Integrating Clinical Classifications Software Refined, Process Indicators, and Geographic Information System Mapping to Inform Population Health Management: Development of an Interactive Dashboard - Report - MDSpire

Integrating Clinical Classifications Software Refined, Process Indicators, and Geographic Information System Mapping to Inform Population Health Management: Development of an Interactive Dashboard

  • By

  • Joshua Kuan Tan

  • Hao Yi Tan

  • Gerald Gui Ren Sng

  • Sing Yi Chia

  • Su-Yen Goh

  • Julian Thumboo

  • Yong Mong Bee

  • July 15, 2026

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Combining Clinical Classifications Software Refined and GIS Mapping for PHM

Background

The rising burden of chronic conditions such as diabetes necessitates effective population health management (PHM) strategies. PHM aims to proactively identify at-risk populations and coordinate care to improve health outcomes and reduce healthcare utilization. Robust information technology infrastructure is essential for integrating diverse data sources to support these efforts.

Data Highlights

No numerical data or trial data was provided in the source material.

Key Findings

  • The dashboard integrates clinical and administrative priorities for diabetes care.
  • It supports varying levels of disease specificity for health care utilization trends.
  • Stakeholder engagement guided the dashboard's development to address critical analytic domains.
  • The SingHealth Diabetes Registry provided comprehensive patient data for analysis.
  • Core analytic domains include health status indicators, process indicators, and inpatient utilization.

Clinical Implications

The dashboard facilitates data-driven planning and targeted interventions for diabetes management. Its design allows healthcare providers to better understand and address the health needs of their patient populations.

Conclusion

The interactive dashboard represents a significant advancement in population health management by integrating essential data for improved diabetes care and health outcomes.

Related Resources & Content

  1. Journal of Medical Internet Research (JMIR) — From Design to Accountable Impact for Data Dashboards in Health Care
  2. npj Digital Medicine — A Decade-Long Population Study on the Progression of Multimorbidity Burden in a Cohort of 5.5 Million Adults
  3. Open Forum Infectious Diseases — Assessing Primary and Incidental COVID-19 Hospitalization Rates in Santa Clara County
  4. npj Digital Medicine — Mixed methods evaluation of a clinical decision support system to reduce variation in healthcare
  5. Clinical Classifications Software Refined (CCSR)
  6. User Guide (v2026.1) for Clinical Classifications Software Refined (CCSR) for ICD-10-CM
  7. 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2026 | Diabetes Care | American Diabetes Association
  8. 6. Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises: Standards of Care in Diabetes—2026 | Diabetes Care | American Diabetes Association
  9. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines | JACC
  10. Guideline on the Management of Dyslipidemia - Professional Heart Daily | American Heart Association
  11. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease
  12. 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome - Professional Heart Daily | American Heart Association
  13. HEDIS Electronic Clinical Data Systems (ECDS) Reporting - NCQA
  14. Health Insurance Exchange 2026 Quality Rating System Measure Technical Specifications
  15. Effects of Semaglutide on Chronic Kidney Disease in Patients with Type 2 Diabetes | New England Journal of Medicine
  16. Semaglutide Effects on Cardiovascular Outcomes in People With Overweight or Obesity - American College of Cardiology
  17. SURPASS-CVOT: Is Tirzepatide Superior to Dulaglutide in Patients With T2D and ASCVD? - American College of Cardiology
  18. Bempedoic Acid and Cardiovascular Outcomes in Statin-Intolerant Patients | New England Journal of Medicine
  19. PLACES Data Portal | PLACES | CDC
  20. Current Release Notes | PLACES | CDC
  21. HEDIS MY 2026: What’s New, What’s Changed, What’s Retired - NCQA

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