ANALY TIC S & H E A LT H CA R E
POPULATION HEALTH
MANAGEMENT
Population health management is about improving health outcomes for a
group of individuals and
removing health inequities. Caring for a population’s health is anything but
trivial. A 1961 report, which
was vindicated 40 years
later in 2001, showed that
only 27 percent of the patient population reports
any health issue to clinical
providers [2]. This means
a health system managFigure 2: Steps in population health management.
(Source: Population Health Management, Institute for Health
ing a large patient populaTechnology Transformation)
tion having one or more
chronic conditions often does not have
overweight and a smoker, and 3) patients
access to accurate information about its
who are relatively healthy with low utilizapatients. It takes patient data, interoperation of the health care resources.
bility and analytics to address this problem.
The middle group is the largest group,
As Figure 2 demonstrates, many steps
and Lisa Bielamowicz, M.D, chief mediand tasks are involved in managing popucal officer of the Advisory Board Comlation health effectively. The application
pany, described them as the “rising risk”
of health IT systems such as electronic
patients. It’s just a matter of time before
medical records (EMR), telehealth, disthey become part of a high-cost patient
ease registries and analytics is a mandacluster. Effective management of this
tory requirement for success. Any given
group is important to reduce the health
population can be divided into three main
system’s total-cost risk exposure. Findclusters: 1) patients with high utilization
ing out who they are and when they need
of health care resources, 2) patients with
intervention is a key to managing a risktwo or more primary diseases, typically
based payment model [3]. Unlike bringing
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