Population health can be defined in many ways, but generally, it is considered the outcomes of a group of individuals, often sharing a geographic location, but can also be divided into employees, ethnic groups, prisoners, insurance enrollees, or any other defined class. It can also include the distribution of health services, which depends heavily on the social determinants of health – where one lives, works, learns, and plays. Tracking the care outcomes of these groups can help providers better understand the complexities associated with them, however, some leaders are skeptical of the population health concept, as being too broad and so not useful in decision making and guiding specific research.1

Think of it in terms of baseball. Managers may be tempted to bench a player who is 0 for his last 20, but there may be more statistics that tell a better story, like his batting average against a particular pitcher, time of day, weather, who is in front of/behind him in the lineup, or his hard-hit percentage in those 20 at-bats. If all those other numbers are good, the manager will have solid reasoning behind keeping him in the lineup. With healthcare, technology and advanced analytics give us a lot of information about these defined groups that providers can use to make general care decisions for an entire population. Although, like any group of individuals, there will be some outliers that require different levels of care based on other environmental factors.

There are several approaches organizations can take to improve population health management and outcomes, such as linking it into its overall strategy, collaborating with community leaders, data tracking, and implementing new technology.

Strategic Planning

The first step to improving population health outcomes is to recognize the main concerns in a specific demographic; this could be a virus outbreak, low-income families, unhealthy food options, limited education, and/or little access to care services. Next, the organization must set objectives and figure out ways to address these needs, which may involve lowering costs or expanding access to care. The Institute of Health Improvement (IHI) developed the Triple Aim method of population health management (see image above) that was crafted to improve care for individuals, better health for populations, and lower per capita costs by extending reach and creating initiatives with a focus on reducing disparities, starting in high-risk and high-cost areas.2 For example, organizations set up free COVID-19 testing tents in high-density urban areas to minimize the spread of the virus. For patients in rural communities, many practices began offering telehealth/virtual visit options to people without any facility nearby during the pandemic, enabling organizations to reach more individuals and cuts costs.

Another way companies can help patients save money is by promoting preventative health measures. Treatment of chronic disease is the largest driver of escalating care cost,3 but when clinicians detect the illness early, it can be more effectively and more affordably treated. By encouraging healthy behavior along with regular testing and screenings, you can improve your bottom line and patient outcomes, while saving patients’ money.


Greater Collaboration

One organization cannot improve the health of an entire community on its own – it must be a collaborative effort between policymakers, providers and individuals. Politicians and lawmakers must recognize the challenges within specific communities and develop new approaches to those challenges with improved community health in mind. A recent example of this was when New York State Governor Kathy Hochul reinstated the mask mandate for private businesses to combat the “winter surge” of COVID cases last December.

Your primary care doctor might not be the best person for your chronic depression – they can refer you to a psychiatrist. Similarly, clinicians can team up with other providers or companies to ensure population health. Providers can connect patients to community assets and resources to improve their well-being, such as group behavioral health programs, volunteer opportunities, church-based activities and community events.4 In addition, organizations outside of healthcare are stepping in to improve population health. When coronavirus was at its worst, Uber partnered with healthcare facilities to give patients rides to their doctor appointments. The rideshare company is still providing these services today.

Every action, as small as sharing a post about mental health on social media, to as large as leading a peaceful protest about a particular policy, can make a big difference in the community. By rallying together, you can make your voices heard and ignite the change you want to see! Individuals have more power than they may think when it comes to population health.


Data-Driven Decision Making

Once community entities implement these strategies and make the necessary changes, it is time to track how much progress is made. Although data never paints the whole picture, it is crucial in decision-making. By integrating internal and external data sources, organizations will have more transparency, and be able to better manage their networks, risks, opportunities and strategies to improve population health. Clinical data inside your EHR is as important as logging information related to social, economic, and environmental behaviors.5

A New York-based provider may not recommend the same treatment plan for someone living in lower Manhattan as someone in Buffalo due to different incomes, surroundings, and lifestyles, even if they have an identical illness or condition.

