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Population Health Management (PHM) and Remote Patient Monitoring (RPM) are a approaches and tools within the healthcare industry that focuses and facilitates care delivery across the general population or a group of individuals.  Remote population monitoring is the part of PHM where patient populations are monitored outside a hospital setting via computer, interactive voice response or nurses from call centers.


PHM is to gather, normalize and analyze clinical data across a patient's many care settings that can reveal opportunities to improve the patient's health and the provider's financial outcomes. By merging clinical care with healthcare economics and outcomes assessment, PHM can help providers, patients and insurers aggregate, exchange and analyze patient data to coordinate care and promote wellness through evidence-based decision support in clinical care.

The next generation of American healthcare is being guided by The Triple Aim of healthcare. Established by the Institute for Healthcare Improvement (IHI), The Triple Aim challenges the healthcare industry to 1) Improve the Experience of Patient Care, 2) Lower the Cost of Care, and 3) achieve the goal of Population Health. The healthcare industry has been making progress on the first two objectives, but population health has been elusive. The reason for this is because early attempts at population are playing the “numbers game.” It has been well-established that 5% of the population accounts for roughly 50% of the cost of healthcare, so early attempts at population health have been in the form of disease management programs for the top 5%.


Ankota understands that true population health management means dealing with the needs of the whole population and understanding that non-medical needs are a key factor in the health of populations.  Ankota’s population management solution is a modular offering that begins with Ankota’s ForsightCare™ system.  ForesightCare has the following capabilities:

  • Manages the demographics or a population
  • For each member of the population, ForesightCare Tracks the following:
    • The health risk factors (generally multiple) for the individual
    • The acuity of the individual (to determine how frequently they require monitoring)
    • Contact preferences
  • Based on the health risk factors, Ankota’s Multi-Morbidity Engine (MME) builds an individual care plan for each member.
  • Based on organizational and member contact preferences, ForesightCare reaches out to members via live phone calls, automated phone calls, and/or text and determines whether they are exhibiting the symptoms that are early warning signs that their risk factors are “flaring.” Based on this, an appropriate escalation is pursued. To give an example, a member who has hip replacement surgery is also likely to have other risk factors from their past such as dehydration, congestive heart failure (CHF), and diabetes.  While a typical hip replacement management program will focus on PT, blood thinners and scar tissue, ForesightCare will monitor the other risk and could, for example, detect that the hip patient is demonstrating early warnings of fluid retention that could result in a CHF readmission.  This is a situation that can be escalated to a nurse in a call center and treated with a diuretic, avoiding an emergency room visit.