Patient Tracking FAQ

Below is a selection of the most commonly asked Patient tracking/registry questions. It is also available as a PDF document. If you have a question that is not already answered in the complete list of questions, please contact Daniel Brusser.

Why is tracking a population of patients important in Collaborative Care?

Effective management of chronic health conditions such as depression and diabetes requires a coordinated team and shared information. The ability of the team to track clinical outcomes for populations of patients and to support systematic changes in treatment for patients who are not improving as expected is one of the basic tenents of Collaborative Care.

What supports a measurement-based, treatment-to-target approach?

A care management tracking system. Care management tracking systems drive care by structuring encounters with patients, identifying those who aren’t improving, prompting changes in treatment, and tracking effectiveness across different providers and caseloads – all while making the work of each team member more efficient and effective. They also track whether or not clinical targets are being met.

Do we have to use a web-based registry?

No. Paper tracking systems and Microsoft Excel®-based systems can also be used. A web-based registry is the tool we most commonly recommend because of its greater functionality.

Are care management tracking systems the same as Electronic Health Records (EHRs)?

No. A disease management registry is not a paper or electronic medical record, nor is it intended to act as a replacement. Medical records are a storehouse of information about a specific patient’s care that can be used for clinical and/or billing purposes. Although some electronic medical records (EMRs) can use queries or filter functions to cue clinical activities or create specified patients list, most have limited functionality in this regard and need extensive – and oftentimes costly – customization.

If we provide Collaborative Care, will we continue to use our EHR?

Most likely. There is information EHRs provide that care management tracking systems do not. Efforts are underway to integrate the two data sets but nothing is currently available.

Can we only use our EHR if we want to provide Collaborative Care?

No. EHRs have limited functionality. EHRs do not allow for population-based, treatment-to-target, or accountable care.

Can we reconfigure our EHR to provide the information we need for Collaborative Care?

Maybe. EHRs can sometimes be designed to cue specific clinical activities but this is not a core feature and typically requires a significant investment in customization of both time and money.

Will using a care management tracking system mean a lot more work?

No. Most care mangers will need to do some double documentation (usually 1-5 minutes extra per patient). However, you will be able assess and triage your entire caseload more efficiently.

Is there key information that should be tracked to implement Collaborative Care?

Yes. The following processes and outcomes should be tracked at both the individual patient and treating provider levels. If possible, it is also helpful to track them at the clinic (site) and organization level. Please refer to the Registry Functions for Population-Based Care and Measurement-Based Treatment to Target document.

Do you have recommendations about choosing a care management tracking system?

Yes. Ask prospective vendors if their product can deliver the ten key metrics above.