Exploring Practice-Level Analytic Solutions for Smaller Health Care Practices that Support Population-Level Analytics

Project Name: Exploring Practice-Level Analytic Solutions for Smaller Health Care Practices that Support Population-Level Analytics

Project Results: View the presentation from CHIIC’s May 2016 meetingCdc-pdf.

Project Status: Completed

Point of Contact: Hilary Wall

Center: National Center for Chronic Disease Prevention and Health Promotion

Keywords: Population health management, Electronic Health Record

Project Description: With Meaningful Use and the supporting CMS EHR Incentive Programs, clinicians who implement a certified electronic health record (EHR) theoretically should now have access to a robust pool of patient data. Large health care systems with the needed resources and personnel often purchase access to or create a clinical data warehouse, a database for reporting and analysis that typically integrates laboratory, imaging, examination, billing, and patient experience data. For some smaller practices, a clinical data warehouse may not be a feasible solution due to resource or personnel limitations. Consequently, despite this influx of EHR data, some clinicians have difficulty accessing it. This is also true for public health professionals who have a need for population-level clinical data but may not be able to access the data or receive it in a way that is most meaningful for their purposes.

Million Hearts® is a national initiative co-lead by CDC and the Centers for Medicare & Medicaid Services with a goal of preventing one million heart attacks and strokes by 2017. Through this initiative, we are actively working with clinicians to implement evidence-based strategies for improving cardiovascular disease prevention. One of those strategies is using regular (i.e. biweekly or monthly) data to drive performance improvement. State departments of health have been mobilized to assist with this issue through multiple NCCDPHP FOAs. Some savvy practices have been able to do this through dashboards or report cards but we have heard feedback from states that it can be very challenging for clinicians to access data from their EHRs and, subsequently, for public health to tap into clinical EHR data in a way that is meaningful for population health surveillance. States need technical guidance on how to best engage with and support clinical settings with moderate- to low-health information technology capacity.

There are software solutions that exist to help fill the gap for practices without robust analytic capacity. Population health management products like i2i PopIQ and Phytel Insight extract select data elements from EHRs and related data sources to allow for quick, near-real-time report generation and data visualization. These data are vital for rapid-cycle continuous quality improvement. No comprehensive guidance exists that summarizes the features and gaps for these types of products; this is desperately needed as clinicians receive escalating pressure to deliver high-quality care. On the flip side, to improve surveillance and target interventions for key health issues, public health professionals need access to aggregated clinical data stratified by pertinent public health demographics (e.g. age, sex, race/ethnicity, zip code, and insurance status) that can be pieced together from multiple clinical settings to provide a community profile. It is likely that some population health management solutions more easily enable data availability for and transmission to public health.

We are seeking funds to hire an expert to:

  1. 1. inventory population health management software solutions for clinical settings without access to a clinical data warehouse and
  2. evaluate the solutions against to-be-established criteria that reflect needs of both clinicians and public health (see example software evaluation criteria below), and
  3. provide recommendations for future projects that are needed to address gaps in the data flow from patient visit to clinical quality improvement to public health surveillance. These deliverables will be useful tools for clinicians and direct technical assistance providers to clinicians (e.g. state and local departments of health, Regional Extension Centers, Quality Improvement Networks).

Example Software Evaluation Criteria

  • For clinicians/health care systems
    • Ability to run regular data reports
    • Ease of use
    • Cost
    • Customizability
    • Innovative visualizations
    • Appropriateness for rapid-cycle CQI
    • Compatibility with ONC standards
    • Utility for different sized practices
  • For public health
    • Ability for clinicians to share aggregated data with public health
    • Availability of pertinent demographic breakdowns
    • Ease of data transmission
    • Security

For more information about this project, please contact the CHIIC at chiic@cdc.gov or Brian Lee at brian.lee@cdc.gov.

Page last reviewed: February 15, 2019