Population Health Management

Population Health Management systems are designed to maintain and improve the health status of all patients, from healthy individuals at one end of the spectrum, to patients with chronic illness at the other. They provide tools and processes that stratify the population by health-risk, helping to design appropriate access to care, and tracking corrective measures. (Corrective measures might include care activities such as home visits, blood tests, risk assessments or hospital encounters.)

Unlike traditional healthcare computer applications, PHMs have been designed primarily for the organisations that pay for care or are accountable for the care they deliver. In the USA this has meant insurance companies, Accountable Care Organisations (ACO) and those that take on financial risk for healthcare of patients.

In the NHS the opportunity is clear. Population Health Management could be the off-the-shelf answer for the new GP commissioners that form a clinical commissioning group (CCG).

Any Payer, ACO or a CCG that can put all of these together has a very realistic chance of delivering the quality and outcomes improvements it seeks at a genuinely lower cost..

Population Health Management (PHM) programs are designed to reduce cost of care by maintaining and improving the health status of patients across the full continuum of care. PHM begins by defining a patient population, assessing its health and stratifying the riskiness of patients becoming sicker or needing high-cost services within this population. Care providers then assign appropriate care interventions using evidence- based guidelines, care management, and case management programs to prevent a patient from moving up the morbidity scale and at times, to help them move down the morbidity scale toward better health and less costly care requirements. PHM tools include analytics to help identify patients that have slipped through gaps so that corrective measures may be instituted in a timely manner. Reporting systems also measure patient outcomes, costs, and quality, in both clinical and administrative metrics.


a population health management (PHM) system with integrated patient engagement tools, has been developed by AxSys using its Excelicare platform. CareVigilance connects the healthcare environment and enables care coordination by ensuring that the right information is available at the right time to the right person. It is based upon a health information exchange hub (HIE hub) and an aggregated clinical data repository that has the ability to construct a life time health record per patient from the information it collects, presenting the key items of data in an easy-to-read continuity of care document (CCD) summary. Identification of populations at risk can be done through information that is already available in various GP and hospital systems or through risk stratification based on health risk assessment questionnaires (HRAs). CareVigilance has the ability to accept HRAs through various channels such as mobile devices, kiosks and PHRs. Clinical rules embedded in CareVigilance help with risk stratification and this information is made available to providers who can proactively reach out to engage with patients to monitor and manage those at risk of progressing up the morbidity scale. Outreach can also be automated using data from the hub to trigger messages to patients alerting them about targets and measures, asking them to complete monitoring information or screening questionnaires, or reminding them about appointments with their providers, so allowing the health service to reach more patients without adding human resources.

All information stored within CareVigilance is available for analytics and can be used to further introduce efficiencies in the healthcare system.