What is population health management?

How it works

Population Health Management (PHM) seeks to improve the health outcomes of a group by monitoring and identifying individual patients within that group. Typically, PHM programs use a business intelligence (BI) tool to aggregate data and provide a comprehensive clinical picture of each patient. Using that data, providers can track, and hopefully improve, clinical outcomes while lowering costs.

A best-in-class PHM program brings clinical, financial and operational data together from across the enterprise and provides actionable analytics for providers to help improve efficiency and patient care. Delivering on the vision of PHM requires a robust care management and risk stratification infrastructure, a cohesive delivery system, and a well-managed partnership network.

While data may be used individually by each hospital or practice, rarely is the same BI tool used across the continuum of care, such as inpatient, hospital outpatient and ambulatory settings. Even less common is a BI tool that integrates information on physician billing, electronic health records (EHR), medical claims, labs and pharmacies.

A successful PHM program will give real-time insights to both clinicians and administrators and help them to identify and address care gaps within the patient population. A well-developed care management program is key to better outcomes and cost savings, especially in populations with chronic disease.

Care management is a critical component of PHM, and while the objectives of care management can vary from organization to organization, they tend to revolve around improving patient self-management, improving medication management, and reducing the cost of care.