Population Health

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What is Population Health? 

According to the Centers for Disease Control and Prevention (CDC), population health is an interdisciplinary approach that connects practice to policy to bring about a positive change in patient care. Population health “brings significant health concerns into focus and addresses ways that resources can be allocated to overcome the problems that drive poor health conditions in the population.”  

Our comprehensive Population Health management modules at Amazing Charts are designed to help your private practice:  
  • Better predict what will happen within your various patient populations.
  • Find ways to engage patients and their care team to take action to address potential health concerns.
  • Manage outcomes to positively impact patient health and care.

In most independent medical practices, the standard method of operation is to look at each patient as an individual with specific needs. Providers review the patient chart before the appointment, discuss current health issues with the patient, provide lifestyle education and prescriptions as needed, and annotate the EHR properly. The EHR is usually not referred to again until the next appointment, or if the patient calls the practice for some reason.

This may be efficient on an individual patient basis, but the provider may intuitively feel that there are significant groups of patients within the practice with a similar condition, such as diabetes, those who are not engaging fully in their own healthcare, or those who may benefit from a directed telehealth communication effort. Instead of just moving on to the next patient or the next administrative headache, Population Health can bring these issues to the provider’s attention, so further action can be taken to improve the overall practice standard of care.

Common Challenges in Population Health:

Some of the most common challenges in population health management include: 

    • Telehealth Population Health: Given the recent increases in telemedicine, one of the biggest challenges in population health management will be how to incorporate telehealth patients into the data plan and healthcare improvement programs. 


    • Where to Begin: There can be so many population health issues within a practice that it may be challenging to determine where to begin the measurement and intervention programs. You could have chronic care patients with diabetes, COPD, obesity, and other health issues which are manageable, but they could require a significant amount of care. Practices must determine which initiative will produce the best clinical improvements with the most cost-effective interventions.


    • Patient Classification: Identifying patients by risk stratification is part of population health management. Choosing parameters as to which patients fall into high-risk categories helps to identify those who might benefit most from active intervention activities. Population health data helps to identify risk trends, so your practice can spot areas for improvement.


    • Population Health Management Reimbursement: Government programs now offer financial incentives to practices which comply with population health measures. The challenge is to identify the software tools which best support these efforts and provide the most accurate information for reimbursement purposes.


  • Patient Engagement: The end goal of population health management is to improve the health of a particular population within your private practice, but those patients must be actively involved in their management programs. Your practice will need to undertake programs to help these patients understand their condition and how to control it, and also maintain consistent contact with healthcare providers.

Learn More About Amazing Charts Population Health Now!

Why Choose Amazing Charts Population Health?

Clinical Quality Measures Module

Clinical Quality Measures, or CQMs, are the data points that CMS utilizes to measure and track the quality of health care services provided to patients. Providers need to submit this data, and could potentially earn incentives based on their results. The benefits of incorporating this module into your practice include:

  • Enhanced Preventative Patient Care: With the data collection and public reporting mechanisms instituted by CMS, practices are incentivized to improve support for providing a culture of safety and reducing the levels of unnecessary care. Reducing reimbursement rates based solely on the quantity of care provided may eventually lead to making care more affordable for everyone. Patients will become more involved in their care, have better access to their records, and receive more motivation to take steps necessary to live a healthier life.
  • Improved Care Delivery: By using incentives to improve levels of care provided to patients, CMS is pushing forward with the objective of achieving a patient-focused era of medical care. They are working to encourage providers to change how care is given by building better teams, increasing coordination across providers and health care facilities, and directing more attention to population health.
  • Increased Bottom Line: The practice benefits financially in the long run when it achieves the ability to receive payment adjustments.

Patient Care Gaps Module

Patient care gaps can hurt your practice’s financial outlook and overall care. Identifying gaps in patient care allows you to: 

  • Save Time: Consistently maximise the number of patients you can see and efficiently treat, leading directly to an increase in practice revenue. A faster timeline is also a benefit for the patient for early intervention and improved pain management.
  • Better Patient Care: Patients who are more engaged in their care experience have better outcomes. Providers can involve patients more actively in their own care in order to reduce office visits, lower costs, and improve outcomes.
  • Improved Population Health: Making sure that each patient has at least one face-to-face appointment with a primary care provider each year is one undeniable way to close the patient care gap. This generates a constant flow of revenue to the practice.
  • Faster Reimbursements: Using a digital program to gather and provide quality metrics makes it much easier to communicate with third party reimbursement entities such as CMS or insurance companies.
  • Financial Growth: Providers will also be able to increase revenue by billing for additional services that were provided as being necessary to close care gaps.

