Primary Care is changing, and so is the role of the physician. We are starting to consider the health of our patients in a more global way by considering the broader (e.g., social, socio-economic) factors and conditions that impact health, often in a significant way. This is why Population Health discussions are front and centre. For example, we know that there are increasing and persistent health inequities within our communities, which a population health approach aims to reduce. As well, we know that 5% of patients consume 64% of Ontario's healthcare budget. But do we know who they are? Do we know the characteristics of this group or any other? The key to reducing the burden of disease in a community is to take a broader look from 30,000 feet. But do we know how? Have we been trained to think this way?
Clinicians are very comfortable with discrete interactions between one patient and one provider, but have not necessarily been trained to think about – and can be baffled when considering – the well-being of our patient population as a whole. Supported by new and emerging technologies, we can now begin to effect real change in improving the health of our patient populations right from our clinics.
I have been thinking and talking about this for some time: “What problem are we trying to solve? How do we need to think differently?” It’s a complex issue and there are no simple answers. We can learn new processes and reframe the work.
We must understand our patients as a community
Imagine data from a group of patients over time. There are trends there. We can analyze the circumstances that surround them, creating a question about our population and trying to answer it. This can be local in our EMR. The analysis can be real-time. Then we can look upstream.
Real excitement happens when we combine health data with other information sources. Social determinants of health data, environmental information like pollution, weather changes, infectious disease outbreaks.,etc, local health promotion activity and even social media posts can be tapped. Together these can produce powerful insights with which to plan at a system level.
Change in population health is not the sole responsibility of government or clinicians - Patients must be involved
99.99% of prevention and care happens without a clinician being present at all. Patients and their caregivers are doing the work in their homes. To be empowered they not only need knowledge but also tools for activation and healthy adaptive behaviours. Patients will come to understand that their health is part of a larger collective or community. Because humans learn best from peers, patients can do much to help address the issues that cause health decline as part of that community.
For this to work best, patients must be able to contribute to and work with their own health data. They need line of sight into the records that capture and hold their story. They need access to their “quantified self”. If they see themselves as true health partners and part of a cohort they will act more decisively
Reporting, showing best practices, and benchmarking against colleagues is not enough
Doctors have access to some population reports now. They can do simple EMR searches, use a dashboard, contribute to data cooperatives like CPCSSN, EMRALD, or UTOPIAN, and receive MyPractice reports from Health Quality Ontario.
These reports are looked at by interested clinicians, but the reach is still small and converting interest to action is difficult. Much mentorship and coaching is required. We have to ask the question “why?” as much as “how?” And “who?”. Carrot and sticks to reward participation can start the process but a full scale cultural shift is required to change populations. Practices would benefit from an organized, validated and robust change management process to facilitate this. We should be building change into our system planning.
Joint leadership is required to ensure population health issues are prioritized
Our health system must evolve to incubate, promote and sustain the changes that occur. This can be achieved when Government, healthcare professionals and patient groups champion change together. Each stakeholder community has a valuable perspective on how to make change happen. Policy can be set by the Ministry with our Associations. Clinical groups can then move policy into practice. Patients can educate each other and prioritize areas for improvement. When combining forces, the effects are more likely to stick.
Benefits are shown by analyzing data and feeding back insights. The hardest step is then translating insight into action. The work cannot be done off the side of our desks. We need tools and resources to provide advanced care to populations. Dedicated energy, space and time is needed to make change happen.
The health system must move beyond pilot projects. Scaling and spreading improvements systematically and effectively requires bold leadership. This must be thought about in the basic design of our population health quality improvement projects.
This is not a technology play - It is a decidedly human one
We do not need highly evolved artificial intelligence systems to make things better. Success depends on education, belief in the process, a common goal, and a relentless desire to make individuals and communities healthier. It will involve clinics, hospitals, public health agencies, schools and even cities thinking and working collaboratively. Iterative thinking and creative co-design is mandatory. It behooves us as clinicians and policy makers to innovate in moving from individual transactions to care of a community. Individual patient-physician relationships can be preserved at the same time as the health of much larger groups is being advanced if we think this through. Doing so will produce a revolutionary shift in how we approach illness and prevention.
We can’t afford not to do this.