Chronic Disease Registries: Supporting Proactive Care and Performance Improvement at New York City Health and Hospitals Corporation

Louis J. Capponi, MD, Chief Medical Information Officer, NYCHHC reviews NYCHHC’s strategic initiative to address chronic illness including the chronic care model and the role of registries. He describes the registry development process and design, data normalization & integration, implementation and spread, and concepts in managing change. The heavy burden of chronic illness in the HHC population includes 60,000 Diabetics and 11,000 Heart Failure patients with common morbidity rates: 40% to 80% diabetics are poorly controlled, blindness, kidney failure, and amputations are common, and mortality in symptomatic heart failure patients is 20%/year. Dr. Capponi describes the successes of the program in terms of avoided admissions and improved outcomes and compliance, and makes a clear case for chronic care management supported by disease registries.