Article Figures & Data
Figures
- Figure 1.
Population Health Assessment Engine (PHATE) uses patient addresses, diagnoses, and quality measures to geospatially identify hotspots, or clusters, of disease prevalence or poor disease control. This is a heatmap of individuals not up to date with depression screening, from the PHATE Demo Dataset.
Tables
Level Function Example System level Adjust payments Massachusetts and Minnesota adjust Medicaid reimbursements based on SDHs Contribute to public health surveillance Macroscope (New York City) and the electronic medical record Support for Public Health (ESP; Massachusetts) use EHRs for public health surveillance Practice level Organize care around hot spots The University of Cincinnati's comprehensive care team aims to reduce hospital admissions for children coming from high poverty neighborhoods Assess patient risk QRISK uses geographic data to calculate risk for cardiovascular disease in the United Kingdom Connect with community organizations Community Rx uses diagnosis codes and links patients to relevant community resources SDH, social determinants of health; BRFSS, Behavioral Risk Factor Surveillance System; NAMCS, National Ambulatory Medical Care Survey; EHRs, electronic health records; QRISK, cardiovascular disease risk algorithm, ESP, Emergency Service Program.
- Table 2.
How the Population Health Assessment Engine Can Be Used to Meet Training Milestones
Attainable Family Medicine Milestones Using PHATE Example Identifies specific community characteristics that impact specific patients' health. PHATE can be used as a primary screening tool to identify patients at risk for adverse health outcomes; once identified, patients can be further screened to determine the effect their SDH have on their health outcomes. For example, knowing that a given community has a high crime rate can prompt a physician to ask patients about the level of safety they experience in their homes. Collaborates with the participants necessary to address important health problems for both individuals and communities. PHATE helps identify community partners like food banks, housing and transportation services, and education resources. Mobilizes team members and links patients with community resources to achieve health promotion and disease prevention. Community health workers and case managers can connect patients with unmet social needs with community resources through Aunt Bertha. Lists ways in which community characteristics and resources affect the health of patients and communities. Clinicians can look at maps of their service areas, which help them have a visual representation of the neighborhood deprivation within the local community. Recognizes inefficiencies, inequities, variation, and quality gaps in health care delivery. The hot spotting tool displays, geospatially, clusters of patients with gaps in quality or poor disease control. Integrates practice and community data to improve population health. Once clusters are identified, PHATE helps clinicians identify risk factors that can account for or address hot spots. PHATE, Population Health Assessment Engine; SDH, social determinants of health.
