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

Section 10

Population & Public Health

In this section

Learn how to:

Public health focuses on protecting and improving health at a population level rather than one person at a time.

The Affordable Care Act (ACA) — which rewards value and care coordination instead of volume and care duplication — requires clinicians to manage this type of patient care at a practice level. This is called practice-based population health.

If you want to improve a population's health, you must be able to measure it. Programs such as the Centers for Medicare & Medicaid Services' (CMS) Quality Payment Program (QPP) identify national focus areas and require the use of electronic clinical quality measures (eCQMs).

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

Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. At the individual and population level, factors such as social circumstances, environmental exposures, and behavioral patterns can be major contributors to the risk of premature death — often more predictive and important than a population’s access to traditional health care.1, 2 As such, clinicians play an important role in disease prevention and health promotion, by working with patients not only to manage acute and chronic conditions but also to address social, environmental, and behavioral factors affecting patients’ health. The movement toward value-based care, which rewards clinicians for results of care rather than activities of care, reflects the understanding that the best patient care incorporates all factors pertaining to a patient’s health — including social determinants of health.

How can addressing social determinants of health help my practice, my patients, and our community?

Non-clinical factors like food, housing, and transportation insecurities can profoundly affect a person’s overall health. The ability to capture and access SDOH data can empower clinicians to work with individuals to support their health goals — and to improve health outcomes and reduce health disparities. SDOH data can also help clinical practices identify health disparities and take action to improve health equity.

There are many screening tools that health care practices can use to identify and address SDOH needs, using standardized electronic vocabulary code sets to ensure interoperability among different IT systems. Many existing clinical practice guidelines already incorporate aspects of SDOH in direct clinical care delivery recommendations.3, 4

Health IT can help clinicians better understand how SDOH affects their patients’ lives and can support person-centered care delivery. Many SDOH health IT standards exist and are part of the ONC Health IT Certification Program or in the ONC Interoperability Standards Advisory. Although SDOH data gaps exist, robust standards for using and sharing SDOH data are emerging. For example:

  • Awareness of a patient’s access to housing can help clinicians better assess a patient’s ability to take medications on a regular schedule. When clinicians are aware that a patient is homeless, they can connect the patient to resources and organizations that can help.
  • Knowing that a patient is experiencing intimate partner violence can offer valuable insight into the patient’s ability to attend scheduled appointments or answer unexpected phone calls — and this knowledge is the first step to getting the patient the help they need.
  • A patient with limited access to healthy foods may have difficulty achieving certain goals, such as making progress with blood pressure or diabetes control. An informed clinician can link the patient to appropriate resources that can address nutritional needs.

After identifying social needs, care team members — including social workers and care managers — can connect patients with appropriate resources. Standards exist to support referrals to and coordination with local resource providers. Products in the marketplace can also facilitate social care referrals. To learn more about social care referral and related health IT solutions, check out Innovative Technology Solutions for Social Care Referrals.

United States Core Data for Interoperability (USCDI)

The United States Core Data for Interoperability is a standardized set of health data classes and data elements allowing for nationwide, interoperable health information exchange. The USCDI defines core data requirements essential for patient data access and other exchange and interoperability uses. This dataset must be included in certified health IT (see Section 2 of this playbook for more information).

USCDI version 2 incorporates 4 standardized SDOH data elements:

  • SDOH assessment
  • SDOH goals
  • SDOH interventions
  • SDOH problems/health concerns

Who it’s for
The health IT community, including health IT developers

When it’s used
To create or update systems to communicate about patient care (e.g., electronic health records or Application Programming Interfaces).

Check out the United States Core Data for Interoperability

The new SDOH data elements in USCDI version 2 have been placed into applicable, existing data classes:

New SDOH data elements
Existing USCDI Data Class New Data Element
Assessment and plan of treatment SDOH assessment
Goals SDOH goals
Procedures SDOH interventions
Problems SDOH problems/health concerns

How can my practice assess, identify, and address unmet social needs?

