Care of a Population

In addition to caring for individuals, the office care team has the responsibility to monitor and manage their ability to care for the population they serve. This may apply to a particular condition (e.g., diabetes) or preventive services (e.g., immunizations, recommended screenings). Although the care each individual receives is important, the aggregate of the care that all patients with a particular condition receive is a better indication of the effectiveness of the overall approach to care.

Registries are used to track and organize information about all patients with a particular condition. For example, a registry for diabetes would include all patients in the practice who have been identified as diabetic. It should provide the office team with information about the patient's most recent visit (e.g., glycosylated hemoglobin and lipid levels, blood pressure results), eye exam date, and patient self-management goals. Many registries provide information for proactive contact with patients whose clinical parameters are missing or out of range. Registries provide the opportunity for patient care and contact between visits, in addition to highlighting needed services during the visit.

Ideally, EHRs should be able to integrate the registry function into the workflow and draw data from appropriate sources automatically. If this function is not integrated into the EHR, stand-alone and web-based products are available to help manage a population of patients.

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