X
GO

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

Using your EHR for Population Health Management

Using your EHR for Population Health Management

A Cross-reference Tool

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.

  4.  

 

Documents to download

Previous Article Integrating Social And Medical Data To Improve Population Health: Opportunities And Barriers
Next Article Results of Population Health Analytics/ Data Integration Survey
Print
14693

Leave a comment

This form collects your name, email, IP address and content so that we can keep track of the comments placed on the website. For more info check our Privacy Policy and Terms Of Use where you will get more info on where, how and why we store your data.
Add comment

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.

Looking for something different or have something you think could assist?

HITEQ works to provide top quality resources, but know your needs can be specific. If you are just not finding the right resource or have a highly explicit need then please use the Request a Resource button below so that we can try to better understand your requirements.

If on the other hand you know of a great resource already or have one that you have developed then please get in touch with us by clicking on the Share a Resource button below. We are always on the hunt for tools that can better server Health Centers.

Request a Resource  Share a Resource
Highlighted Resources & Events
Need Assistance?
Would you like more assistance regarding Population Health Management and Social Determinants of Health strategies or support in using any of the included resource sets?

  Request Support

 

Upcoming Events
The Quadruple Aim
Quadruple Aim

A Conceptual Framework

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

Learn More