In all the time I’ve been writing about population health, I’ve somehow managed not to discuss pharmacists or pharmaceuticals very much. Partly that’s because I associate the two topics closely and, apart from briefly mentioning efforts to make medications more affordable, I haven’t devoted much thought to how medications – or those who distribute them – fit into a population health framework.

Like many people, I’ve always seen the pharmacist as standing somewhat apart from the medical establishment. Yes, many pharmacists work in clinical settings (around 34% according to a 2019 national workforce study), but I’d argue that most people for most of their lives only see pharmacists in the community pharmacy setting, and even then they mainly deal with pharmacy technologists, not the actual pharmacist. If they had a role to play in population health management, went my logic up till now, it would’ve already happened. 

But as it turns out, there’s a lot more to the pharmacist profession than simply dispensing medications. After digging into how pharmacists actually interact with clinicians and the general public, how their role evolved basically overnight during the COVID pandemic, and how much potential they have to move the needle on population health, I have come to see pharmacists and pharmacy technologists in an exciting new light. 

Location, Location, Location

As it turns out, my own perception that you can’t swing a recently-deceased cat without hitting a pharmacy is actually quite accurate to most people’s experience in the U.S. In fact, a study published last year in the Journal of the American Pharmacists Association (JAPhA) reported that “Across the overall U.S. population, 48.1% lived within 1 mile of any pharmacy, 73.1% within 2 miles, 88.9% within 5 miles, and 96.5% within 10 miles.”

Now that’s what I call patient access! If you’re new to this blog or the concept of population health in general, accessibility of care is of central importance when it comes to improving patient outcomes. If you create too many obstacles for patients to seek care (long waits, exorbitant costs, too little time with their primary care physician), they often won’t comply with preventative care strategies. This in turn often results in patients presenting at the hospital with preventable health issues, and puts further strain on an already overstressed healthcare system.

On the contrary, opening up availability of medical services to the maximum number of patients (or potential patients who are dealing with risk factors) puts healthcare providers in the best position to maintain healthy populations. Although most pharmacists in the U.S. aren’t as highly trained as the average clinician – which, as we’ll soon see, can cause very real challenges to physicians delegating clinical services to pharmacists – they are still generally very knowledgeable about how to deploy medications to improve patient outcomes.

So the upside of there being so many pharmacies is that, unless you live in Alaska, South Dakota, North Dakota, or Montana – where there are fewer pharmacies per capita – you shouldn’t encounter much trouble in speaking either directly to a pharmacist or to a trained pharmacy technologist. The downside is that while you might be able to ask a pharmacist or technician more questions than you might to your PCP due to time constraints placed on the latter, you often won’t have the assurance that A) the medical practitioner is as highly trained as your primary care doctor, and B) unless they work within a healthcare network alongside prescribing providers as coordinated members of a patient’s care team, the pharmacist may not be able to as readily access as much of your medical information through an electronic health record. Limiting access to the EHR, as the linked article notes, “makes ensuring that patients are receiving proper medications and monitoring for efficacy and safety a challenge, if not impossible in some situations.” 

These barriers, both regulatory and technological, present tough challenges to creating a fertile environment in which PCPs and pharmacists can become more equal partners in value-based care delivery. That said, I still believe that the framework is in place for pharmacists to begin taking a more active role in population health management. The fact that most Americans can conveniently receive care from a trained pharmacy employee (in both clinical and community settings) positions pharmacists and their staff members to greatly improve the health of the communities they serve.

Your Friendly Neighborhood Pharmacist (and Tech)

Before we delve too far into the specifics around how pharmacy teams can more tightly coordinate care with PCPs to become key value-based care delivery partners, let’s talk about another commonly-held perception: their trustworthiness.

