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Population health management software: The ultimate guide

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Population Health Management Healthcare Analytics

Success in population health management requires several moving parts working together to improve health outcomes without inflating costs. This includes every decision that informs modern healthcare strategies, from illness identification to condition management.

To keep these decision-making processes efficient and informed, organizations need a reliable solution to consolidate and organize population data. That’s where population health management software comes into play.

In this guide, we’ll answer all of your population health management software questions and provide recommended vendor solutions. Here’s a roadmap of where we’re headed:

By the end of this guide, you should have a complete understanding of population health management software basics and capabilities. Then, you’ll be well on your way to selecting a solution that meets your organization’s population health needs.

Population health management software FAQ

What is population health management software?

Definition of population health management software

Population health management (PHM) software refers to a set of digital tools used to manage the health outcomes of a group of individuals within a predefined population. The goal of PHM software is to provide proactive, value-based care through preventive solutions that reduce the risk of illness progression.

For example, let’s say an organization is following a 61-year-old patient, named Jim, who was diagnosed with Type 2 diabetes and also suffers from cardiovascular disease. With PHM software, your organization can match Jim with personalized recommendations, from in-network care teams to programs that will deliver personalized interventions to help manage his conditions.

PHM software works by gathering social determinants of health data (SDoH) and comparing it to the patient to contextualize his care needs. This workflow enables providers to set relevant goals based on population benchmarks.

In summary, PHM software also helps reduce overall costs through informed resource allocation that prioritizes high-risk populations. As a result, costly last-minute interventions are substantially reduced.

How does population health management software support value-based care?

Value-based care is an innovative payer-provider model developed by the American Academy of Pediatrics in 1967 as a solution for children who were experiencing a lack of care coordination between multiple providers. Today, it’s a popular model that promises better patient experiences, increased efficiency, more reliable cost controls, and decreased risk.

According to the New England Journal of Medicine, the value-based care model can pay healthcare providers, including hospitals and physicians, based on health outcomes. This differs from the “fee for service model” in which providers are paid based on the amount of healthcare services they provide.

PHM software supports value-based care by providing organizations with the tools and insights to balance patient health outcome improvement and cost reduction. Specifically, PHM software enables:

  • Patient-centric care. PHM software allows providers to tailor interventions to individual patients and care plans while keeping an eye on how niche groups compare to broader population trends.
  • Care coordination. With the right tools, providers can collaborate with stakeholders on every level to assess and track care management notes and patient histories against pre-defined benchmarks.
  • Risk-sharing models. PHM software uses advanced analytics to categorize patients based on their risk profiles. Providers can use these insights to proactively allocate resources to compensate for higher-risk patients.
  • Patient engagement. PHM software empowers patients to take control of their health by allowing them to schedule appointments and communicate with their care teams efficiently. In turn, this engagement can lead to increased care plan adherence and improved outcomes.
  • Value-based contracting. Through data-driven decision-making, providers can focus on adding quality, efficiency, and overall value to their services rather than quantity of care. This way, they can reduce unnecessary healthcare utilization.

PHM software aligns all stakeholders — providers, payers, and patients to experience success in value-based care. When implemented properly, this solution can increase care quality and significantly reduce associated costs.

What are the key features of population health management software?

Although there are several PHM software providers, there are a few common features across each solution. These features are built to manage large data volumes so organizations can focus on both large and small populations. They include:

Population health management features listed and explained in text below.
  • Data aggregation and integration. PHM software can collect and integrate data from several sources, including EHRs, insurance claims, and patient self-reported data to offer a comprehensive view of population health needs.
  • Population health analytics. With the power of population health analytics, organizations can identify and understand trends and insights related to specific populations. Using these insights, they can implement preventive strategies.
  • Integrated care management. This feature streamlines patient care across various healthcare services to bring disparate data together under one roof. Integrated care management keeps care consistent and reliable for patients with complex health needs.
  • Patient engagement. PHM software often includes tools and strategies that enable patients to actively manage their care. This includes accessible patient portals, mobile apps, and administrative reminders that promote care plan adherence.
  • Referral management. When patients need to be referred to specialists or other healthcare services, referral management features streamline the process. This feature also tracks and analyzes referral trends and patterns to maximize the outcomes.
  • Quality management. This feature uses performance tracking indicators, health outcomes, and patient satisfaction to monitor and provide suggestions for healthcare service quality.

When each of these features is leveraged properly, healthcare organizations can transition from reactive care to preventive health management. However, the specific solution your team chooses will also depend on your population health goals.

For instance, you might prioritize finding a solution with user-friendly capabilities that connect disparate care teams. This way, you can feel more confident in disease management across different settings and referral networks.

10 population health management software solutions to explore

Choosing a PHM software provider is a significant decision that requires a thoughtful approach. Involve cross-functional teams in your decision-making process, including IT professionals, clinicians, and administrators to ensure the platform meets everyone’s needs.

We’ve provided the top ten PHM solutions to kickstart your research below:

The top ten population health management solutions are listed below.

