The Office of the National Coordinator for Health Information Technology Health IT Playbook

Section 10

Population & Public Health

In this section

Learn how to:

Population health, or public health, focuses on preventing, diagnosing, and treating an entire population of people rather than one person at a time.

The Affordable Care Act (ACA) — which rewards value and care coordination rather than volume and care duplication — requires clinicians to manage this type of patient care at a practice level. It’s referred to as practice-based population health.

If you want to improve a population’s health, you must be able to measure it. Programs such as The Center for Medicare & Medicaid Services’ (CMS) Quality Payment Program identifies national focus areas and requires the use of electronic clinical quality measures (eCQM).

Public health agencies also require electronic reporting, because it improves the timeliness and accuracy of the data they need to identify disease outbreaks and to track disease trends over time.

Care management is defined as a set of activities intended to help patients and their caregivers manage medical and behavioral conditions. Care-management objectives are designed to:

  • Improve patients’ functional health status
  • Enhance care coordination
  • Eliminate service duplication
  • Reduce the need for expensive medical services

Care management occurs at various levels of the health care system, including the population level, the practice or panel level, and the individual patient level. Care-management programs often focus on the challenges presented by patients with chronic conditions, such as heart disease, diabetes, or asthma.

Learning Guide: Strengthening Care Management with Health IT

Learning Guide: Strengthening Care Management with Health IT

A learning guide focused on using health IT to strengthen care management. It organizes knowledge and lessons learned from 5 federally-funded communities that implemented IT-enabled care-management strategies.

Who it’s for
Communities interested in using health IT to support the integrated and comprehensive delivery of care-management services

When it’s used
To learn about using health IT that supports the integrated and comprehensive delivery of care-management services

Download Learning Guide: Strengthening Care Management with Health IT [PDF - 385 KB]

Workflow Impact of Health IT for Care Coordination in Ambulatory Care

Workflow Impact of Health IT for Care Coordination in Ambulatory Care

Findings from a 6-site qualitative study that highlights opportunities to improve the impact of health IT on care-coordination activities in primary care

Who it’s for
Ambulatory and primary care clinicians

When it’s used
To find examples and data related to workflow impact of health IT-enabled care coordination

Download Workflow Impact of Health IT for Care Coordination in Ambulatory Care [PDF - 2 MB]

Population health focuses on improving health outcomes for large groups of people by monitoring and identifying individual patients within those groups.

Population health management (PHM) tools help clinicians aggregate and analyze data to create a comprehensive, actionable clinical picture of each patient. Using the information generated by these tools, clinicians can track and improve clinical outcomes — and lower health care costs.

Use these AMA STEPS Forward™ modules to learn about population health management tools

These modules offer innovative strategies that can help your practice provide better care by proactively identifying patients’ preventive and chronic care needs.

Panel Management — This strategy can help your practice identify and track all your patients’ care needs — whether or not they are coming in for appointments regularly.

Implementing a Point-of-Care Registry — This system can be integrated into your practice’s electronic health record, providing customized visit protocols for each patient visit and facilitating targeted outreach between visits.

Learning Guide: Building Technology Capabilities to Aggregate Clinical Data and Enable Population Health Measurement

Learning Guide: Building Technology Capabilities to Aggregate Clinical Data and Enable Population Health Measurement

This learning guide teaches how to build technology capabilities to aggregate clinical data and enable population health measurement. It combines the experiences and lessons learned from 6 Beacon Communities as they set goals, engaged community partners, invested in a technology infrastructure, and developed a strong foundation for measuring and improving population health

Who it’s for
Care management organizations, and learning-collaborative organizers interested in aggregating and using data from multiple sources to improve population health

When it’s used
To learn how to use data from multiple sources to improve health population

Download Learning Guide: Building Technology Capabilities to Aggregate Clinical Data and Enable Population Health Measurement [PDF - 366 KB]

Public health departments work hard to prevent epidemics and the spread of disease. They also:

  • Protect against environmental hazards
  • Prevent injuries
  • Promote healthy behaviors
  • Respond to disasters
  • Assist in recovery

They do all this by monitoring the health status of populations, investigating health problems —such as outbreaks — and mobilizing when problems arise. Public health departments depend upon data from clinicians captured during the regular course of clinical care. The data lets them measure the prevalence and incidence of diseases in populations.

All clinicians are required to capture and electronically report:

  • Diagnosis
  • Laboratory results
  • Radiographic results
  • Medications
  • Vital signs

Clinicians also report to registries — databases that contain patient health information about a specific disease or program — such as immunization, cancer, and death registries. Clinicians use electronic health record (EHR) and health information exchange functions for required reporting.

Learn more about public health reporting. Visit the Meaningful Use Public Health Reporting Requirements Task Force website.

