Population Health Management: All you need to know about

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What is Population Health Management?

PHM can be broadly defined as “operational processes designed to foster health and quality improvements while managing costs (McAlearney, 2003).” Thus Population Health Management is the aggregation of patient data across multiple health information technology resources, the analysis of that data into a single, actionable patient record, and the actions through which care providers can improve both clinical and financial outcomes. The idea is to produce a healthcare service which does not start and finish at the hospital door, although intertwines all aspects of community and primary care.

Some key drivers in this definition include the following:

  • Access
  • Cost
  • Quality
  • Lifestyle Management
  • Demand Management
  • Disease Management
  • Care Coordination

KLAS describes four pillars of Population Management as:

  • Data Aggregation / Collection: Collection of data from various sources to bridge the gap between providers
  • Risk Stratification / Analysis: Segmenting patients to prioritize interventions and mitigate high utilizers
  • Care Coordination / Reporting: Efficient use of resources for better clinical outcomes
  • Outreach / Communication: Patient engagement and education for those who are at high riskWhy it matters?
Population Health management has many advantages:

  • Better Health Outcomes: The ultimate goal is to improve the quality of care by reducing goals
  • Preventing diseases: IT solutions that track and monitor patient health to manage care
  • Closing care gaps: When physicians have real time access to patient data, they can address patient needs in a timely manner. When all the systems like laboratory, EHR, Billing systems are integrated, providers can address gaps in service quality
  • Cost savings for providers: PHM helps in reducing costs by improving clinical outcomes

Conclusion: Automation is crucial to ensuring that every patient receives appropriate preventive, chronic and transitional care. Automation can also help organizations perform PHM efficiently so that they can make the transition from fee for service to Accountable Care while enhancing financial and organizational sustainability.

EHRs and automation tools should be used to support these essential PHM functions:

  • Population identification
  • Identification of care gaps
  • Stratification
  • Patient engagement
  • Care management
  • Outcomes measurement

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