SIM small grants fuel practice transformation part 3

By Meg Quiat, JD, SIM grants administrator


This regular column features SIM small grant recipients and the ways in which they are using grant funds to help them in their practice transformation journeys. Read last month’s column about how grantees are integrating behavioral health providers (BHPs) into their practices. Learn more about how the SIM small grants are helping practices by clicking the links below and stay tuned for more updates.

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Electronic patient registries at work in SIM practices

Electronic patient registries collect patient data from electronic health records (EHRs) and sort/filter the data by health condition or other variable sets determined by a practice. Primary care practice sites that participate in the Colorado State Innovation Model tell us that electronic patient registries can improve workflow efficiencies and help improve patient outcomes in multiple ways, including:

  • Creating a risk stratification of patients
  • Identifying gaps in treatment for patients
  • Following up on whether patients implement their care plans
  • Sending out automatic reminders to patients to engage in self-care activities, schedule follow-up appointments or go in for lab tests
  • Understanding variations in treatment and outcome in patient groups

Using an EHR is a prerequisite for SIM participation, and some products include the capability to create electronic patient registries and others do not, which is why some cohort-1 practices that received small grants used the funds to create these registries. Here are a few examples:

  1. Target high-risk populations and health disparities: One practice hired a consultant to build registries to extract data from the EHR to target high-risk patient populations and those with health disparities, including obesity, asthma and attention deficit hyperactivity disorder. The registry has improved the practice’s ability to quickly identify and follow up on patients with specific health disparities, which allows providers to collaborate on patient needs and develop protocols for specific health disparities.
  2. Identify high-spend patients and opioid use: One practice is implementing a “QlikViewTM” registry dashboard to identify high spend patients, behavioral health patients and patient use of high-risk medications, such as opiates, opioids and other narcotics.
  3. Track screenings, treatment and outcomes: One practice is working with Enli Health Intelligence to create registries for patients with depression, anxiety and/or substance use disorders. When fully implemented, the practice plans to track screenings, treatment and outcomes for this patient population.
  4. Population management, care coordination and patient self-management: This practice purchased a registry module, CCMR™, from its EHR vendor to support population management, care coordination and self-management goals. The practice reported an increase in the number of patients with self-management goals recorded in the EHR from 45% to 56% of all patients. Patients with diabetes increased their self-management goals recorded in the EHR from 65% to 80%.
  5. Depression diagnoses, screening and interventions dashboard: One practice is implementing a registry dashboard to measure depression diagnoses, screenings and interventions, and identify patients receiving care coordination and at what level. The practice is also tracking how teaching self-management to patients with chronic disease is improving depression scores.
  6. Data reports: The practice aligned its EHR with the PRIME registry, and learned how to more effectively use the registry to create accurate data reports. The team is using the improved registry for disease management and risk stratification.
  7. Tracking depression screening, interventions and outcomes: This practice worked with its EHR vendor to create a behavioral health registry to (1) identify patients who screened positive for depression, anxiety or substance use disorder, (2) discover what interventions were used with these patients and (3) determine outcomes as a result of these interventions.

Learn more about how primary care practices can use registries to improve their practices by using the tools provided in the SIM practice transformation toolkit, Building Block 2: Data-Driven Improvement Using Computer-Based Technology.