On top of being highly accessible, pharmacists are generally considered honest and ethical by the public. According to a series of Gallup polls run over the course of many years, pharmacists have consistently ranked near the top of the most trusted professions. In parallel with this trend, the rates of pharmacists seeking advanced degrees are increasing; indeed, according to the aforementioned workforce study, “the proportion of licensed pharmacists whose highest degree is a Doctor of Pharmacy (PharmD) degree was 53.5% in 2019 compared to 37.8% in 2014 and 21.6% in 2009.”

Also of note, in 2019 “36.2% of licensed pharmacists held a BS degree as their highest degree compared to 52% in 2014 and 66.3% in 2009,” a clear indication that pharmacists are looking to arm themselves with more knowledge at an ever-increasing rate. I can’t prove that the two data points are correlated, but it certainly does seem that achieving ever-higher levels of education has made a favorable impression on the public. Since a discussion of regulatory barriers could fill a whole separate blog post I won’t go into it much here; suffice it to say, however, that if pharmacists were allowed practice to the top of their license, many could better tailor their care to the patients who live and work in the communities they serve.

Stepping Up in Challenging Times

Remember that part above about clinicians delegating authority to pharmacists, and how important it may be to the future of population health? Well, this theory was put to the test during the COVID-19 pandemic, which proved to be a watershed moment for the pharmacy profession. The fact that pharmacists became an integral partner not just in dispensing COVID-19 vaccines, but also in testing people for the illness, was lost on neither physicians nor patients.

Up until then, many people viewed their local pharmacist as someone who stood behind a counter dispensing medications ordered by their doctors; but when COVID hit, these benign figures snapped to action, becoming indispensable foot soldiers in a life-and-death battle, administering needed vaccines directly to members of their community when the need exceeded the capacity of primary care physicians to do so.

This dramatic shift in course is borne out in the numbers. In a report published last year that surveyed more than 3,000 patients, 1,000 pharmacists, and 500 providers, the latter of which included physicians and nurse practitioners, with the purpose of understanding the expanding role of pharmacists, the following results begin to tell a compelling story:

• A majority of pharmacists anticipate transitioning from transactional care to taking on more direct patient care responsibilities.

• More than half (53.3%) of pharmacists agreed their current training and education are sufficient to manage patients. However, pharmacists did identify opportunities for additional training in chronic disease education, diagnosing, and prescribing.

• Nearly half of patients would find it helpful to have routine testing and medical visits done from home. Many pharmacists are equipped to interface with patients using telepharmacy technology, and of the pharmacists who use this technology, more than a third told the report authors that “it gives them more time to interact with patients, allowing them to provide crucial information and support when – and where – patients need it most.”  

So if pharmacists could step up during a public health emergency to ensure patient backlogs didn’t build up in clinical settings, might they not also be able to play a more active role in preventative healthcare more generally?

Pharmacists and Population Health

I was reading an article by the American Society of Health-System Pharmacists (ASHP) on how pharmacists can influence population health, and I happened across my new favorite definition of population health management:

“While population health refers to the outcomes of a defined group of individuals and the…drivers and determinants of health, population health management refers to the infrastructure that enables programs to target defined populations and employ a variety of interventions aimed at slowing disease progression, improving health-related outcomes, and decreasing total cost of care.”

There is a growing consensus within the pharmacy field that participation in population health should be a priority for pharmacists. In fact, as part of their 2030 Patient Advancement Initiative, the ASHP puts forth several recommendations pertaining to population health:

• Pharmacists in all care settings should be included as integral members of the healthcare team and share accountability for patient outcomes and population health.

• Pharmacists should use health information technologies to advance their role in patient care and population health.

• Pharmacy should establish standards for the application of artificial intelligence (AI) in the various steps of the medication-use process, including prescribing, reviewing medication orders, and assessing medication-use patterns in populations.

• Pharmacists should be leaders in federal and state legislative and regulatory policy development related to improving individual and population health outcomes. 

These statements are, of course, only aspirational and don’t necessarily signal progress in any of the specified areas. Still, the ambitiousness of these goals speaks volumes about where ASHP sees the future of pharmacy with respect to population health.

