This is the aggregation of patient data across multiple health IT resources, analyzing that data, and using that data to improve outcomes and better track the health of communities and specific populations. Population health management is mainstream thanks to widespread adoption of electronic health records and using those records to create actionable databases and disease registries, which group patients by disease states such as diabetes, hypertension, HIV/AIDS and depression.
Population health management can help providers identify high-risk and frequent users of hospital resources, like emergency departments, who may need special outreach and management. It also can track rates and test interventions for community public health concerns including annual flu vaccines and tobacco cessation. The federal government encourages population health management through its Shared Savings Program, state Medicaid waivers and the Medicare Advantage program.
Population health management can reduce health care costs by moving interventions “upstream“ to reach patients in more individualized ways before they end up seeking care in more acute (and costly) settings. It operates in concert with patient-centered medical homes, where primary care providers use a team-based approach to improve care coordination, patient engagement and quality and safety.