Population Health Management

Overview

Population Health Management (PHM) is new 11.2 functionality and provides the ability to generate "pursuit lists" based on specific demographic or clinical criteria for a patient population. PHM allows patients to be clinically tracked and placed into groups for management (i.e. males over 50 who haven’t had a colonoscopy in the last year). Queries can be defined to create these pursuit lists from which tasks, reminders, patient lists and patient preferred method of communication can be generated to improve quality of patient care and overall disease management. Queries can be define and modified witihin the Clinical Rules Editor workspace. It is important to know that Population Health Management runs the defined query through the event bus and can update data within the database when actions are performed; therefore administrators should be utilizing this functionality during patient off hours as it may cause performance issues.

This functionality provides the ability to:

Capture all patients from a population group (including those who are non-compliant or have otherwise missed health management items.) Identifies patients who could apply for Disease Management programs (i.e. females under the age of 18 with a BMI over 28). Identify patients with specific high needs for chronic conditions to effectively monitor and treat the condition. Improve quality of care and consistency across populations by defining patient health actions to each patient who meets the criteria (i.e. females over 12 can be offered the Gardasil Immunization, but are not required to receive it.) Can alert patients automatically to schedule health management appointments.

Workflows

• High Level Workflow: Creating PHM Queries with the Clinical Rules Editor

• Creating a New Population Query
• Creating or Editing an Action Set
• Running a Query

Additional Information

Population Health Patient Communication Text Template Examples

RecruitAssist

PHM Known Issues

• After a query is active, the query does not run nightly with the ETL, even though you are able to manually run the query and return the first 500 patients. This is an Allscripts issue case and is fixed in 11.2.3 HF4 and beyond.
• (04568317) - Reminders created from PHM action sets are not linked to the correct diagnosis, most seem to default as linked to Health Maintenance. This issue is currently in development (as of 7/31/12) and a fix has yet to be planned out.
• (03658992) - Patient List defaulting to user.
  • From the patient list type even though the enterprise is selected list navigates back to personal.
  • Expected: 'Enterprise' should be highlighted when the user tries to add the next entry, but instead "personal" gets highlighted although he had selected ' Enterprise' for the previous entry.
  • Actual: When the enterprise is selected list navigates back to personal.
• (03812194) - Vaccines which are present in OID are not available to select as part of a PHM query or the available options for vaccines do not match what is present in the OID.
• (05236865) - Unable to cancel queries that are in an executing status.
• (394403) - Active queries that participate in the nightly update process are failing to update the patient lists and action sets in TWEHR.