In the document “FAQ: Getting started with population health management” I quoted earlier in the post, the ASHP elaborates on the above goals, stating that, “Identification of barriers, both clinical and non-clinical, that prevent patients from achieving better therapeutic outcomes is a key to successful and sustained care” and providing the following examples of ways pharmacists can participate in population health management: “performing comprehensive medication management, transitions of care services, wellness promotion classes, monitoring for high-risk or specialty medications, and employee health assessments.”

All of the above functions are important, and most share a common feature: they involve collaborating closely with other members of a patient’s care team, particularly the patient’s primary care provider.

Partnering with Clinicians

The term “comprehensive medication management” (CMM) or, as it’s also called, “medication optimization” or, more broadly, “medication management services,” can mean many things to many people. But in this context, a definition that appeared in a 2021 article in the journal American Health & Drug Benefits, seems to fit best: “when a patient’s medication has been optimized by the healthcare team and the patient uses the regimen in the ideal manner to improve health outcomes.”

It’s also important to note that CMM is often delivered in clinical settings, as noted in this definition offered by the American Association of Colleges of Pharmacy (AACP):

“CMM is a patient-centered approach to optimizing medication use and improving patient health outcomes that is delivered by a clinical pharmacist working in collaboration with the patient and other health care providers.”

Key here is the term “clinical pharmacist”; I couldn’t find many examples of CMM happening widely in community or retail pharmacy practice, at least not without the supervision of a more highly-trained physician (a point I’ll elaborate on in a minute). One of the case studies highlighted in the AACP article illustrates the potential effectiveness of a CMM approach in improving the health outcomes of defined patient populations, a key feature of population health. As described in the article, a center called the Monroe Clinic that serves rural Southern Wisconsin sought to solve a problem: chronic disease patients there were waiting up to six weeks to see their PCPs and, as a result, many ended up in the emergency department.

To solve this issue, the pharmacy team at the Monroe Clinic approached their PCP colleagues about allowing the pharmacists to meet with patients for chronic disease management. As part of this effort, the pharmacists provided their clinical colleagues with a CMM framework that would relieve the primary care doctors’ caseload and allow the latter to see patients who had more acute issues. The approach is paying dividends and, according to the article, one of the pharmacists has been offered a full-time role managing the CMM process.

As in the example of the Monroe Clinic, CMM is an important step forward when it comes to pharmacists becoming key players in population health management. But in my research, I didn’t turn up many ways – aside from being part of an integrated specialty pharmacy within an accountable care organization (ACO) – that pharmacists are directly being reimbursed for implementing CMM or other sorts of value-based care.

Chronic Care Management

One potential exception to pharmacists not being reimbursement for value-based care exists in the form of something called “medication management.” For those pharmacists working in community practice and who deal with Medicare beneficiaries with two or more chronic health conditions, medication management offers an avenue for reimbursement through a program formalized in 2015 by the Centers for Medicare & Medicaid Services (CMS) called Chronic Care Management, or CCM.

Not to be confused with CMM, CCM is defined by CMS in the following way:

“CCM is care coordination services done outside of the regular office visit for patients with two or more chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. These services are typically not face-to-face and allow eligible practitioners to bill for at least 20 minutes or more of care coordination services per month.” 

As I mentioned above, medication management is an integral component of a comprehensive care plan for chronic care management and, according to the ASHP, pharmacists can engage in CCM services in the following ways (and please note, “QHP” here stands for “qualified healthcare provider”):

“Under CMS guidelines, pharmacists are recognized as “clinical staff” who can provide CCM services within their scope of practice under general supervision of a QHP. The pharmacist can be directly employed, or under contract (independent contractor) or leased employment of the qualified billing healthcare professional that is providing CCM services. The QHP must be able to provide general supervision of CCM services provided by a pharmacist but is not required to be physically present or colocated (must be available by phone). Under CCM guidelines, a pharmacist cannot consent a patient, develop a comprehensive care plan, or bill for CCM services.”

