New paradigm in medicine: population health — a Q&A with Dr. Brita Roy

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(Photo by Michael Marsland / Yale University)

Dr. Brita Roy started her career in biomedical engineering, focusing on problems such as how to develop better artificial hearts or drugs. But with a desire to work more directly with patients, she switched to medicine where she started to see that the advanced medical technologies she’d studied as an engineer would have little impact if patients did not learn how to manage their own health and well-being.

After extending her time in medical school to get a master’s in public health, Roy completed her residency in Birmingham, Alabama, where health disparities were all too common. The Robert Wood Johnson Foundation Clinical Scholars Program brought her up north to Yale, where she now serves as an assistant professor of general medicine, with a specialty in an emerging area of medicine: population health. YaleNews recently spoke to Roy about her work; the following is an edited version of that conversation.

What is population health?

It is a specific focus on improving the health outcomes — and the distribution of such outcomes — of a group of individuals, usually within a geographic area. Under this umbrella is also “population health management,” which is focused on improving the care and management of a group of patients in a systematic way. That can include quality improvement, and improving workflows and systems of care.

For example, with electronic health records, health systems and other public and private organizations are developing automated protocols for treating patients with very common chronic diseases such as high blood pressure. If I have patients who come in with high blood pressure, a dashboard would pop up and tell me what their last blood pressure reading was, what medications they’re on, how much they are exercising, and whether their pressure is under control. The tool may also have an interface to help patients self-manage outside of the clinic by allowing them to monitor their pressures, physical activity, and the salt they eat.

That is a critical part of population health, but it’s insufficient to support total population health, which addresses all of the determinants of health. Clinical care only accounts for 10%-20% of health outcomes. The remainder comes from largely socioeconomic and environmental factors — factors related to the physical environment where people live, work, and play — and health behaviors. Focusing on that larger picture requires multi-stakeholder collaboration, working together with people in the community to support the health of a population. For Yale, New Haven County is our population, whether or not people seek care here. It’s for the good of the community, helps people stay healthy longer, and is projected to reduce costs of care over the long-term.

What will your research agenda entail?

I have two streams. I’m focused on what I call positive health, or positive social and psychosocial determinants of health. In medicine, we have focused a lot on the negative — on disease, and disease prevention, and that has gotten us a long way. But there is a growing amount of evidence and theory to suggest that actually promoting the positive may have preventive effects as well as positive effects.

Well-being is more than the presence or absence of disease. It includes physical and mental health, social support, connectedness to the community, and sense of purpose.

— Dr. Brita Roy

I have been doing a fair amount of research looking initially at optimism and emotional regulation, which is the ability to be conscious of when you are stressed and be able to handle it effectively so you can cope. Those types of skills are now being taught to children at select schools, but they are also useful skills for adults. Adults who have positive coping mechanisms tend to have better health and are able mitigate risk factors and prevent disease by adopting healthier behaviors. They also have lower levels of chronic stress, which independently lowers their risk for developing heart disease and diabetes.

In addition, I’ve been moving more toward the community level. I was doing a project here with residents of New Haven to build a model of community resilience, specifically through creating and strengthening social ties and social cohesion among people who live in two local communities —  Newhallville and West River — so we can reduce exposure to gun violence. It’s a new way to think about addressing violence and trying to get at the root causes. People don’t become violent on their own; often they are exposed to traumatic events during childhood. For young people exposed to trauma, a connection to others in the community who are positive influences rather than negative influences could make a difference.

Nationally, I am using data to identify community characteristics that support total population health and well-being. Well-being is more holistic than the presence or absence of disease. It includes physical and mental health, but also social support, connectedness to the community, and sense of purpose. These are outcomes that really matter to people. I am examining the health outcomes of people living in communities with different levels of well-being. And I’m working with many communities around the country to see what types of interventions are most successful in creating higher well-being.

It’s challenging enough to change the behavior of an individual. How do you approach change for a population group?

It’s actually much easier for an individual to change behavior in a healthy community. We think of behavior as individual, but if you talk to behavioral economists, they will very quickly tell you that your actions are strongly influenced by your environment. If you live in an area that is easily walkable, for example, you are much more likely to walk or bike to work rather than jump in your car. It’s that type of change that is actionable at a community level that influences individual behavior.

You mentioned gun violence. What are some of the other key health problems in New Haven that you might address?

Asthma and teen pregnancy are key priorities for the city. High blood pressure, diabetes, and cancer are other very common problems here. Smoking is about average compared to the rest of the country, but it is a preventable condition. I would say those are the top health issues.

It’s been suggested that population health could be the future of medicine. Is it? Why?

I’m biased but I think it is. Nationally, there is a strong push toward population health. The Center for Medicare and Medicaid Services, which spends the most on health services in the nation, is actively trying to design payment systems and programs to shift to a model that focuses on what’s called an accountable health community. That would be a multi-stakeholder type of model that includes not only health care but also education, transportation, and public health in taking responsibility for the health of the community.

I also worked with the Center for Disease Control and Prevention last year to develop a community health improvement navigator. It’s an online resource that explains this model to address all of the determinants of health. It encourages hospitals to develop a diverse portfolio that focuses partly on clinical care but then also supports these other aspects of health.

That’s an effort to encourage hospitals. What about individual practitioners?

There is certainly encouragement for individual providers to do so, but with the recognition that it’s going to be more challenging for an individual provider. Hospitals have an additional incentive right now because in order to meet 501c3 requirements, nonprofit hospitals have to perform tri-ennial health needs assessments and submit a plan for how they are going to address community health needs. That requires some partnership or consultation with local public health officials and encourages and incentivizes partnerships outside the health system as well.

Population health is also being promoted within public health through the National Association of County and City Health Officials, among other organizations. Additional national stakeholders in education, transportation, and housing are now thinking more creatively about what health means and what everyone can do to contribute to it.

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