Setting up a Diabetes Register using GP Practice Management System

What is a Diabetes Register?
A Diabetes Register is a list of all patients in your practice with Diabetes Mellitus. A basic register will include patient details (Name, Address, Date of Birth, Gender, Tel. No., etc.), and the type of Diabetes (Type 1, Type 2 or Gestational) and the date of diagnosis.

Why is a Diabetes Register important?
A diabetes register is a tool to help the practice team identify and track patients with diabetes. It can help the team ensure their diabetes patients receive the care they need when they need it. A diabetes register is essential for reliable call and recall of people with diabetes.

Specifically GPs can use a diabetes register to:
Identify how many people have diabetes in the practice;
Provide key information for patients and doctors during a practice visit;
Establish the care currently provided to diabetes patients in the practice;
Register your diabetes patients for community-based screening programmes e.g. retinal screening
Identify diabetes patients with apparent gaps in their care e.g. those who have not attended for the annual flu vaccination;
Highlight at-risk patients who need extra care and help target them for follow-up;
Support audits of diabetes care. These may cover overall quality of care, how patient care matches clinical guidelines for the management of diabetes, or to work on improving one aspect of diabetes care in the practice.

Using your practice management system to generate a Diabetes Register

Using ICPC2 coding to search for diabetes patients
If your practice routinely uses ICPC coding then the easiest and quickest way to identify your diabetes population is to search on the relevant diabetes codes:
T89 (Type 1)
T90 (Type 2)
W85 (Gestational)

Using medications to search for diabetes patients
If your practice does not use ICPC2 coding or does not always use it, then it may be useful to search on medications commonly prescribed for diabetes patients. For example the following trade names should pick up most of your diabetes patients who take medication to manage their diabetes:
Metformin
Diamicron
Lantus
Levimir
Humalog
Apidra

Searching on meter types to identify diabetes patients
Searching on medications will not identify patients who have diabetes but do not currently take medication to manage their condition. To identify these patients it might be useful to search on the most commonly prescribed blood glucose meters, for example:
One touch Ultra
Ascensia Contour
Glucomen
Optium Xceed

The lists generated by the above searches will then have to be cross-checked to create a master list as duplicates will exist across the different lists. Once this master list has been created we would advise you to access each patient file and code any patients that have not yet been coded with the appropriate ICPC2 code: T89 (Type 1), T90 (Type 2) or W85 (Gestational). This means than when you run a search again to identify your diabetes patients you will be able to use the quicker and simpler method of searching using ICPC2 coding only.

The master diabetes register should also be validated. Often a discussion with the practice team can help identify any patients that have not been picked up by the searches and any RIPs or non-practice patients (visitors, once-off patients). When diabetes patients attend the practice for a visit it might also be useful to double-check that their names are on the diabetes register.

Managing the Register
Keeping the register up to date is essential to reap the benefits. Any changes involving a person with diabetes should be noted as they occur (e.g. new diagnosis, death, patient leaving the practice). Although all the practice team need access to the register, responsibility for maintaining and reviewing the register is better assigned to one named member of the practice team.

Further Information
For instructions specific to your practice management system, you might find one of the attached guides useful - Dynamic GP, Socrates,
Helix Practice Manager and Health One and GP Mac. Alternatively, you can contact your system provider directly.