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Applied Population Health Delivering Value Based Care with Actionable Registries 1st Edition by Barbara Berkovich, Amy Sitapati ISBN 0367404567 9780429516979

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Applied Population Health Delivering Value Based Care with Actionable Registries 1st Edition Barbara Berkovich Digital Instant Download

Author(s): Barbara Berkovich, PhD, MA (Author); Amy Sitapati, MD (Author)
ISBN(s): 9780429516979, 0367404567
Edition: 1
File Details: PDF, 7.23 MB
Year: 2019
Language: english
SKU: EB-11907094 Category: Tags: , , , ,

Applied Population Health Delivering Value Based Care with Actionable Registries 1st Edition by Barbara Berkovich, Amy Sitapati – Ebook PDF Instant Download/Delivery: 0367404567, 9780429516979
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ISBN 10: 0367404567 
ISBN 13: 9780429516979
Author: Barbara Berkovich, Amy Sitapati

Electronic Health Record (EHR) systems today provide increasing levels of clinical decision support and are the fulcrum for change for value-based healthcare delivery. Billions of dollars of government and insurer payments are dependent on evidence-based workflow design and quality report. In this context, quality measurement is no longer a retrospective exercise, but an essential prospective process embedded in clinical operations. Population health tools in the EHR enhance the efficiency and effectiveness of interventions thus improving the quality of care at lower cost. Population health methods are effective in ensuring that the right patient receives the right care at the right time. This book provides a clear framework for design, implementation, and monitoring of innovative population health tools to accelerate measurable improvements in care delivery. Key benefits for readers include conceptual framework, team approach, and technical insights that result in improved patient care, improved performance on quality measures and increased revenue from quality performance incentives and risk-based contracts. This is also a practice guide to the healthcare professionals many roles who are eager to build or improve population health programs with the goal of delivering high quality value-based care.

Applied Population Health Delivering Value Based Care with Actionable Registries 1st Table of contents:

1 Introduction
Part 1: Fundamentals
Part 2: Effective Delivery of Applied Population Health
Part 3: Applied Population Health of Today and Tomorrow
Let’s Get Started
Part 1 Fundamentals
2 Policy: Drivers for Value-Based Payment Models
Pay-For-Performance (P4P)
Risk Sharing Programs
Risk Adjustment
Savings
Healthcare Measurement Frameworks
Published Results
Cardiac Health
Tobacco Cessation
Diabetes
Human Immunodeficiency Virus (HIV)
Benefits of Early Intervention
3 People
Organizational Characteristics
Engaged Leadership
Data-Driven Value Improvement Workgroups
Empanelment and Attribution
Team-Based Care and Care Management
Promoting Information Flow Using a Communication Plan
Case Study: Provider Engagement at OCHIN
Conclusion
Understanding Patients and Patient Groups
Social Determinants of Health
Race, Ethnicity, and Language Standard
Case Study: Lessons Learned on Patient Perception of Ethnic Background
Sexual Orientation and Gender Identity
Finding and Addressing Health Disparities
Patient Engagement
4 Process
Clinical Interventions
Cascade of Care
Harmonize Measures
Create a Population Health Protocol
Case Study: Doing the Right Thing … with Medication Monitoring
Direct and Indirect Interventions
Value Improvement Cycles
Technology Flaws Underlying Healthcare Waste
Why Have One Way When We Can Have 10?
If I Can’t Find It, the Data Aren’t There
If It Works for the Computer, It’s Fine for Human Use
5 Technology of Health Registries
Early Operational Registries
Actionable EHR Registries
The Spectrum of Registries
Active Patient Registry
Payor Registries
Managed Care Registries
Affiliate Registries
Acute Care Registries
Post–Acute Care Registries
Primary Care Registry
Wellness and Prevention Registries
Patients at Risk
Chronic Condition: Diabetes, Hypertension, Coronary Artery Disease, etc.
Registry Suites
Medication Management Registries
Patient-Based Registries
Event-Based Registries
Decedent Registry
Case Study: Use of Social Security Decedent Data in an EHR Registry
Registry Architecture
Registries: From Taxonomy to Ontology
6 Measuring the Quadruple Aims
Health Outcomes
National Quality Forum
International Consortium for Health Outcomes Measurement (ICHOM)
Per Capita Cost
Patient Experience
Provider Experience
Part 2 Effective Delivery of Applied Population Health
7 Applied Population Health Technical Foundation
8 Quality Measure Management Systems
What Is Healthcare Quality Measure Management?
Do-It-Yourself (DIY) Quality Measure Management
A. Quality Program Cash Flow Report
B. Quality Program Submission Planning Report
C. Quality Baseline and Goals Report
D. Quality Measures Details Report
Case Study: Tactical Planning for Quality Programs
9 EHR Population Health Projects
Judicious Use of Redundancy
Case Study: Automated Clinical Documentation Project
Best Practices for Population Health Projects
Population Health Project Request Form
Case Study: Registry Project Request
10 The Who: Cohort Management with EHR Registries
Active Patient Registry
Wellness and Prevention Registry
Chronic Condition Registry
Medication Registry
Case Study: Complex Cohorts ACO-30 Aspirin Therapy for Ischemic Vascular Disease
11 The What and the When: Building the Feedback Loop
The What: Registry Metrics
The When: Intervention Scheduling
Precision Medicine
Case Study: Complex Measures ACO-17 Tobacco Assessment and Cessation
12 Applying Clinical Decision Support
Workflow Modeling
Ambulatory Care Screening Order Protocol
Dynamic Orders
Bulk Orders
Key Technical Components That Require Support of the EHR Team
Key Operational Steps in Building This Process
13 Calculating Risk
Risk Adjustment
Risk Stratification
Human Judgement
Heuristics
Risk Calculators
Case Study: Implementation of HIV Risk Calculator in an EHR
Machine Learning
Evaluating Risk Scores
14 Analytics Dashboards
Measure Performance
Provider Feedback
Case Study: OHSU Ambulatory Quality Reporting White Paper
Troubleshooting
Prediction
Technology Performance
Monitor Technology Use
Monitor the Technology Platform
Monitor Technology Efficacy
Quadruple Aim Outcomes
Part 3 Applied Population Health Today and Tomorrow
15 Moving Into the Future With a Learning Health System
Learning to Deliver Better Healthcare
Creating a Learning Health System
Funding Research and Development
Standardizing Financial Outcomes and Economic Impact
Progress to Date
16 We’ve Come So Far … Lessons Learned and Call to Action
Case Study: Discovery of the EHR as a “Therapeutic”
How Good Is Good Enough?
Manage Complexity
Design Systems for People
Improve the Clinical Accuracy of Patient Groups
Caught in the Middle
Call to Action
17 Visioning Population Health of Tomorrow
Population Health in the Patient Digital Health Era
Precision Medicine for Individual Health Balanced With Population-Level Standards
Predictive Analytics With Dexterity Between Cost, Benefit, and Timing
Aggregation and Risk Scoring of Data for State, National, and International Sharing Inclusive of Disparity Perspectives
Improved Access to the Right Clinical Expertise
Pushing the Envelope on the Subtleties of Prevention
Epilogue
Funding and Support
References
Answer Key
Appendix A. Implementation of CDC Race and Ethnicity Codes (CDCREC)
Appendix B. Population Health White Paper
Appendix C. Job Descriptions for Population Health Team Members
Job Description: Chief Medical Information Officer for Population Health
Job Description: Healthy Planet Application Analyst
Job Description: EMR Reporting Analyst
Job Description: Population Health Lead Application Analyst
Job Description: Enterprise Population Health Architect
Appendix D. DIY System for Quality Measure Management
Quality Program Table
Quality Measure Table
Import Additional Measure Details from CMS
Appendix E. Ambulatory Care Health Screening Order Protocol
Appendix F. Population Health Project Request
Appendix G. Registry Best Practices
Glossary of Registry Terms
Diagnosis Value Sets
Registry Testing Environment
Required Reports
Appendix H. Resources
Centers for Medicare and Medicaid Services (CMS)
Outcomes
IHI Institute for Healthcare Improvement
Public Data Set
Electronic Clinical Quality Improvement (eCQI)
Learning Health
Information Usability, Visualization, and Presentation

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Tags: Barbara Berkovich, Amy Sitapati, Applied Population, Health, Actionable Registries