Tips for starting a population health management system

Nov. 1, 2021 / By Felisha Bochantin

Population health is central for health care providers and payers striving to improve quality of care and lower costs. Population health is defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” In other words, focusing on a group of individuals versus one individual. The groups are often made up of a specific geography, such as global or local communities, but can be groups like employers, ethnic groups, disabled persons or any other defined group. The health care outcomes of such groups are of relevance to policymakers in both the public and private sectors. If you are considering beginning your population health management system journey, here are a few things to keep in mind.


When starting a population health management system, it is important that you have data. Without data, you don’t have anything to measure. Data serves to stratify populations of patient cohorts, allows classification by assessing the risk of medical events, enables targeted patient care and can deliver reportable outcomes. Technology can help sort and analyze this data. Remember, when you import data for risk stratification include the number and type of chronic illnesses, history of high utilization or frequent hospitalizations, mental health and substance use.

Building the team

A team-oriented approach is a crucial driver for good health care outcomes. Interactions between members of health care teams can provide a more targeted approach to provide care, eliminate redundant investigations and repeated procedures, and lower health care expenditure. The Healthcare Information and Management Systems Society reports patient engagement includes patient and provider education, preventive initiatives and population health control.

Physician acquisition strategies should meet the health needs of the population being served. A careful evaluation should be done on the target population, assessing health needs and gaps in health care delivery to determine the required network of professionals. For example, in a region with high rates of diabetes, a health care organization will require a strong network of endocrinologists, dieticians and other health care personnel who have training in diabetes care.

Relationships matter

Patient-provider relationships play a vital role in population health management and can influence a patient’s health. Effective patient-provider engagement builds strong relationships which can improve health outcomes and treatment compliance, ultimately reducing costs. Patients are more likely to actively participate in their health care and in the decision-making process to determine a care plan appropriate for their health needs if they have an established relationship with their care team. Strategies for continuous engagement with patients at all life stages – from childhood to advanced age –  should be based on individual preferences. For example, communicating via email, video messaging or online patient forums.

Identifying how patients wish to engage is key to creating appropriate measures and technological initiatives to connect effectively with patients and provide adequate support. This ensures a timely flow of necessary information between patients and providers.

The follow up

These strategies are fundamental in addressing treatment noncompliance by providing treatment dispensers, for example, and appropriate follow-up support. Other strategies to address treatment noncompliance involve patient-centered education, assessing each patient’s cognitive capacity to understand their health needs and help patients create reasonable health care goals. This requires careful interaction with patients to gain insight into their knowledge of their care plan and how it could be properly followed.

None of us can individually fix the wide variety of issues the health care industry faces, but we can make an incredible difference by prescribing lower cost drugs to control spending, increasing outreach and engagement for patients with chronic conditions and extending physician office hours so patients aren’t forced to overutilize  the emergency room. By coordinating with patients, providers can offer the highest quality, most cost effective option for their patients’ health care needs.

Felisha Bochantin is an International Population Health Clinical Analyst with 3M Health Information Systems.