Stratifying data based on demographics gives providers a better understanding of variation and gaps in outcomes, which could lead them to tailor original strategies to meet their goals more efficiently.6 Data extracted by Beth Israel Medical Center concurred that their population was facing a high readmissions rate, extended lengths of stay, and increased health complications due to a considerable rise in medical errors. The NYC-based hospital improved health and achieved its goals by establishing a best-practices group, replacing critical leaders, and introducing new clinical guidelines to improve safety and communication.7 If they did not change their approach, the health gap would have continued to widen, and perpetuated the cycles of poor health and high costs.


Leverage Technology

Many tools can help your organization improve population health outcomes, and that’s where Cantata comes in! Our Arize EHR offers patient profiles in which all demographic information is stored, such as name, birthdate, gender, social security number, personal and emergency contact information, allergies, vital signs, medications, medical conditions (physical and mental) and much more. Having complete data available in one central location gives clinicians the necessary information to treat patients safely and efficiently. Providers can also run reports on user-defined fields to provide them with a more unified view of their patients, tracking trends and the progress an individual or a group has made. Arize users can generate reports in real-time from existing EHR data.

Our Convergence Care Platform has multiple assets to improve population health outcomes, starting with a private Health Information Exchange (HIE). HIE is a scalable cloud-based care coordination solution designed to exchange, integrate, and provide data to stakeholders, manage incoming and outgoing referrals, and connect to a network of providers through secure data sharing and reporting. Providers can directly and securely message other clinicians with questions, comments, concerns, and clarifications regarding patient care. When all the patients’ doctors are working together, and on the same page about their treatment, services, and progress, positive outcomes become much more likely.

Other features of Convergence Care include its Family and Consumer Portal, which gives individuals and their family members access to their records, including test results, treatment plans, upcoming appointments, financial information, etc. Patients can also instant message their providers about billing, clinical services, etc. This increases communication, understanding, and engagement, which often results in better outcomes. Vaccination tracking allows clinicians to manage all their patients’ immunizations, giving them a more comprehensive view of their health status. Users can schedule vaccination appointments and run group reports to see what percentage of their population has been immunized.


Healthcare is not and will never be a one-size-fits-all solution – there is always a bigger picture, and providers must recognize all the factors before making crucial health decisions on a patient’s behalf. Your organization can improve population health care outcomes by following these steps, and Cantata’s solutions can help your organization achieve those outcomes more quickly and affordably.

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  1. Kindig, David. “What Is Population Health?” Improving Population Health, https://www.improvingpopulationhealth.org/blog/what-is-population-health.html.
  2. “Overview.” Institute for Healthcare Improvement, http://www.ihi.org/Topics/TripleAim/Pages/Overview.aspx.
  3. Hamilton, Charlotte. “How Can a Population Health Approach Be Used to Improve Outcomes & Lower Costs?” Colleaga, https://www.colleaga.org/article/how-can-population-health-approach-be-used-improve-outcomes-lower-costs.
  4. Moffatt, Sharon G, et al. “Opportunities to Improve Population Health by Integrating Governmental Public Health and Health Care Delivery: Lessons from the Astho Million Hearts Quality Improvement Learning Collaborative.” National Academy of Medicine, 6 Feb. 2015, https://nam.edu/persectives-2015-opportunities-to-improve-population-health-by-integrating-governmental-public-health-and-health-care-delivery-lessons-from-the-astho-million-hearts-quality-improvement-learning-collab/.
  5. Rimmasch, Holly. “4 Population Health Strategies That Drive Improvement.” Health Catalyst, 19 Apr. 2018, https://www.healthcatalyst.com/insights/4-population-health-strategies-drive-improvement.
  6. Delgado, Pedro, et al. “Accelerating Population Health Improvement.” The BMJ, British Medical Journal Publishing Group, 8 June 2021, https://www.bmj.com/content/373/bmj.n966.
  7. Rivera, Mara P. “8 Examples Of Quality Improvement In Healthcare & Hospitals.” Clear Point Strategy, https://www.clearpointstrategy.com/examples-of-quality-improvement-in-healthcare/.
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