Population Health: Connecting Population Health to Patient Safety

By Patrick Stevenson, BS, CSSE, NCP

The topic of population health often comes up in conversations about healthcare quality as organizations aim to leverage information about their patient populations to improve the quality of care they provide. However, a focus on population health goes beyond just improving quality—at its core, population health management enhances the fundamental safety of patient care. Population health programs should be designed with patient safety in mind to pinpoint patients in need of care who may not be receiving it and transition those patients into care, allowing an organization to proactively address the patients’ health risks and avoid potentially severe negative outcomes.

Patient safety in the traditional sense deals with error prevention and reduction of risk to the patient. In this article, I’ve chosen to hone in on this risk reduction, rather than patient safety as defined by AHRQ, which states, “An act of commission (doing something wrong) or omission (failing to do the right thing) that leads to an undesirable outcome or significant potential for such an outcome.” By zeroing in on the risk reduction aspect of patient safety, its link to population health becomes clear. Furthering population health is a risk-mitigating strategy that an organization can pursue to make sure patients who need care actually receive it.

Developing a strategy for population health management is key for reducing risk and ensuring the health and safety of an organization’s patient population. This strategy relies on effectively gaining insight into the health of a patient population, which can be achieved by pulling volumes of data over a period of time and analyzing that information to identify risk. To promote patient safety, organizations must also incorporate the following three elements as part of their population health management strategy: building a strong cultural foundation for population health management, integrating technology that supports streamlined information gathering, and developing processes for communicating and responding to risk.

Setting Cultural Expectations

Designing and implementing a population health strategy to elevate patient safety requires a change in mindset for many organizations. This type of program does not work when an organization is concerned with quantity versus quality. For example, if an organization’s main goal is to see as many patients as it can, as quickly as it can, then identifying patients that need more in-depth attention may not be a priority. Delivering quality care that boosts patient safety takes time, and an organization must be willing to dedicate that time in order to realize success.

Organizational leadership plays a critical role in establishing expectations for a population health program and nurturing the move from quantity to quality. Clinical and administrative leaders, as well as the board of directors, must be engaged in shifting the organization’s mindset, or even the most well-crafted population health strategy won’t get far.

To communicate expectations, leaders should be actively involved in strategic planning meetings and communication efforts with clinical staff. In general, they need to be a visible presence in any effort that prioritizes the use of data to improve quality. Garnering buy-in from physician leaders is especially important, since physicians will be leveraging population health information to target patient care and enhance safety.

Automating the Effort

Although manually managing the health of a patient population is possible, it can be quite time-consuming and take away from other patient care activities. Consider the example of Infinity Primary Care—a Michigan-based group practice that sees approximately 50,000 patients annually. The practice takes an automated approach to identifying patients who are not as involved in their care as they should be. These patients frequently have chronic conditions or multiple comorbidities and do not have an appointment scheduled or have any plans for an appointment in the future.

Previously, the practice identified these patients through a manual process in which a full-time equivalent waded through spreadsheet data to highlight patients who should be seen by a physician. The staff member then reached out to these patients to encourage them to see the doctor. This process was not only time consuming for the staff member—typically a medical assistant (MA)—but took the MA away from his or her patient care responsibilities in the office.

A few years ago, Infinity Primary Care automated its population health processes, turning to software to identify high-risk patients. The software scrubs the entire electronic health record database against a list of quality measures, including National Quality Forum measures, clinical quality measures, and Physician Quality Reporting System measures as well as a measure of multiple co-morbidities created by the practice.

After scrubbing the data, a list of patients who fall outside the range of measure parameters is generated. For example, patients who had an A1C test result >9 or who haven’t had a flu shot in 6 months can be flagged. Likewise, patients with two or more comorbid conditions, including diabetes, asthma, hypertension, chronic obstructive pulmonary disease, chronic heart failure, chronic heart disease, and obesity can also be tagged.

Once the patients are identified, the system checks to see if they have an appointment scheduled. The software hones in on those patients without an appointment, resulting in a list of high-risk patients who have serious health conditions and are not being monitored adequately.

The system then contacts these patients through one of several automated methods, including via a secure patient portal message, text message to the patient’s phone, letter, email or automatic voice solution message.

By automating its population health processes, Infinity Primary Care is able to efficiently identify those patients at risk for negative health events and quickly move those patients into care, allowing the practice to proactively address chronic conditions before they become emergent.

In addition, the practice can free clinical staff to pay more attention to the patients who come to the office instead of spending valuable time tracking down patients who need care but do not seek it. This enables the staff to delve deeper into patient problems during the onsite visit, possibly uncovering issues that would have been missed with a shorter, less targeted appointment.

Communicating Risk to Stakeholders

Identifying at-risk patients is only one part of a good population health management strategy. Organizations also need to communicate information about these patients with everyone who touches their care. For example, at Infinity Primary Care, after the automated population health solution identifies and contacts high-risk patients, it puts a red flag in the medical records of those patients. When the patient calls to make an appointment and the scheduling staff pulls up his or her medical record, staff can quickly see why the patient is calling and what healthcare needs have to be addressed during the appointment. For example, if the patient needs a flu shot and a repeat A1C test, the scheduling staff can allow time for that during the visit.

The practice’s scheduling system is also able to allot varying times for different kinds of appointments. For example, if a patient has multiple co-morbidities, the patient appointment may be scheduled for 45 minutes, while a standard sick visit may only need 15. This ensures that the sickest patients receive the most attention from their physicians.

To loop physicians in, the system generates a report at the beginning of the week that summarizes which patients coming to the office have been identified through the population health solution and communicates information about what conditions and treatment needs those patients have. This allows physicians to better plan for patient visits and anticipate what care activities need to occur. Note that this is different than the typical approach where a physician might glance at the patient health record a few minutes before entering the exam room. By having more lead time to prepare, the visit can be more productive and comprehensive.

Getting everyone on the same page about high-risk patients ensures an organization is focusing its attention on those patients who need it rather than providing the same care to everyone, regardless of risk.

Embracing the Model

When implemented appropriately, a population health strategy can help an organization close gaps in care and reduce risk by targeting patients who need care but are not receiving it and proactively addressing their conditions. By taking this data-driven approach, an organization can ensure it prioritizes care for its most vulnerable patients, enhancing their safety while improving the health of the entire patient population.

Patrick Stevenson is the director of information technology at Infinity Primary Care. He has worked in the healthcare field for more than 10 years filling roles in service, support, management, and strategic direction. He currently hosts the Midwest NextGen Users’ Group meeting and participates actively in the healthcare community. Stevenson may be contacted at pstevenson@ipcmd.com.


Agency for Healthcare Research and Quality. (n.d.). Glossary. PSNet. Available at http://psnet.ahrq.gov/glossary.aspx?indexLetter=P