Clinical Decision Support and Beyond (Third Edition): Progress and Opportunities in Knowledge-Enhanced Health and Healthcare - Chapter 26: Population health management

Population health management (PHM) is a systematic approach that uses information technology and digital health tools to improve health and healthcare at the population-level. PHM programs identify individuals who could benefit from a set of PHM interventions; implement computable logic to stratify patients according to risk; and implement protocol-based logic to assign individuals within each stratum to specific interventions. PHM is a promising approach to help achieve the Quintuple Aim of healthcare: (i) improving population health through population-level interventions; (ii) enhancing the care experience by shifting healthcare from the clinic to the patient's home; (iii) reducing costs by focusing on health promotion and prevention; (iv) improving the work life of the health care workforce by reducing clinic workload; and (v) advancing health equity by maximizing reach through a combination of digital and human-based patient outreach interventions. This chapter discusses the components of a technical infrastructure to support PHM, including data sources (registries, electronic health records), data analytics tools, patient outreach and engagement tools, and patient tracking dashboards. We also describe real-world examples of PHM programs focused on chronic disease management, genetic testing for hereditary cancers, colorectal cancer screening, COVID-19 testing and vaccination, and tobacco cessation. PHM is expected to experience substantial growth with novel digital health technologies, such as sensors, phone apps, conversational agents, and virtual reality; artificial intelligence; and new data sources.