A Guide to Successful Outcomes Using Population Health Analytics



Articles on population health management—and population health analytics— are showing up everywhere. It seems there is a lot of curiosity and concern about implementing a population health management strategy and getting solid population health analytics in place. But what do those two terms really mean?

A quick review of the literature shows that there are a lot of different definitions for population health management. And there are different ideas about how population health analytics can help. For example: Is population health management managing the health outcomes of a population of patients with a similar condition? Does it mean going at risk with payers for the outcomes of a population of patients (fee-for-value)? Is it using care management to improve outcomes for high-risk, high-cost patients? Or is population health management simply engaging patients and communities for better health outcomes?

Common Thread in the Definitions: Outcomes

There is a common thread running among these disparate definitions, though. And that thread is outcomes. Put simply, population health management’s objective is to provide the highest quality care (quality outcomes) with an optimal care experience for a population of patients (experience outcomes) at the lowest appropriate cost (cost outcomes).

The key question for population health management is this: How do we systematically improve outcomes for a population of patients, one patient at a time?


To get started, an analogy is useful. Just as it takes three things to create fire (oxygen, fuel, and heat), it takes three things to ignite outcomes improvement in populations (these will be covered in depth later, but as a high-level summary: it takes best practices, analytics, and adoption.)

So to reiterate and continue the analogy, fire and combustion take oxygen, heat, and fuel. If any one of these three elements is missing, the fire doesn’t work, and there is less efficient combustion. All three elements are needed for outcomes improvement too; not just technology; not just population health analytics.

three ingredients fireFigure 1: Three Ingredients of Fire

And the Three Ingredients of Outcomes Improvement

The goal is to create a combustion-like outcomes improvement engine. This can only be accomplished by systematically asking and finding solutions for the following questions:

  • What should the organization and individual clinicians do to provide optimal care? What are the evidence-based guidelines? (This is best practices.)
  • How are the organization and individuals within the organization performing? What is the compliance rate with a given guideline? Is care being provided to patients in the most effective and safest way? (This is analytics.)
  • Finally, how does the organization transform? How are innovations diffused across the organization? How are improvements deployed at every facility and with every clinician? (This is adoption.)

In summary, there are three essential questions in this approach: What should be done? How well is it being done? And how to get better and transform? Again, if one of these is missing—if one of these questions is not being asked—the outcome improvement effort suffers, and there is no outcomes improvement engine.

Redesign for Improvement

Paul Batalden, M.D., Emeritus Professor at the Geisel School of Medicine at Dartmouth, said, “Every system is perfectly designed to get the results it gets.” So, why doesn’t an organization redesign its systems to get better results and better outcomes?

3 ingredients improve PHMFigure 2: The Three Ingredients of Improved Population Health Management

Returning briefly to the fire analogy, leaders should ask if the organization rubbing two sticks together to get a fire. If so, that is a labor-intensive, inefficient approach—if it works at all. Does the organization have a machine that systematically produces combustion like an engine? One where it can produce outcomes improvements time after time, efficiently and sustainably?

Systematic approach to outcomes improvementFigure 3: A Systematic Approach to Outcomes Improvement


Best practices describe what the organization and its clinicians should be doing to provide optimal care to patients. They provide a repeatable method for integrating new medical knowledge into evidence-based guidelines. Clearly…

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