List of Tables |
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xiii | |
List of Figures |
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xv | |
Acknowledgements |
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xix | |
About the Authors |
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xxiii | |
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1 | (8) |
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3 | (2) |
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Part 2: Effective Delivery of Applied Population Health |
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5 | (2) |
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Part 3: Applied Population Health of Today and Tomorrow |
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7 | (1) |
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8 | (1) |
Part 1 Fundamentals |
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9 | (84) |
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2 Policy: Drivers for Value-Based Payment Models |
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11 | (12) |
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Pay-For-Performance (P4P) |
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13 | (2) |
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14 | (1) |
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15 | (1) |
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15 | (1) |
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Healthcare Measurement Frameworks |
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15 | (3) |
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18 | (3) |
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18 | (2) |
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20 | (1) |
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21 | (1) |
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Human Immunodeficiency Virus (HIV) |
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21 | (1) |
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Benefits of Early Intervention |
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21 | (2) |
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23 | (24) |
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Organizational Characteristics |
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24 | (10) |
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24 | (3) |
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Data-Driven Value Improvement Workgroups |
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27 | (3) |
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Empanelment and Attribution |
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30 | (2) |
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Team-Based Care and Care Management |
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32 | (1) |
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Promoting Information Flow Using a Communication Plan |
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33 | (1) |
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Case Study: Provider Engagement at OCHIN |
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34 | (2) |
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36 | (1) |
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Understanding Patients and Patient Groups |
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36 | (6) |
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Social Determinants of Health |
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37 | (1) |
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Race, Ethnicity, and Language Standard |
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37 | (5) |
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Case Study: Lessons Learned on Patient Perception of Ethnic Background |
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42 | (5) |
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Sexual Orientation and Gender Identity |
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42 | (1) |
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Finding and Addressing Health Disparities |
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43 | (1) |
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44 | (3) |
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47 | (18) |
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48 | (7) |
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48 | (3) |
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51 | (2) |
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Create a Population Health Protocol |
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53 | (2) |
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Case Study: Doing the Right Thing...with Medication Monitoring |
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55 | (5) |
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Direct and Indirect Interventions |
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56 | (1) |
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57 | (3) |
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Technology Flaws Underlying Healthcare Waste |
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60 | (5) |
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Why Have One Way When We Can Have 10? |
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61 | (1) |
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If I Can't Find It, the Data Aren't There |
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62 | (1) |
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If It Works for the Computer, It's Fine for Human Use |
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62 | (3) |
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5 Technology of Health Registries |
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65 | (22) |
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Early Operational Registries |
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66 | (1) |
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Actionable EHR Registries |
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67 | (1) |
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The Spectrum of Registries |
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68 | (12) |
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69 | (1) |
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70 | (1) |
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70 | (1) |
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70 | (1) |
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71 | (1) |
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Post-Acute Care Registries |
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71 | (1) |
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72 | (1) |
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Wellness and Prevention Registries |
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72 | (1) |
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73 | (1) |
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Chronic Condition: Diabetes, Hypertension, Coronary Artery Disease, etc. |
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73 | (2) |
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75 | (1) |
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Medication Management Registries |
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76 | (2) |
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78 | (1) |
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78 | (1) |
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79 | (1) |
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Case Study: Use of Social Security Decedent Data in an EHR Registry |
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80 | (1) |
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80 | (2) |
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Registries: From Taxonomy to Ontology |
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82 | (5) |
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6 Measuring the Quadruple Aims |
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87 | (6) |
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87 | (2) |
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88 | (1) |
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International Consortium for Health Outcomes Measurement (ICHOM) |
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89 | (1) |
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89 | (2) |
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91 | (1) |
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92 | (1) |
Part 2 Effective Delivery Of Applied Population Health |
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93 | (70) |
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7 Applied Population Health Technical Foundation |
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95 | (4) |
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8 Quality Measure Management Systems |
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99 | (16) |
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What Is Healthcare Quality Measure Management? |
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100 | (11) |
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Do-It-Yourself (DIY) Quality Measure Management |
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101 | (49) |
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A Quality Program Cash Flow Report |
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102 | (1) |
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B Quality Program Submission Planning Report |
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103 | (3) |
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C Quality Baseline and Goals Report |
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106 | (2) |
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D Quality Measures Details Report |
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108 | (3) |
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Case Study: Tactical Planning for Quality Programs |
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111 | (4) |
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9 EHR Population Health Projects |
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115 | (10) |
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Judicious Use of Redundancy |
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116 | (1) |
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Case Study: Automated Clinical Documentation Project |
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117 | (1) |
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Best Practices for Population Health Projects |
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118 | (1) |
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Population Health Project Request Form |
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119 | (3) |
