Table 1.

Summary of approach to health disparity through demographic data collection, stratification quality measures, and registry-based infrastructure

Population health informatics approach	Quality measurement	Informatics workflows and registry infrastructure
Standardized demographic data collection	Complete documentation of race, ethnicity, and language Complete documentation of sexual orientation and gender identity	Structured standardized fields for data collection of REAL and SOGI Mandatory completion of REAL by all registration staff Patient portal enabled completion of REAL SO/GI Clinical back office and nurse entered SO/GI detail for all primary care patient face to face visits Clinical REAL SO/GI navigator section for clinicians
Stratification of quality measures by race, ethnicity, language, sexual orientation, and gender identity	Controlling blood pressure [National Quality Forum (NQF) 0018] Ischemic vascular disease [NQF 0068] Prevention of quality overall composite [Agency for Healthcare Research and Quality Indicator (PQI )#90] Alcohol and drug misuse [Stewards: Alameda Health System, San Francisco Health Network, University of California Irvine] Screening for depression and follow-up [NQF 0418] Tobacco assessment and counseling [NQF 0028e] Colorectal cancer screening [NQF 0034] Hemoglobin A1C poor control [NQF 0059]	Analytics enabled stratification of quality measures by demographic strata showing measure performance and percentage of total population Performance by race Performance by ethnicity Performance by language Performance by sexual orientation Performance by gender identity
Electronic health record-based registries to support population health informatics infrastructure	Hypertension registry for improved opportunities to identify patients with poor blood pressure control Ischemic vascular disease and hemorrhage registries to identify patients appropriate for antiplatelet therapy Diabetes, chronic obstructive lung disease, heart failure registries to support improved chronic disease management reducing acute utilization as measured by the prevention of quality overall composite No current registry for alcohol and drug misuse Depression registry to support appropriate level of screening for depression and follow-up Tobacco registry to support assessment and counseling	Registry-based rule driven patient engagement, clinical decision support tools for providers, and care gap outreach System level rules set at a patient level for health maintenance Patient portal engagement through display of current care gaps and receipt of registry driven outreach Nurse tee-up of orders based on registry-based care gaps Provider-based decision support for care gap completion, summary of chronic disease control, navigator banner alert, and dynamic rule-based links to medication, laboratory testing, and referrals Collaborative care team outreach based on registry driven metrics identifying need for follow-up Pharmacist outreach by registry cohort Nurse and patient navigator outreach by registry