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What You Need to Know About Population Health

March 7, 2018 BY Alanna Moriarty

What You Need to Know About Population Health

*Updated October 2019

What is Population Health Management?

Population health addresses the specific wellness needs of a local or regional community. This could include age-related illnesses like heart attack or high blood pressure, or environmental factors such as air quality or prolonged stress. Population health management refers to the improvement of regional health outcomes through the identification and monitoring of individuals within a target group. Providers collect and analyze relevant data to create a comprehensive view of individual patients and local populations.

Physicians and providers throughout the healthcare continuum use various tools and methods to collect patient data. This includes information tracked by EHR systems, Medicare and all-payor claims, lab results, prescription patterns, referral data, and more. Successful population health management programs offer providers real-time data and updates that enable them to address gaps in care as well as new issues that may arise.

Most Important Data for Population Health Management

  • Diagnosis and procedure data, including charges and payments
  • Patient-reported outcomes and developments
  • Social and environmental health determinants

Getting Value from Your Data

When managing population health, it is essential that your practice or facility has a plan in place. The data you collect, as well as the methods you use, will depend on the results you’re aiming for. Before you begin gathering data, your practice or facility should be able to answer these questions:

  • What is the purpose of this data collection?
  • What data is most relevant?
  • In what ways would you like to improve? i.e., care outcomes, cost reduction, readmission reduction, etc.
  • Is there any information missing from the data you currently have?
  • How can your data collection techniques improve?

For example, if you’re looking to decrease the instance of COPD or lung cancer in your community, your practice could sponsor a smoking cessation campaign or host a support group for smokers. The purpose of this data collection is to understand the root causes of smoking, as well as the lifestyles of your patient population. Relevant data could include stress levels, socioeconomic class, individual and family health history, etc. The goal of this program would be to decrease the number of cigarette smokers in order to reduce the overall risk of tobacco-related illnesses.

Additionally, your physicians may have data on the length of time a patient has smoked cigarettes, but lack data on a patient’s employment—which could influence smoking habits. Perhaps your patients don’t return surveys sent out in the mail but respond well to surveys sent via email. Consider using incentives, like a gift card or free follow-up visit, to encourage more patients to share relevant information.

Top Vendors of Population Health Management Systems

Vendor Name # Installations
Epic 1,642
Cerner 481
IBM 151
eClinicalWorks 147
Meditech 70
athenahealth 67
Phillips Healthcare 67
Advisory Board 42
Evident 34
Allscripts 31

Fig 1 Data from Definitive Healthcare’s Technology Insights tool within the Hospital and IDNs platform, accessed October 2019.

Communication and Data Sharing

Nurses play a critical role in treating patients and spotting trends in population health. They’re the first care providers that patients encounter — establishing a rapport and earning patients’ trust. Nurse practitioners can gather data and glean insights that a physician may not notice or have time to fully process. They are also more likely to hear patient concerns and frustrations regarding the check-in and appointment-making process, which are valuable insights and can be used to improve patient experience.

Additionally, because nurses see so many patients, they are more easily able to note when multiple patients are coming in with similar symptoms, or have comparable environmental factors affecting their health. Nurses can alert physicians to large number of patients visiting urgent care clinics between primary care appointments, which can indicate chronic health conditions or a spike in infectious diseases. Clear communication between nurses and physicians not only improves care delivery, but also enhances the data collection process for increased understanding of a patient population.

Partnerships between physicians in the same geographic location, or between those with patient populations facing comparable health issues can also be valuable in many ways. Building affiliations with local hospitals and care providers allows physicians to refer patients to capable specialists, and can have the added benefit of keeping a patient within one care network— potentially reducing associated costs, and making it easier for providers to coordinate care. 

From a population health standpoint, data sharing between providers within one region can highlight widespread problems or common illnesses. It could also alert providers to specific regional health issues, such as low air quality, water contamination, or other environmental factors. Providers whose patient populations are facing similar health and wellness issues — even in disparate locations — can benefit from shared data on treatment methods and care outcomes.

Data collection and sharing has been made even easier with the near-ubiquitous adoption of electronic health record (EHR) systems, wearable fitness trackers, and other technologies. EHR systems allow providers to easily access and record patient data, which follows them to whichever care facility they visit. The ease of data collection also improves reporting processes and offers greater insight into health and wellness patterns on a small, community scale or on a large national scale.

Top Vendors of Patient Portal Applications

Vendor Name # Installations Market Share
Epic 2,000 28.2%
Cerner 1,011 14.2%
Meditech 510 7.2%
Evident 413 5.8%
Medhost 311 4.4%
Allscripts 298 4.2%
Perficient 187 2.6%
Change Healthcare 174 2.5%
InteliChart 133 1.9%
HealthGrid 110 1.5%

Fig 2 Data from Definitive Healthcare visual dashboard on Technology Vendor Market Share, accessed October 2019.

Patient access to their personal health history and giving them improved access to their care providers increases the probability that they will be more involved in their care. Patient investment leads to better care outcomes, including lower readmission rates and reduction in care costs. Technology and communication enable providers to collect even more useful data on individual and population health. However, there is still no standard method of measuring the value of data that’s been collected—and such a method isn’t likely to debut any time soon.

What constitutes valuable or actionable patient data is very specific to the goals of an individual provider or care facility. Useful information could mean learning more about patient lifestyles, or it could mean analyzing historic claims data from counties with high rates of opioid dependence. Regardless, the role of technology in collecting, sharing, and analyzing data is unlikely to decrease in the near future.

Learn More

Interested in staying up to date on the latest trends in population health management? Want to know which EHR vendors are being utilized in hospitals and healthcare facilities across the U.S.? Definitive Healthcare tracks technology for more than 8,800 hospitals and IDNs, as well as hundreds of thousands of physician groups and outpatient surgery centers. Definitive’s platform allows you to search for hospitals and providers participating in population health management, and benchmark your progress against competitors with:

  • Detailed hospital financial, clinical, and quality metrics for your practice, and that of competitors
  • Population health analytics and vendor market share
  • Merger and acquisition activity, new hospital services, and other provider developments

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