Insights (Essays)

Insights (Essays) November 2019

Clinical Population Medicine: A Population Health Roadmap for Ontario Health Teams

Aaron Orkin


  •  The population health goals of OHTs are among their most promising features, but few healthcare organizations are doing population health or have existing capacity and expertise to take on this challenge.
  • Clinical Population Medicine (CPM) is the conscientious, explicit, and judicious application of population health approaches to care for individual patients and design healthcare systems. CPM is a framework to deliver population health within OHTs.
  • A roadmap to build Clinical Population Medicine in OHTs includes:
    1. Put the right people in the right place.
    2. Think of patients as numerators and populations as denominators. Do “denominator work”.
    3. Create health, treat disease.
    4. Link data with practice.
    5. Build partnerships beyond patient care.


The introduction of Ontario Health Teams (OHTs) is challenging health leadership and healthcare organizations across the province to deliver care that is more connected and coordinated. Our healthcare leaders and organizations are rising to the challenge and building on existing partnerships, expertise, and capacity to propose OHTs province-wide.

But the OHT concept goes beyond connected and coordinated care. OHTs are not only expected to deliver a continuum of connected care, but a continuum of connected care to achieve a healthier status for a defined population. The OHT model calls on healthcare institutions to deliver population health.

This is a new challenge for healthcare organizations. From Ontario’s rural community practices to its metropolitan academic health sciences centres, few healthcare organizations have an existing population health mandate or strategy, population health expertise or leadership, or established capacity to marry population health and patient care. For OHTs to deliver a population health approach, they will need to reach beyond existing ways of doing business, solving problems, and delivering care.


  • To define and describe population health and clinical population medicine in the context of Ontario Health Teams.
  • To set a roadmap for the implementation of effective population health approaches and practices within emerging OHTs.

Defining Population Health and Clinical Population Medicine


Health Canada defines a population health approach as focusing on improving health status through action directed toward the health of an entire population, or sub-population, rather than individuals. (Public Health Agency of Canada) This definition is intended for the health system at the broadest level, and is inherently ill-suited for healthcare organizations that focus on delivering care to individuals.

Clinical population medicine (CPM) is population health for healthcare systems. CPM is “the conscientious, explicit, and judicious application of population health approaches to care for individual patients and design healthcare systems. CPM integrates clinical care and community health by engaging with both patients and populations simultaneously.” (Orkin et. al.) CPM practitioners and systems work in the healthcare sector to enhance community health, influence determinants of health, and redress health inequities. This occurs not only at the systems design and policy level, but right at the bedside as well.

Creating and implementing CPM practice positions OHTs as integrator institutions that are equipped to deliver care that meets the needs of both patients, populations and providers and ultimately achieve the Quadruple Aim. (Berwick et. al.) (Bodenheimer & Sinksy) Our health system is in desperate need of these integrators to address vexing problems at the intersection of individual patient care and population health — problems like an aging population, complex multimorbidity, mental health and substance use disorders, and the health effects of fractious social inequities. (Washington et. al.)

Population health is a team function for OHTs, requiring the coordinated engagement of primary, secondary, and tertiary care providers and institutions alike. Like excellent case management, a rigorous quality improvement program, or a leading-edge surgical service, CPM is an embedded set of professionals and practice that serves the entire organization, supports a network of interdependent professionals, and is available to all of the people that the OHT serves. Implementing CPM within OHTs therefore requires personnel with both clinical and population health skills, positioned and resourced to design and implement a population health mandate across the OHT.

CPM in OHTs: What it is and what it is not

Clinical Population Medicine is:

  • A deliberate practice applied by OHTs, their members and practitioners
  • Engaged institutions that reduce health inequity through coordinated access, health promotion, and disease prevention.
  • Using data to deliver immediate and accessible indicators for clinical decisions and system design that are responsive to changing community needs.
  • Able to improve health and treat disease simultaneously
  • Grounded in epidemiology and the complementary practices of population health and clinical care.

Clinical Population Medicine is not:

  • Delivering clinical care to underserved patients.
  • A threat to patient-centered clinical care through rationing or undermining patient or clinician choice.
  • A substitute for public health agencies and practices.
  • The sole responsibility of primary care or family medicine partners within OHTs.
  • A new specialty or discipline limited to specially trained practitioners.
  • The same as research, quality improvement, guidelines, health administration or resource allocation.

Adapted from Orkin AM, Bharmal A, Cram J, Kouyoumdjian FG, Pinto AD, Upshur R. Clinical population medicine: integrating clinical medicine and population health in practice. Annals of Family Medicine 2017:405-409.

Let’s also be explicit about what CPM is not. CPM is not about delivering quality healthcare services to presently underserved or poorly served groups of patients, although this is certainly part of what’s needed. CPM is not quality improvement or health administration, it is not research or knowledge translation, and it is not epidemiology or big data analysis — though it draws on these domains and more. Similarly, CPM is not Choosing Wisely, not patient safety, not a threat to patient or clinician autonomy, nor a strategy for rationing resources. CPM is not a new medical specialty or discipline, although developing CPM leadership within an organization requires the deliberate engagement of leaders and personnel with specific skills in this area.

