July 2, 2018

A Personalized Approach is Pivotal to Population Health

By Peggy Fischer

Ivor Horn, MD, MPH, Chief Medical Officer


đź“·Population health management (PHM) is gaining the interest of employers searching for ways to improve the health and well-being of employees at lower cost. But in order to meet the true promise of population health, we need to make PHM meaningful to individuals, not just groups. We need to personalize it.

What is Population Health?

When “population health” emerged as a concept in 2003, it was defined as “the health outcome of a group of individuals, including the distribution of such outcomes within the group.”


A “group” could mean a country of people, an ethnic group, a community of cancer patients, an employer workforce or any other kind of population. And the goal wasn't that most people in the group would be healthy while a few remained quite sick, but instead that big health disparities within the group would be eliminated.

Technology Advances are Enabling Population Health Management

From this vision emerged “population health management (PHM),” strategies designed to identify the healthcare needs of groups and sub-groups and to target interventions to improve health outcomes at lower cost. Advances in technology - mobile apps, wearables, connected devices, web services, patient portals and analytics, to name a few - have played a critical role in shaping current PHM efforts.


For example, by applying predictive analytics and risk scoring to a person's health data, we can identify congestive heart failure patients at risk of hospital readmission and put processes in place to mitigate that risk. Monitoring devices and patient portals, in theory, can help engage people in their health and keep them on track with their care plans.

PHM: A Step Forward from Traditional Disease Management

In this way, PHM represents an evolution from traditional disease and case management. While disease management focused on one condition, e.g., diabetes or cancer, PHM attempts to put the individual patient at the center of care and provide services across multiple chronic conditions. Whereas traditional disease management relied solely on retrospective claims data to identify patients with a chronic condition, PHM tries to gain a broader data profile of the patient and use predictive modeling to analyze patient risk levels. And while traditional disease management programs have a standard care plan and protocol based on diagnosis, PHM attempts to incorporate contextual life factors and social determinants of health, which influence an estimated 80% of patient health.


But Achieving True Population Health Demands Personalization

In reality, though, PHM has a long way to go before bringing about better population health for lower cost at scale because challenges remain. Health data sharing continues to be difficult, forcing many providers to remain stuck using retrospective claims data to understand patient needs. And diagnosis-based risk models have no way to incorporate social determinants of health or other life context. Compounding that issue, the majority of doctors don't think it's their responsibility to address social determinants of health.


As a result, PHM efforts often take us right back to the 30,000 foot view of patient needs, rather than a personalized one - to standardized processes and protocols for managing chronic conditions, rather than individualized support for the unique, complex needs of each person. Many members will have their care needs met through that standardized approach, but when there is any variability - when someone doesn't fit the “standard” profile - we need to have a way to adjust to meet their specific needs.


đź“·Personalized Population Health: A Human + Technology Approach

Personalized population health is not about a 30,000-foot view of patient needs. It's about having actionable data and information about an individual - in real time - to deliver the right care at the right time in the right place. To achieve personalized population health, we need technology and people working together:

  • People: Doctors, nurses, social workers, behavioral health clinicians, pharmacists, community service directors, public health officials, Health Information Exchange directors, HR Benefits managers, family members - everyone has a role to play in helping individuals get the personalized support and care they need, within and beyond the walls of healthcare.
  • Technology: Open technology that connects systems, programs and applications across the healthcare landscape, enabling a wide range of health data to be shared and used when it's needed to improve the health of people and populations. And solutions that allow individuals to engage in the manner that makes sense for them personally.

Digital solutions are not enough. To realize the goals of true population health, we need humans and intelligent technologies working together to build trust, uncover the full life context of each person, develop deep insight about their needs, and deliver deeply personalized, evidence-based healthcare support in the most efficient manner possible.

Real-World Examples of Progress

Providing personalized population health isn't easy. It takes commitment. And there is no one way to do it. Examples of bringing these pieces together happen in many places. In practice, Aledade is putting data in the hands of primary care providers to empower them to ask questions about more than a patient's diagnosis but to inquire about those contextual factors that impact on health outcomes such as financial and social barriers to care.

The power of personalized population health cannot be realized in a silo. In order for providers, health systems and communities in the ecosystem to partner to personalize population health beyond the four walls of the healthcare setting, data sharing is essential. Groups like Data Across Sectors for Health (DASH) and other partners in the “All In” community are doing the hard work of understanding how to integrate data, in addition to identifying what data matters.

These are just two examples. At Accolade, we recognize that we are part of an amazing community of learners and leaders - all passionate and focused on improving health outcomes and driving to make personalized population health a real part of the healthcare experience.

To learn more about our approach, read our new paper: Making Value-Based Care Work for People and Employers.


1 Kindig, R., MD, PhD and Stoddart, G., PhD. (2003 March), What is Population Health? American Journal Public Health. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447747/

2 Reynolds, A, PhD, RN; Rubens, J., MD, MHPE; King, R., MBA; Machado, P., MBA (2016 July), Technology and Engagement: How Digital tools are Reshaping Population Health; Population Health Alliance. Retrieved from: http://www.populationhealthalliance.org/publications/technology-and-engagement-how-digital-tools-are-reshaping-population-health.html

3 Sprague, L., (2003, May 16). Disease Management to Population-Based Health: Steps in the Right Direction? National Health Policy Forum, Issue Brief No.791 Retrieved from: https://www.nhpf.org/library/issue-briefs/IB791_DiseaseMgmt_5-16-03.pdf

4 Heath, S., (2017, July 24), 5 Patient Engagement Terms Shaping Value-based Care, 5 Patient Engagement Terms Shaping Value-based Care, Patient Engagement HIT. Retrieved from: https://patientengagementhit.com/news/5-patient-engagement-terms-shaping-value-based-care

5 Partners, (2018, May 9). Leavitt Partners Releases “Social Determinants Matter, But Who's Responsible? 2017 Physician Survey on Social Determinants of Health' White Paper [Press release].Retrieved from: https://leavittpartners.com/press/leavitt-partners-releases-social-determinants-matter-but-who-is-responsible-2017-physician-survey-on-social-determinants-of-health-white-paper/