Three Essential Systems for Effective Population Health Management

People in the healthcare industry use the term population health management (PHM) to refer to a wide range of initiatives that vary wildly in scope and purpose. However, there is broad agreement that population health requires a healthcare organization to deliver the most effective clinical care at the lowest necessary cost. Providers must identify populations of patients with similar clinical conditions and apply evidence-based interventions and treatment protocols. To effectively manage population health, healthcare organizations need three essential capabilities.

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Healthcare Analytic System

An effective PHM program must manage and measure the care delivered in many different care settings: a hospital, a physician’s office, a skilled nursing facility, a long-term care facility, and even the patient’s home. Because of the varying financial and clinical requirements of providing care in these different settings, technology vendors have specialized their products for each of these care settings. While these products typically meet the needs of the care setting for which they are designed, they are ill-suited to measure care delivered across multiple care settings.

Deploying an enterprise data warehouse (EDW) is the best way to measure the revenue, costs, and the quality of the care provided in these various care settings. An EDW aggregates information from a variety of different care settings to provide clinicians and administrators a complete picture of the care provided.

Best Practice System

There are approximately 28,000 articles published each year in peer-reviewed clinical journals. These articles advance our understanding of the practice of medicine and contribute to the body of knowledge available to clinicians. Few clinicians have the time to identify and absorb the advances relevant to their field of expertise. Medical schools have long recognized the value of journal clubs, an informal forum where physicians can present and discuss papers and findings from the literature.

Healthcare delivery organizations must develop a systematic approach for assimilating new knowledge and making it available to clinicians in a way that makes it easy to do the right thing. For example, infection is one of the primary complications of an appendectomy procedure. In 2010, the American Pediatric Surgical Association Outcomes and Clinical Trials Committee published a review of studies on antibiotic therapy in children with acute and perforated appendicitis. The review shows that use of pipericillin/tazobactam monotherapy was just as effective and cost less than more expensive triple agent therapies. The paper recommends preoperative prophylaxis for all pediatric patients having an appendectomy.

Using the information from that paper, a hospital knowledge manager might create a new order set for appendectomies that includes this antibiotic. He or she may also prepare an educational summary of the paper and the recommended order set changes for review by clinicians.

Healthcare Adoption System

The Institute of Medicine asserts that it takes 17 years for new knowledge generated by randomized controlled trials to be incorporated into practice, with the caveat that even after 17 years, the application of knowledge is still highly uneven.

A dependable mechanism to affect change throughout an organization takes a lot of effort to nurture and develop. It requires executive sponsorship from the CEO and clinically focused improvement teams with participation from physicians, nurses, administration, and information technology. It often requires investments of human capital which do not yield immediate benefits. However, the long-term returns are compelling. Organizations that can efficiently implement change are those that thrive in a dynamic environment.

Symptoms of Weak or Ineffective Capabilities for Population Health Management

Healthcare delivery organizations often have only fully developed one or two of these capabilities. Frequently, an organization’s maturity and expertise in one area is far ahead of their abilities in another. Here are some frequently observed symptoms of missing, ineffective, or unbalanced capabilities.


Analytics System Only – Focus is on reducing the information request queue, without a clear path to effective interventions and process improvements. This is an information-centric approach, often sponsored by IT, with the idea that if we build it, they will come.

Best Practice System Only – Focus on academic research, with lots of published papers. Minimal practical application.

Adoption System Only – Infrequently encountered because it’s a self-solving problem. Clinicians stop coming to meetings if best practices and analytics are both missing.

Analytics System and Best Practice System – Science projects with pockets of excellence but limited roll-out of improvement across multiple facilities.

Best Practice System and Adoption System – Temporary improvements with limited scale. Ultimately not sustainable because manual measurement with spreadsheets can’t scale to dozens of improvement projects.

Adoption System and Analytics System – Paved cow paths. Processes have been automated but not improved.

Effective Population Health Management

An effective population health management program requires fundamental changes to the way patient care is delivered and managed. An analytic system aids understanding of where a health system is, a best practice system helps the system figure out where it needs to be, and an adoption system empowers the journey. Healthcare delivery organizations with all three of these capabilities have the essential components for an effective population health management program.

For a more detailed description of each of these systems, read Dr. David Burton’s executive report, Population Health Management: Implementing a Strategy for Success.

Learn the 12 critical steps necessary to evaluate a population health management company in A Landmark, 12-Point Review of Population Health Management Companies.

What do you think of the three systems approach to population health management? Have you seen inefficient capabilities in your organization?

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