CPM is not primary care, although there are important synergies between some primary care models and CPM. CPM is not public health, and does not deliver functions under the mandate of local public health agencies governed by the Health Protection and Promotion Act, nor is it the work of Public Health Ontario. Public health agencies are critical partners for OHTs, but their mandate is separate, and independently vital to community health. (Grey & Riccardi)

Core Functions of Clinical Population Medicine in OHTs

Within the structure of an OHT, CPM practitioners would play a leadership role in coordinating and implementing an OHT’s population health strategy, enhancing population health capacity across all members of the OHT, advancing new population health innovations, and measuring population health impact. Within the OHT, CPM takes on three functions: (1) Population Health Assessment, (2) Policy Development, and (3) Population Health Assurance.

Functions of Clinical Population Medicine in OHTs
Population Health Assessment
  • Support OHT’s to define and characterize target populations and services
  • Monitor and characterize the health, disease, and healthcare utilization of the OHT’s target population to address population changes and emerging health problems
  • Monitor and characterize health equity in the OHT’s target population
  • Diagnose and address priority health problems at the population level
Policy Development
  • Inform, educate, and empower all OHT member organizations about population health issues
  • Mobilize community and patient partnerships to identify and solve health and healthcare problems
  • Develop policies and plans that support OHT members and partners to address priority population health concerns.
Population Health Assurance
  • Advance policy and practice across the OHT to improve, protect and promote health and health equity across the OHT priority population.
  • Design and deliver bedside clinical consultation for patients with priority population health concerns
  • Serve as the primary point of contact and partnership for OHTs with local and regional public health agencies
  • Evaluate the population health effectiveness, accessibility, and quality of OHT care and services
  • Innovate for new insights and solutions to population health problems

Adapted to CPM in clinical settings from the US Centers for Disease Control Core Functions and Essential Services of Public Health.

Roadmap to Clinical Population Medicine in OHTs

This roadmap lays out the essential steps to create effective population health and CPM capacity within emerging OHTs.  These elements are prerequisite if OHTs are to design ambitious population health strategies and deliver on their population health vision.


Put the right people in the right place.

  • The right practitioners are integrators with genuine fluency in both population health and clinical medicine.
  • Establishing real population health capacity and achieving ambitious population health goals requires dedicated personnel with a mandate, resources and responsibility to implement the OHT’s population health mission.
  • CPM practitioners need to be positioned among the OHT’s leadership, with the capacity to operate between and across member organizations.


Think of patients as numerators and populations as denominators.  Do “denominator work”.

  • Our patients represent just a portion of the population that we aim to serve. To do population health work, think of patients as numerators and populations as denominators. Consider for example an OHT that targets people with complex multimorbidity as its target population.
    • With this goal, the numerator is people currently receiving appropriate care for complex multimorbidity. The OHT should seek to improve this care however possible.  This is “numerator work”, and is the core work of existing healthcare institutions.
    • The denominator is all of the people with complex multimorbidity or who may develop complex multimorbidity in the community. To do population health, the OHT must drive initiatives that prevent the preventable, improve access to care, and create health and health equity beyond the clinical environment. This is “denominator work”, and it cannot be achieved through individual patient care alone.
  • The OHT’s CPM personnel should lead its denominator work, including a population health strategy and services.
  • Doing “denominator work” is a seismic shift from the day-to-day activities of most healthcare providers and organizations.


Create health, treat disease

  • The population health approach calls on healthcare organizations to reconsider health not merely as the absence of disease, but as a personal and community ability and resource.
  • The OHT is responsible not only for treating disease, but for community “salutogenesis” — the creation of health.


Link practice with data

  • Gather disease prevalence, healthcare utilization, and health data.  Demand and deliver real-time data on local patients and populations, rather than regional or provincial estimates.
  • Use predictive analytics and artificial intelligence approaches to bring patient care and population health data together at the bedside. Inform patients and providers how they fit into the local population with respect to priority socio-demographic and healthcare utilization variables.
  • Develop data sharing models across the OHT and with existing data hubs from the beginning — they are prerequisite to being able to population health effectively.


Build partnerships beyond patient care

  • Population health requires new partnerships beyond the boundaries of clinical healthcare organizations.
  • Engage partners for population health, drawn from public health, social and community services, education, technology and more.

About the Author(s)

Aaron Orkin MD MSc MPH CCFP(EM) FRCPC is a family, emergency, and public health and preventive medicine physician and researcher. He is Ontario’s first fellowship-trained Clinical Population Medicine specialist, and holds graduate degrees in history and philosophy of medicine (Oxford) and Epidemiology (UofT). An Assistant Professor in the Department of Family and Community Medicine at the University of Toronto, his practice and research focuses on the integration of clinical medicine and population health, and strategies to engage underserved and structurally marginalized populations into health care delivery. He practices emergency medicine at St. Joseph’s Health Centre and Humber River Hospital, and serves as Population Medicine Lead for Inner City Health Associates in Toronto.


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