Population Health: Basic Terms

Duke Community and Family Medicine has developed common language around the study and practice of population health for use in the Duke Family Medicine Center and its associated training programs.

Population health is an overarching concept encompassing a number of distinct activities that share a common goal of improving the health of populations (as opposed to individual patients). 

According to Kindig and Stoddart (2003), population health is “the health outcomes of a group of individuals, including the distribution of such outcomes within the group. …The field of population health includes health outcomes, patterns of health determinants, and policies and interventions that link these two.”  

The sub-categories of population health can be conceptualized in a number of ways, including:

Population Health Improvement

Efforts to improve the health of a population that is not defined by a shared healthcare setting or disease, but rather by a geographic jurisdiction or other shared social trait. Examples of population health improvement include renovating public housing to help with the control of asthma, building a supermarket in a “food desert,” establishing a pro bono system to provide specialty care to the uninsured, etc.

Primary Care Practice Redesign

Efforts to improve primary care practice at one site or across the field in order to enhance: quality of care, access to care, patient satisfaction, cost-effectiveness, workflow redesign, and/or the work life of clinic staff.   Examples of primary care practice innovation include experimenting with new team models of care, using continuous quality improvement to improve the patient experience, etc.

Population-Based Panel Management

Data-informed efforts to improve the health services utilization and health status of a clinical panel to which patients are administratively assigned.  Panel management is performed by the personnel associated with the clinical site.  Examples include outreach to patients who are not obtaining needed preventive care, assignment of care managers to patients with uncontrolled chronic disease, etc.

Population Management/Population Medicine (as conceptualized by the Institute of Healthcare Improvement (Lewis, 2014))

The term population management should be clearly distinguished from population health (which focuses on the broader determinants of health). From what we have seen through our work at IHI, population management as presently practiced is best conceptualized as population medicinePopulation medicine, in this case, is the design, delivery, coordination, and payment of high-quality health care services to manage the Triple Aim for a population using the best resources we have available to us within the health care system.  Much of the efforts today such as the Accountable Care Organization, risk stratification methods, patient registries, Patient Centered Medical Home, and other models of team-based care are all part of a comprehensive approach to population medicine.


  1. David Kindig and Greg Stoddart. “What is Population Health?”  American Journal of Public Health March 2003: Vol. 93, No. 3, pp. 380-383. 
  2. Niñon Lewis. “Populations, Population Health, and the Evolution of Population Management: Making Sense of the Terminology in US Health Care Today” Institute for Healthcare Improvement Leadership Blog, March 19, 2014.  Accessed at http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=81ca4a47-4ccd-4e9e-89d9-14d88ec59e8d&ID=50, June 10, 2015.