January 2018 blog: Creating Synergies Between IT and Population Health Management

Creating Synergies between IT and Population Health Management

Population Health Management is the aggregation of patient data across multiple health information technology resources, the analysis of that data into a single, actionable patient record, and the actions through which care providers can improve both clinical and financial outcomes.


Johns Hopkins, a forerunner in developing population health offers the following definition: a cohesive, integrated, and comprehensive approach to health care considering the distribution of health outcomes within a population, the health determinants that influence distribution of care, and the policies and interventions that are impacted by the determinants.


Likewise, Hopkins includes a definition of population health management as the process of addressing population health needs and controlling problems at the population level; strategies that address population health needs. An effective population health management program brings together clinical, financial and operational data together from across the enterprise and provides actionable analytics to improve efficiency, patient care and reduction in waste across the continuum.


As organizations explore population health and develop a plan to address the needs of a cohort of vulnerable populations, integration of data linkage is an essential element. The term “interoperability” should immediately come to mind since having the ability of a system to exchange electronic health information and use this information from other systems with ease is a must and sometimes a challenge. Technology is one of the major enablers of disruptive innovation that will likely reduce the use of intuition to make decisions, and instead will focus on data.


One must consider all of the numerous data sources that must be integrated into the population health management plan; some of the more obvious sources are the patient, providers, HIEs, the electronic health record, and the management information system (claims data). Other sources may not be so obvious and include: a variety of web portals, social networks, case (care) management, family and other types of care givers, public health systems and national datasets.


These types of data sets provide invaluable information that helps organizations analyze and ultimately determine the cohort(s) to involve in population health management. Since population health management has generally been a focus of public health, it is time for health care organizations to learn from public health, thus leveraging their expertise when creating your plan. A second consideration is to assure that care coordination/case management is refined since care managers generally focus on improving patient self-management, improving medication management, and reducing the cost of care by concentrating on keeping patients well and assuring that care is delivered at the right place, at the right time for the right cost.

  1. Phillips Wellcentive.
  2. Kindig, D. & Stoddard, G. American Journal of Public Health. 93(3). 380-383.


Lessons and Recommendations:

o Define what population health and population health management mean to you and your organization.
o Create the infrastructure to support population health
o When using consultants, identify requirements upfront and clearly communicate your needs
o Make sure that all stakeholders are at the table, especially IT, providers and public health
o Start small and build from there since nothing remains static
o Utilize all available data resources
o Determine champions with defined accountability to assure progress
o Define care coordination/case management’s role
o Review processes, especially those that can be automated to improve efficiencies
o Create meaningful metrics to determine improvement or not
o Evaluate and be willing to course correct to achieve desired results
o Innovate and use technology effectively


‘Good health is not something we can buy. However, it can be an extremely valuable savings account. ‘
-Anne Wilson Schaef


Host: Diane Bradley, PhD, RN, NEA-BC, CPHQ, FACHE, FACHCA, Regional Chief Clinical Officer

Bradley has more than 30 years clinical management experience having previously served in leadership positions in acute-care, long-term and behavioral healthcare facilities. In the past, she also served in the U.S. Army as Chief Nurse of a 400-bed field hospital and large Army Medical Centers.

Bradley earned a Doctorate in Healthcare Administration from Baylor University; a Master’s degree in Nursing Administration from St. John Fisher College; a Master’s degree in Public Administration from SUNY Brockport; a Bachelor’s degree in Nursing from Alfred University; a Bachelor’s degree in Psychology from the University of Rochester; and a Diploma in Healthcare Administration from Baylor University in Fort Sam Houston.

She is also Certified in Nursing Administration, Advanced through the American Nurses Credentialing Center and a Licensed Nursing Home Administrator in New York State. In 2010 and 2011, Bradley became a Baldrige Examiner. She is also a Fellow of the American College of Healthcare Executives and the American College of Health Care Administrators. Bradley is currently serving as the President of the New York Organization of Nurse Executives.