Santa Cruz County Diabetes Mellitus Registry

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Project Details -
Completed

This project was built on a history of productive collaboration among Santa Cruz County's public and private health care providers for the purpose of operating a community-wide diabetes registry. The original aims were to: 1) Build a collaborative to support the spread of best practices in chronic care management starting with diabetes; 2) Implement a widely adopted point of care electronic registry tool; 3) Reduce complications for persons with diabetes; 4) Reduce disparities in diabetes care; and 5) Demonstrate the business case to sustain a community-wide registry. Project scope included developing the governance structure for the Community Chronic Care Network and implementing a community-wide diabetes registry. The method for developing the registry was to extend existing software developed by a local physician group to as many providers as possible and to obtain data from multiple sources including electronic medical records. Lessons learned regarding the challenges of registry development, adoption and sustainability led to changes in strategy for collaborative improvement of chronic care.  Current aims are to support community-wide adoption of electronic medical records with disease registry capability and to wait for a future opportunity to exchange data for a community-wide registry.

Wells Shoemaker, M.D.
Can a diverse partnership of health care organizations and stakeholders pull together to deploy a web-based, community-wide diabetes registry that connects patients with needed care, provides clinicians with real-time decision support, and disseminates best practices?

The Community Chronic Care Network (CCCN) of Santa Cruz County, Calif., will answer that question. And Wells Shoemaker, M.D., the principal investigator for the AHRQ-funded project, is optimistic.

"A lot of trust is needed to make a project like this succeed," says Shoemaker, who is also medical director of Physicians Medical Group (PMG), a local IPA. "But we have an interesting culture here in this community of health care organizations working together around issues of common interest."

Under the three-year AHRQ grant, CCCN will adapt an Internet-based diabetes registry developed by PMG for community-wide use among all patients, all providers, and all payers in Santa Cruz County. The registry will import data from claims, labs, pharmacies, and points of care for patients in a master index.

Authorized users -- physicians and their clinical teams -- will be able to access the data from any location to review patient-specific information and generate reports that tell them, for example, which of their patients have high blood-sugar levels or which patients are overdue for a retinal exam. The registry software will also integrate diabetes care measures with clinical guidelines and patient-specific data to generate real-time action prompts for providers, including educational interventions for patients. Screening for depression and dental care will also be incorporated.

Shoemaker says the technology for the registry is simple and relatively inexpensive. For the partners in the project, which include two competing private medical groups, the regional MediCal managed care plan, safety net clinics, the local community college, and the public health department, it's a win-win proposition.

Adult-onset diabetes affects 7 percent of area residents - about 18,000 people. Shoemaker estimates that the disease costs the county more than $130 million a year.

"No one health agency has enough money, manpower, knowledge, or clout to solve a problem this pervasive by acting alone," Shoemaker says. "In Santa Cruz County, we have teamed up." That collaboration has been in place for several years, and the diabetes registry is only one component of a concerted local effort to manage and control diabetes through education, prevention, better care coordination, and expanded public insurance.

But Shoemaker believes that the registry, once it is up and running, will improve provider performance for the entire community, thereby reducing health disparities. "All of us can do better," he says, "and because performance makes a huge difference in our patients' lives, we have a moral obligation to improve."