Interoperability and Public Health Training Course

A training course on interoperability and public health consisting of 6 self-guided lessons

Who it’s for
Physician practices

When it’s used
To prepare for meeting Stage 2 Meaningful Use objectives

Check out the Interoperability and Public Health Training Course website

Public Health Issue Brief

Public Health Issue Brief

This brief describes electronic public health reporting progress and discusses opportunities to further improve public health reporting and information systems

Who it’s for
Health care clinicians

When it’s used
To learn about using health IT to report health care data to public health agencies

Download Public Health Issue Brief [PDF - 716 KB]

Working with Data – The Basics

Tips for, and examples of, collaboration between public health and primary care clinicians

Who it’s for
Clinicians, public health professionals, health IT implementers

When it’s used
To learn how to use data to collaborate with public health professionals

Check out the Working with Data – The Basics website

What is a patient registry?

A clinical data registry, or patient registry, is a system for uniform information collection. This information helps evaluate specified outcomes for a patient population defined by a certain disease, condition, or exposure — such as hepatitis C, fibromyalgia, or thalidomide.

Use registries to:

  • Describe the natural history of disease
  • Determine clinical effectiveness of health care products and services
  • Determine cost-effectiveness of health care products and services
  • Measure or monitor safety and harm
  • Measure quality of care

A patient registry can help clinicians improve patient care by serving a predetermined scientific or clinical need. For example:

  • A prosthetic-joints registry can help determine failure rates of specific product types or track functional outcomes of various postoperative therapies
  • A vaccinations registry can help practices judge the success of, and identify further challenges with, immunization efforts in their area

Types of patient registries

The Centers for Medicare and Medicaid Services (CMS) recognizes 2 types of patient registries: qualified clinical data registries (QCDR) and clinical data registries (CDR).

It’s important to understand the distinctions between these registries:

  • Clinicians use QCDRs (the most important registry type for this playbook) to collect and submit Physician Quality Reporting System (PQRS) and/or Quality Payment Program data for their practice
  • CDRs offer limited reporting value. They’re used only to report some public health data for the CMS Quality Payment Program.

You can use QCDR information for many purposes beyond the QPP. For example, you can use it for:

  • Clinical research
  • State medical licensing
  • Supporting American Board of Medical Specialties (ABMS) Maintenance of Certification Part IV

Note: This Playbook only provides information for QCDRs.

Who runs a patient registry?

Groups with an interest in clinical outcomes can run a patient data registry. The following clinical professional societies have run patient data registries for years:

Use the Center for Disease Control’s (CDC) interactive map to find contact information for a state’s Immunization Information Systems (IIS).

Initially, data collection for patient registries involved manual chart abstraction. Today, widespread EHR use makes greater data collection and analysis possible. The result? A dramatic improvement in a registry’s capacity to understand and monitor the quality of care for the practices and patients it serves.

How can my practice or group start using a qualified clinical data registry?

The first step is understanding your QCDR options. Start by asking colleagues in your specialty about using a QCDR. Their opinions may help you decide.

Specialty societies also serve as valuable resources. Contact any associated with your practice, such as:

  • The American Academy of Family Physicians (AAFP)
  • The American College of Surgeons (ACS)
  • The American Academy of Ophthalmology (AAO)

Select a registry

Once you select a QCDR, you must complete the application process. You’re not limited to one registry, but most practices participate in only one. During the application process, you will verify your certified EHR system and complete business associate agreements (BAA).

Merit-Based Incentive Payment System (MIPS) 2017 CMS-Approved Qualified Registries

Merit-Based Incentive Payment System (MIPS) 2017 CMS-Approved Qualified Registries

A list of the MIPS-qualified, CMS-approved clinical data registries for 2017 including contact information, supported measures, activities, performance categories, services offered and expected costs

Who it’s for
Clinicians, physicians, and physician practices or groups

When it’s used
To find and select a MIPS-qualified clinical data registry for 2017

Download the MIPS 2017 CMS-Approved Qualified Registries [PDF - 942KB]

Mapping EHR data

Your EHR must be configured to provide the correct data — in the right format — to the QCDR. “Mapping” refers to matching specific elements of your EHR data to the corresponding elements in the QCDR files. After mapping your EHR data, a practice scorecard shows which measures your current EHR data can accommodate. Your scorecard may list “unmapped” measures. That means — in its current configuration — your EHR can’t supply complete data to report those specific measures. Sometimes adjustments to your EHR, or to practice workflows, can turn unmapped measures into mapped measures.

Select your measures

Select which practice measures you will report for QPP. Base this decision on your:

  • Practice scorecard
  • Quality goals
  • EHR data

Choose any measures your practice will use for other reporting, such as medical licensing or ABMS certification.

Testing, testing

Your QCDR organization will show your practice how to test data submission and how to receive registry reports based on your performance. Make sure your clinical staff understands what activities and services affect the practice performance score.

Set goals and improve

Practices participate in a QCDR to better understand the clinical care they provide to patients with similar conditions. Reporting your performance on QCDR measures is just the first step to improve overall quality of care. The next step involves setting goals for improvement — which includes the entire staff identifying actions they can take to improve performance. Regularly review the QCDR reports and measure your own improvement. This will set your practice on the road to better patient outcomes.

Section 10 Recap

Use health IT to strengthen population health management.

  • Strengthen care management
  • Use population health management tools
  • Support public health data reporting
  • Participate in a patient registry

Join the conversation.

Do you have a tip or suggestion for supporting population health management that's worked well in your practice? Share it here!

Content last updated on: February 28, 2018