Provide Timely Reminders for Providers and Patients with Chronic Conditions

Improving Chronic Care: Clinical Information Systems
  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. Use the registry periodically to generate lists of patients who are missing a service or have a service that is overdue.
  3. Use the registry to generate lists of high-risk patients for specialized care and follow-up.
  4. Divide the population of chronic conditions patients into categories (e.g., ethnicity, language, insurance, needs/limits, homelessness) to identify special needs.
    Decide how to handle patients with missing services. Consider using planned visits and group visits. (See Delivery System Design.)
  5. Use the registry to invite patients to health fairs, informational meetings, etc.
  6. Use the registry to identify the under-insured population to solicit for special services and medical assistance programs. 



  • Determine how to identify patients with chronic conditions prior to a visit, and create a process to ensure that the treatment record form is on the chart in the examining room.
  • Determine if your appointment system has the capability to flag patients with chronic conditions.
  • Flag charts to help identify patients with chronic conditions.
  • Create a protocol for which you are going to follow up and how.
  • Use lists to send reminders by mail or make follow-up phone calls. To protect patient confidentiality, do NOT use postcards.
  • Use patient wallet cards to remind patients what needs to be done, when.
  • Create a take-home patient summary sheet.
  • Create a 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.
  • Have a team huddle at start of day to review that day's patients for missing services.
  • Assign the role of keeping updated on community activities to a team member.
  • 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.

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