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Using Data for Collaborative Population Health Improvement

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Andrea Martin

on 28 February 2015

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Transcript of Using Data for Collaborative Population Health Improvement

Using Data for Collaborative Population Health Improvement
Farhad Modarai, DO
Duke University Medical Center
Department of Community and Family Medicine

Carolinas Healthcare System
Alameda County, California
San Diego Partnership
New York City Primary Care Information Project
Project focus - New York neighborhoods with greatest health disparities

Helped PCPs implement EHRs, assistance to improve preventive quality measures,

Bureau of Epidemiology and CUNY School of Public Health to explore how EHR data can inform population health surveillance

Camden Diabetes Program
7,041 Diabetics
62,000 ED/hospital encounters
Over $1.2 billion in charges

City wide services and initiatives to reverse these trends
Ohio Narcotic Surveillance Project
Southeast Minnesota Beacon Project
School districts
Primary care physicians and medical centers
Public health offices

Collaborate around disease action plans for asthma and diabetes
NC Pregnancy Medical Home
350 practices and 1,500 individual providers
Home visits, reconcile medications, link patients back to PCP for follow-up, ongoing education, self-management, risk screening
Reduction of low birth weights, from 11.5% to 10.5%

Reduction of infants weighing <1500g by 3%

Reduction in cesarean deliveries by 6.5%
Community Health Workers Program Colorado
Outreach, Screening,
and Referral System
A Practical Playbook: Public Health. Primary Care. Together
A cornerstone of the next transformation of health, in which primary care and public health groups work collaboratively to achieve population health improvement.
Practical Playbook Steering Committee
Lloyd Michener
Brian Castrucci
Jim Sprague
Denise Koo
How Can the Practical Playbook help?
Data & Informatics Resources
Guidance on using EHRs
Now What? Using Data in Your Own Context
Start with a shared need.
Build your relationship first.
Align to incentives.
Assemble the right skills.
Start small.
Address security, privacy, and data governance from the start.
Consider local capabilities and infrastructure.
IOM (Institute of Medicine). Primary Care and Public Health: Exploring Integration to Improve Population Health. Washington, DC: The National Academies Press, 2012.
Centers for Disease Control and Prevention. Automated Detection and Reporting of Notifiable Diseases Using Electronic Medical Records Versus Passive Surveillance. Morb Mortal Weekly Rep 2008:57(14);373-376. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5714a4.htm . Accessed February 12, 2014.
Centers for Disease Control and Prevention. CDC Grand Rounds: The Million Hearts Initiative. Morb Mortal Weekly Rep. 2012:61(50);1017-1021. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6150a1.htm . Accessed February 12, 2014.
Clinical Decision-Support Systems Improve Provider Practices for Cardiovascular Disease Prevention. The Community Guide. http://www.thecommunityguide.org/news/2013/CVD-CDSS.html . Accessed February 12, 2014.

Hsiao C, Hing E. Use and Characteristics of Electronic Health Record Systems Among Office-based Physician Practices: United States, 2001–2013. Centers for Disease Control and Prevention January 2014. http://www.cdc.gov/nchs/data/databriefs/db143.pdf . Accessed February 12, 2014.
Institute of Medicine (US) Committee on a National Surveillance System for Cardiovascular and Select Chronic Diseases. A Nationwide Framework for Surveillance of Cardiovascular and Chronic Lung Diseases. Washington (DC): National Academies Press: 2011. http://www.ncbi.nlm.nih.gov/books/NBK83155/ . Accessed February 12, 2014.
Klompas M., Murphy M., Lankiewicz J et al. Harnessing Electronic Health Records for Public Health Surveillance. Online J Public Health Inform. 2011; 3(3). doi: 10.5210/ojphi.v3i3.3794

McVeigh K, Newton-Dame R., Chernov C., et. al. Electronic health record surveillance systems: A new approach to chronic disease surveillance. American Public Health Association annual meeting, November.2013: Boston https://apha.confex.com/apha/141am/webprogram/Paper295185.html Accessed February 12, 2014.
Nichols GA, Desai J, Elston Lafata J, Lawrence JM, O’Connor PJ, Pathak RD, et al. Construction of a Multisite DataLink Using Electronic Health Records for the Identification, Surveillance, Prevention, and Management of Diabetes Mellitus: The SUPREME-DM Project. Prev Chronic Dis 2012; 9:110311. DOI: http://dx.doi.org/10.5888/pcd9.110311
Wang JJ, Sebek KM, McCullough CM, Amirfar SJ, Parsons AS, Singer J, et al. Sustained Improvement in Clinical Preventive Service Delivery Among Independent Primary Care Practices After Implementing Electronic Health Record Systems. Prev Chronic Dis 2013;10:120341. DOI: http://dx.doi.org/10.5888/pcd10.120341
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