​For practices just beginning the medical home transformation process, managing your patient population can start by implementing small changes (such as a reminder system of procedures for high-risk patients) and grow into a larger tracking system, such as a patient registry.

A patient registry allows a practice to organize their patients by specific characteristics, such as a chronic disease or condition. By organizing a patient population in this manner, a practice can keep track of necessary labs and preventive services for such patients.

For example, a reminder system for flu shots for high-risk patients (such as those with asthma) can eventually grow into a patient registry for children and youth with asthma. This will allow a practice to proactively care for its patients with asthma, thereby providing comprehensive, coordinated, preventive health care that is critical to the function of a medical home.​​

Remember: Patient registries are effective ways to measure and document care and can help to monitor and evaluate practice performance.​

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American Academy of Pediatrics