Maryland Department of Health (MDH) has been preparing for alignment of its population health initiatives with Maryland’s unique All-Payer hospital global budget program. In order to operationalize population health initiatives, it is required to identify a starter set of measures addressing community level health interventions and to collect interoperable data for those measures. The broad adoption of electronic health records (EHRs) with ongoing data collection on almost all patients in the state, combined with hospital participation in health information exchange (HIE) initiatives, provides an unprecedented opportunity for near real-time assessment of the health of the communities. MDH’s EHR-based monitoring complements, and perhaps replaces, ad-hoc assessments based on limited surveys, billing, and other administrative data. This article explores the potential expansion of health IT capacity as a method to improve population health across Maryland.First, we propose a progression plan for four selected community-wide population health measures: body mass index, blood pressure, smoking status, and falls-related injuries. We then present an assessment of the current and near real-time availability of digital data in Maryland including the geographic granularity on which each measure can be assessed statewide. Finally, we provide general recommendations to improve interoperable data collection for selected measures over time via the Maryland HIE. This paper is intended to serve as a high- level guiding framework for communities across the US that are undergoing healthcare transformation toward integrated models of care using universal interoperable EHRs.
Population Health Initiatives for Primary Care at Duke University School of Medicine