Diabetes is a complex disease characterized by chronic hyperglycemia and multiple phenotypes. In 1995, we used a doctor-nurse-clerk team and structured protocol to establish the Hong Kong Diabetes Registry in a quality improvement program. The detailed phenotypes at enrollment and follow-up medications have allowed us to develop a series of risk equations to predict multiple endpoints with high sensitivity and specificity. Using this registry, we were able to validate findings from clinical trials in real practice, confirm close links between cardiovascular and renal disease, and demonstrate the emerging importance of cancer as a leading cause of death. Inspired by the extremely low clinical endpoints in clinical trial settings, we systematically proven the marked benefits of protocol-guided team-based care. In 2007, we incorporated these risk equations, care protocols and decision support into the web-based Joint Asia Diabetes Evaluation (JADE) Program to enable doctors to establish their own clinic registries and to promote shared and informed decision between doctors and patients. More than 35,000 patients from Asia have been enrolled in this ongoing registry and patients who underwent repeat assessments had significant improvement in risk factor control suggesting that systemic collection and communication of information have reduced clinical inertia and improved self care. These research findings highlight the importance of using an integrated approach including change of practice environment and use of team and protocol to translate evidence to practice with ongoing evaluation.