An important aspect of healthcare is population health or public health, which is focused on the prevention, diagnosis and treatment of an entire population of people rather than one individual at a time. The Affordable Care Act provides the opportunity to reward value and care coordination – rather than volume and care duplication. This will require providers to effectively manage this type of patient care at a practice level, referred to as practice-based population health, or population health. To improve a population’s health, one must be able measure it. Programs, such as The Center for Medicare & Medicaid Services (CMS) Quality Strategy including Physician Quality Reporting Programs, identify areas of national focus and require the electronic reporting of clinical quality measures. Additionally, electronic reporting to public health agencies is required to improve the timeliness and completeness of data necessary to identify disease outbreaks and track disease trends over time.
Population & Public Health
9.1 Strengthen care management
Summary: Care management is defined as a set of activities whose objectives are to assist patients and their support systems in managing medical and behavioral conditions to improve patients’ functional health status, enhance coordination of care, eliminate duplication of services, and 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. Because of the challenges presented by patients with chronic conditions, the focus of care management programs is often a chronic condition such as heart disease, diabetes, or asthma.
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 five federally-funded communities that undertook and implemented IT-enabled care management strategies
Who it’s for
Communities that are interested in using health IT to support the integrated and comprehensive delivery of care management services
When it’s used
To educate about using health IT to support the integrated and comprehensive delivery of care management services
Workflow Impact of Health IT for Care Coordination in Ambulatory Care
Findings from a six-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/Primary care providers
When it’s used
When seeking examples and data related to workflow impact of health IT enabled care coordination
9.2 Use population health management tools
Summary: Population Health seeks to improve the health outcomes of a large group by monitoring and identifying individual patients within that group. Typically, providers use population health management (PHM) tools to aggregate and analyze data and provide a comprehensive and actionable clinical picture of each patient. Providers can track and, hopefully, improve clinical outcomes, and lower costs by using these tools and information.
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 aggregates the experiences and lessons learned from six 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
ACOs, communities, care management organizations, and learning collaborative organizers that are interested in aggregating and using data from multiple sources to improve the health of populations of patients
When it’s used
To educate on how to use data from multiple sources to improve the health of populations of patients
9.3 Support public health data reporting
Summary: Public health departments work to prevent epidemics and the spread of disease, protect against environmental hazards, prevent injuries, promote healthy behaviors, respond to disasters, and assist in recovery. They do this by monitoring the health status of populations, investigating health problems such as outbreaks, and mobilizing to address problems. Public health depends upon data captured by providers as a result of clinical care to measure the prevalence and incidence of diseases in populations. Providers are required to capture and electronically report diagnosis, laboratory results, radiographic results, medications, and vital signs. Providers also electronically report to registries, which are databases of patient health data about a single disease and/or program, such as immunization, cancer, and death registries. Providers use EHR and HIE functions to accomplish required reporting.
Interoperability and Public Health Training Course
A training course on interoperability and public health made up of a set of six self-guided lessons
Who it’s for
When it’s used
When preparing to meet Stage 2 Meaningful Use objectives in these areas
Public Health Issue Brief
This issue brief describes electronic public health reporting progress and discusses opportunities to further improve public health reporting and information systems
Who it’s for
When it’s used
For educating about reporting healthcare data to public health agencies using health IT
Working with Data – The Basics
Tips and examples of collaboration between public health and primary care providers
Who it’s for
Providers, Public Health professionals, Health IT Implementers
When it’s used
When seeking to learn how to use data to collaborate with public health professionals
9.4 Participate in a patient registry
What is a patient registry?
A clinical data registry, also known as a patient registry, is a system for uniform information collection (clinical and other). This information is to evaluate specified outcomes for a patient population defined by a particular disease, condition, or exposure (e.g. hepatitis C, fibromyalgia, or thalidomide). Registries can be used to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care. The ultimate purpose of a patient registry is to improve the care of your patients by serving a predetermined scientific or clinical need. For example, a registry of prosthetic joints could be useful in determining the failure rate of a specific type of product or the functional outcomes with various types of postoperative therapies, while a registry of vaccinations will help practices in your community judge the success and further challenges with immunization efforts in your area.
