Transform Your Practice: How Population Health Can Help You and Your Patients


Population health represents a massive shift in the cultural foundation of healthcare.

You probably hear the term tossed around at conferences and in social media, but we want to use this article to familiarize you with what exactly it is, how it’s being used, the technology around it, and how you can expect it to impact your world as a provider.


What Population Health Is

In its broadest sense, population health is the health outcomes of a group of individuals, but it also includes looking at the distribution of those outcomes within the group. Those groups can be determined by multiple demographics including


  • Geography
  • Race/Ethnicity
  • Gender
  • Socioeconomic status
  • Nations/Communities
  • Company of employment
  • Disability
  • Relationship with the penal system


One of the broad goals of population health as a management initiative is to eliminate differences of health within groups, or at least reduce them substantially. It’s most important to note the distinction between the overall health within these populations and the distribution of health within those same groups.

Another important distinction to make is between that of population health and public health. Public health refers the critical functions of state and local public health entities (e.g. epidemic prediction, containment of environmental hazards, the encouragement of healthy behavior.) That said, broader definitions that include the insurance of the health of the public can intersect with the concept of population health.

Whether it intersects with public health or not, population health will involve multiple stakeholders, technologies, and principles in its application.


How Population Health Is Being Used

Since population health is such a broad concept, you’ll see it popping up everywhere from the treatment of different diseases to the basis of tech development and research. Here are a few examples of the most prominent areas you’ll see it referenced.


Disease Management

The world is losing its battle against diabetes. In the U.S. alone it is the sixth leading cause of death as well as the leading cause of non-traumatic amputations, new cases of blindness, and the leading cause of kidney failure. Population health-based initiatives are promising a new way of addressing this growing problem.

disease management

One of the most challenging aspects of the addressing diabetes is the sheer complexity of the condition. Because of fragmented services, chronic patients may visit over a dozen separate physicians in a year, increasing their chance of being subject to the effects of a medical error, even within the same provider community of one hospital. Much of this is caused by the disconnect in information sharing between acute care and other settings. Patients and their families are left to coordinate care through the healthcare continuum themselves, leaving us with the fact that only 56% of care that is recommended by physicians is actually received. Add on the issue of self-management in the diabetic patient (a heavy influencer of health outcomes) and the results aren’t surprising.

Both payers and providers are coordinating their efforts to use population health to address some of the shortfalls in diabetes management. Once an organization has identified a cohort of interest (this might be age, geography, diagnosis, or another demographic factor) they can identify gaps in care, begin stratifying the cohort based on risk, and then move on to properly engaging the patient, managing care, and measuring outcomes.


This involves outreach, education, treatment and assessment, and prevention to maintain contact with a patient that flows through all points of the care process — before, during, and after medical intervention. Clinicians, financial analysts, and IT teams have been organized by strategists to map three, population health-based paths that lead to better diabetes outcomes with lowered costs.


  • Stratifying patients based on clinical risk: This involves the use of aggregated data and predictive analysis to identify patients, cut back on delays in their diagnosis, establish consistently managed care, and improve resource allocation.
  • Coordinating care across the continuum: This path means eliminating miscommunication and ineffective transitions between providers to improve collaboration across the entire care community. Care management programs are deployed to provide better guidance to the most at-risk patient groups.
  • Improving outcomes by engaging patients: The inclusion of the patient and family in the work of the care team is effective in increasing satisfaction and better enabling compliance with established preventative practices.


Government Programs

While the benefits of population health are largely obvious, coordination at a national level has required the involvement of the federal government. CMS, with its traditional focus on the elderly and lower-income brackets, has moved to focus on supporting programs that prioritize behavioral, social, and environmental factors.

Their initiative, Quality Strategy, was launched at the beginning of this year and, according to, aims to “reconcile clinical and community views of ‘population health’, or the groups beyond those enrolled in a health system.”


To expand program outreach, CMS is developing its Innovation Center where it tests new approaches to achieving goals such as connecting providers and patients to social services and care management payments to “non-face-to-face” services.

Medicare and Medicaid may offer more flexibility in comparison to fee-for-service contracts in reimbursing population-based services. Accountable Care Organizations (ACOs) are also looking at ways to pull non-clinical members into care teams to address connecting high-risk patients  and help them address barriers to care that are socially and community-based.

