It is essential to manage the health of an entire population to ensure each patient receives the appropriate care for them. Chilmark Research describes population health management (PHM) as the proactive management of the health of a given population by a defined network of financially linked providers in partnership with community stakeholders (social workers, visiting nurses, hospice, patient, caregivers/family, etc.)

Globally there is a rise in noncommunicable diseases (NCDs) or chronic diseases, these are also called lifestyle diseases, and they are attributed to tobacco use, physical inactivity, the harmful use of alcohol and unhealthy diets. Cardiovascular disease (heart attacks and stroke) accounts for the majority of NCDs, followed by cancer, respiratory disease and diabetes. The key to curbing the rise in NCDs is early detection, screening and treatment in at-risk individuals, placing an increased burden on healthcare organisations to provide care for larger numbers of patients who require more intense and costly interventions and it has resulted in spiralling costs. 

The result has driven the healthcare market to experience unprecedented change, with the rapid evolution from volume to value-based care. There are widespread efforts to transform the care delivery process, control and reduce costs, improve health outcomes, and obtain more value from each healthcare dollar spent.

This evolution impacts all healthcare stakeholders and requires healthcare organisations to adopt new care delivery models by transitioning from a fee-for-service model to an emerging payment mechanism, with the goal of providing a patient-centred, integrated approach. It also presents opportunities for healthcare organisations to gain market advantage, by growing their services and becoming more cost-effective. It also poses challenges to these organisations with ongoing revenue concerns, reduced growth and market share.

Healthcare organisations face a changing landscape and need to evolve their business and care models in pursuit of shared savings and improved clinical outcomes. Successful value-based care delivery puts the patient at the centre of care, requiring a single, comprehensive view of patient information, analytics tools to identify cohorts of patients and gaps in care, shared workflow across multiple providers and intuitive tools to help improve communication and efficiency.

Organisations require complete and real-time data to understand the health of their population correctly, requiring tools to engage with high risk and high-cost communities directly. They also require a health IT solution that can span the healthcare continuum, from an acute setting, through to community-wide clinical care coordination, incorporate social determinants of care, and effective patient engagement.

Successful PHM requires three pillars to integrate seamlessly


To identify individuals and cohorts within a population who may be at risk or experiencing a gap in care, so that the health system can react proactively to improve patient outcomes and reduce healthcare costs.

Care coordination and management

Ensures that a broad range of providers are involved in coordinating care around a patient. This includes setting up personalised care plans, shared pathways and workflow, managing who is involved in care, enabling multidisciplinary care teams, and managing a patient’s medicines, problem list and referrals across the system.

Patient engagement

The ability to engage patients and their families to assist them to become more active in their care, including effective sharing of information with the patient, secure communication with the care team members, patient-completed questionnaires and sharing of educational materials to help patients understand their condition. 

Underpinning these three pillars, there needs to be a comprehensive platform that can aggregate all types of health data, from both traditional (e.g., claims, clinical, medical devices) and non-traditional (e.g., behavioural, social) sources. To deliver value to both a patient and a system, the solution must be able to provide a single, comprehensive view across care settings and ensure the three vital elements are delivered effectively and seamlessly.

The benefits of investing in a PHM solution

Access to a comprehensive longitudinal patient record

Our solutions simplify the challenging task of data aggregation from across all care delivery settings, All information is in one place, empowering clinicians to make the most informed decisions.

The solution provides an invaluable view of a patient’s longitudinal record, including context and history as recorded by providers across care settings which provides information critical for quality care. Clinicians can access reports, dashboards, and work lists for improved coordination of care across organisations and care settings. There is the ability to sort patient populations by risk or care gap, and immediately know which patients require attention.

Enables transition to proactive and preventative care

Providing real-time clinical decision support is critical for the delivery of optimal healthcare. The PHM solution provides clinicians with access to the full patient record, and notifications alert them to gaps in care so that they can take proactive action for high need patients.

Effectively coordinate care

Shared actions and tasks ensure all members of a care team have the full picture of a patient’s plan and their role within it. They can implement a patient-centred care plan and leverage the tools to ensure all patients enjoy a well-coordinated care experience. This is in in the best interests of the patient, helps to decrease costs, manage gaps in care, and avoid duplication of services. 

The PHM solution enables easy coordination across clinicians, including those at different organisations, to deliver seamless care with minimal delays. Patient engagement tools allow the patient’s entire Circle of Care to contribute information, helping build an accurate, up-to-date patient record.

Rapidly identify at-risk/high need patients

The solution enables users to rapidly identify cohorts of patients that require proactive intervention and assign the necessary tasks and actions to ensure they receive appropriate and timely care. Patients with multiple chronic conditions demand complex care, placing a disproportionate burden on limited resources. The PHM solution helps healthcare organisations achieve desired outcome metrics, effectively identifying at-risk patients, managing their chronic diseases, and following the patient’s journey post-discharge to avoid acute care re-admission.

A key part of PHM is having in place the infrastructure to deliver effective care management, especially for those who require intensive or long-term care. Users can assign tasks, track patients’ progress, engage with their patients and perform necessary risk assessments for future care planning. 

Improve the patient experience

Healthcare is becoming more consumer-driven, and there will be increased demand by patients for improved access to information, transparency into the cost and quality of care, and better healthcare experiences. Organisations can strengthen relationships with their patients to build future loyalty. 

Gain a deeper understanding of the process and costs involved within a healthcare organisation

 The solution provides the tools to effectively manage multiple contracts, which can improve the management of resources enabling the ability to deliver successful healthcare outcomes while containing and reducing cost in the system. By achieving a deeper understanding of cost, analysing and showing cost performance the solution can provide an identifiable return on investment.

Orion Health Orchestral Health Intelligence Platform for population health and precision medicine provides the tools that healthcare organisations need

The solution provides near real-time access to complete patient information from clinical, claims and consumer data sources; the integrated tools to identify, assess, understand and manage patient populations; and the ability to identify treatments and prevention strategies perfect for an individual.

The solution helps healthcare organisations to optimise clinical decision support at the point of care, coordinate care delivery and reimbursements; transition to new payment systems; reduce costs in the system and achieve increased patient satisfaction. The open platform supports PHM initiatives, value-based care models, and provides healthcare professionals with real-time cognitive support at the point of care. The platform can help healthcare organisations to manage the health of an entire population while ensuring each patient gets the appropriate care for them.

Learn more about the Orchestral Health Intelligence Platform.