Tools for Population Health Management

Proactive health care for patient populations

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Population health is defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group” (Kindig and Stoddart, 2003). Population health also addresses determinants of health, such as medical care, public health programs, social factors, physical environment, personal behavior, and genetics. Examples of populations include geographic regions, ethnic groups, employees, patients in a health care setting, or groups sharing other common characteristics, such as disabled persons or prisoners.

In the clinical setting, population health management is concerned with high-risk patients, but also addresses the preventive and chronic care needs of every patient. The goal of population health management is to improve and maintain patients’ health while avoiding unnecessary and costly treatments, tests, and health care visits. To this end, health care organizations aim to provide proactive care during and between encounters with the health care system, an endeavor which requires information technology tools to improve the effectiveness, reach, and efficiency of health care providers.

The following sections highlight the basic building blocks of population health management in the clinical setting, as well as the health information technology required to support each function. The framework is adapted from a report from The Institute for Health Technology Transformation.

Data Collection, Storage, and Management

Population health management relies on robust systems to collect, store, and manage health data. The electronic health record (EHR) is the foundation of the technological infrastructure for population health management. Data in an EHR include demographics, contact information, medical history, immunizations, allergies, medications, vital signs, test results, and progress notes.

However, EHRs are not designed for population health management, and other sources of data are necessary to inform the processes of care.

A clinical data warehouse is a centralized repository of patient-centered data from multiple sources, such as EHRs and administrative and billing databases. Health information exchanges are necessary for aggregating data from disparate organizations.

Population Monitoring and Stratification

An organization involved in population health management must use the available health data to monitor patients’ health and stratify patients according to a variety of factors. Stratification can be done according to health status, chronic diseases, behavioral patterns, and socioeconomic factors. The organization then offers relevant services to patient subgroups with specific needs. For example, patients with uncontrolled hypertension could be invited to enroll in a coordinated care program.

A clinician using an EHR can identify whether a patient falls into a high-risk group.

However, this type of assessment only happens during the traditional patient-provider encounter. To achieve population health management, monitoring and stratification must be applied to whole patient groups apart from the health care appointment (i.e. between visits). 

A patient registry is a more powerful tool for supporting population-wide monitoring and stratification. Patient registries are organized systems which use observational methods to collect data in defined patient populations. Reporting functions embedded in registries allow users to identify groups of patients who meet specified criteria or are at high risk for poor health outcomes. For example, a registry could generate a report on all patients with chronic lung disease who have not yet had a pneumococcal vaccine.

Patient Engagement and Communication

After collecting data and stratifying patients, the next step in population health management is to communicate with patients outside of the clinical setting to engage them in their own care. Health outcomes are largely determined by habits, processes, and events that occur in daily life, between clinic visits. Therefore, organizations dedicated to improving and maintaining a population’s health must be proactive, not reactive, about engaging patients. While many health care systems continue to rely on phone and postal mail, electronic communication venues offer considerable advantages in scale and efficiency.

For example, suppose that a case manager uses a registry to identify 165 patients who are overdue for colon cancer screening. Rather than call or send a letter to every patient, the case manager could use email, text messaging, web-based, or mobile applications. Platforms that facilitate automated messaging would expand the capacity of the care management team to reach patients.

Telemedicine also offers opportunities for patient engagement through remote monitoring, education, and peer support. Remote health sensors can track a patient’s physical activity, body weight, blood pressure, heart rhythm, blood glucose, and other variables, provided that the patient continues to use them. Care management teams can respond to concerning findings by providing education and self-management training, facilitating access to online health communities for peer support, and recommending specific courses of treatment.

Patient portals are valuable components of patient engagement. A patient portal is an online tool that gives patients access to much of the personal health information stored in the EHR, such as test results, medications, and care summaries. Some patient portals allow patients to communicate with health care teams, request medication refills, schedule appointments, and view educational material.

Team-Based Care

Population health management requires a multidisciplinary team of physicians, mid-level practitioners, nurses, medical assistants, case managers, social workers, and other professionals. These care management teams will need to use a communication platform for real-time and asynchronous collaboration. 

Outcomes Assessment

Data analysis and visualization tools are needed to yield a snapshot of a population's health according to clinically meaningful metrics. Dashboards can display trends in health outcomes over time and thus highlight areas where the organization needs to invest more resources. Data sources include ambulatory and inpatient settings, billing systems, and patient self-report instruments. 


The range of health information tools described in this summary can facilitate population health management. However, technology alone is not sufficient for improving the health of a group of patients. Critical elements for success include committed leadership, training of health care providers in population health principles, supportive reimbursement models, workflow redesign, and harmonious care coordination teams and processes. The degree to which health information tools work seamlessly together will also influence the effectiveness of population health programs.


American Telemedicine Association. What is Telemedicine? Accessed on May 31, 2014.

Institute for Health Technology Transformation. Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare. Accessed on May 30, 2014.

Kindig D and Stoddart G.  What Is Population Health? Am J Public Health. 2003 Mar;93(3):380-3. Accessed on May 31, 2014.

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