4 Types of Patient Registries to Boost Performance
Creating registries to focus improvement efforts is one of the more common strategies teams take to impact outcomes. But there is no denying that getting registries to target the right areas of opportunity can take you closer to your goals, whereas getting it wrong can turn out to be a futile effort. Here we breakdown some of the more common registries we’ve supported clients with so you can better evaluate what type of registry, or combination of registries, is best to set your team up for success.
Registries – a list of patients – based on disease types are prevalent in population health efforts for the simple reason that it makes sense to organize your team around patients that have similar care needs. Commonly, we see disease registries around those chronic conditions that have shown to cause significant adverse health outcomes and have high costs of care, or that are correlated with public health surveillance programs, like the American Cancer Society’s cancer registries or state health department COVID-19 registries. For teams that want a dependable way to segment patients by certain disease types, Ninja Universe conveniently comes pre-built with more than 30 different disease registries.
Creating a perfect registry is impossible, but you can certainly make sure you are focused on the right areas by aligning your registries to the measures that you must report to your payors. Measures that are part of value-based programs are designed to make you improve in areas of recognized population health priorities. Accordingly, you can create registries based on measure numerators or denominators. Take for example creating registries on different measures, like Controlling High Blood Pressure or Prenatal and Postnatal Care, to make sure you are focused on monitoring and improving the health status of your patients.
We’ve also supported clients with measure registries with expanded definitions. Take the breast cancer screening measure. Instead of creating a breast cancer registry for patients 50 – 74 years of age per the measure definition, we created a registry of patients aged 49 – 74 to account for those individuals turning the eligible age in the next 6 to 12 months. With hundreds of measures built to specifications within Ninja Universe, including our certified HEDIS and eCQM logic, it’s easy to create measure-centric registries that fit teams’ population health needs.
Also under the measure category are registries built on financial metrics. As many are focused on controlling health care costs, we’ve supported clients with financially oriented measure registries that are centered on total cost of care, per member per month (PMPM), predicted total cost ranges and other financial metrics that help teams respond sooner.
We are all aware that there is plenty of uncertainty in trying to understand and predict patients with the greatest needs. It serves teams well to adopt evidence-based methods that have proven to reduce the uncertainty. The Johns Hopkins ACG® System, which has been referenced several times in our risk stratification toolkit, is one such example. Rather than focusing on a single diagnosis, as the presence of a diagnosis is not necessarily a predictor of high cost, the ACG System takes a patient-centric measurement of an individual’s risk. The algorithm holistically considers all an individual’s conditions and scores them based on several factors like duration, severity, and etiology to provide a more patient-centric risk score, that then can be used to create cohorts or registries against. Some example registries include rising risk patients, patients with conditions that make them more likely to seek out inpatient hospital care, or patients that have a high risk of uncoordinated, fragmented care.
While disease, measure and risk-based registries are commonly used, such registries do not always align to organizations’ internal goals. For that reason, Ninja Universe is an agile solution that allows for easy customization. Here are a few examples of custom registries that can be implemented:
- Patients with unstable, chronic medical conditions that live in targeted census tracts
- Patients with a malignant condition that are at high risk for uncoordinated care
- Patients with a “primary care preventable” emergency room visit, and no primary care visit in the last 3 months or within 2 weeks of the discharge
- Patients that have been in the top 15% high cost for two consecutive years
Registries make it easy for you to identify, monitor and improve the health of your patients that need it most. Make sure the purpose of the registry and how it is designed is aligned to your goals. With KPI Ninja’s dynamic Rule Engine and built-in-house User Interface, it’s easy to make sure you are best utilizing the value of patient registries, in addition to other analytics like predictive insights, real-time dashboards, and analytics on top of cohorts of interests.
About the Author
VP of Population Health at KPI Ninja, Inc.
Renee provides operational leadership of quality initiatives at KPI Ninja. Towne has a background in occupational therapy, education and experience in operational excellence across a variety of healthcare domains. Based on prior experience as a clinician that drove outcomes patient by patient, she is leaving a larger footprint by improving health care more comprehensively, population by population.
About KPI Ninja
KPI Ninja is a data analytics company that helps healthcare organizations accelerate their quality, safety, and financial goals with a unique combination of software and service. We are differentiated by our signature mix of technology, performance management consulting and healthcare expertise. We don’t merely offer software solutions but work shoulder to shoulder with clients to help them draw on the power of analytics and continuous improvement methodologies to become more efficient. In harmony with our data-centered ethos, we truly believe that our success is strongly co-related with yours.