Electronic Health Record (EHR) systems today provide increasing levels of clinical decision support and are the fulcrum for change for value-based healthcare delivery. Billions of dollars of government and insurer payments are dependent on evidence-based workflow design and quality report. In this context, quality measurement is no longer a retrospective exercise, but an essential prospective process embedded in clinical operations. Population health tools in the EHR enhance the efficiency and effectiveness of interventions thus improving the quality of care at lower cost. Population health methods are effective in ensuring that the right patient receives the right care at the right time.
This book provides a clear framework for design, implementation, and monitoring of innovative population health tools to accelerate measurable improvements in care delivery. Key benefits for readers include conceptual framework, team approach, and technical insights that result in improved patient care, improved performance on quality measures and increased revenue from quality performance incentives and risk-based contracts. This is also a practice guide to the healthcare professionals many roles who are eager to build or improve population health programs with the goal of delivering high quality value-based care.
Table of Contents
List of Tables
List of Figures
About the Authors
PART 1 FUNDAMENTALS
2 Policy: Drivers for Value-Based
5 Technology of Health Registries
6 Measuring the Quadruple Aims
PART 2 EFFECTIVE DELIVERY OF APPLIED POPULATION HEALTH
7 Applied Population Health Technical Foundation
8 Quality Measure Management Systems
9 EHR Population Health Projects
10 The Who: Cohort Management with EHR Registries
11 The What and the When: Building the Feedback Loop
12 Applying Clinical Decision Support
13 Calculating Risk
14 Analytics Dashboards
PART 3 APPLIED POPULATION HEALTH TODAY AND TOMORROW
15 Moving Into the Future With a Learning Health System
16 We’ve Come So Far . . . Lessons Learned and Call to Action
17 Visioning Population Health of Tomorrow
Appendix A. Implementation of CDC Race and Ethnicity Codes (CDCREC)
Appendix B. Population Health White Paper
Appendix C. Job Descriptions for Population Health Team Members
Appendix D. DIY System for Quality Measure Management
Appendix E. Ambulatory Care Health Screening Order
Appendix F. Population Health Project Request
Appendix G. Registry Best Practices
Appendix H. Resources
Applied Population Health: Delivering Value-Based Care with Actionable Registries
Barbara Berkovich, PhD, MA
Founder, CEO Applied Population Health
Dr. Berkovich founded the consulting and professional education company, Applied Population Health in 2019. She is developing courses in Applied Health Data Analytics and Population Health for academic year 2019-2020. Her goal is to assist health providers with implementation of their population health goals, and to train the next generation of health informatics professionals in a standardized practice of Applied Population Health.
She accrued ten years of work experience at the University of California San Diego Health (UCSDH) where she designed and built tools in the Electronic Health Record to drive quality, safety, and outcomes to enhance patient care and meet state and national performance targets. As Lead Population Health Architect, she became an expert in sustainable timely operational registries in the EHR and managed an extensive portfolio of registries to track active patients, payer groups, affiliate members, medications, wellness, and chronic diseases. In 2018, her local work on the Get to Green quality campaign helped claim nearly $5 million of at-risk PRIME incentive payments that were in jeopardy.
Her Ph.D. research focused on the automated selection of disease cohorts for the delivery of evidence-based care. She has lectured nationally on population health methods, registries, and medical terminologies and has taught graduate level courses at the University of California San Diego. In addition to a Ph.D. in biomedical informatics from the University of Texas Health Science Center at Houston, she holds a Master of Education degree from San Diego State University and a Bachelor of Science in Industrial and Systems Engineering from the University of Southern California.
Amy M. Sitapati, MD
Clinical Professor, Department of Medicine, Division of Internal Medicine and Division of Biomedical Informatics
Chief Medical Information Officer of Population Health
Internist, La Jolla Internal Medicine
University of California San Diego
As Chief Medical Information Officer of the Population Health for UC San Diego Health, Dr. Sitapati provides strategic vision and oversight. Using enterprise solutions that improve quality, safety, and outcomes, she leads the design of population level systems that support workflows for organizational goals. Dr. Sitapati is the executive lead at UCSDH for two CMS programs called PRIME and QIP, worth more than $25 million annually in eligible performance incentive payments. In this role, she directs more than 20 projects containing more than 80 quality measures supported by more than 150 active team members. Across the health system, Dr. Sitapati synchronizes the strategic vision, mapping, prioritization and expertise related quality infrastructure supporting Pay for Performance (P4P), Physician Quality Reporting System (PQRS), Meaningful Use (MU), Merit-based Incentive Payment System (MIPS), Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), and California’s third largest Medicare Shared Savings Program Accountable Care Organization (MSSP ACO) using more than 80 EHR based registries.
Dr. Sitapati’s expertise includes Board Certification in Clinical Informatics and Internal Medicine, a bachelor’s in engineering at Case Western Reserve University, doctorate in medicine at Case Western Reserve University, coursework in clinical research at UC San Diego, business at UC Los Angeles Anderson School of Business, EHR training in Epic as a physician builder, and lean black belt training. Dr. Sitapati has been recognized for her work in promoting culturally competent care through recognition of the Sexual Orientation and Gender Identity workgroup which she chairs by the Chancellor’s 2018 UC San Diego Inclusive Excellence Award Recipients diversity award.
With more than a decade of experience in informatics associated quality improvement, Dr. Sitapati brings substantial experience in using data to drive improved clinical workflows that ultimately provide healthier patient populations. She began this journey nearly eighteen years ago caring for HIV/AIDS patients in inpatient, outpatient, and border care delivery sites. This evolved into a deep appreciation for the care continuum, complexity of multimorbidity, shortage of human health workforce, influence of social determinants and remarkable foundational importance that registries can serve to anchor and improve care. Dr. Sitapati has given much thought and daily iterative work in mastering patient centered care delivery, implementation of meaningful risk acuity scoring, development of dynamic decision support, quality driven care, and access to research. As a former member of the Agency for Healthcare Research and Quality (AHRQ) health information technology study section, and a current member of the National Comprehensive Cancer Network (NCCN) breast panel, Dr. Sitapati has experience in considering academic needs related to population health. Dr. Sitapati is the local investigator for the California Vital Records and give thought to the intersection between public and health system level data. She provides instruction in clinical informatics and Kelee meditation in the school of medicine to physicians, pharmacists, computer and computational scientists. From the perspective of research, she leads the local recruitment team for the NIH precision medicine movement, All of Us, and thinks about how the intersection between research and population health. Dr. Sitapati believes that medicine of the future will integrate research, continuous quality improvement, and population driven healthcare delivery into the daily practice of medicine in remarkable ways to serve as the ‘penicillin’ of the future by directing the right care to the right patient with the right resources.