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Population Health Tool that Provides City-Level Data Expands to 500 Cities

May 21, 2018
by Heather Landi
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A data visualization tool that helps city officials understand the health status of their population, called the City Health Dashboard, has now expanded to 500 of the largest cities in the U.S., enabling local leaders to identify and take action around the most pressing health needs in their cities and communities.

The New York University School of Medicine’s Department of Population Health, with support from the Robert Wood Johnson Foundation and in partnership with NYU's Robert F. Wagner Graduate School of Public Service, the National Resource Network, the International City/County Management Association (ICMA) and the National League of Cities, created the City Health Dashboard, an online resource with community-level health, social and economic data.

The City Health Dashboard gives local governments the ability to track 36 key measures and drivers of health, such as obesity and opioid overdose deaths, as well as the conditions that influence health, including housing affordability, third grade reading proficiency, and income inequality. The dashboard was piloted in 2017 in four cities—Flint, Michigan; Kansas City, Kansas; Providence, Rhode Island; and Waco, Texas.

“It represents a first-of-its-kind effort to provide city- and neighborhood-level data from multiple national sources--creating a one-stop online resource to help city leaders and residents pinpoint and take action on gaps in health and opportunity. The City Health Dashboard gives users the ability to view many of its measures according to race and gender. The dashboard also allows users to compare their city to others and provides resources for best practices and policies, creating an opportunity to explore how to address specific challenges,” according to a press release.

Unique to the dashboard is its neighborhood-level detail and economic/demographic data cross-tracking. These informatics features empower cities to easily pinpoint differing health outcomes as well as contributors thereto. According to the City Health Dashboard program leaders, the city-specific data offers a revealing look at how health outcomes and opportunities for health vary widely depending on where you live.

According to an article by Healthcare Informatics Contributing Editor David Raths, writing for Government Technology, back in 2017, Marc Gourevitch, chair of the Department of Population Health at the NYU School of Medicine and principal investigator for the City Health Dashboard, said the dashboard puts into a framework data that hasn’t been visible to city-level managers before.

“Many of these data elements are available at the county level, but city managers are responsible for making policies that influence the people who live in their boundaries,” he explained. If a city is in the far southwest corner of a county that is four times as big as the city, the obesity rate data for the county is not that helpful, he said, and collecting that kind of data can be very expensive and time consuming. “The goal was to take data sets that power county-level data and code it to the city level.”

In a press release statement, Gourevitch said, “There’s a saying: 'what gets measured is what gets done.’ Only with local data can community leaders understand where actionable gaps in opportunity exist and target programs and policy changes to address them.”

Other findings from the City Health Dashboard include:

Health behaviors and conditions vary widely between cities. For instance, the prevalence of smoking ranges from less than 12 percent among adults in the 50 cities with the lowest rates, to 25 percent or more in the cities with the highest rates. In the 50 cities with the lowest diabetes rates, less than 7 percent of adults have diabetes, while in the 50 cities with the highest rates, 14 percent or more of adults have the condition.

Economic opportunities for children vary greatly between cities: Poverty and other economic stressors pose risks to the health of communities, and substantial variation exists between cities. For instance, while only 3 percent of children live in poverty in the wealthiest cities, greater than 60 percent of children are below poverty in the most deprived cities.

Cities in the West consistently have better health: On average, cities in the West have lower rates of obesity, hypertension, and diabetes compared to cities in other regions and the U.S. as a whole.

“We all have a role to play in improving well-being in our communities and ensuring that everyone has the same opportunities to be healthy, no matter where they live,” Abbey Cofsky, RWJF managing director, program, said in a statement. “With city and neighborhood-specific data, community leaders, city officials, and advocates now have a clearer picture of the biggest local challenges they face, and are better positioned to drive change.”

Overseen by a team of population health and urban policy experts, epidemiologists, and geographic information system specialists, the City Health Dashboard website displays measures and drivers of health through interactive maps, tables and charts. The population health tool is now available to 500 cities with populations of about 66,000 or above to target their efforts to improve the well-being of residents by comparing outcomes with peer cities, and across their own neighborhoods to guide local solutions.

 

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All of Us Team Building Data Browser, Researcher Workbench

January 23, 2019
by David Raths, Contributing Editor
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Software tools to help researchers explore, analyze research data set

As the national All of Us research program begins collecting health data, its Research Hub, which will house an array of data collected in the program, is developing software tools to help researchers explore and analyze the All of Us Research Data Set.

The Data and Research Center (DRC) located at Vanderbilt University Medical Center houses the All of Us research database. In a newsletter, the Research Hub noted that in 2019 it expects to release information that participants provided via surveys, physical measurements, and electronic health records. Researchers will be able to access participant research data, with personal identifiers removed in order to explore how various factors contribute to individual health and disease.

