The TSWF MHS Pop Health Portal AIM form is intended for input of metric-related (e.g. HEDIS) clinical data that is not already captured in the routine MTF data systems (lab,radiology, etc.). In most cases, the form is not used by providers, but by designated support staff, usually those responsible for population health actions.

MHSPHP AIM form updates effective 14 Nov 2019


MHSPHP Recent Changes

See Visual Change Log (below) for Core-Compatible form changes that apply to this form.

Mid-Cycle Changes

Added fields for:

    • Date admitted to hospice
    • Date of death
  • Added clinical clue: “Enter date when a patient either was admitted to hospice or the date a patient died. Add auditable documentation as appropriate. In either case, the patient will be excluded from all population health metrics and due/overdue notifications.”

Added fields for:

    • Colorectal cancer screening: Next due date: (and options list)
    • Cervical cancer screening: Next due date: (and options list)
    • Breast cancer screening: Next due date: (and options list)
  • Added clinical clue: For Patients at Increased RiskFor patients whose provider determines a need for a non-standard testing interval, such as family history or other reasons, enter the date when the next screening is due and what test has been recommended to be done at that time.A date entered here will trigger corresponding due/overdue reminders in the MHSPHP.


  • Added clinical clue:*These tests do not count toward or replace HEDIS metric criteria for routine preventive services exams and therefore do not impact the patient’s due/overdue status in the registries.
  • Created by TSWF and DHA Information Delivery Division
  • Solve the problem of missing HEDIS-related tests or results
  • Form elements added from user feedback
The MHSPHP AIM form was created by a joint effort between the TSWF team and the DHA Information Delivery Division who manages the MHS Population Health Portal and associated metrics. It was created to solve the problem of enrolled patients having a HEDlS-related service completed, without the MHS having a record of the test or result. This was occurring because the test/result was completed outside the MTF and not billed to Tricare. Elements on the MHSPHP AIM form have been added as a result of user feedback, so please share your input.
Form Lead
Dr. James Neville, MD, MPH, FACPM

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