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Understanding population health management is crucial to providing smarter care to the entire Canadian population. At Cerner, we believe that smarter care is proactive care.

Population health management is the proactive application of strategies to a specific group of people with the responsibility of improving their health and well-being. This responsibility focuses as much on the individual’s needs as it does on the entire population.

It must be viewed as part of a wider health and well-being strategy and include factors such as income, status, and environmental impact. Health and social services, education, labour, and finance ministries in Canada are all run by provincial or territorial governments and although broadly siloed, these valuable sources of information should be better leveraged to create a truly integrated system of care.

European approaches

Many European countries with similar social systems have taken advantage of this strategy. One example of successful population health management is in the United Kingdom’s Wirral Peninsula where, across a 24-kilometer radius, there are major differences in life expectancy — especially among the parts of the population suffering from chronic diseases such as diabetes or depression. Using population health management technology, the community is improving the well-being of citizens through new care models that provide holistic solutions to instances where there are poor health indicators. Working with local resources to help set up citizens for success.

There are stories within Canada that are strikingly similar and provide the very same opportunities for us to shift gears and act fast.

Going beyond informatics

There is no doubt that research is a vital component of population health management, but it can’t stop there. Shifting from a reactive to a proactive system requires more than data aggregation and analytics, especially for a data-rich nation like Canada. The way we organize, share, and create recommendations with our data that are actionable will determine how real change occurs. We need to get that intelligence to the front lines.

These outputs have the potential to push data wherever, and whenever, a patient intersects with the health care system — positively affecting their treatment plans. Using predictive analytics and data sharing in the emergency room, during a routine check-up, or at the pharmacy can ensure our health care system is working proactively to help people before they deteriorate.

Population health management informatics are rapidly evolving to support these opportunities as aggregation of “Big Data” enables the investigation and discovery of a wide range of problems. While most Canadian health care organizations have an understanding where their issues lie, most seem to be wary of what may seem to be another analytics solution. A different way of aggregating data is crucial to how they will deal with the growing health care needs of populations, integrate with other social systems, and make data actionable at the key touchpoints when people interact with anything impacting their health. Cerner is making the data management part of the equation much easier.

Canada’s path to systematic change

Informatics in population health management is certainly a key enabler, but the real challenge lies in maturing other key capabilities in the health care system. This includes leadership with a clear vision, organizational redesign with new and evolving jobs, payment reform and incentives, citizen engagement strategies, and most importantly, cultural change.

Canada needs to evolve with the needs of its citizens. We need to mature our capabilities to stay competitive with other nations at the risk of staying in a stagnant, reactive health system. A population health management maturity plan requires an overhaul of the entire system, and that overhaul needs to happen now.

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