CMS also emphasizes the fact that it can use its authority in other ways, one example of which is its State Innovation Models (SIM). These require that participating states use their payment, regulatory, and policy authority to improve the health of their populations.



Universities around the country are making amazing strides in multiple aspects of population health.

Clemson University has recently announced its plan to worth with community partners in using population health to improve the well-being of South Carolinians overall. Recently, the school invited experts from different land-grant universities across the country to discuss and share ideas around Cooperative Extension Service programs that have been effective in their respective states.


South Carolina presents a host of health issues including high obesity rates (17 percent of their children are obese and fewer than half meet the recommended levels of physical activity.) Over 80 percent don’t eat enough fruits and vegetables and the state overall ranks 42nd in the country in terms of health, largely due to its high rates of diabetes and obesity.


Extension programs in the population health management vein include youth development, food safety and nutrition, agricultural production, environmental stewardship, forestry, water quality, and community development.


The Technology Behind Population Health

The application of population health relies heavily on modern technology, most notably, data/analytics and mobile health solutions.


Data and Analytics

Much of the core technology and tech concepts behind population health are already common on the healthcare scene…EHRs, Meaningful Use, interoperability, disease state management, the patient-centered medical home, and accountable care organizations all tie back because population health is founded on data — data that must be measured and managed.

One of the most important goals of population health is finding gaps in care.

This is done most commonly by leveraging data and analytics to empower providers to deliver on population health management goals. Companies like Dallas-based Phytel are pioneers in this area and on their end have found a way to integrate with the EMR to reach out to patients and physicians under the health organization brand, since it’s something patients recognize well.


referralMD report Example of a referralMD report that helps manage referral status between organizations. –


Proper implementation of population health also requires that the truth in data be found. According to Eric Mueller, president of WPC Services in Nashville, TN, this requires three, core points of knowledge:

  • Knowing the data you have access to
  • Knowing how easy it is to access that data
  • Knowing what data points you have throughout the continuum of care


All of these have different data points and require different types of expertise. These points are especially important when it comes to managing chronic conditions and reducing hospital readmissions, as they all point back to helping people stay engaged and make informed decisions.

That engagement is what keeps patients and family caregivers motivated and feeling connected to the care team. When patients are empowered with pertinent information, they’re more highly motivated to change their behavior.

Beyond individual patients, population health management data is also used in monitoring and containing the spread of contagious diseases and food-borne illnesses. Look at the example of the recent Ebola outbreak and the use of health IT by the WHO and CDC in the form of data from local hospitals, local doctors’ offices, individuals, and other health entities to gather insight and statistics as a basis for implementing protocols and understanding the spread of the disease itself. This situation highlighted a need for improved data in population health when patient Thomas Duncan was sent home after his initial ER visit because his recent trip to Liberia was not properly populated in an area of the EHR.

The importance of data analytics to population health was being discussed well before the outbreak though. A report released in 2013 by the Institute Of Health Technology Transformation found the following statistics


  • Clinical data warehousing and mining tools were being used by only 30 percent of U.S. hospitals
  • Only 33 percent of healthcare organizations were using business intelligence (BI) tools at the time of the report
  • A full 80 percent of electronic health data was unstructured


All of these point to a healthcare environment that is collecting the data needed for population health management, but that is still developing the best ways to do so.



The heart of population health management is data, but that data cannot be properly collected without the patient.

Up until now, health information was collected at a point of interaction with a provider, but advances in mobile health (mHealth) have meant that patients can contribute to population health management in ways that are engaging and simple, and that they may not even be aware of at all. The ubiquity of cell phones and mobile services along with the timeliness of data has opened a world of patient information collection that was simply impossible before now.

Mhealth technologies

mHealth at the patient level includes technologies such as:

  • Cell phones
  • Wearables like Fitbit and Apple Watch
  • Sensors
  • RFID and beacon technology


The effectiveness of using these tools in population health initiatives have already been proven. A study was conducted on HIV-infected patients in Kenya around adherence to their antiretroviral medication. The patients were sent text reminders and after a year, it was found that those who were receiving the messages were 27 percent more likely to be adherent to their medications and 19 percent more likely to display fully suppressed viral levels in comparison to patients receiving standard care. The patients specifically indicated that they felt like somebody cared and that they had access to personalized advice when needed. Similar techniques are being applied to smoking cessation programs in the U.S.

