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

2020

AUTHOR(S)
Bambekova, Pavela G
Liaw, Winston R
Phillips, Robert L
Bazemore, Andrew W
TOPIC(S)
Achieving Health System Goals
Education & Training
Role of Primary Care
KEYWORD(S)
Graduate Medical Education
Payment
Population Health
Prime
Quality Of Care
Shortage Areas
VOLUME
33(3):463-467

Clinicians are concerned about their patients' social determinants of health (SDH); yet, they are unsure how to effectively gather patient-level SDH data and intervene without adding to current administrative burdens. Designed properly, clinical registries offer solutions to integrate neighborhood SDH data with clinical data from electronic health records, enabling the understanding of community factors to guide patient care. Federal and state interest in adjusting reimbursements based on SDH further underscores the need for strategies that integrate SDH and clinical data. The Population Health Assessment Engine (PHATE) exemplifies a registry-based SDH data integration solution that adjusts payments, contributes to public health surveillance, organizes care around hot spots (gaps in quality or uncontrolled disease), assesses patient risk, and connects with community organizations. PHATE also permits residency training to meet community health competency milestones by incorporating the PHATE curriculum. These functions enhance value, and their utility in education and care delivery would benefit from further investigation.

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