Digital transformation essentials — Population health

January 28, 2025

Digital population health solutions represent an integrated ecosystem of technologies designed to proactively manage the health outcomes of specific populations through data-driven insights, automated engagement, and coordinated care delivery. This framework encompasses key components that enable health systems to deliver preventive care, manage chronic conditions, and improve overall health outcomes.

Population health framework

Population intelligence and decision enablement	Solutions that provide data-driven insights and predictive capabilities to identify risks and prioritize interventions Data integration and analytics: Aggregates clinical, claims, and SDOH data to create comprehensive patient profiles and identify trends across populations Risk stratification and scoring: Uses advanced algorithms to segment populations by risk level and predict future health events or complications Care gap analysis: Identifies missing preventive services, screenings, and interventions across patient populations to drive proactive outreach Quality performance tracking: Measures and monitors clinical quality metrics, cost metrics, and outcome measures to support value-based care initiatives Example Companies: Innovaccer, Arcadia, Health Catalyst
Care journey orchestration	Platforms that coordinate and optimize the delivery of care across teams and settings Care planning and protocols: Creates and manages evidence-based care plans tailored to patient conditions and risk factors Team collaboration: Enables seamless communication and task management across care teams, including primary care, specialists, and community partners Referral management: Coordinates patient transitions between providers and care settings while tracking completion and outcomes Social care integration: Screens for social needs and connects patients with community resources through closed-loop referrals Example companies: ZeOmega, TigerConnect, ReferralMD
Patient activation and outreach management	Tools that drive patient engagement and behavior change through personalized communications and interventions Multi-channel engagement: Delivers targeted communications through text, email, phone, and apps based on patient preferences and needs Automated care gap closure: Proactively reaches out to patients for preventive services and follow-up care using automated workflows Digital self-service: Enables patients to schedule appointments, access health information, and complete pre-visit tasks through digital tools Education and self-management: Provides condition-specific education and tools to support patient self-management of health conditions Example companies: Luma Health, Notable Health, Welldoc
Virtual care and remote monitoring	Solutions that extend care delivery beyond traditional settings through technology Biometric monitoring: Collects and analyzes patient vital signs and symptoms through connected devices to enable early intervention Virtual visit solutions: Facilitates secure video visits and messaging between patients and care teams for routine and urgent care needs Ongoing clinical surveillance: Monitors patient data in real-time to identify deterioration and trigger appropriate interventions Condition management: Supports ongoing management of chronic conditions through remote monitoring and virtual check-ins Example companies: Datos Health, Teladoc, Omada Health
Healthcare navigation and support	Solutions that provide personalized guidance and advocacy to help members navigate their healthcare journey effectively Care navigation and advocacy: Guides patients through clinical decision-making and benefits optimization with personalized support and recommendations Benefits education and utilization: Helps patients understand and maximize their healthcare benefits while optimizing costs Provider matching and scheduling: Connects members with appropriate providers based on quality, cost, and accessibility factors Complex care support: Provides enhanced support for members managing complex conditions or treatment decisions Example companies: Cedar Gate Technologies, Included Health

The case for digital in population health

Healthcare systems today face numerous critical challenges that digital population health solutions are uniquely positioned to address. The rising burden of chronic diseases accounts for a significant portion of healthcare spending, while an aging population increasingly strains healthcare resources. These demographic shifts, combined with persistent health disparities among vulnerable populations, create a complex landscape that traditional care delivery models struggle to navigate effectively.

Facilitating holistic connected care

Healthcare organizations today struggle with tracking and managing patients across different care settings, with limited visibility into patient care outside their immediate system. This fragmentation leads to poor outcomes, increased costs, and frustrated patients and providers alike.¹

Digital population health management platforms have revolutionized this landscape by providing unified patient views and automated workflows, allowing providers and their systems a holistic view of the patient at all times even after they have left the walls of the facility. Organizations implementing these comprehensive solutions have witnessed remarkable improvements, with reducing hospital readmissions and improving post-discharge outcomes.²

Data driven decision making

The shift toward value-based care has intensified the pressure on health systems to simultaneously reduce costs and improve outcomes. Particularly, organizations face the complex challenge of managing chronic diseases–which account for 90% of the nation’s $4.5 T in annual healthcare expenditure–while meeting increasingly stringent quality requirements and performance metrics.³ Traditional approaches to cost control often fall short, lacking the predictive capabilities and automated systems needed for effective population-wide management. Digital PHM solutions have emerged as a powerful answer to these challenges through predictive analytics that identify high-risk patients before costly events occur, combined with automated quality measure tracking and sophisticated cost analytics. Remote monitoring capabilities and personalized interventions provide proactive strategies that prevent expensive complications and hospital admissions. These digital innovations have transformed the economics of care management, with organizations significantly reducing the total cost of care while simultaneously improving quality measure performance.⁴

Improving access and equity

Healthcare systems have long struggled with profound disparities in care access and delivery, particularly among vulnerable populations. Geographic isolation in rural communities creates barriers to regular care access, while urban underserved populations face challenges with transportation, work schedules, and healthcare literacy. Traditional healthcare models have failed to address these systemic barriers, resulting in delayed care, poor chronic disease management, and worse health outcomes for these populations.⁵ The cost of traveling to appointments, taking time off work, and navigating complex healthcare systems has historically placed quality healthcare out of reach for many communities, perpetuating cycles of health inequality.

Digital health solutions have transformed this landscape by fundamentally reimagining how care can be delivered and accessed. By leveraging telehealth services, culturally appropriate resources, and remote monitoring capabilities, these platforms have eliminated many traditional barriers to care. Virtual visits reduce transportation burdens and lost work time, while multilingual digital resources and culturally tailored education materials make healthcare more accessible and relevant to diverse populations. Mobile health applications and remote monitoring tools bring healthcare directly into patients’ homes, enabling consistent care management regardless of location or socioeconomic status. Organizations implementing these solutions have witnessed dramatic improvements in care delivery and access.⁶ The digital transformation has particularly benefited traditionally underserved communities, with studies showing significant improvements in chronic disease management and preventive care compliance among vulnerable populations.⁷

Elevating patient engagement and empowerment

Traditional healthcare models have long suffered from a fundamental disconnect between periodic clinical visits and ongoing health management. Patients often struggle with understanding and following complex treatment plans, leading to poor medication adherence and suboptimal self-management of chronic conditions.⁸ The limited touchpoints between healthcare visits create gaps in care continuity, while insufficient education and support leave patients feeling overwhelmed and disconnected from their healthcare journey. These challenges are compounded by communication barriers, lack of timely feedback, and difficulty in accessing healthcare resources between scheduled appointments.

Digital population health platforms have revolutionized this paradigm by creating a continuous, interactive healthcare experience. These solutions deploy comprehensive engagement tools that maintain ongoing connections between patients and care teams through multiple channels. Automated education systems deliver personalized health information at the right time and in the right format, while smart reminders and monitoring tools help patients stay on track with their care plans. Interactive platforms enable patients to ask questions, report symptoms, and receive guidance in real-time, creating a more responsive and supportive healthcare environment. The integration of mobile apps, wearable devices, and remote monitoring capabilities provides patients with immediate feedback on their health status and behaviors, fostering greater engagement and accountability in their health management. These innovations have yielded impressive results, with organizations reporting significant improvements in patient engagement and care compliance, resulting in earlier detection, better clinical outcomes, and reduced complications.⁹