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Case Study: Registry Project Request |
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122 | (3) |
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10 The Who: Cohort Management with EHR Registries |
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125 | (4) |
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126 | (1) |
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Wellness and Prevention Registry |
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126 | (1) |
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Chronic Condition Registry |
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127 | (1) |
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127 | (1) |
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Case Study: Complex Cohorts ACO-30 Aspirin Therapy for Ischemic Vascular Disease |
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128 | (1) |
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11 The What and the When: Building the Feedback Loop |
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129 | (4) |
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The What: Registry Metrics |
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130 | (1) |
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The When: Intervention Scheduling |
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130 | (1) |
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131 | (1) |
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Case Study: Complex Measures ACO-17 Tobacco Assessment and Cessation |
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131 | (2) |
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12 Applying Clinical Decision Support |
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133 | (8) |
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133 | (4) |
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Ambulatory Care Screening Order Protocol |
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137 | (1) |
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137 | (2) |
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139 | (1) |
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Key Technical Components That Require Support of the EHR Team |
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140 | (1) |
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Key Operational Steps in Building This Process |
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140 | (1) |
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141 | (8) |
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141 | (1) |
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142 | (1) |
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143 | (1) |
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143 | (1) |
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144 | (1) |
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Case Study: Implementation of HIV Risk Calculator in an EHR |
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145 | (2) |
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147 | (1) |
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147 | (2) |
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149 | (14) |
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150 | (3) |
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151 | (2) |
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Case Study: OHSU Ambulatory Quality Reporting White Paper |
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153 | (4) |
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156 | (1) |
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157 | (1) |
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157 | (4) |
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157 | (1) |
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Monitor the Technology Platform |
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158 | (1) |
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Monitor Technology Efficacy |
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159 | (2) |
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161 | (2) |
Part 3 Applied Population Health Today And Tomorrow |
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163 | (32) |
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15 Moving Into the Future With a Learning Health System |
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165 | (10) |
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Learning to Deliver Better Healthcare |
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166 | (1) |
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Creating a Learning Health System |
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167 | (3) |
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Funding Research and Development |
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170 | (1) |
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Standardizing Financial Outcomes and Economic Impact |
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171 | (1) |
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171 | (4) |
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16 We've Come So Far...Lessons Learned and Call to Action |
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175 | (12) |
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Case Study: Discovery of the EHR as a "Therapeutic" |
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175 | (3) |
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178 | (1) |
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179 | (1) |
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Design Systems for People |
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180 | (2) |
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Improve the Clinical Accuracy of Patient Groups |
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182 | (3) |
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185 | (1) |
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186 | (1) |
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17 Visioning Population Health of Tomorrow |
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187 | (44) |
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Population Health in the Patient Digital Health Era |
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188 | (1) |
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Precision Medicine for Individual Health Balanced With Population-Level Standards |
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188 | (1) |
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Predictive Analytics With Dexterity Between Cost, Benefit, and Timing |
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189 | (1) |
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Aggregation and Risk Scoring of Data for State, National, and International Sharing Inclusive of Disparity Perspectives |
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189 | (2) |
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Improved Access to the Right Clinical Expertise |
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191 | (1) |
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Pushing the Envelope on the Subtleties of Prevention |
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191 | (2) |
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193 | (1) |
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193 | (2) |
References |
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195 | (8) |
Answer Key |
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203 | (14) |
Appendix A. Implementation of CDC Race and Ethnicity Codes (CDCREC) |
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217 | (8) |
Appendix B. Population Health White Paper |
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225 | (6) |
Appendix C. Job Descriptions for Population Health Team Members |
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231 | (14) |
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Job Description: Chief Medical Information Officer for Population Health |
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232 | (2) |
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Job Description: Healthy Planet Application Analyst |
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234 | (1) |
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Job Description: EMR Reporting Analyst |
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235 | (2) |
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Job Description: Population Health Lead Application Analyst |
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237 | (6) |
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Job Description: Enterprise Population Health Architect |
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243 | (2) |
Appendix D. DIY System for Quality Measure Management |
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245 | (6) |
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245 | (2) |
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247 | (3) |
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Import Additional Measure Details from CMS |
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250 | (1) |
Appendix E. Ambulatory Care Health Screening Order Protocol |
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251 | (12) |
Appendix F. Population Health Project Request |
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263 | (6) |
Appendix G. Registry Best Practices |
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269 | (4) |
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Glossary of Registry Terms |
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269 | (1) |
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270 | (1) |
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Registry Testing Environment |
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270 | (1) |
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271 | (2) |
Appendix H. Resources |
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273 | (4) |
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Centers for Medicare and Medicaid Services (CMS) |
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273 | (1) |
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273 | (1) |
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IHI Institute for Healthcare Improvement |
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274 | (1) |
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274 | (1) |
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Electronic Clinical Quality Improvement (eCQI) |
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275 | (1) |
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275 | (1) |
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Information Usability, Visualization, and Presentation |
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276 | (1) |
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276 | (1) |
Index |
|
277 | |