Applied Population Health Delivering Value-Based Care with Actionable Registries HIMSS Book Series

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.

List of Tables
List of Figures
Acknowledgements
About the Authors
1 Introduction
PART 1 FUNDAMENTALS
2 Policy: Drivers for Value-Based
3 People
4 Process
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
References
Answer Key
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 RegistriesIndex

Barbara Berkovich, PhD, MAFounder, 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 Info