Managing Populations, Maximizing Technology

This report supports primary care clinicians in their efforts to adopt a population health approach that leverages health IT solutions. The report titled, “Managing Populations, Maximizing Technology: Population Health Management in the Medical Neighborhood,” offers a first-time, comprehensive view of health IT-enabled population health management that is built on a foundation of the patient-centered medical home, and further extends into the medical neighborhood. The report serves as an essential primer for physicians and practices that are considering partnerships with a broad range of organizations in their community using health IT to help deliver population health.

Many providers are already working with neighboring medical providers in an integrated and coordinated manner, but should also engage with schools, employers, public health agencies, faith-based organizations, and others in order to provide the level of person-centered care that is essential to improving the health and well-being of individuals, families, and communities. A relatively new term, the medical neighborhood is centered around the patient-centered medical home (PCMH), which serves as an individual’s primary care “hub.” The medical neighborhood is even more inclusive, connecting primary care practices to hospitals, home health agencies, mental health providers, as well as community organizations that encourage healthy living, wellness, and safe environments. While strengthening the medical neighborhood requires significant efforts in governance and community organizing, the guide emphasizes that the widespread adoption of health IT will be critical to its success.

The guide presents an overview of the population health approach, and provides a number of health IT tools that are embedded in the five key attributes of the PCMH and medical neighborhood. It also includes a recommended “Top Ten List” of health IT-based population health management tools, including:

• Electronic Health Records (EHRs)
• Patient registries
• Health information exchange
• Risk stratification
• Automated outreach
• Referral tracking
• Patient portals
• Telehealth / telemedicine
• Remote patient monitoring
• Advanced population analytics