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 2016 Reducing Burden, Assuring Competence, Improving Quality, and Enhancing Professionalism: How Can Abfm Contribute to All? Go to Reducing Burden, Assuring Competence, Improving Quality, and Enhancing Professionalism: How Can Abfm Contribute to All? 2021 Uniting Public Health and Primary Care for Healthy Communities in the COVID-19 Era and Beyond Go to Uniting Public Health and Primary Care for Healthy Communities in the COVID-19 Era and Beyond 2018 Board Certified Family Physician Workforce: Progress in Racial and Ethnic Diversity Go to Board Certified Family Physician Workforce: Progress in Racial and Ethnic Diversity 2014 Aligning Expansion of Graduate Medical Education with Recent Recommendations for Reform. Go to Aligning Expansion of Graduate Medical Education with Recent Recommendations for Reform.
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 2016 Reducing Burden, Assuring Competence, Improving Quality, and Enhancing Professionalism: How Can Abfm Contribute to All? Go to Reducing Burden, Assuring Competence, Improving Quality, and Enhancing Professionalism: How Can Abfm Contribute to All? 2021 Uniting Public Health and Primary Care for Healthy Communities in the COVID-19 Era and Beyond Go to Uniting Public Health and Primary Care for Healthy Communities in the COVID-19 Era and Beyond 2018 Board Certified Family Physician Workforce: Progress in Racial and Ethnic Diversity Go to Board Certified Family Physician Workforce: Progress in Racial and Ethnic Diversity 2014 Aligning Expansion of Graduate Medical Education with Recent Recommendations for Reform. Go to Aligning Expansion of Graduate Medical Education with Recent Recommendations for Reform.
2016 Reducing Burden, Assuring Competence, Improving Quality, and Enhancing Professionalism: How Can Abfm Contribute to All? Go to Reducing Burden, Assuring Competence, Improving Quality, and Enhancing Professionalism: How Can Abfm Contribute to All?
2021 Uniting Public Health and Primary Care for Healthy Communities in the COVID-19 Era and Beyond Go to Uniting Public Health and Primary Care for Healthy Communities in the COVID-19 Era and Beyond
2018 Board Certified Family Physician Workforce: Progress in Racial and Ethnic Diversity Go to Board Certified Family Physician Workforce: Progress in Racial and Ethnic Diversity
2014 Aligning Expansion of Graduate Medical Education with Recent Recommendations for Reform. Go to Aligning Expansion of Graduate Medical Education with Recent Recommendations for Reform.
