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Provider Toolkit – Population Health Management & Registries

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Milestone 4: Population Health Management & Registries

Establish and maintain Population Health Registry and reports for patient outreach, closing gaps in care, and managing prevention and chronic disease needs of patients  
 
Identifying the patient population is the backbone of, and essential to, an effective population-based care delivery system. Without identification of the patients included in the population, changes cannot be effectively achieved. It is for this reason that physicians and their care teams participating in the Program are expected to utilize registry functionality to systematically maintain patient demographic and clinically relevant information based on evidence-based guidelines.  
To identify patients within the population of focus, you need to be able to access data that pertains to your patients. The tools used to collect and access information about a specific group of patients is often referred to as a registry. Simply stated, a registry is a mechanism for keeping all pertinent information about a specific group of patients at your fingertips. The information can be used to schedule visits, labs, educational sessions, as well as generate reminders and guidance of the care of patients (both in groups and individually).  
Your Patient-Centered Care Team will work closely with you to determine the mechanism and workflow for you to implement registry functionality, manage your patient population and their care needs. This process will include review of your current health information technology systems, if applicable.  
Resources:  
This self-evaluation form created by Improving Chronic Illness Care (ICIC) can help practices that already have a registry in place identify its strengths and weaknesses. 
A starter list to use to help your practice initiate building a chronic disease registry focusing on one of five different chronic diseases including diabetes, heart disease, congestive heart failure, asthma or chronic obstructive pulmonary disease. 
A compilation of Excel registries and evidence based guidelines supporting our "Core 5" chronic disease focus areas. To be used in starting population health management implementation.  
Colorado Academy of Family Physicians article describing basic registry functionality and physician commentary on its value in medical home transformation. 
This Continuity of Care Guide (CCG), developed by the HIMSS Continuity of Care Task Force, will help ambulatory care practices optimize Health Information Technology (HIT) and Electronic Health Records (EHR) capabilities to support the continuity of care for patients. The CCG will help your primary care practice develop a foundation of basic care planning for patient transitions of care and hand-offs with specialists and other providers. 
This American Academy of Family Physicians (AAFP) article gives readers an idea of the purpose a patient registry serves, and how to use them to guide a practice’s care management activities. 
This report from the California Healthcare Foundation (CHCF) provides an overview of the function and use of computerized disease registries and outlines issues for consideration in obtaining registry software and integrating registry products into the routine work of the physician practice. 
This fact sheet from the California Healthcare Foundation (CHCF) compares the key features of these essential health IT systems and examines the pros and cons of different approaches for a new implementation. A video discusses disease registry tools. 
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