The Population Health OutcomEs aNd Information Exchange (PHOENIX) Program - A Transformative Approach to Reduce the Burden of Chronic Disease

Abstract

This concept article introduces a transformative vision to reduce the population burden of chronic disease by focusing on data integration, analytics, implementation and community engagement. Known as PHOENIX (The Population Health OutcomEs aNd Information EXchange), the approach leverages a state level health information exchange and multiple other resources to facilitate the integration of clinical and social determinants of health data with a goal of achieving true population health monitoring and management. After reviewing historical context, we describe how multilevel and multimodal data can be used to facilitate core public health services, before discussing the controversies and challenges that lie ahead.

Realizing the Potential of Social Determinants Data: A Scoping Review of Approaches for Screening, Linkage, Extraction, Analysis and Interventions

“…The most common external SDoH data sources linked to EHRs were US census and community survey data (at both patient/individual and area/neighborhood levels), administrative data/claims records, and disease registries. Commonly linked community surveys and systems include the Behavioral Risk Factor Surveillance System (BRFSS), the National Health and Nutrition Examination Survey (NHANES), the National Health Interview Survey (NHIS) [62], the National Institutes of Health PROMIS® (Patient-Reported Outcomes Measurement Information System) [63], the National Survey of Children's Health (NSCH) [64], the Center for Disease Control Youth Risk Behavior Surveillance System (YRBSS) [65], the Center for Medicare and Medicaid Services (CMS) Accountable Health Communities' Health-Related Social Needs Screening Tool [66], the National Center for Education Statistics, the Uniform Crime Reports, and the American Community Survey [67][68][69][70].…”

“…In our review, we identified 76 articles (details see Supplement Table 4) describing Health-Related Social Needs Screening Tool [66], the National Center for Education Statistics, the Uniform Crime Reports, and the American Community Survey [67][68][69][70].…”

Database derived from an electronic medical record-based surveillance network of US emergency department patients with acute respiratory illness

“…We will be able to integrate county-level CDC SVI and other health equity relevant exposure data, but not at the census tract level. This effort will leverage methodology used in Wayne State’s PHOENIX Virtual Data Warehouse, which has already assembled troves of social determinants of health data for ZIP codes, and has established standard operating procedures for integrating the information with investigator-generated person-level data [ 8 ]. We hope that publication of this protocol (and subsequent original research manuscripts) will enhance the visibility of RESP-LENS and encourage further investments to pursue deeper data, including viral genomic sequencing.…”

Origins of a novel mobile health unit program to prevent cardiovascular disease in vulnerable communities

“…Given our mission to increase access to preventive care in socially vulnerable populations, we further implemented a data‐driven strategy to optimize the targeting of geographic deployment. We began using Wayne State University's (Detroit, MI, USA) PHOENIX (Population Health Outcomes Information Exchange) Prevalence Profiler (phoenix‐data.wayne.edu) 6 to identify and reach “hotspots” with high social vulnerability and increased chronic disease burden. By using spatial analysis and data‐driven vehicle deployment, the fraction of patients presenting for care who resided in high vulnerability neighborhoods increased by more than 60% (i.e., from 25% to 41%).…”