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Research ArticleSpecial Communications

Integrating Community and Clinical Data to Assess Patient Risks with A Population Health Assessment Engine (PHATE)

Pavela G. Bambekova, Winston Liaw, Robert L. Phillips and Andrew Bazemore
The Journal of the American Board of Family Medicine May 2020, 33 (3) 463-467; DOI: https://doi.org/10.3122/jabfm.2020.03.190206
Pavela G. Bambekova
From Long School of Medicine, University of Texas Health San Antonio, San Antonio (PGB); Department of Health Systems and Population Health Sciences, University of Houston College of Medicine (WL); American Board of Family Medicine, Lexington, KY (RLP, AB).
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Winston Liaw
From Long School of Medicine, University of Texas Health San Antonio, San Antonio (PGB); Department of Health Systems and Population Health Sciences, University of Houston College of Medicine (WL); American Board of Family Medicine, Lexington, KY (RLP, AB).
MD, MPH
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Robert L. Phillips Jr.
From Long School of Medicine, University of Texas Health San Antonio, San Antonio (PGB); Department of Health Systems and Population Health Sciences, University of Houston College of Medicine (WL); American Board of Family Medicine, Lexington, KY (RLP, AB).
MD, MSPH
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Andrew Bazemore
From Long School of Medicine, University of Texas Health San Antonio, San Antonio (PGB); Department of Health Systems and Population Health Sciences, University of Houston College of Medicine (WL); American Board of Family Medicine, Lexington, KY (RLP, AB).
MD, MPH
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    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.

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    Table 1.

    How the Population Health Assessment Engine Can Be Used to Improve Health

    LevelFunctionExample
    System levelAdjust paymentsMassachusetts and Minnesota adjust Medicaid reimbursements based on SDHs
    Contribute to public health surveillanceMacroscope (New York City) and the electronic medical record Support for Public Health (ESP; Massachusetts) use EHRs for public health surveillance
    Practice levelOrganize care around hot spotsThe University of Cincinnati's comprehensive care team aims to reduce hospital admissions for children coming from high poverty neighborhoods
    Assess patient riskQRISK uses geographic data to calculate risk for cardiovascular disease in the United Kingdom
    Connect with community organizationsCommunity 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.

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    Table 2.

    How the Population Health Assessment Engine Can Be Used to Meet Training Milestones

    Attainable Family Medicine Milestones Using PHATEExample
    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.

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The Journal of the American Board of Family     Medicine: 33 (3)
The Journal of the American Board of Family Medicine
Vol. 33, Issue 3
May/June 2020
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Integrating Community and Clinical Data to Assess Patient Risks with A Population Health Assessment Engine (PHATE)
Pavela G. Bambekova, Winston Liaw, Robert L. Phillips, Andrew Bazemore
The Journal of the American Board of Family Medicine May 2020, 33 (3) 463-467; DOI: 10.3122/jabfm.2020.03.190206

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Integrating Community and Clinical Data to Assess Patient Risks with A Population Health Assessment Engine (PHATE)
Pavela G. Bambekova, Winston Liaw, Robert L. Phillips, Andrew Bazemore
The Journal of the American Board of Family Medicine May 2020, 33 (3) 463-467; DOI: 10.3122/jabfm.2020.03.190206
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    • Introduction
    • Using PHATE to Practice Community-Oriented Primary Care
    • A New Paradigm for Care Delivery Built on COPC
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Keywords

  • Electronic Health Records
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  • Public Health Surveillance
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  • Social Determinants of Health

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