Applicable to PCPs; and to specialists for the patients for whom they have primary or co- management responsibility (regardless of insurance coverage and including Medicare patients).

For all Patient Registry capabilities except 2.9, registry may be paper or electronic. A fully electronic registry may be the last capability to be implemented.

Nine of the Patient Registry capabilities identify the population of patients included in the registry (2.1, 2.10, 2.11, 2.12, 2.13, 2.15, 2.16, 2.17, and 2.18). The other nine Patient Registry capabilities pertain to registry functionality (2.2, 2.3, 2.4, 2.5, 2.6., 2.7, 2.8, 2.9, and 2.14). All capabilities pertaining to functionality that are marked as in place must be in place for each population of patients marked as “included” in the registry. 

2.1

A paper or electronic all-payer registry is being used to manage all established patients in the Practice Unit with: Diabetes

(For specialists, relevant patient population not addressed in other capabilities)

PCP Guidelines:

1. A patient registry is a database that enables population-level management in addition to generating point of care information, and allows providers to view patterns of care and gaps in care across their patient population. A registry contains several dimensions of clinical data on patients to enable providers to manage their population of patients.
2. Relevant clinical information that is the focus of attention in generally accepted guidelines,and is incorporated in common quality measures pertinent to the chronic illness, must be incorporated in the registry (I.e., physiologic parameters, lab results, medication use,physical findings, and patient behaviors such as peak flow meter use or daily salt intake).
3. Registry data must be in the form of data fields that are accessible for tabulation and population management.
4. Registry must include all established patients with the disease referenced in the capability,regardless of insurance coverage (including Medicare patients)
5. Patients assigned by managed care organizations do not have to be included in registry if they are not established patients (reference 2.15).
6. Patient information may be entered by the practice, populated from EMR or other electronic or manual sources, or populated with payer-provided data
   1. Registry must include data pertinent to the clinical performance measures contained in the EBCR (e.g., BCBSM-provided data or similar data from other sources)
7. Registry may initially be a component of EMR for basic-level functioning, as long as the practice or the PO has the capability to use the EMR to generate routine population-level performance reports and reports on subsets of patients requiring active management.
   1. Subsets of patients requiring active management refers to those patients with particular chronic illness management needs including but not limited to those who have physiologic parameters out of control, or who have not received specified,essential services
8. Reference AAFP article for additional information on creating a registry

Specialist Guidelines:

1. A patient registry is a database that enables population-level management in addition to generating point of care information, and allows providers to view patterns of care and gaps in care across their patient population. A registry contains several dimensions of clinical data on patients to enable providers to manage and improve the health of their population of patients.
2. Relevant clinical information that is the focus of attention in generally accepted guidelines and is incorporated in common quality measures pertinent to the patient population must be incorporated in the registry (e.g., physiologic parameters, lab results, medication use,physical findings, and patient behaviors such as peak flow meter use or daily salt intake).
3. Registry data must be in the form of data fields that are accessible for tabulation and population management.
4. Registry must include all established patients for which the specialist has ongoing primary orco-management responsibility with the condition referenced in the capability, regardless of insurance coverage (including Medicare patients)
   1. For ER physicians, a registry that tracks frequent ER users, or patients with drug seeking behavior, may qualify
5. Patients assigned by managed care organizations do not have to be included in registry if they are not established patients (reference 2.15).
6. Patient information may be entered by the practice, populated from EMR or other electronic or manual sources, or populated with payer-provided data
   1. Registry must include data pertinent to key clinical performance measures (e.g.,BCBSM-provided data or similar data from other sources)
7. Registry may initially be a component of EMR for basic-level functioning, as long as the practice or the PO has the capability to use the EMR to generate routine population-level performance reports and reports on subsets of patients requiring active management.
   1. Subsets of patients requiring active management refers to those patients with particular management needs including but not limited to those who have physiologic parameters out of control or who have not received specified, essential services
   2. For example, for behavioral health providers, I.e., psychologists and psychiatrists,common relevant conditions would be depression and anxiety
8. Reference AAFP article for additional information on creating a registry.