As key as pharmacists are to a successful CCM program, most are not considered billing providers and, as stated above, must work under the supervision of a physician or other qualified provider. ASHP lists the following as QHPs who can bill for CCM services: physicians, nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse midwives, with only one practitioner per patient being eligible to receive payments for CCM services per calendar month. The document goes on to say the following:

“CCM services may also be furnished by clinical staff that meet Medicare’s “incident to” rules. Licensed clinical staff include the following: clinical pharmacists, RN, LSCSW, LPN, MAs or CMAs. The time spent by clinical staff members furnishing CCM services directed by a QHP counts towards the time thresholds. Non-clinical staff time cannot be counted.”

Since most pharmacists aren’t as highly trained as physicians, their avenues for participation in CCM are limited to collecting data, maintaining and informing updates for the care plan, providing 24/7 access to care, and documenting CCM services, and, again, their work for the most part is subject to the supervision of a physician.

CCM in Practice

A real-world example of pharmacists acting as highly effective practitioners of so-called medication therapy disease management (MTDM) appeared in a 2018 article in the journal ClinicoEconomics and Outcomes Research. The authors noted that the approach “has shown improvement in clinical outcomes in patients with certain chronic diseases.” One of these diseases, diabetes mellitus (DM), affects over 30 million people in the U.S. and represents an enormous cost burden for those who suffer from the disease; indeed, states the article, “the cost burden for an individual with DM is more than twice as high as it is for an individual without DM, while the total direct and indirect cost burden of DM in 2012 was estimated to be $245 billion.” 

Additionally, studies suggest that when healthcare teams treat diabetes patients and include a pharmacist instead of other healthcare professionals like nurses, doing so is associated with “greater reductions in patients’ blood glucose levels.” Incredibly, despite this clear advantage, at least one study noted that fewer than 10% of U.S. adults with DM have had the factors contributing to their illness adequately controlled. This is primarily because of a lack of data on the impact of this approach on both health care utilization and overall cost of care. 

There are any number of other ways that pharmacists can enhance their role in population health, from becoming members of transitions of care teams to working with patient-centered medical homes. But since reimbursement pathways haven’t kept pace with innovation, population health management care approaches have been unevenly adopted throughout the pharmacy industry. It will be interesting to see how areas like medication management and CCM evolve, and if other payers adopt these proven ways for pharmacists to positively influence patient outcomes.

While researching a separate blog post on artificial intelligence in healthcare, I kept running into articles about precision medicine, a relatively new field that holds much promise for optimizing patient outcomes. As I took a detour down the precision medicine rabbit hole, I soon happened upon a related approach to public health that I’d like to explore in more depth here. It’s called “precision public health” (PPH) and despite its name, the concept is very much in line with the principles of population health, a subject I discuss often on this blog.

If you’ve heard of precision medicine, you might be wondering how a discipline whose purpose is to map out care plans based on a given patient’s genetics (i.e. medicine practiced on a molecular level) can possibly tie into public health, a field that, as the CDC Foundation notes, concerns itself “with protecting the health of entire populations.”

Aren’t the scales of these two endeavors too dissimilar to admit of any overlap?

You can be forgiven for wondering about this seeming paradox, because at first I couldn’t quite grasp it either. But stick with me and I’ll walk you through the main ideas so that by the end of this post, you’ll be armed with enough information to not be caught off guard when someone brings up PPH in conversation.

Defining Precision Medicine

Although the concept of precision medicine has only been in the public consciousness for about twenty years, it has made major inroads into healthcare delivery in the United States. With an attendant boom in the field of genomics over the past few decades, the field of precision medicine has matured at a rapid pace. Its rise to notoriety has been so swift, in fact, that in 2015, President Obama revealed the Precision Medicine Initiative, a major push to move precision medicine into common clinical practice.

