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Resource Overview

Population Health Management requires aggregating patient data from a number of sources, and conducting analytics and modeling to derive actionable insights that translate to increased patient engagement and improved outcomes.  Resources in this section describe data sources that are available to health centers, how to access and integrate them, and ways to enrich them with patient-provided data through health risk assessments and patient engagement technologies.

Getting and Using PHM and SDH Data

Community Vital Signs Provides Additional Insights for Population Health Management
HITEQ Center
/ Categories: Population Health, Using Data for PHM and SDH

Community Vital Signs Provides Additional Insights for Population Health Management

There is growing awareness of the impact of upstream social determinants on population health, but until recently these have been considered best addressed by policy makers on a large scale, and beyond the control of the medical system to influence.  That view may be changing, as discussed in this article by Ravi Narayanan, a member of the HIMSS Clinical & Business Intelligence Committee, and a Data Strategy and Management Consultant.  Mr. Narayanan describes how the adoption of value-based care and population health management has led health care providers to incorporate addressing unmet social needs into the provision of medical care.  This article discusses an innovative approach to incorporating social determinants data into population health, through geocoded address data to integrate Community Vital Signs, publicly available data about the community in which the patient lives.

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Tags: social determinants data Population Health data for population health
Intended AudienceHealth Center QI staff; Health Center IT Staff; Health Center Administration; Health Center Analytics Staff

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1 comments on article "Community Vital Signs Provides Additional Insights for Population Health Management"

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Suzanne Cohen

Just wanted to mention that Health Federation of Philadelphia is working with Drexel Dornsife School of Public Health to pilot a similar approach using geocoding of health center data and association with community level variables. We are early on in the project but see great potential for this approach. The intent is to use the data both to understand better how SDOH impact clinical outcomes and to look at ways to integrate community level information back into clinical workflow and population health management.

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Acknowledgements

This resource collection was cultivated and developed by the HITEQ team with valuable contributions from the National Association of Community Health centers (NACHC) as well as HITEQ's Advisory Committee and many health centers who have graciously shared their experiences with HITEQ.

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Improving the U.S. health care system requires four aims: improving the experience of care, improving the health of populations, reducing per capita costs and improving care team well-being. HITEQ Center resources seek to provide content and direction aligned with the goals of the Quadruple Aim

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