Population Health Management and Cancer Screening

Population health management (PHM) is a new health care model being implemented. It has been defined as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group." This includes health outcomes and patterns of health determinants, and policies and interventions that link these two. Moving from a fee-for-service payment system to a quality- or value-based system, this model places on the clinician more responsibility for the costs of health care and its reimbursements. Screening for disease is an area that could benefit from PHM. Electronic health records (EHRs) employ algorithms to capture PHMrelated data such as diagnostic codes, clinical quality indicators, and other parameters useful in identifying those for whom screening is appropriate and in monitoring the efficacy at implementing the screening in the clinic's population. Registries of patients at risk for a variety of diseases are created in the EHR, and these patients can be notified to visit with their clinician for a shared decision-making conversation about the screening. PHM requires a team approach to input, analyze, and implement this data. The physicians must be the driving force behind population health, but advanced practice clinicians, nurses, case managers, quality coordinators, information technology support, and many others collaborate to make this successful.