Population Health Management (PHM) is an approach to primary healthcare provision that integrates active patient outreach and engagement. It has shifted primary care service delivery from reactive to proactive management of a certain group of the community or population.

Effective population health management typically occurs in established clinics, healthcare provider organizations — and even in the community. In this approach, health solutions include a broad range of activities, such as curative and preventive care, public health initiatives and engagement with social determinants of health (SDOH) to improve health outcomes.

What is Population Health?

Population health refers to the health of a specific group of individuals which form a population. Most of the time, a population is made up of people within the same geographic location, such as a city, county, state or country. In population health analytics, we are concerned about the medical and health outcomes of individuals who belong to the same population or group. Health systems will look at the differences in health outcomes in this population, then assess the causes, such as income disparity, levels of education, resources, quality of healthcare management and even the ratio of medical professionals to patients.

Meanwhile, is it also essential to look at public health. Public health systems tackle a variety of population health issues, such as vaccination reminders, quarantining people with communicable diseases, holding mobile health check events and focusing on other front-line aspects to safeguard the general health of everyone in the community — without looking at individual patient needs. Public health is the reference for policy and laws.

Population Health Analytics

Population health analytics uses patient data to enable healthcare providers to make informed management and strategy decisions based on data analytics.

Healthcare organizations can utilize data analytics to improve population health management by employing models for value-based care. For health systems to successfully transition to this paradigm of value-based care delivery, actionable analysis on data from individual patients and populations is needed.

Physicians, healthcare providers and payers also need access to better data insights. These insights can improve clinical, financial, operational and even health outcomes to achieve more significant change in patient outcomes.

According to the Centers for Medicare & Medicaid Services (CMS), the groups focused on population health management are driving the need for population health analytics. These include groups of doctors, hospitals and other healthcare providers collaborating and accepting accountability for the cost and quality of care delivered to patients.

To embrace the value-based care model and integrate population health management into their operational processes, work culture and information technology systems, healthcare organizations must start by looking at data analytics.

Using population health analytics will allow healthcare organizations to:

  • Enable healthcare workers to ask and answer their own questions with science-backed data
  • Measure population health with segmented data
  • Use data visualizations to coordinate care across the community
  • Track and understand the population and individual risk factors
  • Proactively manage patient relationships and improve patient outcomes