Resource Overview
There are many tools available and a number of vendors serving the market for PHM technologies, making implementation decisions and planning a challenge for health centers.  Resources in this section provide a framework for PHM vendor selection and a roadmap for PHM and SDH implementation.  Case examples are provided to demonstrate health centers’ experiences implementing PHM and SDH.
Implementation of PHM and SDH Resources

PRAPARE Implementation and Action Toolkit

The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE)

HITEQ Center 0 389

The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) is a national effort to help health centers and other providers collect the data needed to better understand and act on their patients’ social determinants of health. As providers are increasingly held accountable for reaching population health goals while reducing costs, it is important that they have tools and strategies to identify the upstream socioeconomic drivers of poor outcomes and higher costs. With data on the social determinants of health, health centers and other providers can define and document the increased complexity of their patients, transform care with integrated services and community partnerships to meet the needs of their patients, advocate for change in their communities, and demonstrate the value they bring to patients, communities, and payers.

Missouri PCA Population Health Management implementation using Azara DRVS

Case Example

HITEQ Center 0 528

The Missouri Quality Improvement Network (MOQuIN) undertook an initiative that aimed to help the state’s health centers adopt, implement, and use Health IT. As part of this initiative, population health management technology was implemented to help MOQuIN and their health centers mine and monitor their data, to identify drivers of performance as well as to test strategies for improvement. This case study describes their implementation experience, selection process and criteria, and lessons learned.  

Implementation and User Experiences with Azara DRVS

Health Care for the Homeless

Azara Healthcare LLC 0 367

This case study presents the PHM implementation story of Health Care for the Homeless (HCH), a Baltimore-based safety net provider.  HCH implemented Azara DRVS, a PHM solution that offers centralized data reporting and analytics for health centers and primary care associations.  Azara DRVS turns EHR data into reports for population health, chronic disease management, care planning, QI, risk and cost monitoring and regulatory compliance and reporting including UDS, Meaningful Use and PCMH.

Using your EHR for Population Health Management

A Cross-reference Tool

HITEQ Center 0 65

Health centers are interested in managing population health but may not have the budget needed to purchase specialty suites. This tool will guide health centers in leveraging the “built in” functionality of certified EHRs to perform PHM functions by mapping the native PHM functionality available in the common certified EHRs used by health centers.  The aim is to help health centers to understand where to start in implementing PHM using what they already have available to them.

Top Tips for Selecting and Implementing Population Health Management Analytic Systems

From organizations who have recently implemented systems

HITEQ Center 0 19

This document includes tips for selecting and implementing population health management analytic and integrated data systems derived from Primary Care Associations, Health Center Controlled Networks, and health centers who have gone through this experience.

The Healthcare Analytics Adoption Model: A Framework and Roadmap

from Health Catalyst

HITEQ Center 0 277

Health Catalyst published the inaugural version of the Healthcare Analytics Adoption Model in 2012, a proposed framework to measure the adoption and meaningful use of data warehouses and analytics in healthcare in ways similar to the well-known HIMSS Analytics EMRAM model. A second version of the Health Analytics Adoption Model was released in 2013.

This can be a helpful framework for understanding what is infrastructure and processes are needed to use data successfully to manage the health of your population and engage in alternative payment arrangements that continue to gain traction. 



This resource collection was cultivated and developed by the HITEQ team with valuable contributions from the National Association of Community Health centers (NACHC) as well as HITEQ's Advisory Committee and many health centers who have graciously shared their experiences with HITEQ.

Looking for something different or have something you think could assist?

HITEQ works to provide top quality resources, but know your needs can be specific. If you are just not finding the right resource or have a highly explicit need then please use the Request a Resource button below so that we can try to better understand your requirements.

If on the other hand you know of a great resource already or have one that you have developed then please get in touch with us by clicking on the Share a Resource button below. We are always on the hunt for tools that can better server Health Centers.

Request a Resource  Share a Resource
Search HITEQ Content
Highlighted Resources & Events
Need Assistance?
Would you like more assistance regarding Population Health Management and Social Determinants of Health strategies or support in using any of the included resource sets?

  Request Support


The Quadruple Aim
Quadruple Aim

A Conceptual Framework

Improving the U.S. health care system requires four aims: improving the experience of care, improving the health of populations, reducing per capita costs and improving care team well-being. HITEQ Center resources seek to provide content and direction aligned with the goals of the Quadruple Aim

Learn More >