Implement SDOH screening for your patients

Several SDOH screening tools exist. The Social Interventions Research & Evaluation Network provides a table showing comparisons of several SDOH screening tools, including the social domains they assess and further information like reading level and languages.

In addition, Arons et al. developed a guide for medical terminology codes related to social risk factors. Their compendium identifies specific screening questions, assessment and intervention codes, the screening tools questions came from, and related medical and diagnosis codes [PDF – 3.1 MB].

Consider using an SDOH screening tool that’s validated and health IT enabled. This means the screening tool is standardized and that its data can be coded, shared, and exchanged, and are reusable. One example is the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE), a validated, health IT-enabled screening tool that community health centers use to support patients’ health and goals.

Telehealth visits may also give you further insights into an individual’s home environment, providing the opportunity for further screening, assessment, and tailored interventions.5, 6, 7

Establish partnerships in your community

Establishing partnerships with other health entities and community-based organizations (CBOs) can help your practice support your patients and the larger community.8 Such partnerships and care coordination can help to fill gaps in services and provide holistic, person-centered care.9 Information technology can facilitate SDOH information exchange so that care may be seamlessly coordinated and so that patients’ social needs may be addressed.10, 11, 12

Monitor practice guidelines and quality measurement

Some clinical practice guidelines include SDOH in treatment and decision making algorithms. Guidelines that reference SDOH concerns are available in some specialty areas, including pediatrics, cardiovascular health, and substance use disorder specialties. Clinicians should monitor guidelines published by their professional societies for SDOH-related recommendations.

Community-level SDOH information exchange, including through closed-loop referral platforms, can help measure and track individual, population, and community-level outcomes.13, 14 Practices can use this information to develop and implement quality initiatives that improve outcomes and address health inequities.15, 16, 17


PRAPARE is a standardized patient risk assessment tool developed by the National Association of Community Health Centers (NACHC) in collaboration with other national organizations. PRAPARE is widely used in the nation’s 1,300+ Federally Qualified Health Centers (FQHCs) and is integrated into most FQHCs’ electronic health record systems. This is a national effort to help clinicians collect SDOH data in a standardized fashion.

Who it’s for
Health centers, social service organizations, community-based organizations, hospitals, and health systems

When it’s used
To understand patients’ clinical and non-clinical needs more thoroughly. To identify appropriate community resources. To better appreciate and meet SDOH needs at a population level.

Check out the PRAPARE screening tool [PDF – 225KB]

The Gravity Project

The Gravity Project is a national public collaborative working to develop consensus-based data standards to improve the use and sharing of SDOH information and data across digital health and human services platforms. National standards promote consistent use of data across health and social services systems; facilitate payment for assessment of SDOH risk factors and SDOH-based interventions; allow for evaluation of interventions; and enable tailored population health management and community-level interventions.

Who it’s for
Any individual or organization interested in helping advance SDOH data use and interoperability

When it’s used
When SDOH standards are developed. For example, the Gravity Project recently published an implementation guide focused on defining standards for SDOH information exchange..

Check out the Gravity Project

Learn more

Please visit the ONC SDOH website to learn more about tools and resources for using health IT to advance SDOH interoperability, data use, and support for your practice, patients, and community.

Learn about work that ONC is supporting to advance SDOH efforts in clinical settings.

Advancing the use and interoperability of SDOH data is important for improving the health and well-being of all individuals and communities. ONC works collaboratively with federal partners and the stakeholder community to advance the electronic exchange and use of SDOH data.

1 Schroeder, S.A. (2007). We can do better — improving the health of the American people. The New England Journal of Medicine, 357, 1221-1228.

2 Marmot, M. (2017). The health gap: Doctors and the social determinants of health. Scandinavian Journal of Public Health, 45(7), 686-693.

3 Andermann, A. (2016). Taking action on the social determinants of health in clinical practice: A framework for health professionals. CMAJ, 188(17-18), E474-483.

