Electronic Health Record (EHR) systems today provide increasing levels of clinical decision support and are the fulcrum for change for value-based healthcare delivery. Billions of dollars of government and insurer payments are dependent on evidence-based workflow design and quality report. In this context, quality measurement is no longer a retrospective exercise, but an essential prospective process embedded in clinical operations. Population health tools in the EHR enhance the efficiency and effectiveness of interventions thus improving the quality of care at lower cost. Population health methods are effective in ensuring that the right patient receives the right care at the right time.

This book provides a clear framework for design, implementation, and monitoring of innovative population health tools to accelerate measurable improvements in care delivery. Key benefits for readers include conceptual framework, team approach, and technical insights that result in improved patient care, improved performance on quality measures and increased revenue from quality performance incentives and risk-based contracts. This is also a practice guide to the healthcare professionals many roles who are eager to build or improve population health programs with the goal of delivering high quality value-based care.

chapter Chapter 1|8 pages


part 1|84 pages


chapter Chapter 2|12 pages


Drivers for Value-Based Payment Models

chapter Chapter 3|23 pages


chapter Chapter 4|17 pages


chapter Chapter 5|21 pages

Technology of Health Registries

chapter Chapter 6|6 pages

Measuring the Quadruple Aims

part 2|70 pages

Effective Delivery of Applied Population Health

chapter Chapter 10|4 pages

The Who

Cohort Management with EHR Registries

chapter Chapter 11|4 pages

The What and the When

Building the Feedback Loop

chapter Chapter 13|8 pages

Calculating Risk

chapter Chapter 14|14 pages

Analytics Dashboards

part 3|32 pages

Applied Population Health Today and Tomorrow