John Glaser: Lets start out with what population health is, and then move to why it matters. Basically, population health centers on a group of individuals who share a common health challenge or health situation. They might all be going through cancer, or they all have spouses with dementia, or theyre all 25 and really healthy and you just want to keep them healthy. But they have a common health challenge or characteristic.

We will design a series of strategies and tactics that will keep them healthy and make sure that when they seek health care, it is of high quality and very efficient. Population health is defining and managing whatever strategies and tactics are applied to this group. They are intended to achieve certain health care quality, cost, and person-experience goals.

In a way, population health is like being an educator. An educator would formulate an approach to teach a class of 10-year-olds a particular subject, an approach that achieves certain goals of subject comprehension.

Population health complements individual health care delivery, which occurs when youre in front of your doctor or nurse. It also complements public health. Public health says, I want to take steps to ensure the health of the community; for example, that the waters safe and people are being immunized. You can imagine the Venn diagrams that illustrate overlaps between population health, individual care, and public health.

The reason it matters and population health has been around for decades is that health care is in the early stages of a multidecade, fairly significant shift in the business model of care delivery. The shift is largely driven by the fact that medical care costs so much, and continues to cost so much, consuming an amazing amount of the GDP. Its also pretty uneven in terms of quality.

How has the business model changed? Its moving from reactive sick care youre sick, you show up, we take care of you to the proactive management of health, where Im going to reach out and keep you healthy. Its moving from fragmented, disconnected care to integrated care across the continuum from a doctors office to a hospital to rehab to end-of-life, etc. Its moving from a fee-for-service model, where Im going to pay you for volume and activity, to a model in which the doctor and hospital are paid on results the quality and efficiency of care. This business model shift is being driven by reimbursement change, largely from the federal government, but also state and private-sector purchasers of care.

Partners Healthcare System Inc., for example, is incentivized for doing a great job of managing the health of a population of people with diabetes or a population of children with asthma. Theyll receive a certain amount per person, per child, per year to cover all the costs of the care. If they spend less than the amount, they keep the difference. If they spend more than the amount, they experience a loss. Regardless of financial performance, they must achieve certain quality-of-care and health-status metrics.

A range of IT resources is needed to help manage the health of a population. There is a significant need for data about the health of the population to be managed.

If I want to hold you financially and clinically accountable for the care and health of 100,000 people with dementia, youll ask, Well, who are they? I have to know who they are and be able to characterize them. How far along are they in their dementia? Are they poor? Where do they live? Do they have a spouse or a caregiver who can help them out? Do they speak English? To characterize them, I need all kinds of data. I need electronic health record data, but I also need social determinants of health data. I must gather all this information and then make sure Mrs. Smith in one electronic health record is (or isnt) the same Mrs. Smith in another electronic health record, because theres no unifying number here that links people across the board.

Having done that, I ask, Whats the plan to manage Mrs. Smiths health and health care? How do I take care of these people? I can turn to a blue-ribbon panel of doctors to get a core plan for a particular disease, but once I get that plan or that algorithm, I have to lay it over the data, tailor the plan to reflect Mrs. Smiths needs and capabilities, and look for deviations from the plan. I might say, Im going to plan to manage Mrs. Smiths dementia, but last night her spouse passed away, and suddenly my plan has to be revised, because I was counting on that person to help out and I cant anymore. Or Mrs. Smith had a car accident, and she shouldnt have been driving, but she was, and was critically hurt. Suddenly my plan is different.

I must have a plan, and then I must monitor deviations that indicate the plan should be revised. And I should also determine how well the plan is working. What are my measures of quality and efficiency? Am I keeping Mrs. Smith out of assisted living, or should she be in assisted living?

You cant make these decisions without IT to aggregate the data to characterize someone, to determine what the plan is and whether it needs to be altered, and then to generate a series of metrics that say, Im doing OK or Im not doing OK at managing the health of the population.

To help define and manage the plan, we must have care managers. They work for a health system (or an employer or a state Medicaid department), and theyre making sure the plan is working and take steps to remove barriers to the plan. For example, we will have people who are poor or who cant drive, so we have to get them a ride. Or they live in what we call a nutritional wasteland. Theres nothing but liquor stores and convenience stores around them, so if we want them to lose weight, we must get them Meals on Wheels or something along those lines. We should have IT applications for care managers who are committed to making the plan work.

In a lot of cases, to stay healthy, patients must manage themselves. They must manage their weight, make changes to a sedentary lifestyle, and monitor a disease such as congestive heart failure. I need a variety of technologies in the home and through social media to help people stay engaged in managing their health.

Although the changes are driven by reimbursement, you cant manage the health of a population without a viable set of sophisticated IT.

One of the challenges, if you go back six or seven years ago, would be that the electronic health record adoption was small, but now its not. Meaningful Use, a Medicare incentive program, has driven this. There has been a lot of progress in adoption.

The next thing we need is the fluid exchange of data between electronic health records data interoperability. Thats made some modest progress, but we still have a ways to go before the data about a patient really flows appropriately and efficiently.

The third challenge is gathering and interpreting data about the social components of health. Were still learning which sets of data really matter in which circumstances. For example, if we want you to get your 10,000 steps a day, what data should we gather to determine the likelihood that you will achieve that goal? For example, how do we motivate people? There are different ways to do it, but I need a set of data to define a motivational construct.

But perhaps the greatest challenge is that we must turn to a series of doctors and say, You guys have to do a much better job of managing the health of people. And they respond, Listen, we actually arent always very good at doing that. We know how to take care of them when theyre sick, but we were never trained to manage health, and were not well equipped to do that. To help caregivers manage health, we need care managers, links to social services and resources, new support processes, and a series of IT investments. The biggest challenge is making this transformation.

Theres a big cultural change, a big education change, and a series of process changes that must go on in health care that are difficult. The industry is beginning to go through that. As often happens with industry transformations, these changes are occurring while people and organizations are under great pressure to perform today under the old business model.

And then frankly its still not clear that if you do all this population health work, you really will bend the cost curve. Medicare has come up with dozens of different population health models and organizational arrangements. Which ones will be the winners? Were still experimenting with different organizational and reimbursement models. Weve got a lot of transformation work left to do, and thats why I think itll take decades.

There are several. But regarding digital ones, we see a whole lot of desire and were not alone for data scientists. The phrase data scientist is fuzzy and has many meanings. In this case, health care needs people who will help providers when they say, Tell me what the data means and whether Im doing a good job or not. Help me think through which data from this long list of social determinants of health I should really be gathering and has significant explanatory power. How do I get this data? How do I deal with uneven data quality? What are the best practices in sharing this data with patients?

Moreover, whos the doctor responsible for Mrs. Smith when she sees seven doctors? Often elderly people do see seven (or more) doctors. But which one do I hold accountable for her care?

Many skills are needed, but the biggest one is professionals who can help caregivers work their way through the data and analytics.