1. Integrated Population Health Bill Young Product Strategist/Principal Thomas Hohner Senior Report Developer

2. Population Health Definition Population Health Management is the aggregation of patient data across multiple health information technology resources, the analysis of that data into a single, actionable patient record, and the actions through which care providers can improve both clinical and financial outcomes.

3. Components of Patient Chart in CPS EMR portion – Structured Data Problems (Not all problems are DX) Medical History Medications Diagnostic Tests (Labs/Radiology) Documents including Clinical Data (OBS Terms) Orders/Referrals with Problems that are DX PM portion – Structured Data Demographics Visits –Diagnoses –Procedure Codes (Services) –Charges/Adjustments/Payments

4. How UDS relates to Population Health –UDS gathers information from: Table 1-6(a) – PM portion of CPS Table 6(b) – EMR (Selected Clinical Measures) Table 7 – EMR Table 8 – Accounting System Table 9(d) – PM system

5. Challenges to Population Health Reporting –Uniform recordation of information, adhering to one group’s interpretation of how clinical data needs to be recorded –Use of multiple applications to collect data due to the shortcomings of core application without customization. –Developing methods to create more structured data and less free text –Vendor inflexibility in addressing differences between practices use of application –Time and expense to report accurately takes away from the reasons for obtaining the data.

6. Tools developed to make the process easier –UDS Maintenance tables –PCMH Reports and extensions Demographics, Language, Race, Ethnicity Clinical Outcomes Patients Not Seen High Risk Patient Populations Disease Registries which include functionality to USE the information obtained to manage the population.

7. Examples

10. Measures Report

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