BACKGROUND: Communities nationwide are recognizing the potential to collaborate across clinical care and public health to improve the health of all people in their communities. The traditional separation of these functions is not effective in addressing a person’s overall health, particularly among people with chronic health conditions that are often impacted by non-medical factors. Furthermore, hospitals and local health departments have a common need to develop actionable, outcomes-oriented, and collaborative population health assessments. Presenters will describe a project that builds from existing collaborations in Minnesota and elsewhere to develop an informatics framework and toolkit of resources for any community to use data from electronic health record (EHR) systems for community health assessments and public health prevention programs.
METHODS: A number of collaborations including local public health departments, health plans, and providers have developed in Minnesota for the purpose of sharing EHR data to support population health assessments. Presenters worked with these data sharing collaborations to gather best practices and lessons learned including definitions for EHR-extracted data, data sharing agreement templates, integration of social determinants of health, data evaluation, and strategies for understanding data limitations. These practices and lessons have been combined into an informatics framework and toolkit for guidance to support any community to develop similar collaborations.
RESULTS: Minnesota has near-universal implementation of EHR systems among hospitals, clinics, and local public health, providing great opportunity to use data from these systems. The Minnesota collaborations were able to recognize this opportunity to build mutual understanding of roles and priorities among community health providers and local public health departments and learn how primary care, local public health, and community stakeholders can partner to improve population health. As a result, they have created a set of practical tools and guidance for communities to develop collaborations, identify shared community health goals, make use of data from EHR systems and other sources, and develop a community health improvement plan.
CONCLUSIONS: Communities face many challenges in acquiring and using actionable data to measure health outcomes. EHR systems have the potential to provide timely and complete data for subpopulations, geographic areas, and health conditions that are typically underrepresented in traditional assessment methods. By working together to understand how these data can describe population health, communities can develop strategies that can “move the needle” toward real health outcomes and monitor change in a timely manner.