The EHR information included depends on what kinds of healthcare has been received and what types of providers a patient has seen. The All of Us Research Program employs Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM) Version 5 infrastructure to ensure feasibility and standardization across EHR data for researchers. EHR data will be accessed longitudinally throughout the life of the program. Within the context of the Research Hub tools, EHR data will be presented at the highest level of granularity, which is by EHR Domain. Domains include: Demographics, Conditions, Procedures, Drugs, Measurements, and Visits.

In the first half of 2019, the DRC plans to release a Data Browser that will allow anyone to view aggregate counts of participant research data. Counts will be available for survey data collected from participants, physical measures collected during exams, and medical concepts from electronic health records (EHR) data. This tool will be available to anyone, with no registration or login required.

A “Researcher Workbench” is slated for release by the end of 2019. The Workbench is an analysis platform designed for researchers to create cohorts of individual-level participant research data, review these cohorts, and analyze and visualize the data in a Jupyter notebook using Python or R.

The initial version of the Workbench provides three tools for working with data:

• Workspaces: Create a project workspace. Store cohorts and notebooks. Share with team members.

• Cohort Builder: Build and review a custom data set.

• Notebooks: Analyze your cohort. Create graphs or tables to showcase your work.

To ensure participant privacy, researchers will be required to register and verify their identity in order to use the Workbench.

The DRC noted that it has sought input from an array of potential users of the Research Hub, collated their feedback, and leveraged these insights to help guide iterative development of the tools. 

Currently, the Research Hub is in its first beta launch within the DRC. The purpose of this release is to open the Research Hub up to vigorous internal testing that includes quality control, quality assurance, data characterization, data validation, and user testing as well as security and functionality testing. 

 

 

 

 

 

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Pediatric Asthma Care Management Program Extends to 7K Schools Nationwide

January 21, 2019
by Rajiv Leventhal, Managing Editor
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A regionally-established pediatric asthma care management program, which includes leveraging a student health record platform, is extending its reach.

Children's Hospital Colorado, the University of Colorado School of Medicine at CU Anschutz Medical Campus, and New York City-based pediatric healthcare technology company CareDox recently announced a new collaboration to scale the reach of the hospital's in-school asthma management program.

CareDox modeled this collaboration after the hospital's "Building Bridges for Asthma Care Program," which began in 2012, and is now offering its new care management platform to the more than 7,100 K-12 schools where the company's student health record platform and wellness services are already deployed.

By combining proven clinical protocols with widely deployed technology and wellness services operations, the three organizations “are poised to dramatically improve outcomes for pediatric asthmatics across the country,” officials of this partnership have attested.

The Building Bridges for Asthma Care Program is now deployed in 28 public elementary schools in Denver, Colo. and Hartford, Conn. The school program in Colorado was developed by Stanley Szefler, M.D., director of the pediatric asthma research program at Children's Hospital Colorado and the CU School of Medicine. Throughout the school year, school nurses train their students on asthma management, inhaler technique and other clinical best practices, and the students' absenteeism, physical activity and asthma control levels are monitored by nurses and communicated to their parents and healthcare providers.

In a study of the impact of the program published in the Journal of Allergy and Clinical Immunology, participants in the program experienced a 22-percent decrease in school absenteeism. Officials have noted that currently, approximately six million children under the age of 18 have asthma. It’s the top reason for missed school, totaling nearly 14 million days each year. Socioeconomically disadvantaged children and minority children are disproportionately affected by asthma. In these two groups, asthma is more often left uncontrolled, leading not only to absenteeism, but also disrupted sleep.

CareDox’s asthma care management program is already in use in the Clay County district schools in Florida, where there are more than 3,700 students who are known to have asthma. In addition to those students, CareDox leveraged medical data that resides on their student records platform to identify 345 additional students who are eligible for the program that weren't already known to school nurses and health officials as asthmatic.

In just three months, CareDox has already implemented the proven Children's Hospital Colorado/CU School of Medicine protocols to qualify about 1,200 students with asthma into the company’s asthma management program, of which 349 are eligible for CareDox's expanded care program for severe uncontrolled asthma.

The expanded care program includes four key components to address uncontrolled asthma among student populations, according to officials. One of these elements is the technology-enabled identification of new enrollees, which CareDox will leverage its student health record platform and enrollment processes for wellness services (flu and other vaccines, annual wellness checks) to screen for eligible asthma students.

