Diabetes is a complex disease with multiple subphenotypes and clinical outcomes, which can be modified by treatment and lifestyle modifications. Due to the silent and progressive nature of diabetes, the International Diabetes Federation recommended the use of protocols, team, registry, reminders, self management and decision support to improve the quality of diabetes care. Given the phenotypic heterogeneity of people with diabetes, it is challenging for doctors to identify and address these needs within a typical 6-minute consultation visit. Since 2005, by changing the clinic setting, reengineering the workflow and using trained nurses, guided by protocol, we established the Hong Kong Diabetes Registry to stratify risk for triage to different care models. In 2007, we incorporated these components into a web-based portal (Joint Asia Diabetes Evaluation, JADE Program) to improve the efficiency of this integrated care program. To date, in collaboration with over 200 doctors and nurses, we have established an Asia Diabetes Database of over 50,000 patients from 9 countries. In this multinational database, 20% of patients were diagnosed before the age of 40 who had worse disease control than those with late-onset disease; 60% had diabetic nephropathy; 10% had chronic kidney disease and 10-20% had depression and/or psychological distress which were associated with higher A1c and risk of hypoglycemia. The systematic evaluation of risk factors and complications followed by communication of individualized risk profile with decision support to both patients and doctors have resulted in improved compliance and disease control in the majority of patients. These findings highlight the possibility of using knowledge transfer and collaborative care in busy settings to make quality diabetes care accessible, affordable and sustainable. The use of protocols and information technology also enable the conduct of large scale observational and interventional projects for prevention and control of diabetes and its comorbidities.