Zai AH et al. 2007 "Lessons from implementing a combined workflow-informatics system for diabetes management."

Zai A, Grant R, Estey G, et al. Lessons from implementing a combined workflow-informatics system for diabetes management. J Am Med Inform Assoc 2007;15(4):524-533.
"Shortcomings surrounding the care of patients with diabetes have been attributed largely to a fragmented, disorganized, and duplicative health care system that focuses more on acute conditions and complications than on managing chronic disease. To address these shortcomings, we developed a diabetes registry population management application to change the way our staff manages patients with diabetes. Use of this new application has helped us coordinate the responsibilities for intervening and monitoring patients in the registry among different users. Our experiences using this combined workflow-informatics intervention system suggest that integrating a chronic disease registry into clinical workflow for the treatment of chronic conditions creates a useful and efficient tool for managing disease."

To "describe the problems in diabetes patient management before we instituted the new application, our implementation of a new workflow model using the [registry population management (RPM)] application, the RPM application itself, and a list of points to consider before building an electronic diabetes registry based on our lessons learned."

Type Clinic
Primary care and specialty care
Type Specific
Specialty: diabetes care
Small, medium and large
Other Information
"The Massachusetts General Physicians Organization includes more than 15,000 patients with diabetes cared for in 20 primary care practices and one diabetes practice."
Type of Health IT
Disease registry
Type of Health IT Functions
The electronic registry system develops a list of diabetes patients and determines which physician the patient "belongs to." Physicians and practices can view graphical representations of the care received by their diabetes patients and see a roster identifying the current status of their patients. Physicians and practices can edit their rosters and remove patients that are correctly assigned to a primary care physician. The system has tools to encourage care coordination and allows users to build customized patient lists for a specific intervention.
Workflow-Related Findings
"Using the original workflow (without the RPM application), [nurses could] review...200 patients with diabetes at a rate of 10 to 30 patients per hour...
With the newly revised workflow supported by the RPM application, one nurse could review 220 patients at a rate of 180 patients per hour. That rate increased to 300 patients per hour during a second cycle... In addition, the delay between patient identification and mailing reminder letters decreased from more than 30 days to fewer than 2 days."
"We found that contacting end users regularly ensured that the application was used. We promptly addressed any problems and issues that were brought up by end users. Engaging end users as application testers also strengthened the overall deployment experience. For example, we regularly received feedback from end users regarding errors in our application as well as inaccuracies and inconsistencies in our data. These issues often frustrate users who see themselves merely as consumers of the application."
"We...put in place a policy whereby all pay-for-performance patients with diabetes received a reminder letter or call if they were due for a laboratory test, but identifying patients who require a reminder did not require a physician's input. Physicians could request that their patients be notified, but they also did not have to do anything to have this done."
"Although we did not specifically measure communication among team members before our intervention, we did discover that not having a formal process (e.g., telephone and e-mail) created confusion and frustration among care team members. We therefore integrated the workflow and design of the RPM application so that administrators could coordinate diabetes management within the various practices via these communication modes."
Study Design
Study Participants
The study participants included administrators, diabetes nurse managers, physicians and others working on diabetes management at the primary care practices and diabetes care practice.