Patient Health Management | SolbegSoft

Patient Health Management

October 23, 2020
    While just one of many levers to tackle health outcomes, Patient Health Management is increasingly viewed as a key to ensuring the affordability and sustainability of care.

Patient health management is the concept of gathering data and insights about population health and well-being across multiple care and service settings, with a view to identify the main healthcare needs of the community and adapt services accordingly.

Today, major advances in data analytics, machine learning, and digital technologies can provide the tools to make PHM a reality, by helping to identify risks and stratify patient populations, improving the speed and accuracy of diagnostics, and designing personalized treatment plans.

Experience across the world shows that there isn’t a single approach or “rule book” for PHM; in the United Kingdom, for example, the administrations of England, Scotland, Wales, and Northern Ireland have adopted different approaches to health and social care, including prioritizing the role of PHM. There are, however, several distinct building blocks and critical success factors to enable a health care system to adopt an effective PHM approach

Four key building blocks and nine critical success factors enabling PHM


  • Having a shared vision, mission, and understanding of the journey
  • Improved shared technology and digital infrastructure
  • Leadership maturity and good governance


  • Focused population targeting and segmentation
  • Robust monitoring, advanced analytics, and insight processes


  • Aligned incentives across the system
  • Delivery of primary care at scale


  • Population engagement and patient activation

Consumer priorities in healthcare

  • Consumers want to be known and understood in order to get a personalized health care experience—providers deliver on this the best.
  • Consumers want affordable care with no surprises—this drives their coverage and care choices.
  • Consumers want access to care when, where, and how best it suits them; convenience dictates behavior.
  • Consumers are looking for tools to help manage their care. Digital tools are increasingly doing this, but they must become easier to use and more connected to make an impact.
  • Consumers are more alike than different, though they may be on different levels of maturity of “consumerism.”
  • Consumers are willing to share personal and health information, especially with their doctor. Trust is critical.
  • Most consumers believe they should own their personal health record.
  • Consumers have access to (and use) tools that keep them healthy.
  • Consumers are no longer passive; they demand transparency, convenience, and access. They also are willing to disagree with their doctors and are engaging in more preventive behaviors than in the past, such as personalized exercise and nutrition.
  • Consumers use technology and otherwise take charge of their health. Those who don’t use technology are interested, suggesting that the right tools haven’t been built yet.

The main goals of PHM:

Chronic disease management. Healthcare organizations use PHM to manage patient populations with chronic conditions such as diabetes or chronic obstructive pulmonary disease (COPD).

Wellness and preventive health. Healthcare organizations launch initiatives that promote healthy lifestyle habits to both youth and adult populations. Weightloss and smoking cessation programs are the examples of this category.

Clinically integrated networks. Primary care physicians, specialists and hospitals create networks together to improve patient care. These networks share health record systems and track data to provide high-quality care and to lower costs.

Patient-centered medical home. A PCMH takes a team-based approach to care. In this model, the primary care doctor serves as the hub in a wheel of coordinated services and communication between the organization’s providers, the patient and his or her family.

At-risk payment structures. These structures focus on improving quality of care for their members and offer payment incentives for doing so.

If PHM is to be embedded throughout the health system, there are numerous barriers to overcome; not the least of which is the challenge of linking previously disparate data sets and developing leadership models that embrace new, integrated, ways of working and a shared culture and mindset. Clinical and care teams also should look to private health insurance for ways to connect with and organize populations in need of care.


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