Population Health

Overview

Population Health powered by TP Amalga is a comprehensive quality solution that integrates clinical decision support with population health management tools that facilitate care coordination. Population Health is a key component of the TeamPraxis transformation solution that enables: (1) clinical decision support at the point-of-care to enhance patient experience; and (2) the retrieval, monitoring, reporting, and manipulation of demographic, claims and clinical data across populations to improve population health.

CQS PHM

CQS PHM provides clinical decision support (CDS) at the point-of-care to ensure patients are up to date with recommended treatments, testing, and screening. It targets key chronic diseases and prevention at the time of the patient visit within the EHR workflow, assisting medical homes to deliver exceptional quality and qualify for quality-based performance payments. The channel includes 35 evidence-based measures targeting diabetes, cardiovascular diseases, asthma and prevention. Measures are presented to physicians at the point-of-care on a dashboard accessed from within the patient’s chart. All high priority information is available at first glance and the measures automatically adapt to a patient’s condition and severity per evidenced-based standards.

Amalga

Amalga is an advanced data repository and reporting tool that collects and analyses demographic, claims and clinical data from disparate sources. It serves as a useful tool for population health management by enabling practices to proactively target populations with quality initiatives and treatments. It enables self-serve ability for staff to create analytical and reporting tools customized for the physician’s practice, and the Amalga solutions provides export capability critical to self-administration, management of patient populations, and care-coordination.

Combined with our ConnxtMD practice management, revenue cycle management, and electronic health records products and services, TeamPraxis offers the independent physician a comprehensive solution to ensure the long-term health and financial viability of their practice.

CQS PHM

• Point-of-care clinical decision support to primary care physicians to make sure patients are up to date with recommended treatment, testing, and screening.
• 35 evidence-based measures targeting diabetes, cardiovascular diseases, asthma and prevention.
• Dashboard shows the status of Care Actions (process measures) to be performed by the physician and the status of patient specific Health Goals (goal measures). All high priority information is available at first glance and the measures automatically adapt to a patient’s condition and severity per evidence-based standards.
• Facilitates Team Huddles with schedule that enables pre-visit preparation and planning for incoming list of patients.

Plan Daily Schedule in Advance

The Population Health schedule enables pre-visit preparation and planning for a day’s list of patients. An alert column on the schedule indicates if a patient has care standards that need to be addressed. This daily population view allows the clinical staff to see what is needed and place orders ahead of time, allowing physicians to optimize time with the patient and focus on the important issues that need to be addressed during the visit.

A daily schedule of patients indicating those who have care alerts be viewed for any date. The patient’s dashboard can be brought up and reviewed right from the schedule.

Proactively Target Populations with Care Gaps

Providers can self-assess their performance on quality measures with an aggregate patient view. Care coordinators can drill down to see lists of patients needing attention, using the drill down as a work list for completing orders.

The aggregate patient dashboard motivates providers to audit themselves and improve performance.

Drill downs provide patient lists to proactively contact patients and improve scores.

Support Quality Transformation

Population Health supports a variety of physician workflows that capture data for quality transformation. As your organization transforms and shifts from free texting to codifying data in the note, the measures can be configured to pick up the data to support and accelerate your quality journey.

• Starter measures – turnkey measures using labs, meds, vitals, and immunizations
• Counseling measures – counseling (e.g., weight management, smoking) and in-office exam measures are supported through care guides, orders and note forms
• Screening measures involving referrals – tracking is assisted by an “in progress” measure status with results automatically picked up from a lab or radiology interface or those entered by a staff member

Amalga

With extensive data readily available, Population Health enables the following functionalities:

• Proactively target populations with quality initiatives and treatments.
• Real-time data ensures quality outcomes and avoids potential errors and redundancies.
• Self-serve capability enhances utility and physician and staff effectiveness.
• Sources data from physician’s practice management and EHR systems to remove dispute over credibility of data.
• Export capability critical to self-administration and management of patient population.
• Software as a service enables physician led definition of requirements and speeds application development and enhancement.

Population Health defaults to a view of your daily schedule to facilitate pre-huddle workflows: review labs, immunizations, prescriptions, and vitals history to close gaps in care.	Population Health allows for easy filtering of a population of patients for quality initiatives. In this Diabetes View, patients are sorted by highest A1C to lowest to gauge their diabetes risk.
In this lab detail view, a physician can review a patient’s lab history in order to assess trends and gauge the patient’s health.	Care-coordinators can easily graph historical lab results and print out for physicians and patients to review trend.