Family physicians training in the Greater Lawrence Family Health Center in Lawrence, Massachusetts recently sought to better understand the geography, or “hot-spots” of their patients with food insecurity. In an article published as a Clinical Innovation in the Annals of Family Medicine, authors describe their use of the Population Health Assessment Engine (PHATE) tool to translate their use of a two-question screening survey (the Hunger Vital Sign) into actionable neighborhood mapping that enabled the center’s physicians to combine clinical and community data to understand and address their patients’ social risks.

Commissioned by the American Board of Family Medicine (ABFM), PHATE was built by the University of Missouri Center for Applied Research and Engagement Systems (CARES) and allows users to create a Community Vital Sign—which is a validated risk score for a variety of undesirable outcomes—for each patient. PHATE also allows users to view community social determinants, neighborhoods served by the clinic, disease and poor quality hot-spots, and relevant, local community resources.

The Health Center uploaded addresses of the 270 patients who screened positive for food insecurity from the electronic health record into PHATE during an 8-month study period in 2018. PHATE then mapped the data, enabling physicians to visualize the specific neighborhoods of food insecure patients and intervene to improve access to healthy food.

Jonathan Lichkus, MD, MPH, lead author and full-scope family physician at Greater Lawrence Family Health Center, said, “PHATE is an easy to use tool that allows clinicians to better understand community characteristics, map their patients, and offers the opportunity to move beyond the clinic walls to address social risk factors fundamental to improving health.”

The full version of PHATE is integrated into the PRIME Registry, and available free to all PRIME Registry users. Free access to the My Community tool in PHATE is available by registering here.