another of our projects.
Related Category 3 Outcome Measures:
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IT-1.11 Diabetes care: BP control
Establishment of a registry in and of itself is of little utility in the care of patients with chronic disease.
Its value is demonstrated by being able to identify populations of patients and then manage them based
on nationally accepted, evidence based, processes. The Improvement milestones selected represent a
common core care issues for patient with diabetes, which aligns with the patient population we intend
to track initially with this registry. Demonstrating improvement in these care parameters through use of
the registry will conclusively demonstrate the value of this effort.
Relationship to Other Projects: Registry functionality is related to:
84597603.1.1 Expansion of Specialty Care in Ophthalmology and
84597603.1.4 Expansion of Breast Care Services to an Indigent and Underserved Population.
To most fully recognize the benefits of a registry system, it is essential that the resources for meeting
the healthcare needs identified through the registry are available. Improving ocular care for patients
with diabetes care requires a significant increase in ocular care professionals as we have proposed, and
impacting the status of women with breast disease requires access to diagnosis and treatment of
conditions identified. Our Expansion of Breast Care Services represents an effort to meet this need.
Relationship to Other Providers’ Projects in the RHP: University Medical Center is significantly
increasing their primary care capabilities through neighborhood health centers and has a project to
develop the PCMH model in these clinics. We will share ‘lessons learned’ in the transition to a medical
home with all RHP participants.
Plan for Learning Collaborative: The performing provider will participate in semi-annual RHP meetings
sharing knowledge learned from this effort.
Valuation: The Performing Provider considered a series of factors in establishing a valuation for each
project. These included the amount of human resources required to meet the milestones of the project,
through new hires as well as the assignment of existing support personnel such as Information
Technology, EMR and administrative support. We considered what non personnel resources would be
required, such as equipment specialized for a certain specialty, and what, if any, additional space would
be required to house the initiative. We considered timing issues related to when we had to add
resources compared to when a corresponding milestone could be achieved. We also considered the
amounts of potential professional fee revenues the project may generate, and offset these against
resource demands.
We made a risk assessment for each project, considering the complexity, the scope, the extent to which
any single point failure in the milestones would jeopardize downstream success, the degree of interdependence on other projects within the waiver program as well as institutional initiatives outside the
waiver, and the amount of time required to manage the project. We made an assessment of potential
general community benefit. Finally, we considered organizational priorities, and to what extent the
Performing Provider was able to justify partial support of these efforts as meeting existing institutional
requirements or objectives.
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i
Paso del Norte Blue Ribbon Committee for a Strategic Health Framework. Phase One: Needs
Assessment Report. March 24, 2011. On File.
ii
http://www.borderhealth.org/files/res_63.pdf. Accessed 10/14/2012
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