Identifying ways to flag patients who are hard to manage or should be excluded
It is difficult to define patients who should be included in a registry and assigning them to accountable physicians. Also challenging is identifying patients in the registry who will be difficult to manage. Every electronic medical record should be able to capture data that reflects the socio-economic indicators that impact health and well-being. These include language barriers, cognitive or physical inability to participate in a care protocol, income and economic barriers, home and local violence, geographic inability to participate, refusal to participate, and medication contraindications to participating in a care protocol.