Dallas County Launches New Diabetes and Hypertension Surveillance Systems
DALLAS – On September 10, 2025, Dallas County Health and Human Services (DCHHS), in collaboration with Parkland Health and the Parkland Center for Clinical Innovation (PCCI), launched the Diabetes and Hypertension Surveillance Systems, which are powerful new tools designed to track and better understand diabetes and hypertension across Dallas County.
The systems will feature publicly accessible dashboards, available on the DCHHS Chronic Disease Prevention webpage, offering timely, reliable data to inform community health strategies, research, and public policy. The surveillance systems integrate multiple data sources to provide insight into key indicators and their impact by zip code or census tract:
-Clinical indicators such as ED visit, obesity, A1c measure, missed BP measure, etc.
-Social determinants of health indicators including education and literacy, household income, disease burden, food insecurity, etc.
-Other indicators such as “number of diabetes prescription fills in the past 3 months, etc.
The dashboards will allow users to explore population data by age, sex, race/ethnicity, and education, giving residents, providers, and policymakers a clearer picture of diabetes and hypertension vulnerabilities and patterns in Dallas County.
“The launch of our new diabetes and hypertension surveillance systems represents a major milestone in strengthening our public health response,” said Dr. Philip Huang, MD, MPH, DCHHS Director/Health Authority. “By combining clinical data with social and demographic information, we can better identify at-risk populations, guide policy, and ensure that prevention and treatment efforts reach those who need them most.”
“It takes a connected community to support the health and wellness of our region, and these AI-driven dashboards provide comprehensive, hyper-localized insights into the risks and underlying factors of some of the most prevalent and harmful chronic conditions. These insights and data are critical to coordinate support and align interventions for maximum impact and we’re excited to make these available to the whole community.”
Steve Miff, PhD, CEO at PCCI
“The creation of this dashboard has brought together the non-medical drivers of health and clinical diabetes data to allow us to both understand what is going on in our communities and how to create a multi-pronged approach to address it,” said Uma Gunasekaran, MD, Endocrinologist and Executive Medical Director of Parkland’s Global Diabetes Center. “This is great information for our health systems but also for the public to see as well.”
Join PCCI’s Mission to Support the Most Vulnerable in Our Community through the North Texas Giving Day
On Thursday, September 18, 2025, PCCI is participating in Communities Foundation of Texas’ North Texas Giving Day, an online giving extravaganza for non-profit organizations from the whole region. We’re raising funds to further our mission to support the health of vulnerable communities in North Texas through the responsible applications of AI and non-medical drivers of health (NMDoH) analytics, and your gift helps make this possible!
Additionally, your support will benefit PCCI’s women in data science intern program, the Sachs Summer Scholars. PCCI developed this STEM-focused program to help open doors to women seeking careers in data science. This is an industry challenge as, according to Girls Who Code, from 1984 to today, the number of female computer science graduates dropped from 37% to 18%. At PCCI we are committed to reversing this trend in the data science and technology industry all while focusing the intern’s contributions, efforts and learnings towards innovative, practical solutions supporting our local community.
Through early giving, you can make your North Texas Giving Day contribution now! The platform makes it simple and easy to give. Between now and September 18, you can make your gift online at NTGD-PCCI.
Save the Date for September 18, when you can follow along by checking the North Texas Giving Day leaderboards, prizes page, and social media channels for exciting updates and announcements.
Thanks for your support of PCCI and for being a part of the North Texas Giving Day movement!
PCCI’s Community Vulnerability Compass Delivers Actionable Data to Municipal, Community-Based Organizations and Healthcare Providers
By Lance Rather, Senior Director, Product & Strategic Partnerships, PCCI
My goal, as part of a healthcare innovation organization, has always been to find factual and data-backed understanding of the community I’m trying to serve. At PCCI, we focus on finding opportunities to support vulnerable populations through actionable data. With our Community Vulnerability Compass (CVC), we’ve been able to go beyond assumptions and deliver hard facts about the health of our community. Currently, hundreds of organizations around the state are either using or are set to receive access to the CVC where they can leverage powerful, data-driven insights.
