– Implementation of a Population Health and Quality Reporting System for FQHCs in CT using popHealth®
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The document outlines the implementation of a population health and quality reporting system for Federally Qualified Health Centers (FQHCs) using the open-source PopHealth tool, which aggregates clinical data to track quality measures and trends. Currently, collaboration among 14 FQHCs in Connecticut is underway, with some facilities live and others in testing phases, preparing to enhance their electronic health record systems. PopHealth, developed by MITRE, is a cost-effective option but faces challenges such as lack of documentation and the need for specialized technical skills.
– Implementation of a Population Health and Quality Reporting System for FQHCs in CT using popHealth®
- 1. Implementation of a Population Health and Quality Reporting System for FQHCs
- 2. FQHC popHealth Pool Project ■ popHealth is an Open-Source Clinical Quality Measure database and reporting engine presented through a web-based interface ■ Centralized repository of clinical data ■ Data is sent from EHRs via nationally recognized standards – Consolidated Clinical Data Architecture (C-CDA) Architecture Continuity of Care (CCD)Document ■ Clinical Quality Measures (CQMs) are calculated for providers and presented through a web-based interface – Drill down ability to the provider and patient-level data – Ability to compare a provider to the aggregate ■ Track trends in quality and health over time ■ Identify areas for improvement in workflow and data capture
- 3. ■ All 14 FQHCS in CT participating – 4 currently sending live data – 2 testing process – Remaining FQHCs upgrading their EHR first ■ Contracted with EHR vendors to create CCD batch extracts ■ popHealth is hosted centrally and data is sent via SFTP from each FQHC – Potential to move to Direct Mail transport in the future ■ eHCT enhanced popHealth – Role-based access – Comparison to aggregate ■ FQHCs send Continuity of Care (CCD) data to popHealth ■ Currently used for MU CQMs – Working with other public entities in CT to use data for grant reporting FQHC popHealth Status
- 4. ■ popHealth is Open Source prototype software that was developed by MITRE through a grant from ONC ■ Pros – No cost to purchase – Active Open Source Community – All users benefit from enhancements/contributions back to the Open Source Community ■ Cons – “Free like a puppy” – Documentation is lacking and support is voluntary through Open Source Community – Requires skill set that is unusual: HL7, QRDA standards Mongo DB Ruby on Rails JSON popHealth Implementation Challenges
- 5. Data Flow for Population Health Management Population Health Reporting Tool Providers Collaborate on Patient Health Electronic Medical Records Database for Practice Clinicians Enter Patient Data into EMR Secure Transfer of Patient Data
- 6. popHealth Today for FQHCs CCD Data Aggregate Data popHealth Database FQHC 1 Data FQHC 2 Data FQHC 3 Data FQHC 4 Data popHealth Reporting Tool Role-based web access MU Stage 1 and 2 Reports Overall measures with ability to drill down HIPAA compliant Aggregated population health reports FQHC 1 EHR CCD DataFQHC 2 EHR CCD DataFQHC 3 EHR CCD DataFQHC 4 EHR
- 7. CCD via Batch Aggregate Data popHealth Database Provider Data Hospital Data FQHC Data Other Data popHealth Reporting Tool Provider CQMs DPH Reporting DSS/Medicaid Cat 3 Docs Comparison to cohort Grant CQMs PCMH ACO EHR 1 CCD via DirectEHR 2 QRDA Cat 1EHR 3 QRDA via DirectEHR 4 popHealth Next Generation
- 8. ■ Extensive clinical data is needed to be present in Continuity of Care Documents (CCDs) for automating the generation of Meaningful Use Clinical Quality Measures in popHealth – Allergies: RxNorm*, SNOMED-CT* – Care Goals, Social History, Medical Equipment: SNOMED-CT* – Conditions: SNOMED-CT*, ICD-9-CM, ICD-10-CM – Encounters: CPT – Immunizations, Medications: RxNorm*, CVX* – Procedures: CPT, ICD-9-CM, ICD-10-CM, SNOMED-CT* – Vitals, Results, Assessments: LOINC*, SNOMED-CT* – Communications: SNOMED-CT ■ * preferred ■ Requires that all continuity of care entries are time-stamped ■ Requires that results and vitals must be provided structured with units and values Continuity of Care Data Requirements
- 12. Measure Criteria
- 13. List of Applicable Patients for a Measure
- 14. Patient Summary