Population Health Data Infrastructure

Data Infrastructure for Populations That Public Health Systems Routinely Miss

We provide technical services at the intersection of clinical informatics, public health surveillance, and health equity research — supporting organizations that need the data infrastructure to study and serve people experiencing homelessness, incarceration, and housing instability.

Discuss a Project Our Services

The Gap We Address

Health condition prevalence data in the United States is primarily derived from survey methods that carry a 2–3 year lag, lack the geographic granularity needed by local health departments, and systematically underrepresent populations with severe and multiple disadvantages. People who have recently experienced homelessness or incarceration — who carry disproportionately high burdens of mental health, substance use, and chronic disease — are largely absent from the national data systems that inform healthcare policy and resource allocation.

Electronic health records, linked to administrative data on homelessness services, corrections involvement, Medicaid enrollment, and mortality, offer a path toward timely, population-level estimates for these groups. Building that path requires technical infrastructure — common data models, federated query architecture, privacy-preserving record linkage, and validated condition codesets — that most public health agencies and community organizations cannot build alone.

That is the work we support.

Who We Work With

State and local public health agencies

Developing community health needs assessments, surveillance infrastructure, or data systems to support equity-focused program evaluation.

Health system research consortia

Operating on OMOP common data model infrastructure who need support with codeset development, federated analytic pipelines, data quality processes, or translation of results into accessible data products.

Academic and community research teams

Studying health outcomes among people experiencing homelessness, incarceration, or Medicaid enrollment, particularly where linked administrative data is needed to identify and characterize these populations.

Organizations pursuing grant funding

From CDC, NIH, HRSA, or state health departments who need a technically credible partner for data infrastructure and evaluation design components of their applications.

Services

OMOP Common Data Model Implementation and Support

We support health systems and research networks in implementing and maintaining OMOP CDM infrastructure, including ETL pipeline development, vocabulary mapping, and standardization of demographic and encounter data across sites. We build condition codesets grounded in established sources — including the CMS Chronic Conditions Warehouse — and validate them through iterative clinical review. We deploy OHDSI quality assurance tools including Achilles and the Data Quality Dashboard, supplemented by custom scripts for longitudinal data quality monitoring.

Federated Network Architecture

We help organizations design and operationalize distributed health data networks in which patient-level data remains within each contributing site. Our work covers the governance structures, data use agreement frameworks, deduplication procedures, and analytic workflows that make multi-site collaboration feasible while preserving data security and institutional autonomy. We draw on established network models including PCORnet and HCSRN and adapt them to jurisdiction-specific regulatory and organizational contexts.

Administrative Data Linkage

Characterizing the health of people experiencing homelessness or incarceration requires linking clinical data to administrative sources that health systems do not control — including Homeless Management Information System records, state department of corrections data, Medicaid enrollment files, immunization registries, and vital statistics. We design and implement privacy-preserving record linkage pipelines using hash-based algorithms that allow cross-source matching without transmitting personally identifiable information, and we build the data enrichment workflows that augment OMOP records with these contextual variables.

Population Health Prevalence Estimation

We produce directly standardized, age- and sex-adjusted prevalence estimates for physical health, mental health, and substance use conditions, stratified by race and ethnicity, geography, and social determinants including homelessness, incarceration, and insurance status. Estimates are generated at the state, county, zip code, and census tract level, providing the geographic resolution that local health departments need to assess community health needs and allocate resources.

Data Product and Dashboard Development

We translate aggregated analytical results into publicly accessible dashboards, structured data exports, and interactive visualizations designed for use by public health practitioners, policymakers, and community organizations. We prioritize clarity, equity framing, and usability by non-technical audiences, and we build data products that can be updated as new cohort data becomes available rather than as one-time static outputs.

Grant Development — Technical Components

We support grant applications as a technical subcontractor or consultant, contributing data infrastructure plans, analytic frameworks, evaluation designs, and IRB-exempt public health surveillance justifications. We have particular familiarity with the technical requirements of CDC public health infrastructure grants, HRSA community health center programs, NIH observational research mechanisms, and the emerging CMS-mandated evaluation frameworks for Medicaid 1115 Reentry Waivers.

Community Health Needs Assessment Data Support

Hospitals and local health departments conducting CHNAs frequently lack access to condition prevalence data with sufficient timeliness, geographic resolution, or coverage of high-need populations. We provide CHNA-ready data packages that include standardized prevalence estimates broken down by demographic group, geography, and special populations — with particular attention to people experiencing homelessness, incarceration, or Medicaid enrollment.

Typical engagement

Engagements typically begin with a scoping conversation covering the organization's existing data environment, governance structure, near-term analytic priorities, and available funding mechanisms. From there, work is scoped as a project-based engagement, a multi-year grant subcontract, or an ongoing technical assistance retainer depending on what fits the organization's needs and timeline.

Engage With Us

Engagements typically begin with a scoping conversation about the organization's current data environment, existing infrastructure, governance constraints, and near-term analytic priorities. Use the contact form to initiate that conversation.

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