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Clinical Information System:
Use the Registry to Generate Reminders and Care Planning Tools for Individual Patients
  1. Use patient treatment record forms that include services needed at time of visit. Before a visit, print out current information from the registry.
  2. Periodically, use the registry to generate lists of patients who are missing a service or have a service that is overdue. Database queries might include the following:
    • Patients with an Asthma Action Plan
    • Patients with persistent asthma not on anti-inflammatory medications
    • Patients with seasonal exacerbations
  3. Use the registry to generate lists of high-risk patients for specialized care and follow-up. Database queries might include the following:
    • Smokers
    • Patients with recent Emergency Room visits
    • Patients with frequent beta-agonist refills
    • Patients with a severity score >3: When last seen?
  4. Divide the population of asthma patients into categories (e.g., ethnicity, language, insurance, needs/limits, homelessness) to identify special needs.
  5. Decide how to handle patients with missing services. Consider using planned visits, fitting asthma care into acute-care visits, and group visits.
  6. Use the registry to invite patients to health fairs, informational meetings, etc.
  7. Use the registry to identify the underinsured population to solicit for special services and medical assistance programs.

Tips
  • Determine how to identify patients with asthma prior to a visit, and create a process to ensure treatment record form is on the chart in the examining room.
  • Determine if your appointment system has the capability to flag patients with asthma.
  • Flag charts to help identify patients with asthma.
  • Ask asthma patients, particularly walk-ins, to identify themselves as such to front office staff.
  • Use these lists to send reminders by mail or make follow-up phone calls. To protect confidentiality, do NOT use postcards.
  • Create a take-home patient summary sheet.
  • Create a written protocol for which patients you are going to follow up and how.
  • Alert community partners to keep you updated on new ways to meet the needs of these populations.
  • Provide information to Administration as part of business planning to obtain new services or expand existing ones.
  • Have a team huddle at start of day to review that day’s patients for missing services.
  • Design a process for the team huddle so that it is efficient and productive.
  • Assign the role of keeping updated on community activities to a team member or staff person willing to become involved.
  • Create electronic links between registry and mailing programs.
  • Establish linkages to community wellness programs for the poor.
  • Partner with existing community coalitions to build linkages to other community-based organizations.
  • Identify state Chronic Disease Programs. Some will have asthma as part of their work. Others may be interested in being involved if approached.