2.2

Registry incorporates patient clinical information, for all established patients in the registry,for a substantial majority of health care services received at other sites that are necessary to manage the population

PCP Guidelines:

1. Registry may be paper or electronic
2. “All patients in the registry” may consist, for example, of diabetes patients only, if practice unit has only implemented capability 2.1.
3. The registry is not expected to contain clinical information on all health care services received at any site for 100% of patients in the registry, but is expected to contain a critical mass of information from various sources, including the PO’s or practice unit’s own practice management system, and electronic or other records from facilities with which the PO or practice unit is affiliated
4. Other sites and service types are defined as labs, inpatient admissions, ER, UCC, and pharmaceuticals (with dates and diagnoses where applicable).
5. The definition of “substantial majority of health care services” is three-quarters ofpreventive and chronic condition management services rendered to patients.
6. If registry is paper, information may be extracted from records and recorded in registry manually, and must be in the form of an accessible data field for population level management of patients

Specialist Guidelines:

1. Registry may be paper or electronic
2. “All patients in the registry” may consist of patients relevant to the specialty type, if practice unit has only implemented capability 2.1.
3. The registry is not expected to contain clinical information on all health care services received at any site for 100% of patients in the registry, but is expected to contain a critical mass of information from various relevant sources, including the PO’s or practice unit’s own 16 practice management system, and electronic or other records from facilities with which the PO or practice unit is affiliated
4. Other sites and service types are defined as labs, inpatient admissions, ER, urgent care and pharmaceuticals (with dates and diagnoses where applicable) when relevant to the condition being managed by the specialist,
5. The definition of “substantial majority of health care services” is three-quarters of relevant services rendered to patients.
6. If registry is paper, information may be extracted from records and recorded in registry manually, and must be in the form of an accessible data field for population level management of patients

2.3

Registry incorporates evidence-based care guidelines

PCP and Specialist Guidelines:

1. Registry functionality may be paper or electronic.
2. Guidelines should be drawn from recognized, validated sources at the state or national level (e.g., MQIC Guidelines, USPSTF).
3. Determination of which evidence-based care guidelines to use should be based on judgment of practice leaders.

2.4

Registry information is available and in use by the Practice Unit team at the point of care

PCP and Specialist Guidelines:

1. Registry functionality may be paper or electronic.
2. Practice unit has and is fully using the capability to generate up-to-date, integrated individual patient reports at the point of care to be used during the visit.
3. EMR would meet the requirements of this capability provided it contains evidence-based guidelines, and relevant information is identified and imported into screens or reports that facilitate easy access to all relevant data elements particular to the conditions under management, for the purpose of guiding point of care services.

2.5

Registry contains information on the individual practitioner for every patient currently in the registry who is an established patient in the practice unit

PCP Guidelines:

1. Registry may be paper or electronic
2. The individual practitioner responsible for the care of each patient is identified in the registry
   1. Occasional gaps in information about some patients’ individual attributed practitioner due to changes in medical personnel are acceptable

Specialist Guidelines:

1. Registry may be paper or electronic
2. The individual practitioner responsible for the care of each patient is identified in the registry
   1. Registry should contain information on both specialist and patient’s primary care physician
   2. Exceptions may granted when patient does not want to identify provider, e.g.,behavioral health providers
   3. Occasional gaps in information about some patients’ individual attributed practitioner due to changes in medical personnel are acceptable

2.6

Registry is being used to generate routine, systematic communication to patients regarding gaps in care

PCP and Specialist Guidelines:

1. Registry may be paper or electronic.
2. Communications may be manual, provided there is a systematic process in place and in use for generation of regular and timely communications to patients.
3. Communications may be sent to patients via email, fax, regular mail, text messaging, or phone messaging.

2.7

Registry is being used to flag gaps in care for every patient currently in the registry

PCP and Specialist Guidelines:

1. Registry may be paper or electronic.
2. Registry must have capability to identify all patients with gaps in care based on evidence based guidelines incorporated in the registry.
3. EMR would meet the requirements of this capability if it can be used to produce population level information on gaps in care for chronic condition patients.

2.8

Registry incorporates information on patient demographics for all patients currently in the registry

PCP and Specialist Guidelines:

1. Registry may be paper or electronic.
2. Registry contains basic patient demographics, including name, gender, date of birth.

