Population Health

True population health involves measuring and examining patients in a community context, but this can be difficult to do when simply comparing patient data. If we can attach geography to our patient data, then we can better associate them with the community in which they live.

PRIME Registry’s population health tools, PHATE and Care Gap help create a visual association between the census tract in which a patient lives, the levels of social deprivation in that area, and the gaps in care for a specific patient, or a group of patients in a geographic area.

How to Access PHATE and Care Gap

Both PHATE and Care Gap are included with PRIME Registry participation at no extra charge, and accessible from your quality dashboard—no separate login required.

Understanding your community through social determinants of health (SDOH), using PHATETM and Care Gap

What Is PHATE?

The Population Health AssessmenT Engine, PHATE(TM) is a population health mapping tool commissioned by the ABFM, funded by the ABFM Foundation, and developed in collaboration with the Center for Applied Research and Engagement Systems (CARES) at the University of Missouri. PHATE provides clinicians with a fuller understanding of their patient population in the context of their community.

PHATE utilizes patient data from the PRIME Registry to assign a social deprivation risk score called a Community Vital Sign to an individual patient based on the characteristics of the census tract in which the patient lives.

The PHATE dashboard, which includes the My Community tool and the Community Hotspots tool, visually connects the geography of the practice or clinician’s service area, based on patient visit data from the EHR, to the social deprivation levels in that area.

My Community calculates and maps the practice or clinician service area. The Community Vital Sign is visually represented by color-coding, while clicking on a specific area of the map, or entering a location in the search bar, displays the details of the social deprivation risk scoring for that area, along with live links to a database of community-based organizations and resources to address those needs based on the selected census tract or area.

Community Hotspots uses patient data from the practice EHR to display geographic clusters of disease, and poorly managed disease, in the patient population, while simultaneously displaying the social deprivation levels in those geographic areas.

What is Care Gap

Care Gap allows the user to examine each patient’s care quality gaps at the patient or measure level. When viewing the performance trend details for a specific measure in the quality dashboard, the user can drill down to the list of patients who fall into the “not met” population for that measure.

Clicking the Care Gap icon next to a patient record in the “not met” list will display the specific gaps for that measure, and any other gaps that patient may have related to other measures. This information may be exported, making it easier to identify and resolve those gaps.

Care Gap also integrates with the PHATE data, displaying the Community Vital Sign data for that patient’s listed address along with the gaps in care.

Identify At–Risk Patients

Using PHATE to Identify Patients in High Deprivation Neighborhoods

PHATE uses your EHR data to identify patients in high deprivation neighborhoods, enabling you to identify patients at high risk. PHATE can also help you understand more about which neighborhoods they come from and identify potential community organization partners to help them.

PHATE uses the patient address and displays that census tract on a map, while displaying the Community Vital Sign for that census tract, and live links to Community Based Organizations to which the patient may be referred for assistance, or with which the practice may collaborate to provide community level interventions.

Using Care Gap to Identify Patients in High Deprivation Neighborhoods

Care Gap pulls in the same deprivation risk information from PHATE, while showing you where patients have gaps in care, at either the patient level or the measure level. You will see the gaps in care listed, if any, along with the Community Vital Sign and live links to Community Based Organizations to which you may refer your patient if they have a high deprivation score on any of the social determinants of health listed.

Do More with PHATE

PHATE Quick Start Guide

Want to just dive in and try it out? Then start here. This Quick Start Guide gives you a brief orientation and introduction to the features available in the PHATE application.

PHATE Curriculum

For a deeper dive into PHATE, and its relationship to Community Oriented Primary Care (COPC), the Robert Graham Center and HealthLandscape have collaborated to develop a curriculum aimed to introduce health care professionals to PHATE. The goal of this PHATE curriculum is to help understand how to integrate community data, clinical data, and community resources in order to address social determinants of health and improve the health of patients and populations.

Register for a Webinar

Each month, we host a webinar to orient users to PHATE and the PRIME Registry Dashboard. You’ll see how each of the components can be used, learn how EHR data, census tracts or de-identified addresses can be used to map a service area, and have a chance to ask questions.