4 Andermann, A. (2018). Screening for social determinants of health in clinical care: Moving from the margins to the mainstream. Public Health Reviews, 39:19.

5 Jauhar, S. (2004). House calls. The New England Journal of Medicine, 351, 2149-2151.

6 Bieber, S.D. & Weiner, D.E. (2018). Telehealth and home dialysis: A new option for patients in the United States. Clinical Journal of the American Society of Nephrology, 13(8), 1288-1290.

7 Chowdhury, D., Hope, K.D., Arthur, L.C., Weinberger, S.M., Ronai, C., Johnson, J.N., & Snyder, C.S. (2020). Telehealth for pediatric cardiology practitioners in the time of COVID-19. Pediatric Cardiology, 41, 1081-1091.











“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 healthcare 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 the workflow impact of health IT-enabled care coordination

Download Using Health IT in Practice Redesign: Impact of Health IT on Workflow [PDF – 2 MB]

Population health focuses on improving health outcomes for large groups of people by identifying and monitoring 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. With the information generated by these tools, clinicians can track and improve clinical outcomes — and lower healthcare 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 population health.

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

All states and territories require clinicians to report specific diseases and conditions to public health agencies through various public health surveillance and information systems. Many of these systems are digital and are connected to electronic health records (EHRs). They include:

  • Electronic lab reporting, which automatically reports laboratory findings from commercial, public health, hospital, and other labs to state and local public health departments.1
  • Syndromic surveillance reporting, through which ambulatory care providers, hospitals, and urgent care centers send symptomatic data to public health agencies, possibly resulting in early detection of potential public health events.
  • Immunization information systems (IIS), which automatically record immunization information from the EHR and merge this information into one reliable source. Clinicians can also receive immunization forecasts and histories from the IIS.
  • Electronic case reporting, which automatically sends information from an EHR about a reportable condition to a public health agency for review and action.2
  • Public health registries (e.g., cancer, death/birth, newborn screening, trauma), which are collections of specific types of information and vary by local and state jurisdiction.

Clinicians use EHR and health information exchange functions for required reporting. Public health agencies depend upon receiving data from clinicians through these systems. This helps public health agencies measure the prevalence and incidence of diseases, maintain high immunization coverage rates, manage outbreak investigations, and plan for and respond to public health emergencies.

To learn more about public health reporting, visit the Centers for Disease Control and Prevention’s Public Health and Promoting Interoperability Programs 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

Working with Data – The Basics

Tips for, and examples of, collaboration between public health professionals 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

1 (Prevention, 2019)

2 (William R. Mac Kenzie, 2016)

What is a patient registry?

With a clinical data registry, or patient registry, information is uniformly collected. This information helps evaluate specified outcomes for a patient population that is 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 the clinical effectiveness of healthcare products and services
  • Determine the cost-effectiveness of healthcare products and services
  • Measure or monitor safety and harm
  • Measure quality of care

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

  • A prosthetic-joints registry can help you determine the failure rates of specific product types or track the functional outcomes of various postoperative therapies
  • A vaccinations registry can help you judge the success of immunization efforts in your area and identify challenges related to those efforts

What are the types of patient registries?

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

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

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

You can use QCDR information for many purposes beyond 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 provides information for QCDRs only.

Who runs patient registries?

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 Centers for Disease Control & Prevention’s (CDC) interactive map to find contact information for a state’s immunization information system (IIS).

Initially, data collection for patient registries involved manual chart abstraction. Today, widespread electronic health record (EHR) use makes greater data collection and analysis possible. The result? A dramatic improvement in the ability to understand and monitor quality of care across practices and patients.

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

The first step is to understand 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:

What do we do after we 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 (BAAs).

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]

What does it mean to “map” 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 you map your EHR data, a practice scorecard shows which measures your current EHR data can accommodate. Your scorecard may list “unmapped” measures. That means that 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.

How do we select 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.

How do we test data submission?

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.

How can my practice set goals to 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 — the entire staff should identify 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.

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

Content last updated on: December 6, 2021