2.9

Registry is fully electronic, comprehensive and integrated, with analytic capabilities

PCP and Specialist Guidelines:

1. Practice unit must have capability 2.2 in place in order to receive credit for 2.9
2. All data entities must flow electronically into the registry
3. Data is housed electronically
4. Linkages to other sources of information (as defined in 2.2) are electronic for all facilities and other health care providers with whom the practice unit regularly shares responsibility for health care.
5. Registry has population-level database and capability to electronically produce comprehensive analytic integrated reports that facilitate management of the entire population of the Practice Unit’s patients.

2.10

Registry is being used to manage all patients with: Persistent Asthma

PCP and Specialist Guidelines:

1. Reference 2.1(a)-(g).

2.11

Registry is being used to manage all patients with Coronary Artery Disease (CAD)

PCP and Specialist Guidelines:

1. Reference 2.1(a)-(g).

2.12

Registry is being used to manage all patients with: Congestive Heart Failure (CHF)

PCP and Specialist Guidelines:

1. Reference 2.1(a)-(g).

2.13

Registry is being used to manage patients with at least 2 other conditions

PCPt Guidelines:

1. Reference 2.1(a)-(g).
2. Registry is being used to manage all patients with at least 2 other chronic conditions for which there are evidence-based guidelines and the need for ongoing population and patient management, and which are sufficiently prevalent in the practice to warrant inclusion in the registry based on the judgment of the practice leaders
   1. Examples of other chronic conditions include (but are not limited to) depression or sickle cell anemia

Specialist Guidelines:

1. Reference 2.1(a)-(g).
2. Registry is being used to manage all patients with at least 2 other conditions relevant to thespecialist’s practice for which there are evidence-based guidelines and the need for ongoing population and patient management, and which are sufficiently prevalent in the practice to warrant inclusion in the registry based on the judgment of the practice leaders

2.14

Registry incorporates preventive services guidelines and is being used to generate routine,systematic communication to all patients in the practice regarding needed preventive services

PCP Guidelines:

1. Reference 2.1(a)-(g).
2. Registry must include all current patients in the practice, including well patients, regardless of insurance coverage and including Medicare patients
3. Preventive services guidelines must be drawn from a recognized state or national source,such as USPSTF, CDC, or national guidelines that address standard primary and secondary preventive services (I.e., mammograms, cervical cancer screenings, colorectal screening,immunizations, well-child visits, well-adolescent visits, and well-adult visits).

2.15

Registry incorporates patients who are assigned by managed care plans and are not established patients in the practice

PCP Guidelines:

1. Patients assigned by managed care plans who are not established patients must be included in the registry, and active outreach conducted to engage them as established patients

2.16

Registry is being used to manage all patients with: Chronic Kidney Disease 

PCP and Specialist Guidelines:

1. Reference 2.1(a)-(g).

2.17

Registry is being used to manage all patients with: Pediatric Obesity 

PCP and Specialist Guidelines:

1. Reference 2.1(a)-(g).

2.18

Registry is being used to manage all patients with: Pediatric ADD/ADHD

PCP and Specialist Guidelines:

1. Reference 2.1(a)-(g).

2.19

Registry contains information identifying the individual care manager for every patient currently in the registry who has an assigned care manager

PCP and Specialist Guidelines:

1. Registry may be paper or electronic
2. Registry includes name of the care manager for each patient with an assigned care manager
3. Where a patient has more than one care manager, registry must identify which care manager is the lead care manager

2.20

Registry contains advanced patient information that will allow the practice to identify and address disparities in care

PCP and Specialist Guidelines:

1. Registry may be paper or electronic.
   1. Registry contains advanced patient demographics, including:
      1. primary/preferred language
      2. race
      3. ethnicity
      4. measures of social support (e.g., disability, family network)
      5. disability status
      6. health literacy limitations
      7. type of payer (e.g., uninsured, Medicaid)
      8. relevant behavioral health information

2.21

Registry contains additional advanced patient information that will allow the practice to identify and address disparities in care

PCP and Specialist Guidelines:

1. Registry may be paper or electronic.
   1. Registry contains advanced patient demographics, including:
      1. gender identity
      2. sexual orientation