Rising health care costs, increasing prevalence of chronic disease, persisting health care disparities and access issues, and the aging population underlie the urgent need for change in the U.S. health care system to simultaneously improve health and reduce costs. This imperative emerges during a time of increasing evidence documenting the impact of environmental and social factors on health, a time of expanding health data resources and health information technologies, and a time of significant opportunity for health care reform through the Affordable Care Act. These trends converge to create unprecedented potential for transforming health care delivery in the United States and effecting sustainable advances in population health.
Population health research examines a diverse set of determinants of the health of populations, including social, environmental, behavioral, and clinical factors. By adopting a population health perspective and engaging in relevant population health research, primary care practice, particularly through efforts outside of the traditional in-office encounter, has the potential to inform, modify, and deliver population-level interventions. Although many of these interventions may appear to belong to the domain of public health, health care delivery experts now recognize how primary care must engage with public health to achieve this potential. Primary care practices must abandon their passive approach to interacting with patients — waiting for patients to contact them and schedule traditional visits — and instead must re-engineer their workflow so that they first and foremost are caring for their panels (their populations) of patients proactively, anticipating their needs and reaching out to meet them — so that the patients’ health needs drive the work of the practice. The realization of this potential—to inform, modify, and deliver population-level interventions — will necessitate a fundamental shift in primary care practice to engender greater patient and community engagement around the shared goal of population health improvement.