Table Of ContentApplied
Population
Health
Delivering Value-Based Care
with Actionable Registries
Applied
Population
Health
Delivering Value-Based Care
with Actionable Registries
Barbara Berkovich, PhD, MA • Amy M. Sitapati, MD
First edition published in 2020
by Routledge/Productivity Press
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© 2020 by Barbara Berkovich, PhD, MA and Amy M. Sitapati, MD
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Library of Congress Cataloging‑in‑Publication Data
Names: Berkovich, Barbara, author. | Sitapati, Amy, author.
Title: Applied population health : delivering value-based care with actionable
registries / Barbara Berkovich, Amy Sitapati.
Description: Boca Raton : CRC Press, [2020] | Series: HIMSS book series |
Includes bibliographical references and index.
Identifiers: LCCN 2019037299 (print) | LCCN 2019037300 (ebook) |
ISBN 9780367196677 (paperback) | ISBN 9780367404567 (hardback) |
ISBN 9780367196714 (ebook)
Subjects: MESH: Population Health | Electronic Health Records | Registries |
Epidemiologic Methods
Classification: LCC RA418 (print) | LCC RA418 (ebook) | NLM WA 300.1 |
DDC 362.10285—dc23
LC record available at https://lccn.loc.gov/2019037299
LC ebook record available at https://lccn.loc.gov/2019037300
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Contents
ContentsContents
List of Tables ..................................................................................xiii
List of Figures ..................................................................................xv
Acknowledgements ......................................................................... xix
About the Authors ........................................................................xxiii
1 Introduction .................................................................................1
Part 1: Fundamentals ..................................................................................3
Part 2: Effective Delivery of Applied Population Health ..........................5
Part 3: Applied Population Health of Today and Tomorrow ...................7
Let’s Get Started ..........................................................................................8
PART 1 FUNDAMENTALS �������������������������������������������������������������������������9
2 Policy: Drivers for Value‑B ased Payment Models ......................11
Pay- For- Performance (P4P) ......................................................................13
Risk Sharing Programs .....................................................................14
Risk Adjustment ................................................................................15
Savings ..............................................................................................15
Healthcare Measurement Frameworks ....................................................15
Published Results ......................................................................................18
Cardiac Health ..................................................................................18
Tobacco Cessation ...........................................................................20
Diabetes ............................................................................................21
Human Immunodeficiency Virus (HIV) ..........................................21
Benefits of Early Intervention ..................................................................21
3 People ........................................................................................23
Organizational Characteristics ..................................................................24
Engaged Leadership .........................................................................24
Data- Driven Value Improvement Workgroups ...............................27
viii ◾ Contents
Empanelment and Attribution .........................................................30
Team- Based Care and Care Management .......................................32
Promoting Information Flow Using a Communication Plan ..........33
Case Study: Provider Engagement at OCHIN..........................................34
Conclusion ................................................................................................36
Understanding Patients and Patient Groups ...........................................36
Social Determinants of Health .........................................................37
Race, Ethnicity, and Language Standard .........................................37
Case Study: Lessons Learned on Patient Perception of Ethnic
Background ......................................................................................42
Sexual Orientation and Gender Identity .........................................42
Finding and Addressing Health Disparities ....................................43
Patient Engagement .........................................................................44
4 Process .......................................................................................47
Clinical Interventions ................................................................................48
Cascade of Care ...............................................................................48
Harmonize Measures .......................................................................51
Create a Population Health Protocol...............................................53
Case Study: Doing the Right Thing . . . with Medication
Monitoring ........................................................................................55
Direct and Indirect Interventions ....................................................56
Value Improvement Cycles ..............................................................57
Technology Flaws Underlying Healthcare Waste ....................................60
Why Have One Way When We Can Have 10? ................................61
If I Can’t Find It, the Data Aren’t There ..........................................62
If It Works for the Computer, It’s Fine for Human Use..................62
5 Technology of Health Registries ................................................65
Early Operational Registries .....................................................................66
Actionable EHR Registries ........................................................................67
The Spectrum of Registries.......................................................................68
Active Patient Registry .....................................................................69
Payor Registries ................................................................................70
Managed Care Registries ..................................................................70
Affiliate Registries .............................................................................70
Acute Care Registries .......................................................................71
Post–Acute Care Registries ...............................................................71
Primary Care Registry ......................................................................72
Wellness and Prevention Registries .................................................72
Contents ◾ ix
Patients at Risk .................................................................................73
Chronic Condition: Diabetes, Hypertension, Coronary Artery
Disease, etc. ...........................................................................73
Registry Suites ..................................................................................75
Medication Management Registries .................................................76
Patient- Based Registries ...................................................................78
Event- Based Registries .....................................................................78
Decedent Registry ............................................................................79
Case Study: Use of Social Security Decedent Data in an
EHR Registry .....................................................................................80
Registry Architecture .................................................................................80
Registries: From Taxonomy to Ontology .................................................82
6 Measuring the Quadruple Aims ................................................87
Health Outcomes ......................................................................................87
National Quality Forum ...................................................................88
International Consortium for Health Outcomes
Measurement (ICHOM) .........................................................89
Per Capita Cost ..........................................................................................89
Patient Experience ....................................................................................91
Provider Experience .................................................................................92
PART 2 EFFECTIVE DELIVERY OF APPLIED POPULATION HEALTH �������93
7 Applied Population Health Technical Foundation .....................95
8 Quality Measure Management Systems .....................................99
What Is Healthcare Quality Measure Management?..............................100
Do- It- Yourself (DIY) Quality Measure Management ....................101
A. Quality Program Cash Flow Report .................................102
B. Quality Program Submission Planning Report ................103
C. Quality Baseline and Goals Report ..................................106
D. Quality Measures Details Report .....................................108
Case Study: Tactical Planning for Quality Programs .............................111
9 EHR Population Health Projects ..............................................115
Judicious Use of Redundancy ................................................................116
Case Study: Automated Clinical Documentation Project ......................117
Best Practices for Population Health Projects .......................................118
Population Health Project Request Form ..............................................119
Case Study: Registry Project Request .....................................................122
