Population Health Management Dashboard

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You have assessed your local population health needs and identified data sources and data sets that are needed to help providers make immediate gains in patient outcomes. Your health systems Board of Directors is requesting that you develop a high-level population health management program dashboard.

For this assessment, you need to assess local population health needs and identify data sources and data sets that are needed to help providers make immediate gains in patient outcomes. It is a major undertaking to plan, design, and implement a robust PHM. Therefore, your health systems Board of Directors is requesting that you develop 1-2 page high-level population health management program dashboard. In this dashboard, list the health needs based on the community needs assessment and the critical data sources and data sets needed for the population health management program your health system is planning to launch.


Using the information from the modules 01, 02, and 03 summative assessments, construct a dashboard that lists the health needs based on the community needs assessment that was performed and the critical data sources and data sets needed for the population health management program your health system is planning to launch.


TALLAHASSEE, FLORIDA; Community Needs Assessment
Whitney Gibson

Healthcare Profile

Population 197,787 according to census in 2020

Lack diversity and proper representation.

Low income

Education attainment

People who are well educated are able to receive better healthcare and those with poor education attainment lacking proper healthcare leading to poor lifestyle and mortality.

The addition of vulnerable groups within Tallahassee makes it hard engage in community healthcare program with some vulnerable without having proper medical history and some hiding in fear of deportation documentation.

Majority of healthcare system lack diversity and proper representation.

Low income makes it hard to afford healthcare and coming up with better affordable care might be the solution.

Education attainment is a problem with many teenagers dropping out of schools and engaging in unruly behaviors.

People who are well educated are able to receive better healthcare and those with poor education attainment lacking proper healthcare leading to poor lifestyle and mortality.

The addition of vulnerable groups within Tallahassee makes it hard engage in community healthcare program with some vulnerable without having proper medical history and some hiding in fear of deportation documentation.

Socioeconomic determinants speaker notes

Race related barrier to health.

Low income population.

Access to job.

Education attainment.

Additional vulnerable population (Fuller et al,. 2020).


Health and medical resources

Healthcare monetarization.

Healthcare investigation.

Healthcare advocacy.

mobilizing community for safety awareness.

Law enforcement.

Accountability .

Healthcare accessibility.

Healthcare research advocacy

Monitor health status to identify and solve community health problems.

Diagnose and investigate health problems and health hazards in the community.

Inform, educate, and empower people about health issues.

Mobilize community partnerships and action to identify and solve health problems.

Develop policies and plans that support individual and community health efforts.

Enforce laws and regulations that protect health and ensure safety.

Link people to needed personal health services and assure the provision of health care when otherwise unavailable.

Assure competent public and personal health care workforce.

Evaluate effectiveness, accessibility, and quality of personal and population-based health services.

Research for new insights and innovative solutions to health problems.


Top Healthcare Needs, Issues & Factors

Growing number of people within the area have an acute health issues within the community that need immediate attention.

The health disparity within Tallahassee are preventable with inclusion of different races being a major problem.

Better and equipped physician that are equipped to handle patients of all care are needed.

Not everyone within Tallahassee is capable of affording healthcare and thus a solution of having affordable healthcare should be discussed.

Technology advancement within healthcare minizes work load at the facility and physician can more patients.

Violence as a result of insecurity and racial profiling within Tallahassee due to lack of proper representation among people of color (Charness et al,. 2019)

Tallahassee, Florida health issues

Chronic diseases and Obesity. Lack of proper health counsel

Health disparities.

Violence within the community.

Behavioral care.

Access to healthcare. Not everyone is able to access care.

Technology advancement in healthcare .


Resources needed for progress

Establishment of more healthcare facilities.

Physical capital


Investments on medic and Medicaid.

Security patrol

Human resources- healthcare physicians

The establishment of more healthcare system will help mitigate the growing number within the Tallahassee.

Investment and physical capital can help get more medics and Medicaid to the people.

Insecurity within any community is a health disaster that need to get mitigated for the people to feel safe.

Hiring more physicians and getting modern equipment is a hindrance that need to get solved.


Key performance indicators


Data collected cleansed and normalization.

Risk Stratification. Actionable insights.

Actionable insight.

Patient engagement

1. Capturing as much relevant data as feasible is the first step to effectively manage populations. The challenge that providers often face is that they must analyze their own clinical data from EHRs separately from claims because many enterprise data warehouse (EDW) platforms only allow organizations to analyze claims without the more timely and complete EHR data. Analyzing both data sources together is crucial for a holistic patient view.

