Practice Management

Useful Tools for Implementing Population Health Management

Improve patient outcomes and reduce costs with these helpful resources


Population health management (PHM) became prominent in 2003 after David Kindig, MD, PhD, and Greg Stoddart, PhD, defined it as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”

Today, PHM has become less a trendy term and more a necessity for survival. In fact, recent research revealed that 68% of health care executives ranked PHM as “very important” to care delivery.

Physicians who wish to implement or streamline a PHM system may find the landscape overwhelming. Starting with a strategic roadmap is essential, says Wendy Vincent, director of advisory services at the audit and consulting firm KPMG. “Organizations that do this well have very clear, well-defined care plans,” she says.

The following tools can help providers institute an effective PHM program.

Electronic health records (EHRs). Providers can use existing EHRs to develop master patient registries and a health maintenance template, according to the American Medical Association. These can track patient immunizations, screenings, and other tests, and the option to create these records is already available in most EHRs. Maintenance templates can even be programmed to prompt providers to deliver certain services.

Patient dashboards/scorecards. Dashboards and scorecards offer an easy way to visualize relevant data that include risk scores, acuity, and wellness trends. Sometimes called “scoreboards,” they are one of the best tools to measure and sustain improvements to outcomes.

Automated outreach. Automated care-management outreach includes tools such as email that are generated based on clinical protocols and connected to a population-wide electronic registry. The software detects when patients need services and contacts them to make an appointment.

Analytics. Analytics for managing patient data and integrating clinical or business intelligence into workflows are essential. Analytics tools not only enable more targeted health management programs but also enhance quality, cost, and efficiency of care.

According to Vincent, it’s important to remember that, ultimately, “technology should support the optimal gold standard in workflow, not the other way around.”