1. Arcadia Analytics: Most comprehensive cloud-based software

Arcadia is an easy-to-navigate platform application built for analytics. It offers a highly user-friendly web portal and deep data mining capabilities that place all the tools an organization needs at the point of care. The desktop solution runs in the background mapping patient IDs to tables in the Arcadia warehouse.

The system curates data from clinical EHRs, claims data, social determinants of health (SDoH), pharmacy records, ADTs, and other sources. This solid foundation of data volume makes sustainable financial success possible within a value-based framework.

With Arcadia, your team can customize workflows for every member involved, from care managers to providers. Then, each member can toggle between related strategic initiatives and member-specific workflows. For example, providers can count on Arcadia to deliver a data-backed summary for each patient complete with predicted gaps in care, recent significant events, and medical history.

2. AthenaHealth: Best software for patient outreach

AthenaHealth is a PHM software platform built to help organizations manage multiple EHRs. This solution aggregates, maintains, and normalizes your clinical, financial, and payer data to offer organizations reliable data sets. Care teams can quickly assess the right care plans with configurable, evidence-based content.

Then, with help from Athena Health, providers can maximize outreach by adjusting their approach to each patient. As healthcare organizations expand, they can rely on reporting dashboards to show you cost and utilization across populations.

AthenaHealth also offers a reliable EHR mobile app for patients to log their progress and message care managers on the go.

3. Azara: Best software for value-based contracts

Azara is a provider of population health solutions for standalone and physician networks, community health centers, and more. Azara engages patients through pre-configured “set it and forget it” programs that automatically initiate patient contact (via text), and track response and follow-up actions.

Additionally, its data analytics capabilities combine EHR data with screening results from SDOH demographic information for a multi-faceted picture of patient health. Its set of dashboards, reports, and measures incorporate data from health plans and other payers with clinical EHR data to offer a detailed utilization view.

4. Conifer Health Solutions: Best software for care planning

Conifer Health Solutions’ PHM tools are created to prioritize outreach and engagement for people serving hospitals, health systems, and unions.

This solution integrates with health plans to bring pharmacy benefit managers, third-party administrators, provider networks, and other benefit solution vendors together. Specifically, Conifer Health Solutions specializes in personal care nursing, case management, disease management, and utilization management to help members find the right care at the right time.

5. Epic Healthy Planet: Best software for community-based care

With Epic’s PHM suite, Healthy Planet, care teams can monitor patient health and take action with engagement tools. Its data aggregation capabilities eliminate duplicate testing and combine a wide range of data from labs, risk scores, paid claims, and external systems.

The solution provides contract performance and improvement opportunities using analytics to track and intervene on target contact metrics. Epic Healthy Planet also promotes patient wellness with integrated health and social care tools that assess patient needs and connect them with the right resources.

6. i2i Population Health: Best software for underserved populations

i2i Population Health technology specializes in providing community health solutions that deliver care for the underserved safety net market. As a healthcare interoperability platform, i2i Population Health leverages scalable data integration services to provide connected services to meet on-demand needs.

The solution’s clinic and in-hospital health application combines workflows with unlimited on-demand registries and reports. Providers also benefit from its standard supplemental data feeds bi-weekly or monthly, with expansive data sets such as SDoH and demographics. Care teams then use insights to enhance coordination and tailor individual care plans.

7. NextGen Population Health Analytics: Best software for referral management

NextGen Population Health Analytics is a care platform created to offer a clear view of your patient population. The comprehensive software incorporates risk management, cost control, revenue optimization, and targeted interventions.

Specifically, NextGen’s referral management capabilities access information on where patients receive health care services, including specialty care at the population and patient level. It then displays these patient insights alongside patient charts in the EHR.

8. Optum Population Health Solutions: Best software for specialized health solutions

Optum Population Health Solutions is built to help employees choose the right doctor and understand their treatment options and medications. Their main areas of focus are case management, condition management, and cancer support.

The platform’s integrated benefits data enables organizations to analyze performance and financial trends against industry norms and prior performance benchmarks. For example, Optum’s dedicated women’s health programs identify related risk factors and educate mothers and families to reduce complications while lowering costs.

9. Oracle Health: Best software for clinical trial research

Oracle Health’s technology solutions emphasize chronic condition management and prevention. The platform also has a nationwide network of diverse health systems that conduct clinical trials and outcomes research alongside them.

Oracle Health provides advanced SDoH solutions to intervene at the point of care by using evidence-based screening tools and suggested goals. This way, care teams can keep an eye out for vulnerable populations and make targeted and informed interventions.

10. Clarify Healthcare: Best software for predictive analytics

Clarify Healthcare’s enterprise analytics platform, Atlas, harnesses the power of big data for business and clinical insights. The platform leverages thousands of trained models to cut and harness data to provide case-mix adjusted predictive values for clear insights.

With Atlas, providers can map the patient journey against predetermined benchmarks and recent trends. This way, they can provide personalized recommendations for each patient based on reliable data.

Population health management software: Final thoughts

Modern PHM software reimagines management with robust analytics and reporting capabilities that keep care teams coordinated and efficient. When deciding which software is right for your organization, choose a solution that will scale with your needs and complement your existing workflows. This will make the transition smoother and provide a higher long-term ROI.