As traditionally defined, precision medicine uses information about an individual’s genome, environment, and lifestyle “to guide decisions related to their medical management” with an overall goal of providing “a precise approach for the prevention, diagnosis and treatment of disease.” The term is analogous to “personalized medicine,” “personalized care,” or “individualized medicine” and, according to the American Cancer Society, “Precision medicine is a way health care providers can offer and plan specific care for their patients, based on the particular genes, proteins, and other substances in a person’s body.”

According to the Brookings Institution, precision medicine “uses personal information, such as DNA sequences, to prevent, diagnose, or treat disease. From targeting late-stage cancers to curing rare genetic diseases, precision medicine is poised to impact millions of people within the next decade.” The American Medical Association goes still further in its assessment of the field, stating that “Precision medicine is a tailored approach to health care that accounts for the individual variability in the genes, environment and lifestyle of each person.”

The emphasis here is mine, and in a bit we’ll delve into how placing more emphasis on a person’s “environment and lifestyle” can represent an area of difference between precision medicine and its cousin, precision public health.

Precision Medicine: A Brief History

As the name would suggest, precision medicine is all about tailoring medical care pathways to individual patients. Throughout most of history, medical treatments were aimed at helping the average patient. Without a detailed understanding of genetic differences between patients, a one-size-fits-all approach predominated. This makes sense given the limited tools available to physicians over the past few centuries; as a consequence, however, some patients benefited from treatments while others did not.

It’s an oversimplification to call this a scattershot approach, but that description isn’t too far off the mark. Thankfully, with the advent of the Human Genome Project (HGP) — an initiative that aimed to map the genetic makeup of humans and other organisms — researchers were able to unlock how disease states operate on a molecular level. The project, which ran from October of 1990 to April of 2003 (with the final 8% of the human genome having been sequenced just last year), resulted in sequencing “around 20,000 genes of those that make up the blueprint of our bodies.”

This advance represented a giant leap forward in human understanding, but gaps in our knowledge remained. Aside from the remaining 8% of the human genome left to be sequenced that I mentioned above, many in the scientific community were concerned about the fact that nearly 70% of the genome referenced during the HGP came from one single man who lived in the Buffalo, New York area and had his genes sequenced as part of the project.

Although the man was likely of mixed race, it didn’t sit well with some that the other HGP participants used to make reference genomes were mostly of European descent. The lack of diversity in reference data prompted a host of questions, including whether variations from the reference genome should actually be considered abnormal, and how much one genome could be relied upon to provide an accurate picture of variation among every person on the globe. Some work-arounds were employed, but evidently none of them provided the accuracy sought by experts.

Fast forward to earlier this year, when it was reported that, in an effort to create a more accurate standard measurement for the human genome, scientists had created what they called the “pangenome.”

The New York Times article linked to above states that “the new ‘pangenome’ incorporates near-complete genetic sequences from 47 men and women of diverse origins, including African Americans, Caribbean Islanders, East Asians, West Africans and South Americans.” Of particular note, the article goes on to say that the “revamped genome map represents a crucial tool for scientists and clinicians hoping to identify genetic variations associated with disease. It also promises to deliver treatments that can benefit all people, regardless of their race, ethnicity or ancestry…”

Precision medicine offers tremendous benefits, because, as a recent article in the Harvard Public Health magazine points out, “not everyone benefits equally from the same intervention. Someone at increased genetic risk for breast cancer, for instance, might benefit far more from regular mammograms than a neighbor at low risk.” This realization, says the author, is driving the development of the field.

Interestingly, with such a strong push to include non-clinical social determinants of health (SDOH) in patients’ care decisions, it is perhaps not surprising that healthcare practitioners are turning to precision medicine and the related — though more encompassing — field of “precision health” to help tailor healthcare delivery that optimizes for positive patient outcomes. But before we delve into the related but separate topic of precision public health, let’s first gain a better understanding of how genomic data is collected and analyzed.

