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How data transformation can support population health strategies

Doctor talking to senior male patient in a home visit

While many organizations define population health slightly differently, its core aim is to provide an opportunity for leaders in healthcare, agencies, education, and business to work together in order to improve the health outcomes in the communities they serve, all while making an impact to reduce the total cost of care. Technology and data can help bring significant health concerns into focus and address ways that resources can be allocated to overcome the problems that drive poor health conditions in the population. We all have a stake in population health, and in our upcoming Health Innovation Forum, we’ve gathered a panel of industry healthcare and technology experts to discuss how critical data insights can transform the way we support population health strategies.

With population health management (PHM) strategies, organizations can approach improvement from a broader continuum of care perspective. Instead of focusing improvement resources on limited populations and acute care, effective PHM strategies drive transformation that addresses all levels of healthcare delivery, including prevention and care management.

Prioritizing data transformation

There are many data factors that make up the complete picture of individuals and population health which can span health behaviors (e.g., diet, exercise, tobacco use, alcohol, and drug use), clinical care (e.g., access to care and quality of care), social and economic factors (e.g., education, family and social support, and income), and the physical environment (e.g., air quality, access to clean water sources, housing and transit).

Organizations should consider prioritizing and integrating the multitude of internal and external data sources to provide better transparency into their population health journey. This transparency helps organizations better manage their risks, opportunities, and strategies to efficiently improve health outcomes. Incorporating health behavior data with captured clinical data (e.g., electronic health records) can provide critical direction on ensuring delivery of the right care at the right time in the right place.

Novant Health achieved its goal to bring siloed data in a more usable way. During the pandemic response, they built a COVID-19 tracker that captured data about who had contracted the disease and created a scoring model that helped identify patients’ risk of having a more severe response to COVID-19. Novant Health staff used these proactive data insights to provide the best possible care from the outset. They went on to use Microsoft Power BI to support its COVID-19 vaccination program, noting patient ethnicity, zip code, and other demographic information to understand which segments of the population are being vaccinated. Novant Health focused on health equity and found ways to use data to close gaps for communities that have either been underrepresented or lack access to healthcare.

Challenges of data-driven decisions

Modern healthcare organizations have data coming from a myriad of sources. In fact, up to 70 percent of the time providers spend analyzing data is wasted on ingestion and unification.1 Unsurprisingly, with such large volumes of structured and unstructured data, providers must spend exorbitant amounts of time trying to glean any meaningful insights.

Focusing on gathering and analyzing the right data sets—clinical, social determinants, comorbidities, mental health, and claims data—healthcare organizations can identify how to get consumer behavior data to inform the most accurate recommendation on next best actions and evaluate opportunities for population health and improvement work. Thinking about the connected healthcare ecosystem, with the expressed goal of improving outcomes in the populations they serve, can lead to lowering the costs of care. It also helps to identify the opportunity to connect what’s going on with the patients when they are not in the physician’s office and helps to paint a detailed picture of the patient’s needs.

Helsinki and Uusimaa Hospital District (HUS), a joint authority formed by 24 Finnish municipalities and comprising multiple hospitals across southern Finland, used Microsoft cloud solutions to create a Virtual Hospital, which provides digital health services that improve patient access to quality care, reduce costs, and enable healthcare providers to treat more patients in less time. In Finland, patients who need secondary, or specialist, care must be referred by a primary healthcare provider. But the ability to access medical information, self-help programs, and virtual treatments via computer or mobile devices has improved access significantly for the elderly, people with disabilities, those who live in remote areas, and others who find it more convenient or affordable to pursue medical treatment from home rather than travel or take time off work to visit the hospital.

By changing how they care for patients, HUS and other hospitals can increase the efficiency of healthcare professionals and do more with the same number of resources. Because many patients access a lot of information prior to their appointments or participate in self-help exercises, they often have fewer questions and can focus on the issues they really need their doctors to address.

Connecting data to care transformation

For health systems looking to enhance the use of data, leaders should first understand what their goals are and how they plan to achieve them. However, fifty-six percent of healthcare leaders say their current population health management solution doesn’t meet their needs, according to a survey from Persivia and commissioned by Sage Growth Partners.2

Data interoperability issues, poor care coordination, and a lack of funding may deter social determinants of health data integration, leading to gaps in care and health disparities for individuals and whole communities. With the pandemic crisis, these gaps and disparities have only grown wider. Individuals living with chronic disease, people in underserved areas, and minority populations have been hit the hardest during the pandemic, highlighting underlying issues that have plagued the industry for years.

FHIR (Fast Healthcare Interoperability Resources) is rapidly becoming the global interoperability standard for secure and private exchange of health data. However, true interoperability in healthcare means enabling all kinds of healthcare data—not just those coming from clinical records. It makes it easier for anyone working with health data to ingest, manage, and persist protected health information in the cloud. The healthcare industry is rapidly transforming health data to the emerging standard of FHIR, which enables a robust, extensible data model with standardized semantics and data exchange that enables all systems using FHIR to work together. Transforming data to FHIR allows health care organizations to quickly connect existing data sources such as electronic health record systems or research databases. Most importantly, FHIR can simplify data ingestion and accelerate development with analytics and Machine Learning tools.

Humana is a health insurance company based out of Kentucky in the United States. The company is committed to helping millions of medical and specialty members achieve their best health. Humana works under three principles: to deliver easy and seamless customer experiences, help members achieve their best health through the five points of influence (primary care, social determinants of health, pharmacy health, home health, and behavioral health), and to gain power through integrated technology.

Humana wanted to represent all the data in one place, rather than looking at individual data in their respective silos. Humana quickly consolidated its high volume of data into a handful of columns and reduced visual load time tremendously. By doing this Humana aims to derive actionable insights and cultivate a data-driven culture to help its members achieve their best health.

Microsoft Cloud for Healthcare makes possible the electronic access, exchange, and use of electronic health information by and between patients, healthcare providers, and health plans. Personal health information (PHI) needs to be handled differently in the cloud, and when FHIR is built-in, it gives organizations the trust and control they need. We’ve innovated the way healthcare organizations can enrich, normalize, and unify protected health information (PHI) through Fast Healthcare Interoperability Resources (FHIR), and longitudinal data to accelerate artificial intelligence (AI), team productivity, and business process workflows.

To really reduce health disparities, it’s not enough to just identify which population groups are most at risk. Healthcare organizations must connect with patients in order to understand how they can best meet individuals’ needs. Unlocking the power of health data allows care givers to gain a holistic view of the patient with insights and actionable next steps for more informed, personalized care management. For many organizations, the ongoing shift to population health data transformation and its impact to care can be challenging—but it’s a worthwhile journey to undertake.

Our continued goal is empowering global healthcare organizations to explore how technology and data can support collaborative efforts to promote health and wellness of the population. Join us at our upcoming Health Innovation Forum on April 29, 2021, 7 AM PDT | 4 PM CEST to explore how critical data insights can transform your organization’s population health strategies.


  1. PwC Health Research Institute. Top health industry issues of 2020: will digital start to show ROI? 2019. Top health industry issues of 2020: Will digital start to show an ROI? – December 2019 (
  2. Sage Growth Partners and Persivia. 2020. PHM Solutions Not Meeting Needs.