Population Health Management
Population Health Management (PHM) is the ability to "zoom out" to look at groupings of similar patients in order to gain greater insights into health patterns. In identifying health patterns, health centers can target opportunities for improving care within a particular population, or spotlighting populations receiving exceptionally high quality care, which can then be shared with others to improve the overall health of Maine.
PHM exists to keep a patient population as healthy as possible, to minimize the need for expensive interventions and to reduce health inequalities, or gaps in care, that could result from specific health conditions or social, cultural, economic or environmental factors. It is a concept that ties in closely with a hallmark of the health center program, the goal of uniting public health and clinical care under one roof, and exemplifies the need for dovetailing health information technology with continuous quality improvement.
While electronic health records serve as a critical tool for health centers regarding clinical care, they are not designed for population health level work. It is with this mind that MPCA began providing support to health centers to bridge patient data from electronic health records, with actionable and reportable information that can be used to improve the health of patient populations.
Working in concert with i2i Systems and a dozen community health centers, touching more than 140,000 lives, MPCA has established a HIT network. CHCNet Maine, was developed specifically to address population health management, as well as supporting clinical quality reporting needs associated with:
- Patient Centered Medical Home initiatives
- The Center for Medicaid and Medicare Services' HIT incentive program, Meaningful Use.
- Annual reporting to the Bureau of Primary Care, UDS and Healthy People 2020
- Cancer screening and prevention.