Big Data and Precision Medicine

While advances in precision medicine represent a welcome milestone in the fight for health equity, mapping varieties in the human genome on an ever more fine-grained level has led to growing uneasiness on a number of fronts. A 2017 paper that appeared in the Journal of Community Genetics encapsulates many of these concerns. Chief among them are the following items:

• How to report genetic variants of uncertain significance (i.e. how to deal with incidental findings unrelated to a given test’s clinical indication)
• The need to expand the availability of genetic counseling services
• Training healthcare providers to interpret and better understand results from next-generation sequencing (NGS) technologies
• How best to deal with the ethical tensions inherent in practicing in this new clinical environment     

Aside from these complications, there is the monumental question of how, in the era of electronic health records and wearable sensors, can clinicians best collect the avalanche of data the new technology has occasioned. This question is hard enough to answer on its own, but perhaps an even bigger challenge lies in how to analyze the treasure trove of new data to find appropriate clinical applications. With data rolling in at ever increasing rates from multiple platforms in a variety of geographic locations, how do physicians and researchers keep it all straight?

Enter big data analysis, a field that has been undergoing an explosion in recent years. According to an article in the International Journal of Molecular Sciences, “Big Data analytics uncovers hidden patterns, unknown correlations, and other insights through examining large-scale various data sets.” The article also states the following:

“While integration and manipulation of diverse genomic data and comprehensive electronic health records (EHRs) on a Big Data infrastructure exhibit challenges, they also provide a feasible opportunity to develop an efficient and effective approach to identify clinically actionable genetic variants for individualized diagnosis and therapy.”

Put another way, as a result of this new wellspring of patient information, the need for big data analytics to search for patterns that can lead to effective medical solutions is paramount. And by “effective medical solutions,” I’m not just referring to treating disease states that have already manifested; indeed, precision medicine can also be deployed to predict illnesses before they occur.

If you want to really be dazzled by precision medicine’s promise of enhancing patient outcomes, consider this outlook on the discipline’s potential to head off diseases before they appear:

“Other genome-based technology platforms [for example, assays for RNA, proteins, metabolites] are also increasingly being used to classify disease states (as diagnostic tests) and to predict future clinical outcomes (as prognostic tests). Together, these approaches form the basis for 1) a new molecular taxonomy of disease, 2) provide more precise ways to screen for and to detect disease at its earliest molecular manifestations, often pre-clinically, and 3) allow the selection of certain drugs guided by a patient’s underlying genetic makeup.”

The authors go on to write the following: “Given that a disease’s evolution from baseline risk to clinical signs and symptoms often occurs over many years, it is likely, in the future, periodic molecular and digital profiling will shift health care strategies from acute intervention and disease management to a focus on assessing health and proactive management of disease risks and prevention.”

I don’t know about you, but I find the prospect of detecting illnesses and diseases before they show up on our doorstep to be nothing short of mind-blowing. New avenues for treatment like personalized drug therapy, creating “digital twins” to help researchers better administer treatments to a range of people, and pursuing mutation-targeted therapies for cancer will likely soon supplant older, less focused treatments and usher in a new era of medicine. 

Precision Health Versus Precision Public Health

If we can get back to definitions for a minute, I’d like to offer an observation: it seems to me that the main difference between precision medicine and its closely-related cousin “precision public health” is one of scale: precision medicine applies to situations where individuals, or perhaps small patient cohorts, are targeted with healthcare interventions that conform to their individual, often molecular-level circumstances. Precision public health, on the other hand, takes a solution that’s designed to target an individual’s biological makeup and scales it up to address health problems shared by entire patient populations.  

It should be noted that, as is often the case with relatively new medical fields, there doesn’t seem to be a consensus on what exactly the term “precision public health” constitutes. More to the point, multiple sources use the terms “precision population health” and “precision public health” in a way that leads me to believe that they can be used interchangeably, at least for now.

An article in the Journal of Translational Medicine makes this point directly:

“Reframing and broadening precision medicine beyond ‘omics’ (e.g., genomics, proteomics, metabolomics) has been referred to as ‘precision population health’ or ‘precision public health.'”    

