Q&A: Understanding population health management

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The widely-accepted definition is ‘the health outcomes of a group of individuals, including the distribution of such outcomes within the group’.

Population health management (PHM) is an analytical use of data collected from multiple sources.

This data is focused on defined segments of the population in order to manage specific diseases in that group. The idea being that this approach will improve clinical outcomes, standardise physician approach, and help to reduce the cost of the disease management, among other benefits.

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Typically, healthcare institutions have kept their data to themselves and the sharing of data on regional or national levels has been sparse

With the increased amount of data available via the modernisation of healthcare systems such as Electronic Health Records (EHR), this has made it easier collate data, often in huge amounts.

PHM has taken the public health approach one step further by using advanced analytics of the data collected from EHR’s, disease registries and other data sources.

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From a patient perspective, PHM would aim to deliver improved patient outcomes, disease prevention, improved management of chronic diseases, and standardised co-ordinated care.

For providers such as physicians, the information available to them enables far-greater understanding of the disease and impact to the patient groups.

Healthcare institutions will expect to see the cost of care reduced with more-targeted, standardised evidence-based treatment being provided to the patients. Lastly, both patients and providers will benefit from the preventative medicine aspect that aims to reduce the need for health interactions once the patient is already advanced to the point of poor health.

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With this expanding older adult population there is also an increase in chronic diseases such as hypertension, coronary heart disease, stroke, diabetes, and cancer.

The management of these chronic diseases in this defined population group can benefit from the data that is being collated, both at hospital, national and international levels.

Using this data to understand how best to treat these chronic diseases will help the outcomes and also reduce the cost of care. Further, with more understanding, better preventative measures can be applied to help reduce the onset of these chronic diseases.

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Firstly, there is a huge reliance on data; where this data is stored and how it is shared to enable a large-enough data set to have meaningful levels of insight.

From a patient perspective, PHM would aim to deliver improved patient outcomes, disease prevention, improved management of chronic diseases, and standardised co-ordinated care

Typically, healthcare institutions have kept their data to themselves and the sharing of data on regional or national levels has been sparse.

Increasingly, the need for this data sharing has become a hot topic and is now beginning to gain traction.

Next, the quality of the data is of paramount importance. Often EHR data is incomplete through poorly-entered patient information or poorly-structured data capture, where the use of free text fields allowed for the important data to be buried in with other information.

There is also the question of funding.

Most healthcare providers globally are funded on a fee-for-service model aimed at treating sickness and not at preventing illness.

Therefore, there is little incentive to focus on preventative care models.

However, this is changing. Countries where there is an insurance-based healthcare system have started to see insurance companies realising the benefit of preventative medicine and more focus is being placed upon this.

In countries such as the UK there is obvious synergy in preventative medicine which is cheaper to implement and reduces the cost of the management of chronic disease over the longer term. There is a shift in thinking, but it has taken time to be realised.

Another challenge with PHM is the patients themselves.

The patient is the key factor in the implementation of PHM and the ability to engage the patient in their own care management.

Changing population/patient behaviours is key. Health is not something an individual should become concerned with only when they are ill, but should be throughout all stages of their life.

Increased access to cheap, high-calorific food is driving obesity globally, more so in emerging nations such as Mexico, India and China.

A clear strategy to engage the patient at all states of their life is critical to create a successful PHM model; and this has to be done not just through primary care, but all the healthcare system.

There may also be an issue if patients are not willing for their personal data to be shared in a PHM system.

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This can be at a trust level for the NHS, or at a national level where they have achieved a single patient record or are planning to implement a new regional or nationwide EHR.

From a technical aspect the key point is understanding the current data and where the challenges lie.

How can a system be optimised to better capture this data to allow for secondary use, for example?

There are many aspects of the system design that allow for this. I would recommend a Data Enterprise Architect team completes a review of the data structure and quality as an initial step to understanding the challenges that may need to be resolved to enable the data capture required for PHM.

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With more understanding, better preventative measures can be applied to help reduce the onset of these chronic diseases

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There has also been a number of initiatives to create national registries via the NHS registries and audit team including the, National Diabetes Audit, National Bowel Cancer Audit, National Oesophago-Gastric Cancer Audit, National Audit of Pulmonary Hypertension, etc.

These registries capture disease-specific data which can then be distilled to certain areas of the population, this level of data is hugely beneficial to the PHM programmes in the UK.

The ME and Asia, in general, are playing catch-up in this regard. But countries such as Qatar and Singapore are making great inroads to this with national EHRs and national patient registries being developed.

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