- The term “population health” was coined in 2003 to determine
the influence of different factors on the state of health in a
- Population health comprises the health outcomes of a certain
population while public health is the approach used to make
the health of a particular population better.
- Health outcomes build upon five factors: genetic
predisposition, environmental factors, socio-economic
conditions, lifestyle and access to healthcare services.
- Three elements make up the core of any population health
management solution: it should be designed to analyse big
data, report on individual and group outcomes, and manage
targeted care delivery by enhancing coordination between
providers, payers, and patients.
The term “population health” was coined in 2003 as
part of an effort to determine the influence of different
factors on the state of health in a particular group.
Almost seven years later, the medical community has
turned to medical app development
in order to facilitate
these efforts, and its popularity has grown significantly
since then. Let’s explore what the population health
management (PHM) tech does and why medical
organisations are adopting it.
Public Health vs Population Health
Before we discuss population health management
solutions, let’s first look at what population health is
all about, as it is often confused with public health.
Population health comprises the health outcomes of
some group of patients — a certain population. The
group can come from just one clinic, a city district, a
county, a state, or the entire country. Public health is
the approach we use to make the health of a particular
population better. Now the terminological fog is
dispelled, so let’s clarify what population health depends
on and how it relates to software.
Population Health Factors
The outcomes of diverse populations’ health do not emerge from nowhere. Health outcomes build upon five
- Genetic predisposition to specific health conditions
- Environmental factors, including housing, availability of
healthy foods, clean air and water, and exposure to toxins
- Socio-economic conditions like income, education,
employment, and culture
- Lifestyle: alcohol consumption, tobacco use in any
form, diet, and exercising
- Access to healthcare services and their quality
But how do experts determine their influence on
populations? Checking and analysing all available
parameters manually would be exhausting and error
prone. This is where automated tools step in to speed up
the process and make it less costly.
Three Pillars of Population Health
Three essential elements make up the core of any
population health management solution: it should be
designed to analyse big data in order to classify patients
into certain populations by the risks of experiencing
some events, report on individual and group outcomes,
and manage targeted care delivery by enhancing
coordination between providers, payers, and patients.
1. Data analytics and reporting
It’s not enough just to store relevant data. A detailed
analysis is needed to stratify patients into cohorts.
However, running it without machine assistance is timeand cost-intensive.
Fortunately, several analytical tools can speed up
these tasks. For example, predictive modelling, in
which algorithms comb through a multitude of historical
healthcare data to create models for forecasting
This analytical approach found its use at Mass
Gen Brigham (Boston, MA). The clinic provided their
congestive heart failure patients with remote monitoring
devices to upload real-time updates on their weight,
blood pressure, and other metrics aggregated in the
hospital’s intelligent system. The system relied on these
data sets to single out at-risk patients in need of specific
intervention. As a result, the tool helped lower the
readmission rate and the number of nurses necessary to
cover patients’ needs, which led to cost reduction.
2. Care coordination
In a clinical setting, treating a patient is rarely a single
doctor’s responsibility. As a rule, the process involves
2-3 professionals in different medical fields, lab analysts,
and nurses. Their efforts need to be coordinated,
especially when dealing with chronic disease patients.
Unfortunately, according to the 2019 CommonwealthFund research
, this lack of coordination is a major
problem in the U.S. healthcare system.
Population health management software allows
creating clinical pathways for mapping diverse patient
journeys. PHM tools don’t automatically transfer paperbased documents to a digital environment and let them
be. Powered by machine learning technologies, these
tools rely on the uploaded clinical documents to set and
coordinate tasks all across teams in the care continuum.
This way, they help clinicians accelerate the care cycle
and refine its quality, which also ensures a better patient
3. Engagement and collaboration
When it comes to PHM, patients, providers, and payers
are on the same page.
Patients want to control their health. According to
Statista, 65% of Parkinson’s disease patients took some
steps to study the disease and/or actively engaged in
their health. At the same time, contacting a doctor or a
clinic whenever they detect some missing lab analysis is exhausting. The majority of patients let go of their health
management until the next hospitalisation.
Insurers are also interested in improving their
clients’ health. The World Health Organization reports
that cardiovascular diseases (CVDs) are the most
frequent cause of death worldwide. The American
Heart Association adds that roughly every 40 seconds
someone falls victim to a CVD. Naturally, for insurers,
this potentially leads to increased reimbursements to the
families of insured individuals. Finally, CVD deaths are
preventable, and prevention is in the payers’ interest as well.
This is where providers join the game. For example,
they may introduce a mobile healthcare app to let
patients connect to their EHRs and make informed
decisions about their health from anywhere. Such
an app can also become a part of the clinic’s digital
environment, allowing teams to access EHRs, supervise
patients’ efforts in managing their health, and intervene
when necessary. At the same time, providers can pilot
population health management and break patients
into several cohorts regarding their conditions and
associated risks. This can help streamline inventory
management and workload to deliver better care,
simultaneously cutting costs.
PHM: Is it Worth the Investment?
Now, as we’ve looked at PHM and the software required
to facilitate it, it’s time to answer the key question:
is it worth going for? Absolutely. Population health
management assists with delivering personalised care
to high-risk individuals, timely preventing relapses, and
improving care outcomes. It also allows caregivers to
fine-tune their resource management and lower costs.
As for the software, it significantly speeds up analytics
and care administration.
Conflict of Interest