Since there doesn’t seem to be a unifying term for this new medical pursuit, for the duration of this blog post I’ll use “precision public health” to denote a wide-scale application of genomics to healthcare. This seems to be the favored term in the research I’ve read, so we’ll go with it.

That being said, however, we should pause to quickly examine a sort of “halfway term” that exists between the two poles of precision medicine and PPH, namely “precision health.”

Precision health can be thought of as an approach to patient care that encompasses more of the factors that impact a person’s health outcomes. According to the CDC, precision health is broader than precision medicine, taking into account not just genetic factors, “but also approaches that occur outside the setting of a doctor’s office or hospital, such as disease prevention and health promotion activities.”

Sound familiar? (Hint: this is what SDOH is all about). The CDC makes the further point that, when precision health is used to elucidate approaches that public health practitioners can take to help improve the outcomes of distinct patient populations, this is called “precision public health.”

A Public Health Approach

With that slight detour out of the way, let me add one final flourish before we discuss the nascent field of PPH: the term “population health” should be kept in mind as an adjunct to any broad approach that applies molecular-level testing to large patient cohorts. Allow me to explain.

Population health has been defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group” and includes considerations of “health outcomes, patterns of health determinants, and policies and interventions that link these two.” Since groups targeted by public health initiatives can be thought of as discrete patient populations, it seems reasonable that the word “population” would be employed when discussing the utilization of genomics to better allocate healthcare resources.

Put another way, although the use of the term “population health” isn’t widespread in the literature focusing on PPH, I think the concept bears keeping in mind as clinicians begin to employ risk stratification and other tactics based on genetic testing that divide patients into groups.

As if to prove my point, the authors of a 2019 article in Frontiers of Public health noted the following when it comes to genomic data:

“One of the many potential roles of PPH is to use population level data to better identify how individuals can be aggregated into larger groups. This could be achieved using the increased knowledge derived from precision medicine about the biological pathways involved in disease. Such an approach may be critical to ensuring that evidence-based research methodologies can still inform decision-making in the context of increasingly smaller target groups for therapies and diagnostics.”

Remember the AMA quote from earlier about how precision medicine accounts not just for the individual variability in genes, but also for a person’s environment and lifestyle? With all due respect to the AMA, in my judgment this is actually where the fields of precision medicine and PPH begin to diverge. The authors of a 2020 paper that appeared in PLOS Medicine neatly encapsulate the field of PPH in a way that I find useful:

“Big data enable the potential for more ‘precision’ in medicine and public health. In theory, more data at the individual level can help redefine the meaning of healthy and the progression from health to disease, helping to uncover preventable disease risk factors and allowing more precision diagnostic and prognostic information. At the population level, big data can help integrate multiple social and environmental risk factors such as air pollution, neighborhood walkability, and access to healthy food.”

It’s this last part that distinguishes PPH from its antecedents: taking genetic-level data and combining it with SDOH information like the air pollution a patient experiences on a daily basis. Doing so helps physicians create a more complete picture not just of a person’s current health, but of the health risks they face in the future.

Put succinctly, the authors of the PLOS Medicine article write, “If precision medicine is about delivering the right intervention to the right individual at the right time, PPH can be simply viewed as delivering the right intervention to the right population at the right time.” 

Of course, employing health surveillance in this way addresses health disparities in a more comprehensive way than has thus far been possible. One can imagine innumerable applications for this technology in fighting health inequities, including fine-tuning social vulnerability indices (which I wrote about in a previous blog post).

Although the rampant pace of development is exciting, significant hurdles to full-fledged adoption of PPH exist. Realities like a lack of incentives for health entities to share electronic health information and entrenched regulatory barriers represent just part of the range of challenges ahead. But despite these pitfalls, I firmly believe that, as the use of artificial intelligence opens up new avenues for health care delivery, PPH will flourish. For this reason, it is a field worth keeping a close eye on.