Personalized population healthis not about a 30,000-foot view of patient needs; it's abouthaving actionable data about an individual to deliver the rightcare at the right time in the right place. (Photo:Shutterstock)

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Population health management (PHM) is gainingthe interest of employers searching for ways to improve the healthand well-being of employees at lower cost. But in order to meet the truepromise of population health, we need to make PHM meaningful toindividuals, not just groups. We need to personalize it.

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When “population health” emerged as a concept in 2003, it wasdefined as “the health outcome of a group ofindividuals, including the distribution of such outcomes within thegroup.” A “group” could mean a country of people, an ethnic group,a community of cancer patients, an employer workforce or any otherkind of population. And the goal wasn't that most people in thegroup would be healthy while a few remained quite sick, but insteadthat big health disparities within the group would beeliminated.

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Related: 17 health care systems launch project to reformhealth care for underserved

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From this vision emerged “population health management (PHM),”strategies designed to identify the health care needs of groups andsub-groups and to target interventions to improve health outcomesat lower cost. Advances in technology – mobile apps,wearables, connected devices, web services, patient portals andanalytics, to name a few – have played a critical role in shapingcurrent PHM efforts. For example, by applying predictive analyticsand risk scoring to a person's health data, we can identifycongestive heart failure patients at risk of hospital readmissionand put processes in place to mitigate that risk. Monitoringdevices and patient portals, in theory, can help engage people intheir health and keep them on track with their care plans.

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A step forward from traditional disease management

In this way, PHM represents an evolution from traditionaldisease and case management. While disease management focused onone condition, e.g., diabetes or cancer, PHM attempts to put theindividual patient at the center of care and provide servicesacross multiple chronic conditions. Whereas traditional diseasemanagement relied solely on retrospective claims data to identifypatients with a chronic condition, PHM tries to gain a broader dataprofile of the patient and use predictive modeling to analyzepatient risk levels. And while traditional disease managementprograms have a standard care plan and protocol based on diagnosis,PHM attempts to incorporate contextual life factors and socialdeterminants of health, which influence an estimated 80 percent of patient health.

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In reality, PHM has a long way to go before bringing aboutbetter population health for lower cost at scale because challengesremain. Health data sharing continues to be difficult, forcing manyproviders to remain stuck using retrospective claims data tounderstand patient needs. And diagnosis-based risk models have noway to incorporate social determinants of health or other lifecontext. Compounding that issue, the majority of doctors don't think it's theirresponsibility to address social determinants of health.

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

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Personalized population health

Personalized population health is not about a 30,000-foot viewof patient needs. It's about having actionable data and informationabout an individual – in real time – to deliver the right care atthe right time in the right place. To achieve personalizedpopulation health, we need technology and people workingtogether:

  • People: Doctors, nurses, social workers,behavioral health clinicians, pharmacists, community servicedirectors, public health officials, Health Information Exchangedirectors, HR Benefits managers, family members – everyone has arole to play in helping individuals get the personalized supportand care they need, within and beyond the walls of healthcare.
  • Technology: Open technology that connectssystems, programs and applications across the health carelandscape, enabling a wide range of health data to be shared andused when it's needed to improve the health of people andpopulations. And solutions that allow individuals to engage in themanner that makes sense for them personally.

Digital solutions are not enough. To realize the goals of truepopulation health, we need humans and intelligent technologiesworking together to build trust, uncover the full life context ofeach person, develop deep insight about their needs, and deliverdeeply personalized, evidence-based health care support in the mostefficient manner possible.

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Real-world examples

Providing personalized population health isn't easy. It takescommitment. And there is no one way to do it. Examples of bringingthese pieces together happen in many places. In practice, Aledade is putting data in the hands of primarycare providers to empower them to ask questions about more than apatient's diagnosis but to inquire about those contextual factorsthat impact on health outcomes such as financial and socialbarriers to care.

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The power of personalized population health cannot be realizedin a silo. In order for providers, health systems and communitiesin the ecosystem to partner to personalize population health beyondthe four walls of the health care setting, data sharing isessential. Groups like Data Across Sectors for Health (DASH) and otherpartners in the “All In” community are doing the hard work ofunderstanding how to integrate data, in addition to identifyingwhat data matters.

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These are just two examples. At Accolade, we recognize that weare part of an amazing community of learners and leaders – allpassionate and focused on improving health outcomes and driving tomake personalized population health a real part of the health careexperience.


Dr. Ivor Horn isthe Chief Medical Officer at Accolade, the market leading personalizedhealth and benefits solution for health plans, employers and theirmembers. Dr. Horn is a board-certified pediatrician with over twodecades of clinical and research experience. At Accolade, Dr. Hornfocuses on health care consumer engagement and blending human touchand innovative technology to help people better navigate theirhealth care benefits.

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