CMS actually recognizes two types of registries and there are some important distinctions between the two. The first, and most important for this Playbook, are Qualified Clinical Data Registries (QCDR). Qualified Clinical Data Registries, QCDRs, can be used to complete the collection and submission of Physician Quality Reporting System (PQRS) measures data for your practice. The second type of registry, simply known as a clinical data registry (CDR) have limited value in reporting and is only used to report public health data for use in Stage 2 or 3 of the CMS EHR Incentive Program, sometimes known as the Meaningful Use Incentive Program.
Qualified Clinical Data Registries, QCDR, information can be used for many purposes, beyond use in the PQRS and CMS EHR Incentive programs. QCDR information is used in clinical research, state medical licensing, and in support of American Board of Medical Specialties (ABMS) Maintenance of Certification Part IV. This playbook will only provide information regarding QCRDs.
Who runs a patient registry?
Any number of groups with an interest in clinical outcomes can run a clinical data registry. Clinical professional societies such as the Society of Thoracic Surgeons, the American Academy of Pediatrics, the American College of Chest Physicians, and the American College of Surgeons have been running clinical data registries for a number of years. When first begun, most of the data collection for this work was done with manual chart abstraction. Now, with the widespread use of electronic health records, greater data collection and analysis are possible, which can result in a dramatic improvement in a particular registry’s capacity to understand and monitor the quality of care for the practices and patients it serves.
Recognizing the long history of substantial work in the creation and use of clinical patient registries to improve the quality of patient care, in 2014 the Centers for Medicare & Medicaid Services (CMS) began accepting reports from qualified registries in the Physician Quality Reporting System (PQRS).
Individual physicians and group practices who satisfactorily participate in 2016 PQRS through a QCDR may avoid the 2018 negative payment adjustment (-2.0%). A list of 2016 qualified clinical data registries can be found below.
How do I get my practice or group started using a qualified clinical data registry?
- Ask around to colleagues in your specialty about using a QCDR; there are a number of choices, so their opinions will be helpful.
- Contact specialty societies your practice may be associated with, such as the American Academy of Family Physicians (AAFP), the American College of Surgeons (ACS), and the American Academy of Ophthalmology.They may serve as valuable resources in getting started.
- Take a look at the PQRS How to Get Started webpage.
- Complete the application process for the registry you have selected. All QCDRs have some form of application process. You are not limited to one registry but most practices will only participate in one registry. During the application process you will verify your certified EHR system and complete Business Associate agreements.
- Set up
- Your EHR must be set to provide the correct data in the right format to the QCDR. The technical term for this, “mapping,” is when the specific elements of data in your EHR are matched to the corresponding elements in the QCDR files.
- After the data in your EHR is mapped, a practice scorecard will be created that shows which measures the current settings for your EHR can provide data for. Your scorecard may list measures that are “unmapped,” which means that in its current configuration your EHR will not be able to electronically supply complete data for reporting those measures. Sometimes unmapped measures can become mapped with adjustments to your EHR and/or your standard staff work assignments. For example, your physician assistant can begin collecting and recording in the EHR the number of blocks each patient can walk. This new information may then qualify your practice to report on one or more additional functional assessment measures.
- Select measures
- Based on your practice scorecard, quality goals, and the measures your EHR is mapped to provide you can select which measures to your practice will report for PQRS.
- Your practice should also decide on any measures that should be used for other reporting such as medical licensing, ABMS certification, etc.
- Your QCDR organization will show you how your practice can test the submission of data and receive registry reports based on your performance.
- All your clinical staff should understand the practice’s performance and what activities and services affect the practice performance score.
- Set goals and improve
- For most practices, the primary reason for participating in a QCDR is to be able to better understand the clinical care your practice provides to a cohort of your patients with similar conditions or exposures. Reporting on your practice’s performance on QCDR measures are just the first step in a plan to improve the quality of care your practice provides. The next step is to select goals for improvement and get the acceptance of the entire practice staff on the best set of activities each of them can do to improve performance. Regularly review the QCDR reports and measure your own improvement. Doing this will set your practice on the road to better patient outcomes.
Content under development - We envision this section to contain helpful resources that address the specific challenges faced by public health professionals when configuring health IT systems to meet their organizational needs. This section currently contains material to support care management and population health in addition to public health resources to showcase the design functionality and demonstrate possibilities for future support of health IT adoption in the public health arena. We invite your organization to submit feedback, suggestions and ideas so that we can continue to build the health IT playbook into a truly useful resource, including public health providers. Please follow the feedback link below to contact us.
Section 9 Recap
- Strengthen care management
- Use population health management tools
- Support public health data reporting
- Participate in a patient registry