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Displaying records 1101 through 1120 of 1546 found.

Using your EHR for Population Health Management: A Cross-reference Tool (2017). Resource Type: Publication. Description: Health centers are interested in managing population health but may not have the budget needed to purchase specialty suites. This tool will guide health centers in leveraging the “built in” functionality of certified EHRs to perform PHM functions by mapping the native PHM functionality available in the common certified EHRs used by health centers.  The aim is to help health centers to understand where to start in implementing PHM using what they already have available to them. 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: Identify patient subpopulations by user selected parameters and perform risk stratification Examine detailed characteristics of patient subpopulations in terms of health status and outcomes, and trigger targeted care Track clinical performance measures to assess the effect and improve interventions Integrate Data - Input and aggregate data within the EHR database Share data with external systems Create and send notifications to provider and patient 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 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. 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. 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.     More Details...

Using the Systems Usability Scale to Assess Patient Portal Systems: English and Spanish Templates (2016). Resource Type: Publication. Description: When deploying personal health information systems such as patient portals Health Centers will often encounter challenges in effectively engaging their patient population. Understanding where these challenges are originating can at times be difficult to determine. One obvious area of evaluation is in determining whether the system being deployed is appropriately usable for the population. When deploying personal health information systems such as patient portals Health Centers will often encounter challenges in effectively engaging their patient population. Understanding where these challenges are originating can at times be difficult to determine. One obvious area of evaluation is in determining whether the system being deployed is appropriately usable for the population. Patient perception of the overall usability of the patient portal system can be evaluated through use of survey instruments such as the Systems Usability Scale (SUS). SUS is a well-established and validated usability scale that helps to determine the value, ease and interest of users of a particular system. Located in the Downloads section below are English and Spanish SUS survey instruments. Also located below is a link to further information on leveraging the SUS measures.  More Details...

Using the Social Ecological Model to examine how homelessness is defined and managed in rural East Tennessee (2016). Resource Type: Publication. Description: Homelessness, often conceptualized as an urban issue, is pervasive in rural communities due to high rates of poverty, lack of affordable housing, inadequate housing quality, unemployment/ under-employment, and geographic isolation. Moreover, homelessness in rural communities tends to be hidden, unacknowledged, and without adequate homeless-targeted resources. This study suggests that rural communities need to improve how they currently manage homelessness using the different levels of influence represented in the social ecological model. More Details...

Using Social Determinants of Health Data & New Technology Tools to Connect with Appropriate Community Resources: We asked the questions, now what? Updated in December 2018 (2018). Resource Type: Publication. Description: The collection of data related to patients' non-medical needs through use of Social Determinant of Health SDoH assessment tools, can accelerate systemic population health improvement, as well as engage patients in addressing their social non-medical needs such as transportation, shelter, or intimate partner violence services through coordinated access to appropriate services. This case study discusses the process a health center may use to identify and stratify need, and profiles a number of new technologies, including Aunt Bertha, Now Pow, and 211 Community Information Exchange, for connecting patients to appropriate community resources.   Download full case study at the bottom of the page. The collection of data related to patients' non-medical needs such as transportation, housing, food security, safety, etc. through use of Social Determinant of Health SDoH assessment tools e.g., NACHC’s PRAPARE, AAFP’s The EveryONE Project, can accelerate systemic population health improvement, as well as engage individual patients in addressing those needs through coordinated access to appropriate services.  According to a 2017 American Academy of Family Physicians AAFP survey, 83% of respondents agreed that family physicians should identify and help with social determinants of health. Research from Kaiser Permanente suggests that, of those patients screened for social determinants of health, approximately two-thirds needed some services. PRAPARE pilot data from participating health centers identified housing, utilities, and food as the most frequently identified needs. Unfortunately, 80% of the family physicians surveyed by AAFP responded that they don’t have time to discuss social determinants of health with patients and more than half feel unable to provide their patients with solutions.  So, tools are needed to help providers meet these newly identified needs, with existing resources. A number of these tools are profiled in the resource available for free download below. Much like other screenings that are embedded in the regular workflow and used to assess the risk or severity of the patient’s condition, such as the PHQ-9, Social Determinants of Health assessment tools like PRAPARE are designed to operate similarly.  Identifying level of risk or need among patients screened for social determinants of health in order to strategize responses is generally done with ‘risk scoring’. Here are two examples: SDoH only: A health center could assign 1 point per social determinant of health identified. Multiple sources: A health center could assign points based on number of chronic conditions, medications, ED visits in the last 12 months, and SDoH, as discussed in this HITEQ population health presentation. Whatever approach is taken, it is important to look at the distribution of risk scores or need levels across the patient population to ensure reasonable proportions identified as high, moderate, and low. Note that Care Management, Competency A in the PCMH 2017 standards is concerned with this. In this resource download below!, we focus on what technology tools exist to address social non-medical needs identified through screening. For those patients with high need, the standard response is likely to be health center-based and intensive. For example, patients with high need may be provided with 1 intensive case management, social workers, and referral coordinators; 2 direct assistance with connecting to resources; 3 follow up with external providers; and 4 regular in-person follow-up visits. This is likely to take up the majority of available staff capacity. However, gathering social determinants of health information may also point to other needs among patients with more moderate needs or in a broader array of areas such as paying utilities or legal services. Given staff capacity and resource limitations, as well as patient preferences, those patients may require another way to be connected with appropriate community resources. It is important that any approaches used allow for tracking and follow-up, as well as provide information about community service capacity. The tools in the case study below including Aunt Bertha, Now Pow, and 211 Community Information Exchange support this process by facilitating connection with community resources and needed follow-up, partially answering the question We collected social determinant of health data, now what do we do? Download the resource below for full case studies and lessons learned from using Aunt Bertha, 211 Community Information Exchange, and other new tools for connecting patients with community resources! More Details...

