Data Driven Quality Improvement

Population Health

Population health management thrives on appropriate data collection. The HCCN works closely with the Massachusetts Department of Public Health (MDPH) on several projects related to the collection and utilization of clinical data for population health improvement, whether it be scaled to an entire service area or perhaps a single patient referral. Several of the most recent MDPH projects are defined below:

  • MDPHnet: The MDPHnet is a distributed network of clinical data repositories (including DRVS) that pools high level, de-identified data from targeted regions around Massachusetts to analyze the health characteristics of specific populations. Click here for more information on the Massachusetts eHealth Institute's MDPHnet Project.
  • HIE: The Health Information Exchange (HIE) allows healthcare providers to access and securely share a patient's medical information electronically, leading to more informed patient care.
  • E-Referral: The Electronic Referral (E-Referral) process developed by the MDPH is a bidirectional linkage between clinical and community based organizations. The program allows partnered clinics to send referrals electronically to community organizations and, upon admission to the program, allows clinics to receive feedback reports that tracks patient progress.

Quality Improvement

Data collection is key to assessing population needs prior to implementing improvement strategies. The HCCN acknowledges the importance of diligent data collection for targeted quality improvement, especially with regard to understanding the social factors that impact our patients.

  • SOGI: The HCCN works with health centers on high-level trainings targeted at Sexual Orientation and Gender Identity (SOGI) health information, supplemented by resources from the Fenway Institute, in hopes of spurring SOGI data collection and improving healthcare for the LGBTQ population. Click here for resources from the Fenway Institute.
  • PRAPARE: Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE) is a survey developed by the National Association of Community Health Centers (NACHC) to standardize the collection of social determinants of health (SDH) such as housing insecurities, employment, income, etc. The HCCN works with centers to encourage the collection of valuable social information such as SDH to more aptly quantify the needs of the patient population. Click here for more information on the PRAPARE tool.


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