The importance of population health monitoring and stratification

Population health management CSC Blogs Journey to Digital

The heart of population health management is having a surveillance capability that recognizes patterns in patient data and care management characteristics and exposes impending high-risk clinical events, gaps in care coordination or non-compliance in patient situations.

To manage population health effectively, an organization must be able to track and monitor the health of individual patients. It must also stratify its population into subgroups that require particular services at specified intervals. From a care management viewpoint, patients should be stratified by their risk of getting sick or sicker.

Grouping patients into categories by condition has been the traditional approach of disease management programs. In contrast, care management stratification focuses on whether patients are ill enough to require ongoing support from a care manager, have less serious chronic conditions that warrant interventions to prevent them from worsening, or are fairly healthy and just need preventive care and education.1

Risk stratification must be dynamic in nature. Payers use predictive modeling algorithms that can help forecast which patients are likely to have significant health costs. Electronic health records (EHRs) can generate alerts for preventive and chronic care, but typically prompt providers only when a patient’s record is opened, usually during a visit. Real-time prompting is needed to assist providers and support patient empowerment. Electronic registries fed by EHRs, administrative data, social status data and other federated data sources are a superior source of actionable data and risk stratification reports. When such registries are coupled with evidence-based clinical protocols based on national standards, specific messages can be generated, reminding patients to make appointments for needed chronic and preventive care.2

The transition to a system of population health management promises to improve access to important resources when they are most needed, like doctors and facilities; to free up public funds for new systemic investments; and to bring better health and well being to a much broader segment of society.

A comprehensive look at how digital can power forward the enterprise:

Read more in this paper, Digital Revolution Enables Population Health Management.


1) Agency for Healthcare Research & Quality, “Practice-Based Population Health,” pp. 21-22.

2) Suzanna Felt-Lisk and Tricia Higgins, “Exploring the Promise of Population Health Management Programs to Improve Health,” Mathematica Policy Research Issue Brief, August 2011.

LadegaFemi Ladega is chief technology officer for DXC’s Healthcare industry group, with experience delivering major transformation engagements to private, public and international organizations globally. Femi provides leadership for driving the solution strategy and technology direction for the industry group.




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