Phoenix Newsletter - October 2025 President’s Message: Enduring Commitments in a Time of Change Read President’s Message: Enduring Commitments in a Time of Change
Home Research Research Library Integrating Community and Clinical Data to Assess Patient Risks with A Population Health Assessment Engine (PHATE) Integrating Community and Clinical Data to Assess Patient Risks with A Population Health Assessment Engine (PHATE) 2020 Author(s) Bambekova, Pavela G, Liaw, Winston R, Phillips, Robert L, and Bazemore, Andrew W Topic(s) Education & Training, Role of Primary Care, and Achieving Health System Goals Keyword(s) Graduate Medical Education, Payment, Population Health, Prime, Quality Of Care, and Shortage Areas Volume Journal of the American Board of Family Medicine Source Journal of the American Board of Family Medicine Clinicians are concerned about their patients’ social determinants of health (SDH); yet, they are unsure how to effectively gather patient-level SDH data and intervene without adding to current administrative burdens. Designed properly, clinical registries offer solutions to integrate neighborhood SDH data with clinical data from electronic health records, enabling the understanding of community factors to guide patient care. Federal and state interest in adjusting reimbursements based on SDH further underscores the need for strategies that integrate SDH and clinical data. The Population Health Assessment Engine (PHATE) exemplifies a registry-based SDH data integration solution that adjusts payments, contributes to public health surveillance, organizes care around hot spots (gaps in quality or uncontrolled disease), assesses patient risk, and connects with community organizations. PHATE also permits residency training to meet community health competency milestones by incorporating the PHATE curriculum. These functions enhance value, and their utility in education and care delivery would benefit from further investigation. ABFM Research Read all 2020 Well‐Being in the Nation: A Living Library of Measures to Drive Multi‐Sector Population Health Improvement and Address Social Determinants Go to Well‐Being in the Nation: A Living Library of Measures to Drive Multi‐Sector Population Health Improvement and Address Social Determinants 2017 Developing the National Family Medicine Graduate Survey Go to Developing the National Family Medicine Graduate Survey 2008 Value of information in virtual patients portraying pharyngitis Go to Value of information in virtual patients portraying pharyngitis 2020 Taking a Closer Look at Mental Health Treatment Differences: Effectiveness of Mental Health Treatment by Provider Type in Racial and Ethnic Minorities Go to Taking a Closer Look at Mental Health Treatment Differences: Effectiveness of Mental Health Treatment by Provider Type in Racial and Ethnic Minorities
Author(s) Bambekova, Pavela G, Liaw, Winston R, Phillips, Robert L, and Bazemore, Andrew W Topic(s) Education & Training, Role of Primary Care, and Achieving Health System Goals Keyword(s) Graduate Medical Education, Payment, Population Health, Prime, Quality Of Care, and Shortage Areas Volume Journal of the American Board of Family Medicine Source Journal of the American Board of Family Medicine
ABFM Research Read all 2020 Well‐Being in the Nation: A Living Library of Measures to Drive Multi‐Sector Population Health Improvement and Address Social Determinants Go to Well‐Being in the Nation: A Living Library of Measures to Drive Multi‐Sector Population Health Improvement and Address Social Determinants 2017 Developing the National Family Medicine Graduate Survey Go to Developing the National Family Medicine Graduate Survey 2008 Value of information in virtual patients portraying pharyngitis Go to Value of information in virtual patients portraying pharyngitis 2020 Taking a Closer Look at Mental Health Treatment Differences: Effectiveness of Mental Health Treatment by Provider Type in Racial and Ethnic Minorities Go to Taking a Closer Look at Mental Health Treatment Differences: Effectiveness of Mental Health Treatment by Provider Type in Racial and Ethnic Minorities
2020 Well‐Being in the Nation: A Living Library of Measures to Drive Multi‐Sector Population Health Improvement and Address Social Determinants Go to Well‐Being in the Nation: A Living Library of Measures to Drive Multi‐Sector Population Health Improvement and Address Social Determinants
2017 Developing the National Family Medicine Graduate Survey Go to Developing the National Family Medicine Graduate Survey
2008 Value of information in virtual patients portraying pharyngitis Go to Value of information in virtual patients portraying pharyngitis
2020 Taking a Closer Look at Mental Health Treatment Differences: Effectiveness of Mental Health Treatment by Provider Type in Racial and Ethnic Minorities Go to Taking a Closer Look at Mental Health Treatment Differences: Effectiveness of Mental Health Treatment by Provider Type in Racial and Ethnic Minorities