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Online Diabetes Registry and Risk Stratification System

Treating diabetes in the primary care setting is complex due to the presence of co-morbidities, complications, and the time constraints of the patient/provider interaction. Joslin’s web-based Diabetes Registry and Risk Stratification System, based on Joslin’s evidence-based Clinical Guidelines, help providers identify and intervene with patients who are most likely to develop costly, debilitating, diabetes-related complications. Both practical and analytical, these web-based tools:

  • Improve the consistency, quality, and effectiveness of patient care at point-of-care.

  • Allow individual clinics and practices to perform quality measurements and comparisons.

  • Reveal opportunities for performance and clinical improvements.

  • Contain links to Joslin’s clear and concise, evidence-based Guidelines.

Systems that are Useful for Providers and Payers

Although the registry and risk stratification system are targeted for use in a provider setting, the data generated can be used for:

  • Stratifying patients by risk

  • Gaps-in-care analysis

  • High-impact interventions based on clinical best-practice Guidelines

  • Provider profiling at the practice or clinic level

Comprehensive Risk Assessment and Guideline-Based Interventions

Joslin's Diabetes Registry and Risk Stratification System:

  • Identify high-risk/high-cost patients and stratifies them into risk categories .

  • Recommend patient interventions at point-of-care in the form of "To Do" lists based on practical Clinical Guidelines related to:

    • Blood glucose control

    • The status of key co-morbidities, including:

      • Heart disease

      • Eye Care status

      • Kidney

      • Foot care

    • Behavioral health status

  • Track patient education.

  • Report practices’ quality and process metrics for both benchmarking and regional comparisons.

  • Provide a means for Diabetes Education Program Recognition (for Medicare reimbursement eligibility).

Quality Improvement

Joslin's Diabetes Registry and Risk Stratification System provides reports for analyzing a population’s or a patient’s resource utilization and compliance, including all of the key diabetes-related performance measures commonly recognized by Health Plan Employer Data and Information Set (HEDIS) and the American Medical Association (AMA):

  • Hospitalizations

  • Emergency department visits

  • Laboratory results

  • Diabetes-related medications

Recognition for Providers and Programs

Joslin's Diabetes Registry and Risk Stratification System provide a means for National Committee for Quality Assurance (NCQA) diabetes provider recognition and Diabetes Education Program Recognition by the American Diabetes Association (ADA) (for Medicare reimbursement eligibility).

Outcomes

Use of Joslin's Diabetes Registry and Risk Stratification System, in combination with care management and education interventions as part of an integrated disease management program, realized:

  • A 20% decrease in average per patient costs and overall costs that were 50% of national average.*

  • An average reduction of 1 point in mean A1C and blood pressure, which can translate into a 30% reduction of a patient’s risk of developing complications.

  • An increase in patient quality of life, including reduction in stress and barriers to self management.

  • Improvement in a variety of process measures, including foot exams, frequency of A1C measurement, use of ACE inhibitors, and so on.

*Realized from a program at the Joslin Diabetes Center in Boston designed for approximately 820 patients (92% with diabetes) in capitated health care plans. The program included primary and tertiary care from Joslin physicians and included the use of software products and educational programs listed below. Results published in the American Journal of Managed Care.

Page last updated: July 26, 2014