Our mission is to improve health systems and outcomes for vulnerable populations through research, technology, and collaboration.

Our strategy to fulfill this mission is 3-fold:

1. We try to understand how concepts related to people’s health can better be captured, displayed, and leveraged in our current systems, especially social determinants, complex patient conditions and needs, and advanced goal setting and care planning approaches.
2. We seek to better understand how the context, structure, and evolution of how people seek and experience health and health care affects the provision and uptake of data, information, and knowledge.
3. We collaborate to create and test solutions involving information systems and the broader systems of care that impact outcomes meaningful to vulnerable people.

Our tactics for the next 3 years include:

1. Creating population-based performance indicators that incorporate broader concepts related to value of care to patients.
   
   1. Adjust and adapt current quality measures, both process and outcomes, to reflect broader system and patient context through mixed methods studies intended to understand how and when action can be taken.
   2. Create logic models that better link patient-centered goals and needs to the broader health system reform concepts, and try to understand success and challenges.
   3. Study how advance care planning approaches can be better initiated and monitored.
2. Seeking funding to better incorporate person-centered and environmental concepts in health care information systems and understand if they can be used to improve health; examples may be:
   
   1. Exploring how social determinants of health can be captured and used in a timely fashion to adjust care plans for patients with complex needs.
   2. Use areal measures like food deserts and social connectedness to identify at-risk older adults.
   3. Using natural language processing to identify novel concepts related to social, behavioral, and lifestyle barriers that may be impacting a person’s health and well-being.
3. Improving the collection and use of metadata about at-risk populations and the care delivery systems to better inform care planning and engagement.
   
   1. Incorporating key information and knowledge into our health information technology systems based solely on their likelihood to change the future care or prognosis of patients.
   2. Adding genetic, socioeconomic, care system, and other information into our population management systems to better understand outcomes important to patients.
4. Improving the relative quality of data and information by studying how to maximize the integration and input of high quality data while reducing the workflow demands.
   
   1. Studying ways to improve the feedback loop for data and information quality by identifying gaps in our ability to apply knowledge to situations.
   2. Highlighting or summarizing very high quality data for presentation to individual care needs.
   3. Better incorporating patient-reported information into standard workflow.
5. Educating and promoting the use of data, information, and knowledge to improve care while avoiding poor outcomes.