Implementation of a Population Health and Quality Reporting System for FQHCs
Jan 10, 2017
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