Using Outreach Data to Support Health Center Board Engagement (2016). Resource Type: Archived Webinar. Description: Outreach programs have unique access to community data that can enhance a health center’s governing board’s ability to make strategic decisions about providing appropriate and responsive care to patients in a financially sustainable manner. This webinar will address how to leverage outreach data to support health center planning and decision-making. HOP will present two effective tools that health center leadership, including board members, can use to inform their work: needs assessments and the Outreach Business Value Toolkit. More Details...

Using Health Center Needs Assessments To Address Legal Needs (2016). Resource Type: Publication. Description: This fact sheet outlines how health centers can use community needs assessments to understand and meet their patients’ health-harming civil legal needs. More Details...

Using Data to Manage Population Health Under Risk-Based Contracts: A background on what you need and how to use it (2017). Resource Type: Publication. Description: This resource will equip health center stakeholders with the understanding of what data-related capacity is needed to succeed under risk-based payment models.   This brief walks health centers through three key questions related to using data to succeed under risk-based contracts: 1 What data do I need and how do I get it?  2  How should I analyze the data? and 3 How should I use the data to manage quality and cost? Understanding the answers to these questions assists health centers in understanding the data-related capacities needed to participate successfully in risk-bearing payment models. Download the brief below! More Details...

Understanding Hospital Community Benefit Obligations: A Guide for Health Centers (2013). Resource Type: Publication. Description: Developed to assist health centers in forming productive collaborations with other providers, this publication describes hospital community benefit requirements and how they can spur community efforts to expand access to care and improve local health outcomes. More Details...

Understanding EHRs, Analytics, Data Warehouses and HIE Repositories: A HITEQ Center-Developed White Paper (2016). Resource Type: Publication. Description: The goal of this paper is to clarify the roles of several health care data technologies that are often confusing to people, including Electronic Health Record (EHR) Databases, Analytic Systems and Data Warehouses, and Health Information Exchange (HIE) Data Repositories. Health Centers entering the realms of Data-driven Performance Measurement and Quality Improvement may find themselves mired in a bewildering assortment of tools, products and terminologies. There are multiple ways in which Health Centers use information, and for better or worse, multiple technologies designed to most efficiently meet their needs. One of the leading sources of confusion emanates from the oft-used term “data aggregation”. We aggregate data because we want to improve our insights into the data and thereby make better and more timely decisions. Data aggregation, put simply, is the assembly of electronic information from multiple sources for these purposes. More Details...

Understanding and Addressing Hypertension and Heart Health in Your Community: A Quick Guide For Community Health Workers (2018). Resource Type: Toolkit. Description: Understanding and Addressing Hypertension and Heart Health in Your Community: A Quick Guide For Community Health Workers provides information surrounding hypertension and heart health. Inside you will find tools for Community Health Workers to use to guide patients with hypertension towards a healthier future. The guide also comes with a blood pressure tracker, which can be shared with patients as they track their progress towards their blood pressure goals. More Details...

