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Electronic Health Record (EHR) Learning Network on Algorithms to Identify Frailty And Functional Disability

The Office of the Assistant Secretary for Planning and Evaluation (ASPE) is leading an interagency effort to validate and expand claims-based algorithms to identify patients with frailty and functional disabilities. These algorithms will make it possible to identify patients with frailty and functional disabilities across patient/payer populations in order to support research and inform value-based care and payment. More information can be found on the main project page.

One component of this project is to create algorithms based on EHR data that will then be tested in a health system and made available to the public. ASPE has contracted with the RAND Corporation to support this work by:

(1) establishing an EHR Learning Network to understand how EHR data is currently being used to collect information on patients’ function status, and

(2) developing an EHR Implementation Guide to sharing findings from the EHR Learning Network and provide guidance on using EHR data to identify patients with frailty or functional impairment.

What is the EHR Learning Network?

The EHR Learning Network is a unique opportunity for providers, health services researchers, health system administrators, and EHR vendors to actively engage with ASPE on how EHR data can be used to identify patients with frailty and functional disabilities. Through the EHR Learning Network, ASPE and their contractor, RAND, will involve stakeholders in the development of the EHR-based frailty and functional disabilities algorithms through interactive webinars, optional small group interviews, and invitations to review and give feedback on draft algorithms and implementation guidance materials.

We invite anyone who works with EHR data and/or health care providers who care for patients with frailty or functional impairment to join the EHR Learning Network by sending us an email at By expressing interest, you will receive project updates, announcements about webinars and presentations, and invitations to give feedback and share your experiences through small group interviews and other channels.

Goals of the EHR Learning Network

ASPE’s specific goals for the EHR Learning Network are to:

  • Learn from administrators and providers about how EHR data are currently used to identify patients with or at-risk for frailty or functional impairment
  • Provide EHR Learning Network participants the opportunity to support the development of claims- and EHR-based algorithms by providing feedback on the draft specifications of the algorithms and/or pilot testing the algorithms in their local EHRs
  • Share new ways that providers and health systems can use EHR data to target interventions and improve patient care by prospectively identifying at-risk patients

Findings from EHR Learning Network activities will be compiled in an Implementation Guide, designed for use by health systems. The Implementation Guide will describe the range of ways that EHRs are being used to capture data on frailty and functional impairment and describe best practices for implementing algorithms using EHR frailty/impairment data for population management and in support of patient-centered care.


Planned activities for the EHR Learning Network include:

August 2020 – Engaging Stakeholders
RAND will share information about the claims-based algorithm development process on this website and through direct emails to EHR Learning Network members.

September 2020 – Small Group Interviews
ASPE, RAND, and partners from Johns Hopkins University will conduct small group interviews with practitioners, health systems, researchers, and EHR vendors about how frailty and disability are captured in their EHRs, how they use EHR data to identify and manage high-risk patients, and the factors that facilitate or prevent EHR data from being used to prospectively identify frail or disabled patients or those at high risk of future frailty or impairment.

November 2020 – Case Studies
RAND will share case studies of how EHR data are being used for tracking and identifying patients at risk of frailty or functional impairment.

Spring 2021 – Algorithm Feedback
ASPE and RAND will share a draft EHR-based algorithm with EHR Learning Network participants and gather their input.

Summer 2021 – Algorithm Testing
RAND will recruit interested EHR Learning Network participants to perform pilot testing of the EHR-based algorithm.

Fall 2021 – Feedback on Implementation Guide
RAND will solicit EHR Learning Network participant feedback on the draft Implementation Guide.

Spring 2022 – Dissemination
RAND will share lessons from the EHR-based algorithm testing with the EHR Learning Network and release the Implementation Guide.

How to Get Involved

ASPE and RAND recognize that the health systems and researchers who use EHR data in their everyday work, and vendors who are developing EHR functionality, are all a rich source of information on how EHR data can be used to identify and manage patients at risk of frailty and functional impairment. Please sign up to be part of the EHR Learning Network by sending us an email at You will be added to our listserv to receive periodic emails with project updates, announcements of learning events, and opportunities to share best practices and provide feedback on the algorithm development.

Visit the Frailty and Functional Disabilities main project page for more information on this topic.