Shared by Dr. Jerry Osband, Former Chief Medical Officer for EXL and Member of the Impresiv Health Executive Advisory Board

Population health management (PHM), as explored in previous articles, has the potential to enhance clinical, financial, and administrative outcomes for specific patient groups. By improving care coordination and fostering patient engagement, supported by effective economic, care delivery, and technological frameworks, PHM creates a more efficient healthcare system. When thoughtfully designed and implemented, a PHM program can help control healthcare costs while optimizing clinical outcomes and overall patient health.

In our previous discussion, we explored the core components of Population Health Management (PHM): data management, identification and stratification, enrollment and engagement, and reporting. Today, we turn our attention to data stewardship—the art of effectively acquiring and aggregating data to drive meaningful outcomes in PHM.

What is Data Stewardship?

Stewardship goes beyond data management—it encompasses data entry, secure cloud storage, HIPAA compliance, and a well-structured framework of integrated platforms. These elements work together to support clinical strategies that reduce health and economic risks while enhancing operational efficiency. The goal is to unify diverse yet actionable data from various healthcare organizations, provider networks, and population health management (PHM) vendors into a cohesive system.

Where to Start?

The first step is to assess the existing data inputs, evaluate the storage capacity for this information, and determine the level of user access that will be permitted. In addition, gaps in data need to be identified for effective socioeconomic, SDoH, and health equity inputs into PHM. This capability will enhance the evaluation of potential data input partnerships and software integrations, aligning seamlessly with the organization’s current IT processes. Additionally, it will support both market demands and accreditation requirements.

Traditional data inputs involve various points of data integration, such as the following:

Electronic health records (EHR), inclusive of treatment plans, vital signs, lab results, and communications with care coordinators. Additionally, provider portals play a key role in transferring care coordination data to healthcare organizations. This data can then be aggregated and stored, ready for seamless integration into population health management (PHM) software.

Claims data is typically well-structured and easily accessible, but it lacks the timely and clinically relevant insights necessary for real-time, intervention-focused engagement. On its own, claims data cannot support prompt interventions to mitigate clinical risks. It is often outdated and missing critical real-time information essential for effective decision-making.

Laboratory information is also a requirement for both timely intervention and tracking of the participant’s success metrics over the PHM program time commitment of the participant. These particulars, when gathered with vital statistics on a timely basis, provide impactability for immediate or early intervention when observed either as stand-alone information or as trends.

Medication use and adherence details from internal inputs, EHR and PBMs are one of the most important action items to be gathered for PHM activities. Failures in ambulatory care management are often attributed to medication-related issues and participants using multiple drug therapies require close monitoring by care coordinators to reduce compliance and complication issues.

Non-traditional data inputs have now become extremely important in providing improved impactability, accreditation, and regulatory compliance. Examples of non-traditional data include:

Social Determinants of Health (SDoH) provides additional support to address gaps in care by providing insight into food options, transportation, employment, etc. By incorporating social challenges into care management software, both care managers and providers can better identify and communicate on barriers that are causing gaps in care and reducing the benefit of out-patient interventions.

Digital data aggregation can support real-time interventions that significantly reduce risk and mitigate the need for inpatient care. Incorporating state-of-the-moment observations can initiate digital and personalized interactions with the participants to rapidly arrange appointments to adjust medications or restructure treatment plans through the portal or other communications, thereby reducing ER and in-patient treatments.

Participant-constructed information is now available from numerous sources and needs to be used as a basis for impactful program enrollment and ongoing engagement. This type of information includes assessments, various types of consumer and satisfaction surveys, portal messaging, and others. This data provides additional strategies to encourage health plan and provider connectivity while also gaining market insights into consumer preferences for care coordination.

Health Equity compliance will be a major issue in the upcoming era of social health management. Resources should be committed to understanding the data needs for healthcare organizations to meet requirements and reporting needs to demonstrate that data management includes the appropriate indicators for race. ethnicity, gender, income, sexual orientation, etc., to show health equity in PHM to address individual, societal, and environmental barriers to improving health status and outcomes.

Data Stewardship in Action

Data stewardship plays a critical role in the success of Population Health Management (PHM) by ensuring that diverse, accurate, and actionable data drives informed decision-making and meaningful clinical outcomes. By integrating traditional and non-traditional data sources—including EHRs, claims, lab results, medication adherence, and Social Determinants of Health (SDoH)—organizations can enhance care coordination, patient engagement, and health equity.

The intentional design of robust data management frameworks, paired with secure and compliant data handling practices, is essential for addressing gaps in care and supporting real-time interventions. Ultimately, effective data stewardship empowers healthcare providers and stakeholders to align with accreditation standards, reduce costs, and improve health outcomes at both the individual and population levels.

With a commitment to ethical and strategic data use, PHM initiatives can achieve their full potential in creating a healthier and more equitable future.

Population Health and Care Management Support

Impresiv Health is a trusted partner in advancing care management and population health strategies. By leveraging our nationally recognized experts and clinical management specialists, we deliver actionable solutions that drive meaningful change. Our focus on best practices, operational excellence, and quality improvements empowers healthcare organizations to enhance care coordination, improve population health outcomes, and reduce costs.

Schedule a call with our SVP of Healthcare Partnerships to learn how we can help your organization drive impresiv results.

Get in touch with Dr. Osband, part of our Executive Advisory Board: josband@impresivhealth.com