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Population Management

Population health management and registries

In order to have an effective population-based care delivery system, practices will need to access data and analyze their patient population to identify care opportunities and target audiences who may be at higher risk and need additional support or resources.

Practices participating in the Patient-Centered Primary Care program are expected to utilize registry functionality to systematically maintain patient demographic and clinically relevant information based on evidence-based guidelines.

A registry is a mechanism for keeping all pertinent information about a specific group of patients at your fingertips. The information can be used to schedule visits, labs, educational sessions, as well as generate reminders and guidance of the care of patients (both in groups and individually).

This process will include review of your current health information technology systems, if applicable.

Resources

MyDiversePatients.com - A website to support your diverse patients, featuring robust resources to help support you in addressing disparities. While there's no single easy answer to the issue of health care disparities, the vision of MyDiversePatients.com is to start reversing these trends one patient at a time.


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