"Children's Hospital Colorado and CU School of Medicine providers created the Building Bridges for Asthma Care Program to address the risk of health disparities and asthma-related absenteeism, as well as its related impact on academic achievement for inner city students," Robin Deterding, M.D., director of the Breathing Institute at Children's Hospital Colorado,  medical director of the Hospital's Center for Innovation and professor of pulmonary medicine in the Department of Pediatrics at the CU School of Medicine, said in a statement. “Building Bridges has proven that a school-centered asthma management program can have a positive impact on pediatric health and ultimately reduce asthma-related absenteeism within a school's population. Now by partnering with CareDox, we have the ability to drastically expand the program's footprint and reduce asthma-related absenteeism on a massive scale,” he added.

Like CareDox's existing school vaccination and annual wellness check programs, the company’s asthma care management program will be offered to eligible students at no cost to the student, their parents or the school district. CareDox partners with public and private health insurance to support the program, officials stated.

 

Related Insights For: Population Health

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Kaiser Creating Evidence-Based Complex Care Models

January 17, 2019
by David Raths, Contributing Editor
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Work aligns with recently published ‘Blueprint for Complex Care’

The National Center for Complex Health and Social Needs recently published a “Blueprint for Complex Care” to develop a collective strategy for promoting evidence-based complex care models. Recognizing that many patient issues have root causes that go beyond the medical, the Blueprint seeks to identify best practices for breaking down silos between the social care delivery system and healthcare.

Perhaps no health system has devoted as many resources to complex care as Kaiser Permanente. Its Care Management Institute, a joint endeavor between the Permanente Medical Groups and Kaiser Foundation Health Plan, has established Complex Needs as one of its national quality initiatives. It has named regional complex care leaders, created common quality measures across regions and established a complex need research arm called CORAL. (Kaiser Permanente has eight Permanente Medical Groups and regions, more than 12.2 million members, more than 22,000 physicians and 216,000 employees.)

In a Jan. 16 webinar presentation, Wendolyn Gozansky, M.D., vice president and chief quality officer, Colorado Permanente Medical Group and national leader for complex needs at the Care Management Institute, described Kaiser Permanente’s efforts and used some personal anecdotes to explain their goals.

She said Kaiser Permanenteis working on the concept of developing core competencies and tools to support a longitiudinal plan of care for patients with complex needs. “These are the folks for whom the usual care is not meeting their needs,” she said. “How do you recognize them and make sure their needs are being met?”

Gozansky gave an example from a patient she had just seen the previous wekend. This women had fallen and broken her hip. She had several chronic conditions, including significant asthma, yet she was not on an inhaled steroid.

“One concept I love from the Blueprint is that this field is about doing whatever it takes to meet the needs of the person in front of you,” she said. In speaking to the woman, she came to understand that singing in a church choir was the most important thing in her life, and the inhaler medication was making her hoarse and unable to sing.  She was fairly isolated socially except for church. “My goal was to get her rehabbed and leverage the patient-defined family that is supportive. Her goals are to sing, so we need to do what is possible to get her back to that. We have to capture that information, put it into a long-term plan of care. The goal is not to get her out of rehab but to get her singing in choir.”

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The health system has to work on care that is preference-aligned. The woman is not on a steroid inhaler but her care is preference-aligned. How does the health system assure that everyone knows they are doing the right thing?

Gozansky said the beauty of Permanente Medicine is that its setup involves an employed medical group focused on value, not volume. They can interact with health plan partners in delivery of new systems of care. “It is a virtuous cycle about value and person-centered care. This is what our complex needs team is trying to understand.”

She described the journey so far: In 2015 there were pockets of work being done across the eight Kaiser Permanente regions. In 2016 they established complex care as a national qualitiy iniative. “We knew we were not meeting these patients’ needs. We had to figure out the right way to do that.” They also realized that most of the previous research on the topic involved examples that were not in integrated systems such as Kaiser Permanente. “We had to figure it out in an integrated system,” she said.

 In 2017 they started working on cross-regional learning — for instance, taking a program from Colorado and trying it in Southern California. Then they sought to align quality measures. In 2018 they got funding to create CORAL, the complex needs research arm.  

The Care Management Institute has created a “community of practice” on complex care to break down silos within the organization and bring together research, operational and administrative executives. They also want to work with external stakeholders to make sure what they are developing is scalable, Gozansky said.

Mark Humowiecki, senior director of the National Center for Complex Health and Social Needs, also spoke during the webinar. He said one of the goals of the Blueprint was to get a clearer definition. Some people get confused about terms such as “hotspotting” and complex care, he said. He said there is a recognition that these patients’ needs are crossing traditional silos, so “there is a need to connect care for the individual but also at the system level.”

The goal, he added, is to create a complex care ecosystem by developing in each community system-level connections between social care delivery and healthcare, which in the past have operated too independently.  The five principles are that complex care is person-centered, equitable, team-based, cross-sector and data-driven. One of the Blueprint’s recommendations is to enhance and promote integrated cross-sector data infrastructures.

 

 


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