Originally published at www.fuhn.org/post/from-guesswork-to-good-data-fuhn-s-population-health-playbook
Population health differs from traditional patient care. Instead of focusing on one patient at a time, it asks: how do we improve outcomes for an entire group, whether people with diabetes or those facing housing insecurity? Answering that question requires more than a good electronic health record. It requires accurate, effective analytics layered on top of it.
That's the strategy behind FUNH's rollout of Azara Healthcare's population health platform across its member clinics. Today, Community Health Services, Inc. (CHSI) is fully live on the tool, while Southside Community Health Services, Indian Health Board, Axis Clinics, Community-University Health Care Center, and Riverland Community Health are nearly there. CHSI Chief Operating Officer Isaac Johnson and Chief Executive Officer Rhonda Eastlund both used Azara at previous clinics and recommended the tool to FUHN.
From Case Worker to Quality Champion
Isaac started his career as a case manager in a Wisconsin for-profit health system. But he found that patients felt like numbers on a ledger. When he shifted to a community health center, he experienced a patient-centered, close-knit, and mission-driven space. A colleague noticed his analytical instincts and encouraged him to join a quality department, where he spent several years building expertise in pulling and reporting clinical data. When his organization transitioned to a new EHR, his specialized reporting role was eliminated. He moved into operations, growing from managing a single clinic to overseeing multiple sites before joining CHSI. That combination—case management, EHR reporting, quality, and operations—means Isaac understands the strategic importance of Azara.
From Guesswork to a Culture of Quality
When Isaac joined CHSI, the network of rural Minnesota and North Dakota clinics lacked a strong data reporting structure. Quality reporting rested on the shoulders of one or two nurses, and when they left the organization, their knowledge of how to pull that data went with them. Clinical teams, including lead RNs and clinicians, often didn't know their quality metrics. A lot of it was guesswork. Azara changed that.
"Azara got the information, all of our data, into the hands of every single individual, from the front desk all the way up to the CEO," Isaac said. "That shift has been transformational."
That information access matters because quality isn't the job of one department. It's shaped by every touchpoint a patient has with the clinic. Isaac points to CHSI's childhood immunization measure as an example: a child needs specific vaccines by specific ages, on a specific schedule. Whether that happens depends on whether the front desk schedules the right visit at the right time. Giving front-line staff—not just providers—visibility into that same measure is what turns a metric owned by a department into a habit owned by the entire team.
Turning Data into Daily Decisions
Azara's technological framework works quietly in the background: an interface connects the clinic's EHR to Azara's database, pulling patient data into a system built for visualization and reporting. Getting there isn't a quick plug-and-play process. Each measure must be validated to ensure it is mapped correctly. Azara can be customized to count information an EHR wouldn't typically capture on its own, such as specific coded phrases or scanned documents.
According to Isaac, that validated data produces a set of dashboards that make quality easier to act on. Color coding and trend arrows let a team see immediately which UDS measures have improved since last year, which have slipped, and which still need work.
For individual patients, that same visualization shows progress over time rather than a flat yes-or-no. A patient with diabetes who started with an A1C of 18 and is now down to 13 hasn't reached the goal of 9 yet. However, the trend line shows real movement, information a provider can use during pre-visit planning to prioritize that day's patients.
CHSI now holds weekly quality meetings across its sites built around this data. Looking at a trend line, rather than a single month's percentage, makes it easier to spot when something changes and start the right conversation about why.
As more clinics come online with Azara, that same visibility will extend to daily scheduling. Providers will be able to look at a day's or week's list of appointments, see each patient's care gaps in advance, and either close them at that visit—ordering the overdue screening or test on the spot—or schedule the follow-up while the patient is still in the clinic.
Learning From Each Other, Not Just Reporting on Each Other
Isaac shares that one of the more useful Azara applications has been comparing performance across sites, service lines, and providers—not to point fingers—but to identify what's working. If two providers manage similar-sized panels of patients with diabetes, but one has better outcomes, that comparison opens a conversation the different approaches.
CHSI has built that insight into a practical cycle: try the higher-performing team's approach for two to four weeks, check whether the metrics trend the expected way, and if they do, adopt it as the standard of care. Involving the whole care team—not just providers—in that process means everyone sees how small process changes translate into healthier patients.
The Value-Based Care Payoff
According to Isaac, CHSI's efficiency gains extend beyond quality metrics. Azara now auto-populates nearly every UDS (Uniform Data System) reporting table except finance, cutting what used to be a heavily manual annual reporting process down significantly.
Pulling a patient panel for a site visit or audit—once a time-consuming task—now takes a few clicks. And because Azara can show the full universe of eligible patients, such as every Medicare patient due for an annual wellness visit, regardless of whether they're formally attributed to a provider, clinics can close care gaps that would otherwise stay invisible.
That capability is also what makes the tool a fit for value-based care, where performance on these kinds of measures determines contract results. According to Isaac, the increase in productivity has been substantial. Even CHSI's Chief Financial Officer—initially skeptical of the cost—supported its implementation after seeing the hours saved on manual data pulls.
What Other Clinics Have Seen
CHSI's experience mirrors what other Azara clients nationally have reported. Waianae Coast Comprehensive Health Center in Hawaii, which serves a diverse and medically underserved population, used Azara's platform to raise depression screening rates from 25% to nearly 60% and saw a 40% increase in patients with documented asthma action plans. Health Partners of Western Ohio used the same platform to centralize its data and improve chronic condition management, driving a 16% improvement in depression remission rates and outperforming the national average by 11 points.
FUHN leaders look forward to seeing similar results at its member clinics as they realize the full potential of Azara.
This blog is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $705,000, with 50% financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.