UDS Sealant Measure FAQ (2019). Resource Type: Publication. Description: Find answers to Frequently Asked Questions (FAQ) about the HRSA UDS Sealant Measure for children ages 6-9 for dental caries. Developed in consultation with oral health specialists and HRSA staff. More Details...

Trauma and Youth (n.a.). Resource Type: Archived Webinar. Description: Speakers share how to provide trauma-informed care to various youth populations and offer recommendations for developing responsive, organization-wide practices and policies. More Details...

TransTalks: Transgender People and HIV (2016). Resource Type: Archived Webinar. Description: This session will help participants understand how the HIV epidemic affects transgender people by examining the barriers to care for those newly diagnosed, specific strategies for medication adherence, and gender-affirmation strategies to improve health care experiences. More Details...

Transportation Quality Improvement Toolkit (2016). Resource Type: Toolkit. Description: HOP's toolkit titled “Transportation and Health Access: A Quality Improvement Toolkit" is an easy-to-use, practical guide to assist health centers with assessing the scope of the problem and finding solutions to missed medical appointments due to transportation barriers. The toolkit guides the user through the two key phases of the quality improvement process: Needs Assessment and Plan-Do-Study-Act (PDSA) cycle, a continuous quality improvement process. Each section contains an overview of the concepts and sample tools. The tools are designed to be a starting point, and can be customized as needed to align with the specific context and resources of each health center. More Details...

Transportation and Health Access Infobook (2016). Resource Type: Publication. Description: Since 2000, Health Outreach Partners (HOP) has conducted bi-annual national needs assessments of community health centers serving underserved populations. The findings have consistently demonstrated that transportation is a top barrier to health care access. This infobook provides a general introduction to the topic of transportation as a barrier to health care access in the United States. The material is drawn from interviews, case studies, and reviews of existing literature. Although geared towards community health centers, it is relevant to all health care providers. More Details...

Transforming Health Centers into Adolescent-Centered Medical Homes (n.a.). Resource Type: Archived Webinar. Description: Adolescents experience unique health care needs that often go unmet. How can your health center’s environment, policies, and practices best serve your adolescent population? The presenter shares information on key components of an adolescent-centered medical home, including award-winning tools and strategies to improve the delivery of adolescent-centered care. More Details...

Tips for Managing Facility Development Risk (2010). Resource Type: Publication. Description: Developed for the National Association of Community Health Center's Risk Management Series, this information bulletin describes the major areas of risk and identifies action steps so health centers can reduce exposure to liabilities related to facilities development. More Details...

Three Domains to Improve Performance: Immunization Coverage Case Study (2016). Resource Type: Publication. Description: Improving performance can be boiled down to three approaches: improving the completeness and accuracy of data, decreasing missed opportunities, and improving the quality of services. Determining which of these is appropriate for your circumstance requires doing some data validation to assess where the issue lies. If you have not taken that step yet, please visit that section of the HITEQ site. Improving performance can be boiled down to three approaches: improving the completeness and accuracy of data, decreasing missed opportunities, and improving the quality of services. Determining which of these is appropriate for your circumstance requires doing some data validation to assess where the issue lies. If you have not taken that step yet, please visit that section of the HITEQ site. This case study walks through improving performance on immunization coverage using one continuous quality improvement process, the AFIX program, and highlights strategies in each of the three approaches to improve performance. More Details...

The Vital Role of Case Management for Individuals Experiencing Homelessness (2016). Resource Type: Publication. Description: This issue provides a synthesis of recent literature on case management and its importance for people experiencing homelessness in achieving optimal wellness. More Details...

The Value Proposition for Population Health Management for Health Centers: Calculating ROI on your PHM investment (2017). Resource Type: Publication. Description: Measuring return on investment ROI and the value of population health management is an emerging concern for health centers.  Calculating ROI on HIT investment is complex, and few health centers have experience in this endeavor.  The definition of value varies by type and size of provider, patient population, and other factors, and may be unique to an organization.  This white paper discusses principles and approaches to measure the value proposition for population health management for health centers.  Although few examples exist, we present the results of one health center’s measurement of the value of PHM. Measuring return on investment ROI and the value of population health management is an emerging concern for health centers.  Calculating ROI on HIT investment is complex, and few health centers have experience in this endeavor.  The definition of value varies by type and size of provider, patient population, and other factors, and may be unique to an organization.  This white paper discusses principles and approaches to measure the value proposition for population health management for health centers.  Although few examples exist, we present the results of one health center’s measurement of the value of PHM. Download the white paper below. More Details...

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $6,625,000 with 0 percentage financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.