2. Once the comprehensive data is captured, it must be cleansed and normalized to ensure the information can be utilized for accurate and reliable guidance about care gaps. An advanced EDW should manage probabilistic patient matching and provide similar matching algorithms for entities such as providers, locations, and hospitals.

3. With data combined, cleansed, normalized and analyzed, organizations must be able to risk stratify patients and deliver prioritized lists to care managers so they can conduct outreach and engage patients in their care.

4. Actionable insights. All these powerful data analytical tools will not help care managers if clinicians cannot understand the reporting or if they are required to search results for actionable insight. Any PHM technology designed to support these care managers, as well as providers, must present easily interpreted dashboards. 

5. Patient engagement. With clearly presented insight and actionable tasks based on care gaps and trends in utilization/cost, care managers can begin conducting outreach using multiple communication methods based on patient preferences. More advanced PHM tools can help reduce care managers’ workload by automating the outreach process via text, phone, or secured email. Outreach efforts engage patients in their care and help them better manage their multiple chronic conditions, which can increase the organization’s fee-for-service revenue, as well as satisfy quality measures for value-based payment contracts



The community assessment program help with the establishment of for a program or interventions.

Help with selecting effective strategies to use within the intervention or the program.

The community assessment program helps establish a baseline for the evaluation progress within the given community new strategies and ideas.

The assessment program also helps with the provision of better healthcare for the people.

The work of the community assessment is to identify factors affecting healthcare within said community.

Finding of business needs that needs to get resolved for better results.

Using the community assessment program the people of Tallahassee are able to mitigate their healthcare crisis (Agarwal et al,. 2018.


Charness, N. H., & Beach, S. R. (2019). DESIGNING TECHNOLOGY TO SUPPORT HEALTHCARE FOR AGING ADULTS. Innovation in Aging, 3(Supplement_1), S31-S32.

Fuller, K., Gravlee, C. C., McCarty, C., Mitchell, M. M., & Mulligan, C. J. (2020). Financial strain and stressful social environment drive depressive symptoms, while FKBP5 variant intensifies the effect, in African Americans living in Tallahassee. bioRxiv.

Dickerson, D., Baldwin, J. A., Belcourt, A., Belone, L., Gittelsohn, J., Kaholokula, J. K. A., … & Wallerstein, N. (2020). Encompassing cultural contexts within scientific research methodologies in the development of health promotion interventions. Prevention Science, 21(1), 33-42.

Jha, A. K. (2019). Population health management: saving lives and saving money?. Jama, 322(5), 390-391.

Agarwal, G., Angeles, R., Pirrie, M., McLeod, B., Marzanek, F., Parascandalo, J., & Thabane, L. (2018). Evaluation of a community paramedicine health promotion and lifestyle risk assessment program for older adults who live in social housing: a cluster randomized trial. Cmaj, 190(21), E638-E647.



Assessing Data Sets for Population Health Management Tallahassee, Florida

Whitney Gibson

January 20, 2022

Rasmussen University

HSA5300CBE Population Health

Assessing Data Sets for Tallahassee Population Health Management

To effectively manage a healthcare organization, the management has to be furnished with the latest data and information that has been compiled with great accuracy. From this compiled data, a healthcare manager is able to analyze the needs of patients and the strain on the hospital amenities. Without this data, it is impossible for a healthcare manager to gauge the effectiveness of health programs being implemented and the initiatives that the health center is undertaking in provision of quality healthcare. To arrive at this the required data, the healthcare provider can source it from the IT system used by the health center or from business partners. The data has to be accurate to give a more realistic depiction of the state of affairs in the health center. Developing a comprehensive data analysis approach helps a health manager effectively address the needs of the patients (Muller, Heimo et al. 2020). Without concrete data to fall back on it become impossible for healthcare providers to predict future health crisis due to a failure to analyze patterns.

When assessing data sets for the purpose of population health management, a huge emphasis has to be placed on the credibility of the collected data. Bad data will result into erroneous judgements that might put the health of patients at risk (Raghupathi et al. 2014). Due to the sensitive nature of the data being collected, the process has to be confidential to avoid exposing the information of patients to unauthorized parties. The data used for healthcare management has to be timely to capture all the emerging trends in health issues that are affecting patients. Outdated data cannot be relied on as it does not depict the current state of affairs, this makes it useless to a health manager as it only shows past patterns.


Patient Demographics

Data collected on the demographics of the patients that visited a health center help the manager in assessing what diseases affect people in a certain age bracket or from a certain sex. Dividing up patients based on demographics gives healthcare providers insight on complications that are experienced by patients at different ages. The information is useful to a health center as it helps in strategic planning of health programs that target specific age groups or sexes. The information of patient demographics is useful in drawing observations on chronic diseases and lifestyle diseases helping a health center plan better on how to handle future patients and possible health programs that could be started to boost their recovery journey.

