Knowledge Center


Population Health Management Program



The Challenge

Altering the course of a Population Health initiative from an Accountable Care Organization (ACO) focus to an enterprise-wide program can be a daunting challenge. One healthcare organization faced this scenario following a simultaneous ACO and Epic electronic health record (EHR) implementation. Utilizing HEDIS (Healthcare Effectiveness Data and Information Set) and health plan standard performance measures, registries and metrics were initially built and aligned with only the ACO in mind. The ACO and other evolving independent population health initiatives were segmented with duplication of effort in play along with a lack of formal governance. Although the payer side is advantageous to implement for obvious cost management reasons, the organization later recognized the need to shift to an enterprise-wide population management solution encompassing patient wellness and provider chronic disease management for the entire population of patients rather than those associated only with payer plans. All provider specialists (Primary Care Physicians, Cardiologists, Endocrinologists, Neurologists, etc.) required the means to identify and track the progress of complex patients along with meeting individual practice regulatory reporting requirements. A new direction was needed to: a) drive patient monitoring along with expedited treatment adjustments by providers and care managers; b) track the management of patient population cohorts for each provider via dashboards; and, c) evaluate the enterprise-wide trends to further define best practice process and procedural changes.

The Solution

HSi provided a Senior Project Director to work in close collaboration with a newly assigned Population Health Management Program Director to formulate and structure an enterprise-wide strategy and program driven by a charter and governance plan with key objectives, goals, and resources defined. Identification of physician champions and business owners across the organization along with establishment of a Population Health Governance Group to guide prioritization of work and decision-making took place. A road map (timeline) including provider specialty registry/dashboard development and roll out plan, the program strategy, success measures, and future opportunities was created to accomplish executive and business owner status-at-a-glance reporting of the numerous simultaneous projects placed under the Population Health Management Program umbrella. A Population Health IT Team to focus only on the work of the Population Health Management Program was formed combining both external contracted and internal resources to expedite development and provide the ongoing maintenance required.

The Benefit

Population Health Management became a fully operationalized program in just a few short months as a result of joint HSi and customer leadership. Additionally, this effort set the stage for ongoing successful leadership and management of the patient population by addressing diseases across provider specialties rather than by individual specialty. It required work to achieve specialist consensus of shared measures and metrics, but the result presented a single picture of the patient’s status to all healthcare workers along the continuum of care. Effective data collection and outcomes reporting are now greatly enhanced allowing providers to truly analyze and make the decisions necessary to improve the quality of patient care for an individual or the population as a whole. Establishing a population health initiative as a program rather than a project conveys to the organization that this is a longstanding and worthwhile endeavor.

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