This article examines how to define population health through a review of the top analytics research firms. It lands on a single theme, but in the process it uncovers six common categories of IT capabilities required to successfully manage population health: Data Aggregation Patient Stratification Care Coordination Patient Engagement Performance Reporting Administrative/Business These six strategic components define the population health ecosystem, and successful organizations must multitask across these domains, working with an enterprise data warehouse, if they hope to thrive in value-based healthcare and become true partners and assets in their respective communities.

1. The 6 Critical Components of
Population Health
̶̶ Dan Soule

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The 6 Critical Components of Population Health
I was recently asked to define the term
population health from a market perspective.
My quick answer was that there are many
definitions, but is this really true?
I pulled recent reports on population health
from four well-respected analysts representing
Chilmark, HIMSS, International Data
Corporation (IDC), and KLAS.
What I found is that they all had a similar
definition, which is something like this:
To manage the health of a specific population using a network
of financially incented providers and community partners.”
Dan Soule
VP of Product Management

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The 6 Critical Components of Population Health
The next consideration were the IT capabilities
identified by each analyst organization,
basically the same six categories:
1. Data Aggregation
2. Patient Stratification
3. Care Coordination
4. Patient Engagement
5. Performance Reporting
6. Administrative/Business
Apparently, I was wrong about
the variety of definitions.

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D ATA A G G R A G AT I O N
The 6 Critical Components of Population Health
Population health is a concept that
extends beyond the borders of the
integrated delivery system.
Kaiser Permanente, arguably the largest
population health organization in the
U.S., has some patient care delivered to
its members by non-Kaiser providers.
A data warehouse is required to collect
member information many data sources
and facilities that must come together to
address the health of a population.
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PAT I E N T S T R AT I F I C AT I O N
The 6 Critical Components of Population Health
This is sometimes called patient risk
stratification or patient identification.
Traditionally, health plans identified and
stratified their members by risk.
What we are finding out is that not only are
there multiple risk models, some models
are better than others for identifying
particular events or diseases.
The purpose of this stratification is really to
identify the health needs of individuals in
the population.
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PAT I E N T S T R AT I F I C AT I O N
The 6 Critical Components of Population Health
2
Low Risk
Rising Risk
Complex & High Risk
• Personal Relationship
• Comorbidity Management
• Cross Continuum
• Risk of Escalation
• Self Management
• Condition/Disease Focused
• Self Service
• Preventive
• Coaching

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C A R E C O O R D I N AT I O N
The 6 Critical Components of Population Health
Also called care management,
this is most often focused on
the top five percent of people
who account for nearly 50
percent of health care costs.
Consider this health care
spending graph from the
National Institute of Health
Care Management.
(Data brief – July 2012)
3

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C A R E C O O R D I N AT I O N
The 6 Critical Components of Population Health
The Agency for Healthcare Research and
Quality (AHRQ) in their Care Coordination
Atlas 2014, goes beyond the Organizational
Design Model, which focuses on specific
outlier patients and coordination activities, to
include the Donabedian Model for quality
improvement (structure, process, and
outcomes), which affects every patient
receiving care (the inliers).
3

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C A R E C O O R D I N AT I O N
The 6 Critical Components of Population Health
3
AHRQ Care Coordination Alas 2014, Chapter 3, Care Coordination Measurement Framework

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PAT I E N T E N G A G E M E N T
The 6 Critical Components of Population Health
This requires providers and community partners
to create personal relationships with patients.
Health IT alone is not the answer, as proven by
the lack of patient portal success in the CMS
Meaningful Use program.
The proposed Merit-Based Incentive Payment
System, appears to move toward outcomes
versus functionality, while opening up new
avenues to explore by leveraging newer
technology systems that connect care teams,
patients, and caregivers.
4

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PAT I E N T E N G A G E M E N T
The 6 Critical Components of Population Health
Nielsen data on smartphone usage
by people age 65 and above
indicates a steady increase of
about 10-15 percent per year.
This data, combined with increased
recognition and encouragement by
family or friend caregivers (who
are often younger), is a strong
argument for promoting mobile
apps to support patient
engagement.
4

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P E R F O R M A N C E R E P O R T I N G
The 6 Critical Components of Population Health
It could be argued that there are so
many measures and metrics
(HEDIS, PQRS, MSSP, CMS Core
Measures, TCPI, commercial payer
measures, etc.) that providers have
a difficult time figuring out on which
ones to focus.
According to research from the
University of Oregon, humans are
only capable of focusing on four to
five things at a time.
5

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P E R F O R M A N C E R E P O R T I N G
The 6 Critical Components of Population Health
Simple dashboards of metrics have not
been shown to significantly change
outcomes.
Instead, analytics are needed to find
the four or five measures that will yield
the biggest return (outcome) on
investment (resource effort).
Dashboards are not enough.
5

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A D M I N I S T R AT I V E / B U S I N E S S
The 6 Critical Components of Population Health
Managing and administering the multitude
of new value-based business models is
something totally new for providers and, to
some degree, health plans, as well.
The new business of population health
must be enabled by the data aggregation
system to ingest and correlate claims from
multiple health plans with a rich set of
clinical and patient reported data.
6

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A D M I N I S T R AT I V E / B U S I N E S S
The 6 Critical Components of Population Health
Balancing patient satisfaction against provider quality and cost requires
new systems that can be deployed in weeks, rather than months or years.
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This population health graphic, with data
aggregation and analytics (a data
warehouse) at the center, surrounded
by overlapping capabilities shows what
must be addressed to be successful.
Identifying which capabilities to
address first and then drafting the
roadmap to build out these capabilities
will enable successful organizations.
Effective population health management must
be powered by population-sized multitasking.

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For more information:
“This book is a fantastic piece of work”
– Robert Lindeman MD, FAAP, Chief Physician Quality Officer

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More about this topic
Link to original article for a more in-depth discussion.
Aiding Analytics Adoption Via Metadata-DrivenArchitecture: If You Build It, They Will Come
A Landmark, 12-Point Review of Population Health Management Companies (Executive Report)
Dale Sanders, Executive VP of Software
A Guide to Successful Outcomes Using Population Health Analytics
Tom Burton, Co-founder and Executive VP
Three Essential Systems for Effective Population Health Management
Jared Crapo, Sales, VP
Population Health Analytics: Improving Care One Patient at a Time
Tom Burton, Co-founder and Executive VP
Finding and Compiling Salient Population Health Data -
Dan Soule, VP of Product Management

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Dan Soule joined Health Catalyst in February 2014 as Vice President of Product Management. Prior
to coming to Health Catalyst, Dan worked for Medicity as Vice President of Product Management. He
brings over 25 years of health IT experience at SpaceLabs, Cerner and Allscript, as well as 12 years of
clinical experience at Good Samaritan Hospital in Phoenix. Dan has a Bachelor’s degree in
Engineering from Arizona State University.
Other Clinical Quality Improvement Resources
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