Vital Signs

When patients are admitted in a health center, it is common practice to check and record their vital signs. The data collected from the checkup is useful in drawing a diagnosis later as it gives insight on potential red flags. Vitals such as the heart rate, body temperature and respiratory rate are useful indicators on the state of health of an individual (Kenzaka et al. 2012). They are tell-tale signs of most chronic diseases and can be used to spot these diseases early to allow for more diligent care and treatment of the patients. Recording these vital signs helps a doctor draw a more accurate diagnostic as the signs serve as indicators on what might be troubling their patients and speed up the treatment process.

Laboratory Results

Clinical lab results are a crucial part of the treatment process as they offer a factual analysis of fluid and tissue from the patient. Lab results eliminate speculations from the treatment process and allow a health care provider to draw a more accurate diagnosis of a patient. Without these clinical reports, doctors would have to rely on wild speculations drawn from general observation to diagnose patients. Data collected from laboratory results is useful in identifying hereditary diseases early, this helps in seeking out early treatment once detected (Frazer et al. 2011). The data collected and compiled from laboratory results is important to health practitioners as it helps in drawing accurate diagnosis as it helps narrow down to the exact cause of a complication without leaving much to speculation.

Progress Notes

Doctors deal with a large number of patients daily, relying on memory would be a poor strategy. Data compiled from the progress notes made on each patient in their personal file helps track the progress of the patient more effectively. These progress notes give the doctor a more concrete reference point that helps in keeping track of how the patient is fairing. From the progress notes a medical practitioner can observe improvements in health made or deteriorations and remedy them before they grow into something severe. Progress notes give a tangible depiction of the state of health of a patient from the time they started treatment to the current stage, this helps in gauging the effectiveness of the treatment.

Problem Lists and Diagnoses

The data compiled from the problem list of a patient and past diagnoses helps to speed up the treatment process of a patient as it gives the doctor a detailed history of past complications the patient suffered. Without an elaborate patient history, a doctor might rush into diagnosing the wrong symptom without factoring in that it is a development from a past complication. The medical history of patients is crucial in drawing future treatment plans of these patients, data from the problem list and diagnoses is used to speed up the diagnoses process (Pine et al. 2012). With a well/ compiled list of patient problem list and past diagnoses, it becomes easier for health care providers to give referrals to their patients as the other medical centers will have something to work with.

Allergy Lists

A diligent medical provider has to have an extensive list of medical allergies that affect the patients seeking treatment at a health center. An allergy list helps the health care provider avoid making fatal errors that might result into severe reactions. The doctor has to inquire from the patient of any past allergies and record the findings. The compiled data helps in avoiding errors in prescribing medication by considering the allergies that the patient suffers from. Without this data, the doctor risks causing harm to the patient by offering treatment without due consideration of the potential risks.

Medication Data

As a health care provider, a comprehensive list of the medication that a patient has been on is extremely useful as it ensures that there are no instances of double medication for the same illness. The medication data list helps the doctor adjust the treatment plan of a patient to speed up the recovery process.


Frazer-Abel, A., & Giclas, P. C. (2011, September). Update on laboratory tests for the diagnosis and differentiation of hereditary angioedema and acquired angioedema. In Allergy and Asthma Proceedings (Vol. 32, No. 5, p. 17). OceanSide Publications.

Kenzaka, T., Okayama, M., Kuroki, S., Fukui, M., Yahata, S., Hayashi, H., … & Hashimoto, M. (2012). Importance of vital signs to the early diagnosis and severity of sepsis: association between vital signs and sequential organ failure assessment score in patients with sepsis. Internal Medicine51(8), 871-876.

Müller, H., Dagher, G., Loibner, M., Stumptner, C., Kungl, P., & Zatloukal, K. (2020). Biobanks for life sciences and personalized medicine: importance of standardization, biosafety, biosecurity, and data management. Current opinion in biotechnology65, 45-51.

Raghupathi, W., & Raghupathi, V. (2014). Big data analytics in healthcare: promise and potential. Health information science and systems2(1), 1-10.

Pine, M., Sonneborn, M., Schindler, J., Stanek, M., & Maeda, J. L. (2012). Harnessing the power of enhanced data for healthcare quality improvement: lessons from a Minnesota Hospital Association Pilot Project. Journal of Healthcare Management57(6), 406-418.



