Toolkit for Implementing the Chronic Care Model in an Academic Environment

Clinical Information Systems

The registry, an information system that can track individual patients as well as populations of patients, is the foundation for successful integration of all the elements of the Chronic Care Model, according to the Institute for Healthcare Improvement

The registry helps the team manage chronic illness by anticipating problems and tracking progress. The system provides access to a summary of patient data before and during the visit, facilitating team dialogue and planning. During the visit, data are used to empower the patient to manage his or her disease.

Consolidated Data Management

An important goal of the University of Cincinnati Academic Health Center's Senior Leadership Group was to reduce the administrative workload of clinicians by eliminating repetitive data collection. Consequently, the group allocated funding for a comprehensive registry to support four of Cincinnati's five teams involved in the collaborative. (Cincinnati Children's Hospital Medical Center used its own registry product.)

For the collaborative, the Health Alliance purchased the Patient Electronic Care System, a clinical information system and registry from the Aristos Group. The system integrates evidence-based guidelines and best practices with patient data and summarizes clinical information at the point of care.

Although the Patient Care Electronic Care System has been an improvement, standardizing data entry to meet the needs of different office practices remained an issue. The intent is to learn from this technology and pave the way for a future electronic health record.

Importance of Workflow: Data and Care Improvement

An important aspect of enhancing system change at Vanderbilt University Medical Center was integrating and improving its electronic medical record through the plan-do-study-act process.

The team has a full-time programmer analyst who worked with clinicians to plan and execute a chronic disease management system to improve access to patient data.

The team also developed a dashboard to organize information on a computer so it is useful for the user. The dashboard is part of the chronic disease management system and tracks up-to-the-minute data of diabetes patients, such as blood pressure, HbA1c and LDL levels, and whether the patient has had a foot exam within the past 12 months.

The chronic disease management system also enables providers to sort patient data by specific requirements, such as by A1c levels, allowing comparisons of individual patient data within the total group.

In addition to these features, the team's Consolidated Data Management (CDM) system provides staff with a daily work list that indicates what patient-related needs are to be accomplished for the date that is accessed. Tasks listed include reminders to call or send letters to patients, to check results from the previous visit, and more.

The list also includes alerts that indicate which patients are overdue for lab tests and allow staff to retrieve patients' lab information and contact status.

The team is also developing a way to integrate self-management data into the diabetes dashboard.

In addition to the diabetes dashboard, a population view was developed that allows providers to simultaneously view the dashboards of all their patients with diabetes to see how well the providers are caring for their patients with diabetes.

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Page last reviewed October 2014
Page originally created January 2008
Internet Citation: Clinical Information Systems. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.