Information Exchange between Providers, Payers and Public Health to Support Rapid Cycle Health Outcomes Improvements in Hypertensives: Experiences from the Million Hearts Learning Collaborative

Chronic diseases in the United States are on the rise, and care models to address chronic disease prevention and care require a systemic approach.  Underpinning this approach is the need for data from multiple sources, including clinicians, payers and public health to create a more complete understanding of individual and community-level risk factors and opportunities for prevention.  Increasingly, chronic disease prevention programs in public health are relying on clinical data sources to better ascertain the risk and burden of chronic disease in their communities.  Multi-directional data exchange among clinicians, state and local public health departments and payers, paired with sound interventions and quality improvement activities is proving to be a powerful model for chronic disease prevention.

 ASTHO’s ten state Million Hearts Learning Collaborative focused on operationalizing the sharing of data between public health and clinical systems utilizing health information technology. States worked closely with multiple clinical system partners including public and private payers, hospital systems, and accountable care organizations to leverage the real time data in both electronic health records and claims databases to control hypertension.  States worked to create bidirectional systems to link local and state data to clinical partners together to identify hot spots and trends and to also work to create a team based care system between public health and providers to provide resources in the community for patients identified with hypertension. 

 Multi-directional data exchange among providers, payers and public health departments to support the prevention of chronic disease should be paired with appropriate interventions and deliberate collaboration among the levels of partners.  The data can support quality of care improvements and community level interventions focused on reducing the burden of disease.