Healthcare Analytics, Population Health Management, Healthcare Big Data

Population Health News

Six Foundational Steps for Better Population Health Management

By Jennifer Bresnick

- As value-based reimbursement and accountable care continue their march towards dominance in the evolving healthcare ecosystem, robust and effective population health management techniques are quickly becoming a critical competency for primary care providers. 

Population health management

Managing populations to ensure that all attributed lives are receiving adequate preventative and chronic disease management care requires a blend of practice transformation and impactful technologies, says the American Medical Association (AMA).  

Using basic EHR functionalities, an accessible level of data analytics, and a team-based approach to patient care, primary care providers can start to integrate population health management techniques into their daily practice without an untenable level of disruption.

As part of its STEPS Forward resource collection, which hopes to guide physician practices towards financial sustainability and the delivery of higher quality care, the AMA has outlined six basic steps for improved population health management in the pay-for-performance era.

Develop a patient registry system

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Patient registries are a window into an attributed patient population, the AMA says, and help to stratify risk, identify patients overdue for screenings or test, and flag patients who may benefit from special attention to chronic disease management for conditions such as high blood pressure or diabetes.

While many EHR products include registry functions, providers who are working with basic technologies – or still largely on paper – can use freely available software like Excel or Access to correlate billing data with patients eligible for increased tracking.

“For example, search for patients by ICD‑9 [or ICD-10] codes or health maintenance data for conditions such as diabetes or hypertension,” the AMA suggests. “Include these patients and select health indicators related to the condition of interest in your registry (e.g., for patients with diabetes, the date of the last eye exam and most recent HbA1c, etc).”

“Use visual cues or color‑coded cells to flag overdue laboratory tests or visits. Flagging will help you proactively and more effectively implement panel management and improve the health outcomes of your patients.”

Create a “health maintenance” EHR template

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EHR developers have been trying to integrate more sophisticated population health management features for several years, in response to growing pressure throughout the industry to equip providers with the tools they need to cut costs and reduce unnecessary services.  As a result, many EHR systems already have “health maintenance” options that help providers keep track of routine immunizations, screenings, and tests.

These tools can often be programmed to proactively prompt the user to ask patients about routine services that may be missing, especially for patients with chronic diseases that require scheduled follow-up.  While alert fatigue and alarm overload are common problems with this type of strategy, providers may be able to correlate the health maintenance template with registry information to prioritize push alerts related only to a specific condition or need.

Revamp clinical practice guidelines

Technology is only one part of the population health management puzzle, the AMA says.  Workflow changes and clinical practice guidelines are required to ensure that providers are paying close and consistent attention to patient management strategies.

Practice leaders should consult with end-users to develop realistic, efficient workflows and regulations to guide population health management programs, and should periodically reevaluate clinical practice guidelines to ensure that they are optimally balanced between the needs of patients and the realities of a busy, constantly changing work environment.

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Recruit and train patient panel managers

Patient panel managers will become crucial leaders for this process.  Nurses, medical assistants, or physician assistants can be trained to lead population health management initiatives that complement their usual duties, and can then educate other staff across the organization.

“Start with staff members who are energized and can act as champions for change,” the AMA advises. “When they enthusiastically motivate patients to receive needed immunizations or get screening tests, they can win over those in your practice who are reluctant to change.”

While some physicians are reluctant to accept the evolving role of mid-level providers in an environment of increased accountability and constant contact with patients, nurses, nurse practitioners, physician assistants, and others believe that they can add significant value to the population health management process while allowing physicians to work to their highest level of training.

This team-based approach to care requires a shift in perspective, the AMA acknowledges, but time and practice will help all members of the organization adjust to their new roles.  “You will know that the culture is changing when you no longer hear your staff saying, ‘These are the doctor's patients,’ but instead saying, ‘These are our patients.’”

Identify gaps in care and opportunities for improvement

Primary care providers are increasingly taking on responsibility to ensure that patients are receiving required services in a timely manner as they transform into “hubs” of patient care

Whether it’s a diabetic patient with an uncontrolled blood glucose level who has missed several appointments or a patient with a wrist fracture who must coordinate x-rays, orthopedic visits, and physical therapy, PCPs are frequently charged with the task of making sure that patients correctly navigate the care continuum.

For preventative and chronic disease care, providers can identify patients experiencing gaps in care by using their registries and health maintenance technologies, or by developing manual checklists of common services that patients can fill out themselves.

“Some practices routinely manage preventive care gaps during annual comprehensive care visits and thus do not need to repeat this work at interval visits,” the AMA notes. This may be an effective management strategy for relatively healthy patients.  “By systematically addressing them at a dedicated visit, staff can close multiple care gaps during a single patient encounter, eliminating the need to contact the patient several times throughout the year.”

Use patient engagement strategies to close the loop

However, for patients with complex needs, or those at risk for falling away from the care continuum, a more proactive approach may be required.  Patient engagement falls into two camps: “in-reach,” or connecting with the patient while they are in the clinic, and “outreach” for patients who rarely make appointments.

In-reach strategies include the aforementioned preventative care checklists, discussions with the patient about screenings and tests, and scheduling future appointments for preventative care services before the patient leaves the office.

Outreach methods include traditional mailings, emails, secure messaging through a patient portal, or phone calls to remind patients about upcoming tests or immunizations.

“Some panel managers even make home visits to personally follow up with patients,” the AMA says, but “much of the communication can be done by sending computerized reminders to patients, and panel managers can follow up by phone with patients who do not respond. Out‑reach is most effective when the staff person knows the patient they are contacting.”

Establishing multiple opportunities for contacting patients can be an effective way of ensuring that services get scheduled and patients understand the importance of showing up for routine testing and screening.  In conjunction with EHR technology and basic population health management analytics, this human touch can provide an important impetus for patients and providers to connect appropriately and stay engaged as the healthcare landscape continues to shift towards more accountable care.


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