Integrated Patient Registry and Care Recommendation System
A large, multi-specialty medical group practice wanted to improve its ability to proactively provide quality
care to its patients through the development of a patient registry and care gap alert system. It needed a
solution that would extract data from disparate patient encounter data systems (including an Epic-based platform)
into a functionality that would be accessible from within the existing EMR. The system would utilize demographic
information to identify relevant subpopulations for targeted, proactive care based on a discrete set of HEDIS
measures. It would provide customized care reminders for treatment and tests clinically indicated for a
specific patient, either at the time of care, or through population reporting. The database would also be
used to track internal performance measures and fulfill HEDIS quality reporting requirements. Ideally, the
system would be built to allow the organization to update the registries and alerts according to its own
internal goals, minimizing the need for continual outside database consulting assistance.
A patient registry tool that targeted twelve quality measurement standards to be applied to demographic and
clinical data, facilitating identification of at-risk patients and recommending evidence-based treatments and
tests at the point of care.
Clinical stakeholders identified the specific HEDIS quality measures they wished to focus on. Ten2Eleven
worked with the organization to identify the various data systems that contained information pertinent to
those specific measures. These systems included an outside patient claims data system, an Epic-based
electronic medical record, and a pharmacy database. Ten2Eleven built an analytical rules-based engine that
would query the data and apply customizable logic which resulted in a care recommendation tailored to the
specific patient. Ten2Eleven constructed a Microsoft SQL-based datamart (a central repository database)
that would house the data. The datamart was designed to be easily queried for all kinds of internal and
external quality measurement and performance reporting.
A functional prototype has been built; some of the anticipated benefits of implementation are individual
patient care planning, more sophisticated performance monitoring and reporting, and improvement of processes
of care for all types of patients, especially those with chronic conditions.