Population Health & Quality Management
Proactive healthcare management focused on improving outcomes across patient populations. Track quality measures, identify care gaps, and manage chronic diseases effectively.
Analytics
Practice performance insights
Care Gaps
Identify needed services
Quality Measures
HEDIS/MIPS tracking
Risk Stratification
High-risk patient identification
Population Health Dashboard
Comprehensive overview of practice performance and patient populations:
- Patient Panel Overview - Total patients, demographics, risk distribution
- Quality Score Summary - Aggregate performance on quality measures
- Care Gap Summary - Outstanding preventive services needed
- Trend Analysis - Track improvements over time
Care Gap Analysis
Identify patients who need preventive or follow-up care:
- Overdue Screenings - Mammograms, colonoscopies, A1c tests
- Missing Immunizations - Flu shots, pneumonia vaccines
- Chronic Disease Follow-ups - Diabetic eye exams, nephrology referrals
- Well-Visit Due - Annual physical examinations
Quality Measures
Track compliance with HEDIS, MIPS, and other quality programs:
- Diabetes Care - A1c control, eye exams, foot exams, nephropathy
- Cardiovascular Health - Blood pressure control, cholesterol management
- Preventive Care - Cancer screenings, immunization rates
- Behavioral Health - Depression screening, follow-up rates
Risk Stratification
Identify and prioritize high-risk patients for proactive care:
- Risk Score Calculation - Based on conditions, utilization, and social factors
- Rising Risk Identification - Early intervention opportunities
- Care Management Enrollment - Assign to care coordinators
- Predictive Analytics - Hospital admission risk prediction
Disease Registries
Track and manage patients with chronic conditions:
- Diabetes Registry - A1c tracking, complications monitoring
- Hypertension Registry - Blood pressure trends, medication compliance
- CKD Registry - GFR monitoring, nephrology referrals
- COPD Registry - Pulmonary function, exacerbation tracking
- Heart Failure Registry - Weight monitoring, hospitalization prevention
- CAD Registry - Cardiac catheterization follow-up, statin compliance
Practice Analytics
Detailed reporting on practice performance:
- Provider Productivity - Visit volume, panel size
- Revenue Analysis - Reimbursement tracking, coding efficiency
- Patient Satisfaction - Survey results and trends
- Operational Metrics - Wait times, no-show rates
Full Population Health Access
Access all population health tools through the EMR:
Population Health Hub