Improving Outcomes for Diabetics in South Texas: RGV Registry

Dr.Joseph B. McCormick, M.D.
Dr. Joseph B. McCormick is the Regional Dean of The University of Texas Health Science Center (UT Health) School of Public Health Brownsville Regional Campus (SPH), professor of Epidemiology at UT Health San Antonio, and Associate Dean at The University of Texas Rio Grande Valley School of Medicine. UT Health SPH provides high quality, public health graduate education to the local residents of the Lower Rio Grande Valley of South Texas, as well as to national and international students. Its strategic location in South Texas provides the opportunity for research and intervention in a Hispanic population (Mexican Americans) with marked socioeconomic disparities. Dr. McCormick served as the RHP5 coordinator for the Texas 1115 Transformation Waiver, and is responsible for 8 projects under the waiver. In one of the 8 projects, UT Health SPH and the Rio Grande Valley Health Information Exchange partnered to implement a chronic disease registry in clinics in the Rio Grande Valley region of Texas.

The Challenge
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.

Our Approach
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.