The information flow around population health has to go both ways though, and solutions that allow patients to send their information to providers and health agencies — patient portals, wearables, telehealth and remote patient monitoring solutions — all play a part in not only informing patients, but also ensuring that their health outcomes are being properly evaluated and monitored.

These devices (frequently associated with the Internet of Things) can use passive patient-generated data to fill gaps in EHRs — an issue that the industry is still struggling with. Data scientists are also using information gathered from social media to monitor information such as casual complaints of health problems, to identifying sleep disorders among users, to gathering information around the occurrence of adverse drug events.


How You Can Expect Your Practice To Be Impacted

Population health management actively involves all healthcare stakeholders, and providers should be ready to make changes to effectively manage their patient populations.

These changes will come most predominately in the form of accountable care organizations (ACOs). Population health management via ACOs changes the relationship between physicians and their patients.

ACOs are being promoted by the Federal government to facilitate the shift away from volume-based reimbursement models to ones based on efficiency and quality. This means that individual practices will have to take on new levels of fiscal responsibility on their part. Practices will be rewarded by Medicare and some private payers through shared savings, but it’s expected that reimbursement will shift toward prepayment models as well as full capitation (fixed monthly payments for a defined set of services for each patient assigned to a practice.) This is expected to incentivize providers to, instead of seeing more patients, focus on improving health and preventing expensive illness and extraneous care. Payment bundling and shared savings will also be founded on this basis of population health.

Accountable Care Organizations

If you intend to stay aligned with newer reimbursement models, expect to feel pressure to move toward a population health management approach.

To help ease this transition, the U.S. Agency for Healthcare Research And Quality (AHRQ) introduced the concept of “practice-based population health (PBPH), emphasizing the responsibility that primary care groups and networks have in positively impacting the health of their patients.

Performance measurement and quality reporting will happen at the level of entire medical groups or healthcare organizations (which is where risk-bearing ACOs fall financially), but on a clinical level, population health management will focus on the primary care doctor, or the “patient-centered medical home”, which serves as the basic building block of the ACO.

For individual practices, that means a necessary awareness of the prevalence of health risks including alcohol use, sexual behavior, smoking, skin protection, and eating habits in your patient population, and also monitoring nutrition, physical activity stress levels and weight patterns. Many employers and third party insurers already include validated health risk assessment (HRA) instruments into their benefit packages to generate the data to evaluate these issues.

To prepare, you will need to begin implementing initiatives around


  • EHRs
  • Care management staff
  • PCMH (patient-centered medical home)
  • Patient portals
  • Quality improvement measures


As it stands, most practices are under-prepared for the era of population health management with workflows still organized around visit-based care models and staffing structures centered around provider needs instead of patients. Re-engineering will require that physicians no longer see themselves as the center of the office, but as part of a team that is centered around the patient.


Healthcare analytics and workflow


These teams will share responsibilities for patient care with other team members with doctors seeing patients only when necessary and passing off visits to other members when possible. Primary care offices will need to increase patient capacity without sacrificing quality of care, something that will require changes in workflow, revamping work processes, and delegating clinical responsibilities.

All of these changes will have to be rooted in a cultural shift in your practice. This will come in the form of longer hours, scheduling that is open-access and the ability of patients to request refills and appointments in online environments. Management of the most severely ill patients may require hiring managers that were never part of the care team before.


First Steps In Implementing Population Health At Your Practice

The road to population health is a long one, but we’d like to suggest a few resources to get you started:

  • The PopHealthSummit: Part of the HIMSS Connected Health Conference. Held in Washington, D.C., November 8-11, 2015.
  • Tech advice from Healthcare Article on optimizing population health care coordination outcomes through the use of technology. Includes advice on workflow automation, using prospective quality reporting data and HIEs, and patient portals post-implementation.
  • Patient-Centered Primary Care Collaborative: Not-for-profit membership organization focused on helping the primary care environment and the patient-centered medical home. Includes over 1,200 stakeholder organizations including payers, purchasers, providers, patients, and families.
  • Population Health Management Solutions: Request a free trial of referralMD’s Population Health solution.



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