The U.S. healthcare system is increasingly moving from an operations-based system towards one that is strategy based. Recent and ongoing reforms focus on preventing medical errors, how care is recorded for reimbursement, what comprises “quality,” and better management of patients with long-term conditions. Taken together, these various aspects of healthcare reform don’t compete with, but rather complement one another. The logical end point is a move towards population health management. Here are five ways to get on board.

1. Make a plan

Population health management can be defined as “the aggregation of patient data across multiple health information technology resources, the analysis of that data into a single, actionable patient record, and the actions through which care providers can improve both clinical and financial outcomes.” It sounds like a tall order, but it can be done — it’s just a matter of breaking down the whole into manageable parts. Before starting, you’ll need to define how you’ll communicate with patients, implement the right technology solutions (or be lucky enough to have them in place), create the right team, and ensure the team’s buy-in. There’s a lot of flexibility for every plan to look different, depending on the needs and makeup of your practice, facility or hospital.

2. Engage patients

For population health to work, care must be patient-centered. Patients need to understand how their empowerment and concordance with care affects their outcomes. Sharing aggregated, appropriate data with them can make patients more active participants in managing their own care, whether it be ongoing treatment for a chronic condition, or rehabilitation after an outpatient surgery. In addition, using certified medical scribes allows for multi-channel patient engagement: physicians are free to give personalized attention to patients, who in turn feel as if they and their care are important; and scribes can document post-discharge care instructions and medication information that doctors communicate orally to patients, so that a written version can be given to patients to take home. These kinds of tasks, which boost patient satisfaction with communications and their experience, and show patients that they matter.

3. Enable data-gathering

The technology exists to create the data needed to embrace population health: “A recent report by KLAS found that 69 vendors now offer population health management products and services,” according to a recent white paper. But these analytical tools work only if you’re able to input the full complement of data. Scribes trained in the particulars of your electronic health record (EHR) system are able to navigate, ensure documentation is complete, and that the clinical data you need will be collected, for later analysis and benchmarking. For example, you could tie a diabetic patient’s visit to a podiatrist for a foot ulcer to the chronic care management plan at the primary care physician, to help track how many patients with diabetes develop wounds. From there, you may be able to spot a common thread that allows better prevention efforts to be implemented across this patient population.

4. Involve non-physician professionals

To help hospitals and providers succeed at population health, non-physicians are vital. Enlist physician assistants or advanced practice nurses to provide ongoing follow-up care — involving a physician as necessary. Use medical scribes to alleviate the physician burden of carrying out duties that are not directly linked to interacting with the patient. And develop a nurse-led patient-education team that:

• Helps patients understand what they’re responsible for after discharge or on an ongoing basis
• Addresses care gaps by arranging for appropriate services (e.g., diabetic education, visiting nurse)
• Identifies barriers to follow-up or ongoing care (e.g., transportation issues, cost of medicine, anticipated medicine side effects)
• Creates an easy-to-understand plan, and teaches it in a way empowers patients to care for themselves.

5. Take advantage of technology

Follow-up and ongoing monitoring of care are big components of population health management. Use technology to remove potential barriers — for example, telemedicine is increasingly being used for follow-up visits that are focused on how the patient is managing, rather than on an acute medical issue that requires in-person attention. Technology solutions can also be used to continue to gather data. For example, there’s an app that helps patients manage all their diabetes-related information — including blood sugar readings from other devices, food intake, exercise statistics — and can send that data to the primary care provider’s EHR system. There are other apps that provide patient education and social support over the long-term, to help patients reduce their risk for heart disease, diabetes and obesity, which are available for computers, tablets and smart phones. Tools such as these keep patients engaged in their own care when they don’t have a medical professional looking over their shoulder.

Population health isn’t about aggregating and anonymizing patient data until patients become just a number. On the contrary, it’s about understanding what care pathways are the most effective for costs and outcomes (and benchmarking yourself against them) so that you have a base to work from. When the base is already in place, it’s a lot easier to give the patient more individual attention and an individualized plan. Maybe population health should be called personalized health.