What kinds of systems or applications are used for population health management?
There are many important and effect systems and applications that are used for population health management. Two I believe are most important include Electronic Health Record systems and Patient Registries.
Electronic health records can improve public and population health outcomes; by efficiently collecting data in a form that can be shared across multiple health care organizations and milked for quality improvement and prevention activities EHRs can do the following:
According to the American Medical Association, patient registries help to stratify risk, identify patients overdue for screenings or test, and flag patients who may benefit from special attention to chronic disease management for conditions such as high blood pressure or diabetes. Furthermore, patient registries consist of clinical registries, clinical data registries, disease registries, and outcomes registries (Gliklich et al., 2014).
How are social determinants being used to improve health of patients?
To make an impact on improving health equity and providing more patient centered care, it is necessary to better understand and address the underlying causes of poor health. Social determinants include factors such as income, social support, early childhood development, education, employment, housing and gender (Andermann et al., 2016). Certain subgroups of the population (particularly those who are less empowered and who have lower socioeconomic status) tend to live and work in more degraded environments and have a higher exposure to risk factors for disease, as well as physiologic impacts from chronic stress (Andermann et al., 2016). Health care professionals can use these social determinants in may ways; examples are as followed:
How might you capture or access social determinant data?
There are many ways one can access social determinant data. On the CDC website, they provide many sources for data of SDOH on the national and state levels which can be useful when trying to focus on a more specific state or focusing on the nation as a whole. Examples of where we can access SDOH include:
Andermann A; CLEAR Collaboration. Taking action on the social determinants of health in clinical practice: a framework for health professionals. CMAJ. 2016 Dec 6;188(17-18):E474-E483. doi: 10.1503/cmaj.160177. Epub 2016 Aug 8. PMID: 27503870; PMCID: PMC5135524.
Gliklich RE, Dreyer NA, Leavy MB, editors. Registries for Evaluating Patient Outcomes: A User’s Guide [Internet]. 3rd edition. Rockville (MD): Agency for Healthcare Research and Quality (US); 2014 Apr. 1, Patient Registries.Available from:
Population health refers to the health outcomes that particular groups of people, typically categorized by geography or other demographics, experience. This is in contrast to acute care where the health outcomes of individuals are considered. Population health plays into some core principles that are utilized by the public health industry such as social determinants of health, and the socio-ecological model (SEM) (Hacker & Walker, 2013). Social determinants of health are factors separate from purely medical care that contribute to overall population health. These factors can be influenced by public policies and can often be found at the root of health inequities. Factors considered to be under the social determinants of health are income, wealth, education level, neighborhood walkability, presence of food deserts and more (Braveman & Gottlieb, 2014). Each factor also affects people at different levels of the socio-ecological model which at its most basic representation, categorizes health factors by the level of influence they have on an individual. A simple version of the model has four levels, the individual level which includes attitudes and beliefs held by an individual, the relationship level which includes the effect other individuals or family exert on an individual, the community level which includes the community or neighborhood around an individual, and the societal level which reflects public policies or infrastructure (Kilanowski, 2017).
Population health management utilizes provided social determinants of health and their accompanying SEM levels to address levels of chronic disease in populations afflicted with common outcomes to attempt to decrease chronic disease frequency, improve chronic health management, and lower the cost of chronic disease treatment. There are several applications or systems that are able to facilitate this. First and foremost, EHR systems contain patient demographics and medical history that are often shared with public health surveillance systems to improve management of individuals with chronic disease or to help report the spread of infectious disease (Kruse et al., 2018). Other helpful systems include patient registries which house patient monitoring information, health information exchanges, referral trackers, patient risk-stratification software, and population analytics software (HIT Consultant, 2013). All of these systems have the ability to store patient demographic information as well as their health conditions which if extrapolated correctly are can help pinpoint social determinants of health for each patient, particularly those with chronic disease. Additionally, social determinants can be tested for using screening tools like questionnaires about housing, food access or transportation (Healthit.gov, 2021). Once patterns have been identified about patients from specific groups, communities, or general geographic areas, targeted community health campaigns and needs-assessments can be advocated for, facility clinicians can be trained on addressing patient groups with the same social determinants to reduce disparities and eliminate potential biases in care, and social change can be rallied for (Andermann, 2016).
Andermann, A. (2016). Taking action on the social determinants of health in clinical practice: a framework for health professionals. Canadian Medical Association Journal, 188(17-18), 474–483.
Braveman, P., & Gottlieb, L. (2014). The Social Determinants of Health: It’s Time to Consider the Causes of the Causes. Public Health Reports, 129(2), 19–31.