Texas counties of Cameron, Hidalgo, Starr, Willacy, Jim Hogg, Webb and Zapata have among the highest rates of Type II diabetes in the U.S. Additionally, this region has a large Medicaid population and the highest uninsured rate in the state; both groups tend to have higher-than-average incidences of diabetes and emergency room visits. Providers are in need of a tool to track patient progress, design customized treatment plans and improve quality of care for individuals with diabetes.
In partnership with University of Texas Health Science Center, the Rio Grande Valley Health Information Exchange (RGV HIE) established a diabetes registry and utilized population health management tools for physicians who treat those with diabetes. Data such as disease status, hospital admission, co-morbidities and treatment recommendations are entered into the registry. Through this integration of electronic health records into the RGV HIE, physicians access registry dashboards to help them prioritize and coordinate patient care, including alerts for patients who have not received their recommended care. The tool incorporates data from major health systems in Cameron and Hidalgo counties, and in the future, will expand to include information from federally qualified health systems and accountable care organizations. The project is being financed through the state’s 1115 Transformation Waiver.
By accessing the RVG registry and using population health management tools, providers spend less time analyzing data and more time talking to their diabetic patients and providing them with key, timely information to manage their condition. The result is better disease management, saving time and money. Overtime, RGV HIE will track the success of the registry, aiming to improve diabetes control – using HbA1c to measure hemoglobin – by 5 percent in year 4 and another 10 percent by year 5.
A diabetes registry and population health management solutions are vital tools in managing chronic disease, controlling costs and improving quality care.