Disease Management Registry Enhances Health Care Delivery to Patients

Maggie Gonzales (left), serves as the tracking and referrals specialist, for the Beaverton Clinic. Also pictured is Erin Kirk, quality manager.

Van Masson, certified medical assistant, works on entering patient data in the diabetes registry.

Fran Oliva, RN, and Erin discuss the reporting tools available in the MediTracks system. Photos by: Maileen Hamto

By Maileen Hamto, Communications Writer, CareOregon

When it comes to your health, knowledge is king and timing is everything.

This is true for everyone: from people who are dealing with chronic conditions such as diabetes or asthma, to women with abnormal pap smears or mammograms. For parents, knowing precisely when childhood immunizations are due is important in making sure their children stay healthy.

Virginia Garcia Memorial Health Center, a “safety net” health care provider serving migrant workers, low-income and uninsured individuals in Oregon, is exploring a new way of ensuring timely, efficient and effective health care for patients.

How? By harnessing the power of information technology.
 
Virginia Garcia has implemented a disease management and registry tracking system, called MediTracks. The system helps staff identify key health information about high-risk patients.

“We want to make sure that no one falls through the cracks,” said Erin Kirk, Quality Manager at Virginia Garcia.

Launched in 2005 with funding by CareOregon’s Care Support and System Innovation Program, MediTracks is enabling Virginia Garcia to collect data for many chronic illnesses, said Ann Turner, M.D., co-medical director. The system also is capable of tracking women with abnormal pap smears or mammograms, those requiring prenatal care, and children who need immunizations.

“Currently, we are only tracking data on our diabetic patients, but soon, we will have access to data on patients with asthma, hypertension and depression. We will also be able to track children and follow-up on those who are overweight or at risk for becoming overweight,” she said.   

How does the new system help clinics deliver better care to patients? Because patient health information is easily accessible, clinic staff and physicians save time looking for pertinent information related to a person’s health condition. For patients, this means shorter wait times at the doctor’s office. The system also expedites the process of scheduling future office visits.

“If the provider has the most recent, accurate data in front of them, they can tell the patient when their next appointment for a pap smear is due. Then, the patient can make an appointment on her way out. In some cases, because we use an open access scheduling system, she might even be able to have it done that day,” Kirk said.

During an office visit, having accurate and up-to-date information about the status of a person’s health enables doctors to make necessary adjustments to a patient’s care plan. An added value of the MediTracks system is its “flagging” mechanism that allows patients to receive timely reminders about follow-up visits or time-critical medical or lab tests.

“We want to help our patients develop self-management goals. With MediTracks, we can print out data trends of individual indicators that can be used as a patient education tool. For example, the provider can review a diabetic patient’s graph of his/her A1c measures over time. This will allow the provider to have a discussion with the patient about what good things the patient was doing when his/her A1c was lower and what s/he was doing differently if it goes up,” said Kirk.

Eventually, the system will be capable of tracking all health information for every Virginia Garcia patient, said Kirk.

“Initially, our goal was to improve management of chronically ill patients, and to provide an efficient system for patient tracking and recall for preventive visits,” said Kirk, who also led the team responsible for the MediTracks implementation project. “MediTracks brings us one step closer to building a database of comprehensive electronic health records for our patients.”

Implementation and customization is ongoing for the MediTracks system.  When  MediTracks is fully implemented, clinic staff will no longer need to search through endless paper trails to determine a patient’s need for standard diabetic care or other chronic disease management.

"I am eagerly awaiting the regular receipt of data on my chronically ill patients to help me know how to improve our care,” said Laura Byerly, co-medical director at Virginia Garcia. “I think the consciousness-raising that these disease registries will provide will be invaluable to us all in improving the quality of care for our patients."

Prior to the MediTracks implementation, different clinics used different methods of tracking patient health information. Finding current and accurate patient health information in a timely manner was often a challenge. In addition, the wide variety of tracking methods made the old systems vulnerable to potential errors.  

MediTracks promises to help Virginia Garcia clinics enhance their efficiencies and processes.

“The system will standardize our processes and greatly improve the coordination of patient health data among our clinics,” said Kirk. “We now have one powerful tool that is being used by all our clinics.”

The MediTracks project is supported by CareOregon’s Care Support and System Innovation (CSSI) Program. CareOregon is partnering with health care providers across the state to deliver innovative system changes in an effort to deliver better patient care. CSSI projects respond to an Institute of Medicine call to action to improve the health care delivery system by emphasizing system enhancements that are safe, effective, patient-centered, timely, efficient and equitable. The projects address areas of importance to CareOregon members: complex care management, chronic care management, reducing health disparities, improving access to care and office efficiency, and increasing patient safety.

About Virginia Garcia Memorial Health Center
VGMHC was established in 1975 following the death of a 6-year-old migrant farmworker girl who died from lack of culturally appropriate health care services. Serving the health care needs of migrant and seasonal farmworkers, as well as the low income and uninsured, Virginia Garcia operates four primary care sites, a maternity clinic and a dental/vision clinic. Virginia Garcia serves more than 21,000 patients in Washington and Yamhill counties in Oregon. For more information, visit http://www.virginiagarcia.org.