Patient disease registries are databases of clinical information used to evaluate care processes and outcomes. Interoperability between electronic health records and registries is essential for integrated care models, chronic care management, wellness initiatives and to reduce disparities in care. Three-quarters of on H&HN’s Most Wired list uses a disease registry to manage gaps in care across a population.

“The true value of a registry is that diseases can be prevented not just managed,” says Bruce Bagley, M.D., CEO, TransforMED, a subsidiary of the American Academy of Family Physicians. He predicts that managing diseases via a registry will soon will become expected best practice and that population-based registries will create an even greater opportunity to manage wellness.

The technology exists for a practice to identify its population that uses tobacco, or to target those over 50 that have not had a colonoscopy, or immunization.

With the creation of EHR-integrated registries, Lancaster (Pa.) General Health leverages disease-based dashboards to enable providers and care teams to closely follow covered lives in their ACO to create effective care transitions, manage gaps in care, reduce preventable admissions and prevent readmissions. Gary R. Davidson, senior vice president and chief information officer, adds that they have begun to look at risk-based/, multi-disease registries to enable the health care team to proactively manage their most at-risk populations. — Suzanna Hoppszallern