Since its creation, we have been able to use the CVC in a variety of ways to reveal actionable insights about the health of communities around Texas. PCCI’s CVC provides an interactive dashboard that helps stakeholders—including community-based organizations (CBOs), safety-net hospitals, health systems, philanthropic organizations, governmental agencies, universities, and managed care organizations (MCOs)—to make informed decisions that enhance health outcomes and drive equity in service delivery. The CVC breaks through “what we think we know” to provide hard facts, including root causes of the overall state of any given area down to the block group.
Using Dallas County as a test case, we demonstrated how the CVC can surface community needs in relation to the area’s socioeconomic realities. For example, we examined the mental health state of Dallas County and the CVC found the areas of the county that have historically faced economic challenges were also the most vulnerable to mental health issues.
The CVC was also able to break through assumptions about communities experiencing high social or structural barriers. We found that in Dallas County, regardless of the economic condition, low vulnerable ZIP Codes had high vulnerability neighborhoods and high vulnerable ZIP codes had low vulnerability neighborhoods. In some areas you could see a high or low vulnerability area separated by a single street. This provides our community leaders an opportunity to reach all vulnerable areas, and it offers root cause insights into a neighborhood’s vulnerability. These insights allow us to appreciate the individual strengths of each area in our communities.
PCCI also conducted a full vulnerability assessment of the five largest counties in Texas (Bexar, Dallas, Harris, Tarrant and Travis counties) where we found more than 4.2 million residents live in high or very high vulnerability block groups. We learned that Bexar County had the most vulnerable block groups of the five counties where the most prominent root cause for its vulnerability is neighborhood safety, followed by chronic diabetes and households without vehicles. Additionally, the largest county, Harris, had the second most vulnerable block groups, but also had the highest number of low vulnerable block groups, with the most vulnerable block groups indicators being Neighborhood Safety, followed by Health Insurance Coverage and Mental Health.
These assessments are powerful examples of how the CVC is helping us gain a better understanding of our communities and the variety of root causes that drive the vulnerabilities throughout the state. Beyond analysis, we are seeing the CVC used in practical daily uses that have a direct impact on our residents.
For example, PCCI’s CVC has been incorporated into a variety of solutions throughout Texas, including adoption across the Parkland Health system, by the Dallas County Department of Health & Human Services, the University Heath (San Antonio) Transplant Center. Beyond dashboard access, for larger organizations, we offer the ability to reverse geocode individual-level data and append block group–level CVC insights. These insights can be integrated directly into electronic health records or customer relationship management systems, allowing organizations to use localized non-medical drivers of health (NMDoH) as a meaningful proxy at the individual level—enhancing precision in population health efforts, risk stratification, and targeted interventions.
PCCI’s CVC also serves as the backbone for the United Way of Metropolitan Dallas’ Data Capacity Building Initiative (DCBI), which is helping hundreds of organizations in North Texas turn insights into impact. The DCBI initiative has shown how the CVC is scalable and usable outside traditional healthcare settings. For instance, one CBO is using the CVC’s block group data to understand more about residents’ situations and tailor services more prescriptively. One organization has become better positioned to help victims and their children get out of harm’s way using the CVC, while another CBO is using the data to confirm service overuse in certain neighborhoods and service deserts in others.
An underlying goal for PCCI is to leverage the CVC to create a standard language and shared understanding around how NMDoH is utilized in Dallas County and beyond. This shared understanding would allow CBOs, governmental and healthcare providers to collaborate around a shared language of data in a more efficient manner.
Above all, the CVC fosters collaboration among diverse stakeholders by creating a shared understanding of community vulnerabilities and empowering organizations to advocate for and implement policy changes that address systemic issues. By addressing both health and overall equity, the CVC empowers safety-net hospitals and clinics serving vulnerable populations, funders, and CBOs to develop comprehensive strategies that enhance access to essential services, improve health outcomes, and ultimately promote social justice. In doing so, the CVC serves as a critical tool in advancing health equity, driving policy change to break cyclical inequity, and addressing systemic issues that impact the well-being of individuals and communities.
Learn more about the development of the CVC in PCCI’s recent publication in JAMIA which highlights how the CVC elevates insights and expands on the performance of existing tools that measure community socioeconomic variation.
Lance Rather is the Senior Director of Product and Strategic Partnerships at PCCI. At PCCI he leverages his extensive expertise in technology and data analytics to develop and refine health-related products. Lance plays a crucial role in the creation and enhancement of tools like the Community Vulnerability Compass (CVC), focusing on making complex data accessible and actionable for healthcare providers and policymakers.