Chronic Care Management Module

The federal government is moving ahead with changes to the way it provides reimbursement for care of patients with chronic conditions. This program benefits your practice with: 

  • Better Outcomes: Better care coordination and increased patient involvement will lead to better health outcomes, and that is something all practices strive to achieve.

  • Reimbursement: Practices receive reimbursement for providing a minimum of 20 minutes of CCM services per patient in a given month.

  • Patient Involvement: Encouraging patients to use CCM services gives them the support and motivation they need to follow good health habits between office visits.

  •  Increased Compliance: Using a digital program to gather and provide quality metrics makes it much easier to communicate with third party reimbursement entities such as CMS or insurance companies.
  • Reduced Emergency Care: Patients with better control over chronic conditions can decrease emergency room visits and hospital stays, thereby reducing costs for their insurance providers.

  • Assured Revenue Stream: CCM provides another method of sustaining and growing your practice without adding additional facilities or an accompanying increase in necessary personnel.

Population Health Frequently Ask Questions

A:  According to the CDC, “Public health works to protect and improve the health of communities through policy recommendations, health education and outreach, and research for disease detection and injury prevention.” On the other hand, population health provides “an opportunity for health care systems, agencies and organizations to work together in order to improve the health outcomes of the communities they serve.

A:  According to the National Committee for Quality Assurance (NCQA), there are six primary components of population health, including:

  1. Care Integration: An Integrated Delivery System (IDS) is a network that links healthcare providers through an organized and collaborative system which provides services to a specific population. IDS systems benefit the population being served, and help to improve clinical outcomes for the involved providers.
  2. Care Coordination: A critical component of population health, this area includes the coordination of all aspects of patient care. It integrates information from various providers to ensure proper steps are taken to improve patient health. The end result is that it also helps to reduce costs and eliminate excessive or redundant tests and procedures.
  3. Teamwork: Teamwork means that patients benefit from an integrated care structure, rather than receiving fragments of care from different areas. Integrated teams leverage patient information and experience by using technology to provide improved value for patients and their families.
  4. Patient Engagement: Practices are motivated to provide education and inclusion so that patients become more actively involved in their own healthcare. The concept of patient engagement merges the patient’s involvement with practice efforts that increase their knowledge and encourage positive behaviors, such as preventative care and regular exercise.
  5. Data Analytics and Health Information Technology: Data is the most critical piece of the population health management puzzle. In order to identify a population and measure its needs, your independent practice must make sure it has the right data available, interprets it properly, and gets the results to the appropriate team members within your office. This is why the Population Health modules from Amazing Charts are so important.
  6. Value-Based Care Measurement: Moving toward a value-based care measurement rather than a quantity of care model means that your practice needs to focus more on the quality of care provided.

A: Population health management is so important because it helps your private practice identify the risks and concerns encountered by a particular population, so you can implement specific remedial actions. Resources can be allocated by the provider management team to provide a customized level of care that best meets the needs of the identified population and the individual members. 

A population health manager is the person in your practice who evaluates the data collected through the Population Health modules, to identify populations in need of improvement plans.

Population Health
Not only for hospitals – Join other independent practices who are improving care and reducing costs.

Understand, Engage, and Measure with Population Health  

You need more than your EMR to understand, engage, measure and improve your patient population health care and risk stratification demands. Your EMR is great at analyzing a single patient but Population Health can analyze your practice as a whole. AC Population Health gives you the tools to aggregate, analyze, and achieve results, such as better patient care, reduced patient costs, and increased practice productivity. 

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Explore Features and Benefits

Clinical Quality Measures Module

Clinical Quality Measures, or CQMs, are the data points that CMS utilizes to measure and track the quality of health care services provided to patients. Providers will soon need to submit this data and could potentially earn incentives based on the results.

Care Gaps Module

Patient care gaps can hurt your practice's financial outlook and overall care. Identifying gaps in patient care allows you to save time, deliver better patient care, improve the health of your patient population, earn faster reimbursements, and increase revenue.

Chronic Care Management Module

Whether or not medical practices have heard about it, the federal government is moving ahead with changing the way it provides reimbursement for care of patients with chronic conditions. The program allows you to improve patient care and earn additional revenue.