Transforming Care from Episodic to Proactive

Duke Primary Care’s Electronic Diabetes Registry Ensures Accountability

By John Anderson, MD MPH

Duke Primary Care (DPC), formed in 1995, is a moderately sized primary care network of community-based practices. The network is a significant component of the Duke University Health System’s primary care strategy. Since inception, DPC has maintained a focus on quality improvement work. We were an early adopter of Open Access scheduling, which was learned through participation in several Institute for Healthcare Improvement collaboratives. Focusing on chronic illness care, particularly diabetes, was a natural successor to this early work.

In 2003, DPC participated in a collaborative hosted by the Primary Care Division of HHS from North Carolina, implementing The Chronic Care model for the care of our diabetic population. This effort highlighted the importance of constructing and implementing a registry to better manage patients from a population standpoint rather than the typical episodic fashion. The registry allowed us to make three critical improvements:

  1. We can measure our performance in achieving appropriate, evidence-based guidelines in the delivery of care for these patients. We can identify areas for improvement as well as create accountability for hitting these targets.
  2. We can implement appropriate interventions for these patients at the point of care. The registry prompts providers and staff at the critical time when interventions are due.
  3. We can identify and manage outlier patients, such as those who haven’t been seen in six months or those who have an A1C and BP that are out of control.

We initially used the DocSite registry product when we began this work. It was a paper-based product that required data entry and thus drove modifications to workflow and staffing. It was implemented at minimal cost and did not require additional staff; an interface was created with IDX, our patient management software, to transfer demographic data into the registry. In 2006, we migrated that data into the Duke Health System registry tool, which was completely electronic and incorporated into our EMR. We now have facilitated the task of populating data into the registry through the standardization of our nursing workflow. This ensures appropriate data collection at the point of care, therefore enhancing accountability.

While we have created internal nurse care managers in our practices to manage the outlier patients, this has proved to be quite labor-intensive and challenging to motivate patients to engage in their care. We have found the greatest success working with patients who ultimately present to the practice for care and using a team-based approach of nurses and dedicated care managers.

To date we have enrolled over 13,000 patients in our diabetes registry. While we track multiple metrics, we also use a common bundled metric that defines “Perfect Care” as A1c < 7, BP < 130/80, LDL < 100, an aspirin regimen, and nonsmoking status. Over the past three years, we have demonstrated significant improvement in this measure, moving our performance from 6 to 20 percent compliance. More than half of our enrolled patients have seen improvements in their A1C levels.

The registry has allowed us to create best practices and guidelines, therefore highlighting instances when processes and outcomes are out of range. We have learned that both patients and providers respond to data that encourages them to adopt a proactive approach to engaging in self-management and improving the care of our diabetic population.

John Anderson, MD MPH, is chief medical officer at Duke Primary Care in Durham, North Carolina. He can be reached at