This Excel spreadsheet has three tabs. Be sure to read Tab 1, “Approach” for guidance in interpreting the information provided by this tool. Tab 2 provides a crosswalk between native certified-EHR functionality and the elements of PHM. Tab 3 contains links to EHR certification specifications on HealthIT.gov for assistance in interpreting EHR certification standards.

Background

Health centers are interested in implementing population health management (PHM), but often lack the resources to purchase specialized PHM software suites to implement in conjunction with their EHR. We assessed the functionality of certified EHRs to assist health centers in utilizing native EHR capabilities to perform PHM functions.

Methods

There is no standardized consensus definition of population health management (PHM). We conducted a review of the literature to identify models and elements of PHM to develop a framework for assessing the degree to which native EHR capabilities perform the functions of PHM. We synthesized results of a recent scoping review of the literature (see references) and a comparison of PHM vendor functionality to arrive at a working definition of PHM and its essential elements.

Our working definition of PHM maps to the triple aim: Population Health Management is the set of activities that simultaneously improve the health status and health outcomes of a population while improving quality and reducing per capita costs.

We synthesized the literature to develop a framework for the essential elements of PHM:

1. Identify patient subpopulations by user selected parameters and perform risk stratification
2. Examine detailed characteristics of patient subpopulations in terms of health status and outcomes, and trigger targeted care
3. Track clinical performance measures to assess the effect and improve interventions
4. Integrate Data - Input and aggregate data within the EHR database
5. Share data with external systems
6. Create and send notifications to provider and patient
7. Aggregate and analyze data within EHR data base

We then mapped the functionality included in certified EHR systems against these essential elements of PHM, to create the EHR-PHM Crosswalk presented on the next tab.

Workbook Contents

Tab 1 - Approach

Tab 2 - Crosswalk 

This tab lists required functionality inherent to all certified EHRs. Columns show how this functionality maps to the elements of PHM.

Tab 3 - Certification Detail 

This tab provides links to the Certification Companion Guide on HealthIT.gov for convenient access to the specifications behind each certification requirement.

Conclusions

• Native EHR functionality can be used to perform the elements of PHM. Certified EHRs, regardless of vendor, may be used to implement a comprehensive PHM program that performs all of the essential elements of PHM. In addition, certified EHR functionality and the EHR data base may be used to underpin the more advanced analytics functionality, and a more robust PHM user interface provided by specialized PHM suites and EHR add-ons offered by vendors.
• What you can't do with a certified EHR alone: Successful, robust PHM that manages risk associated with a population of patients necessitates integrating data on utilization and cost of care provided outside of the primary care provider's EHR. This requires some form of data import and/or integration such as provided by a data warehouse, HIE, all-payer database, or other infrastructure. This infrastructure typically includes multi-source integration of data within and external to the organization; in-depth, robust analytics capabilities; and a menu-driven, user-friendly interface. These functionalities are NOT inherently provided through standard EHR certification requirements, but may be available in some vendors’ offerings as add-ons or bundled functionality.

For More Assistance

Using the native functionality of EHRs to conduct PHM may require the availability of and expertise in additional tools such as registries, excel, SQL or a reporting tool such as Crystal Reports. For consulting and assistance in applying these tools to customize your EHR for PHM, request HITEQ technical assistance here.

References

1. Steenkamer Betty M., Drewes Hanneke W., Heijink Richard, Baan Caroline A., and Struijs Jeroen N.. Population Health Management. February 2017, 20(1): 74-85. doi:10.1089/pop.2015.0149.


2. Public Health Informatics Institute. 2016. "Population Health Management Software: An Opportunity to Advance Primary Care and Public Health Integration." Decatur, GA: Public Health Informatics Institute.


3. Jeroen N. Struijs, Hanneke W. Drewes, Richard Heijink, Caroline A. Baan, How to evaluate population management? Transforming the Care Continuum Alliance population health guide toward a broadly applicable analytical framework, Health Policy, Volume 119, Issue 4, April 2015, Pages 522-529, ISSN 0168-8510, http://dx.doi.org/10.1016/j.healthpol.2014.12.003.