Automated registry helping patients better manage their diabetes

December 15, 2017 | By | 1 Reply More

Woman tests her blood glucose - diabetes

By Nicholas Moy, MD
Virginia Mason Medical Center

In many cases, diabetes can be prevented and, in those it cannot be prevented, careful management can reduce the risk of the serious complications associated with this common condition, including heart disease, stroke and kidney disease.

That is why the American Diabetes Association recommends that people with diabetes see a primary care, internal medicine or endocrinologist every three to six months, depending on how well their diabetes is being controlled.

Unfortunately, life circumstances don’t always allow that to happen and it’s not uncommon for patients to fail to follow up with their caregiver as often as they should. Helping patients stay on track is hard for their physicians as well, since many doctors in primary care are often responsible for 1,500 or more patients.

According to the Centers for Disease Control and Prevention, in 2015:

  • An estimated 30.3 million people of all ages – or 9.4 percent of the U.S. population – had diagnosed or undiagnosed diabetes.
  • This total included 30.2 million adults aged 18 years or older (12.2 percent of all U.S. adults), of which 7.2 million (23.8 percent) were not aware of or did not report having diabetes.
  • The percentage of adults with diabetes increased with age, reaching a high of 25.2 percent among those aged 65 years or older.
  • An estimated 1.5 million new cases of diabetes (6.7 per 1,000 people) were diagnosed among U.S. adults aged 18 years or older.
  • More than half of these new cases were among adults between 45 to 64 years old, and the numbers were about equal for men and women.

To help our physicians keep track of their patients with diabetes or who are at risk, the primary care providers at Virginia Mason developed a Diabetes Registry, proprietary software, that automatically analyzes our medical records to identify patients with or at risk for diabetes, track how well they are doing; and bring them back for care when needed, even if its just for a blood pressure check or help with exercise and weight loss.

The Registry also helps the entire VM healthcare team, doctors, nurses and medical assistants, to coordinate their efforts to make sure patients receive the support they need to reach their individual goals.

Courtney Yates, a Certified Medical Assistant at VM’s Kirkland Medical Center, says the Diabetes Registry, which is still being refined, is proving to be very effective in getting patients in for important lab tests and checkups.

“The Diabetes Registry has been helping us keep a close eye on patients,” Yates says, “and patients are responding well to the simple reminders we’re sending them, whether they are messages though our online patient portal,, calls, or mailed letters. In fact, we recently started to contact patients who are ‘out of care’ for all our providers at Virginia Mason Kirkland, not just those with diabetes.  Our goal is to get 100 percent of our out-of-care patients back in care.”

Currently, primary care providers who practice at Virginia Mason Hospital and Seattle Medical Center and Virginia Mason Kirkland Medical Center are trialing and refining the Diabetes Registry. Once the tool is proven, it will be used at Virginia Mason’s other Puget Sound area medical centers starting sometime in 2018.

Nicholas Moy, MD, is board certified in Internal Medicine and practices Primary Care at Virginia Mason Hospital and Seattle Medical Center. His special interests include quality improvement and geriatrics. Dr. Moy is a Bellevue resident.

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Category: Diabetes, Virginia Mason

Comments (1)

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  1. Val Marquardt says:

    This is such fantastic (and important) work, we appreciate all the efforts to keep our patients as healthy as possible!

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