I have been to the last few HiMSS conferences and each year population health is a big topic.  It seems everyone is talking about population health. From booth to booth, the vendors discuss how they are doing population health; when in fact each of these vendors brings a potential solution to some segment of the population health ecosystem. Population health is so broad that to do it completely requires collaboration between the person, family, providers, vendors, non-profit organizations, communities and the government.
But there are unique features I’ll be looking for from vendors in this space.  I base these features off the Population Health Alliance Framework for Population Health from the Outcome Guidelines Version 6. The framework is at the bottom of this post.

Identification
Identification is fairly straight forward, we can identify our population through claims data, EHR Health Risk Appraisal or self report, patient panels, people in a zip code.  But is anyone doing any big data mashups and/or algorithms identifying people likely to have a condition based upon other variables, identifying people who perhaps have not touched the health care system much or at all?
Assessment.
We can assess populations based upon clinical indicators, health risk appraisals, costs, diagnoses, but who is going beyond these measures?  The next step should be on readiness to change, Patient Activation Measures, and the likes, and many vendors do this. What about social measures, where they live, access, support services, family? Who is baking that information into their assessments.  What about genetics whose using that?  Who might be overusing that? Sure genetic testing is cool and can provide some insights, but are they relevant, is there an intervention if someone has a genetic marker for something? And what about personalization? We know that people are different. There  are psychographic measures used heavily in the retail industry that could have profound impacts in population health. Lets also not forget the mental health side of this and its effect on the health of populations. Are we assessing that?
Stratification
Now that we’ve broadened our identification and assessment tools and criteria, what’s the stratification methodology? How many buckets are there, are the stratifications based upon impact-fulness.  You can stratify some people on conditions, but there may be little or nothing one can do about that (see the genetic example above). Are there unique stratifications’ that will allow for targeted interventions that are much more meaningful; creating even better identification of those to intervene with, resulting in much improve outcomes? Whose got that?
Engagement
Ah, the holy grail, engagement. First how do you define engagement, how do you measure it and then how do you create it? We are still seeking answers to many of these, so I tend to take engagement statistics with a grain of salt.  One company I spoke with was impressed with their 15-20% engagement of a population, which is low to start in their industry. Turns out it was even worse than it appeared when I learned that they consider the person engaged if they signed up on the website.  The person didn’t have to use the website ever again to be counted as engaged!
So what am I looking for? Unique approaches utilizing technology and people, approaches that segment and personalize the messaging, approaches targeted to health literacy, approaches that provide linkages or engage through family, friends or caregivers as well, even old fashioned face to face.
Interventions
What is the intervention? Phone call, messaging, education, reminders, in home, telemedicine. What’s it for? Care coordination, medication adherence, monitoring, cost reduction, readmission reductions,improved outcomes, improved health, improved quality of life. There are a myriad of  interventions and no silver bullet.  We are all just a bit different, that’s why it’s so important to use the assessment and stratification to help in identifying what types of interventions are likely to move the population one person at a time. I’m looking for things that I know to work from experience and the literature, as well as unique ideas perhaps on the bleeding edge that may prove to move the needle. What about the behavioral issues and mental health, we could use a lot of help there, how about end of life?  These two areas certainly in need of better interventions.
And finally
Outcomes
Who’s got them, how do they measure them, are they valid, are they reproducible, are they meaningful.
Am I missing anything? I’m sure I am, what else should I be looking for?  I would love to be blown away by some of the vendors in attendance.
If you’ve got something you think might knock my socks off.  Contact me, I’ll stop by or we can meet and check it out.
See you at HiMSS16!