Data Sources and Sets for Population Health Management

Whitney Gibson

January 25, 2022

Rasmussen University

HSA5300CBE Population Health

Data Sources and Sets for Population Health Management

Efficient population health organization schemes need healthcare specialists to depend on major information derived from health Information Technology schemes from federal and state database sets that are also present for specialists. It is crucial to choose the right big data sources for supporting population health management initiatives. The report aims to develop a broad portrait of social, financial, and clinical risks, crucially aggregating data from the care continuum earlier for leveraging risk scoring models and interventions to people.

Big Data Sources and Health Management Program

As a leader of the PHM program, the main focus is on particular population health medical critical for the local population, such as diabetes management. Hospital records, medical evaluation, devices, medical records of patients, biomedical research, clinical trials data, telemedicine, and personnel management in Florida are the best big data sources. Personal ideas have the right to access the records, and healthcare plans can send records to other health plan providers with the need for treatment or consent (Cantor & Thorpe, 2018). Medical records of patients comprise documentation of the history of patients, operation notes, operative care, and diagnostic tests with regular notes of patients’ medications. Electronic healthcare records collect digital documentation of patients related to laboratory tests, allergies, and medical history. Records are also shared through protective information systems for private and public-sector specialists. In Florida, the health management program plays an effective role in developing healthcare practices. Demand for qualified directors and managers also focus on regular operations, social strategy, and critical problems with growing days. Florida, health management program sustains customer health documentation in electronic and paper form following applied regulations, rules, and laws. The development of innovative policies to handle and manage big data sources might exceed by utilizing computing and high solutions for big data analysis and equipment with proper infrastructure to examine and produce data. The physicians can examine patients for decreasing insignificant visits to hospices while evading expensive in-house treatments (Raghupathi Raghupathi, 2018). Therefore, patients’ experience would bring improvement in satisfaction level and a reduction in operational prices.

Data Elements

Numerous data elements are required to aid providers in making effective gains in patient well-being while delivering top practices for upcoming initiatives. Healthcare quality can improve by supporting visionary leadership, availability of capitals, training and education, and appropriate planning for efficient management of capitals. Healthcare distribution schemes are operating to bring improvement in patients’ experience while facing issues and deliberating the requirements for aligning the modifications in practices and behaviors across numerous areas and levels of the healthcare organization. It is important to deliver data while developing data and complicated innovation (Schmidt et al., 2019). Gathering, cleaning, processing, organizing, and examining a huge amount of data is an issue. A huge amount of data can be created, consumed, and replicated each year so that digital universes can store and gather big data with a huge influence on the transmission of international healthcare departments and influence on regular lives. It might also decrease medical errors, prediction of treatment risk, and precise treatment. It delivers doctors insights that were not present earlier and permits them to comprehend effectively and focus on changes and challenges extracted from them (Phillips et al., 2018). It can be implied in every stage, from medical investigation to the outcome and experience of patients. Application of big data solution needs can include a clear idea for the goals and requirements.


Learning to utilize available data like ADT alerts, ICD-10 codes, and demographics can be a crucial step for examining the integration of varied and complicated big data into a population health organization environment. Stakeholders in healthcare aim to create personalized preventive care and severe disease management initiatives that must work with their peers, health IT sellers, and partners to access and examine big data that can improve the distribution of patient care quality. Healthcare analytic permit for bringing improvement to care of the patient by the precise diagnosis and informed decisions. Big data can aid in recognizing the intervention of high-cost and patients at higher risk. Efficient methods of organizing data can facilitate precise medicine by detecting patients’ responses to treatments and particular requirements of people.


It is concluded that healthcare specialists have an approach to updated patient health information and deliver more effective, personalized, safer, and higher-quality as well as coordination. Patients also look into attaining health data insights into how health evolves with time.


Cantor, M. N., & Thorpe, L. (2018). Integrating data on social determinants of health into electronic health records. Health Affairs37(4), 585-590.

Raghupathi, W., N Raghupathy, V. (2018). An empirical study of chronic diseases in the United States: a visual analytics approach to public health. International journal of environmental research and public health15(3), 431.

Schmidt, M., Schmidt, S. A. J., Adelborg, K., Sundbøll, J., Laugesen, K., Ehrenstein, V., &Sørensen, H. T. (2019). The Danish health care system and epidemiological research: from health care contacts to database records. Clinical epidemiology11, 563.

Phillips, K. A., Deverka, P. A., Hooker, G. W., & Douglas, M. P. (2018). Genetic test availability and spending: where are we now? Where are we going?. Health Affairs37(5), 710-716.


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