Measure and Understand Patient Outcomes

Population Health Data Dashboards

Data dashboards allow clinics to view up-to-date summaries of information captured by their electronic health records, such as patient demographics, hypertension control and diabetes management.

As payers move from a fee-for-service model to payments based on outcomes, it’s important for healthcare facilities to be able to measure and understand their patient outcomes. Electronic Health Records (EHR) track immense amounts of valuable information, but many healthcare organizations are unable to view this data in a way that would inform clinical decisions. Population heath data dashboards can be utilized to inform clinic quality improvement initiatives and simplify the reporting process for Medicare and Medicaid.

Typically, many population health tools that interface with a facility’s EHR to create dashboards are expensive. With subscriptions costing thousands of dollars each year, smaller healthcare facilities are often unable to afford these valuable tools. Well-Ahead Louisiana and Collective Healthcare Solutions collaborated to create a cost-effective solution for rural healthcare providers in Louisiana to utilize as a population health tool—the Well-Ahead Louisiana Health Improvement Portal. Access to the health improvement portal is free for all sites participating in the Population Health Cohort.

What is the Health Improvement Portal?

The Well-Ahead Louisiana Health Improvement Portal is a SharePoint platform that allows Population Health Cohort members to:

  • Communicate with Well-Ahead practice coaches and other healthcare organizations
  • View patient demographics and chronic disease control rates via interactive Power BI dashboards
  • Upload and store documents in a secure location
  • Access resources from a Well-Ahead practice coach

Members of the Cohort can access the improvement portal through a Microsoft Office account. Information shared on a facilities account page is only available to those who have been granted access.

  • How Do the Health Improvement Portal Data Dashboards Work?

    As part of the Cohort, Well-Ahead Louisiana and Collective Healthcare Solutions will work with your site to extract various reports from your EHR that contain de-identified information on patient demographics and biometrics. Well-Ahead will then show your facility how to save these report templates for easy data extraction in the future.

    Next, the facilities designated practice coach will help you upload your data to the portal. Once the data is uploaded, the Collective Healthcare Solutions team will create a Power BI dashboard where you can view your population demographics, hypertension control rate, and other indicators, depending on the data you submit.

    After quarterly reports are standardized, Collective Healthcare Solutions will work with your team to automate the dashboard process, so that as you upload new reports, your visuals will automatically update. Once the health improvement portal dashboard has been created and the report format has been finalized, your site will be able to use these dashboards independently for as long as your organization would like.

    Not all EHRs are created equal, and some EHRs are unable to produce all of the elements for the health improvement portal data dashboards. Well-Ahead and Collective Healthcare Solutions will work with your site to determine what is feasible within your EHR system.


    • 13 sites involved in the first Population Health Cohort
    • 10 have been able to extract de-identified patient population reports from their EHRs
    • 10 sites have operational dashboards in their portals
    • 67% of sites reported improvement in their ability to pull patient data and generate reports from their EHR system1

Population Health Quality Measures

According to the Centers for Medicare and Medicaid Services (CMS), quality measures are defined as tools that help us measure or quantify health care processes, outcomes, patient perceptions, and organizational structure and/or systems. To determine quality of care for heart disease prevention, for example, healthcare organizations are encouraged to track quality measures such as the percentage of patients with hypertension that have their blood pressure adequately controlled, the percentage of adult patients screened for tobacco use, and the percentage of patients with Ischemic Vascular Disease that are using aspirin, among other measures. Some Medicare and Medicaid payment programs such as the Medicare Access and CHIP Reauthorization Act (MACRA) and Merit-based Incentive Payment Systems (MIPS) use clinical quality measures to determine reimbursement. 

Quality measures allow your healthcare organization to collect data about processes and outcomes across your patient population and use this data to set goals for improvement. Collecting individual data through EHRs can also allow your organization to identify differences in outcomes amongst different patient demographic groups. Identifying these disparities allows your organization to take targeted action. For example, if your organization found that hypertension control was lowest among adults ages 25-35, your organization could provide targeted follow-up and tools for that group.

  • Why is it Important?

    Healthcare providers are on the front lines of chronic disease prevention and management in Louisiana. As such, they are uniquely positioned to improve health disparities within our state. Data dashboards allow providers to identify the disparities that exist within their patient populations and take action to improve them. Once sites are able to identify disparate outcomes, providers can formulate plans to address those issues and monitor the effectiveness of their approaches.

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    All staff involved in patient care should have an understanding of your organization’s clinical quality measures. Your organization’s quality improvement leader can determine your quality measures, set goals for improvement and track how those measures improve over time. Progress towards quality measures goals can be shared with team members via data visualization applications, like Azara or Premier, or verbally during regular team meetings. Data visualization software often utilizes interactive dashboards, which allow your team to quickly spot trends and identify disparate outcomes.

  • How Often Should Quality Measure Data be Collected?

    The frequency of data collection depends on how your site extracts quality measures from your EHR. If your site uses a quality improvement tool that directly interfaces with the EHR, changes in your data can be extracted and visualized in real time.

    For EHRs that don’t have these capabilities, your site can examine data once per quarter or bi-annually.

  • How Can My Organization Use Quality Measure Insights?
    1. Identify the quality measures your site will examine. Consider reporting requirements for payer reimbursement, organizational processes you’d like to evaluate and outcomes of interest to your team.
    2. Identify your current numbers. Your site should examine quality measure values across your entire patient population and within priority populations in order to identify disparities.
    3. Set goals. Using your existing data, set an annual improvement target for your quality measures. Resources such as the Million Hearts program and the Centers for Disease Control and Prevention can help your organization form a plan for how they will reach those targets.
    4. Implement your plan. Implement your organization’s strategy for improving quality.
    5. Monitor progress towards your goal. Document how your quality measures change over time and gather data to determine if your improvement strategy was implemented as planned. This can be done through observations, interviews with key players, or by extracting data from your EHR.
    6. Reassess your goals and implementation plan. Through implementation, set new goals based on your progress. Reassess whether your plan was implemented as intended and if it produced the desired outcomes. Make modifications as needed and repeat the process.
  • When Will My Organization Use Clinical Quality Measures?
    • If your organization is interested in improving patient outcomes for a certain disease or diseases
    • If your organization would like to receive increased reimbursement from payers for better outcomes
    • If your organization would like to target outreach to groups with poor health outcomes in order to reduce health disparities
    • If your organization would like to determine the health impact of a new program or process

    Through the  Population Health Cohort, Well-Ahead provides tools and technical assistance for creating data dashboards to monitor clinical quality measures.

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1 2020 Population Health Cohort Assessment