Implementation of a

Population Health and

Quality Reporting

System for FQHCs

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

■ 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

■ 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

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

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

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

■ 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

Main Dashboard

Individual Provider Statistics

Individual Provider Dashboard

Measure Criteria

List of Applicable Patients for a Measure

Patient Summary