The opening leadership panel at Healthcare IT News' Pop Health 2016 event on Thursday was populated by physicians and clinicians. That's ironic, perhaps, since, "writ large, population health is about people, not patients."

So said Gregory Weidner, MD, medical director of primary care innovation and proactive health at Carolinas Healthcare System. "At the end of every data point is a person trying to live their life," he added.

Achieving population health is easier said than done, of course. It requires fundamentally rethinking ingrained processes left over from a fee-for-services world, and the embrace of new strategies, technologies and mindsets.

In fact, even just defining pop health is an elusive task: Shafiq Rab, MD, vice president and CIO at Hackensack University Medical Center, called it "a journey … hard to define."

Nonetheless, "one thing I can say for sure," he said. "As the pressure has come for value-based care, and to take risk, we have to understand the people we're taking care of."

Pop Health Forum 2016 live coverage: care coordination, patient engagement, analytics.

Doing that means more than understanding a patients' medical record, or even their genomics, but also "how you spend money, the language you speak," said Rab.

But accompanying that challenge is a big opportunity, said Weidner. The rise of savvier patients, more informed about healthcare (necessarily so, given the realities of high-deductibles health plans), equipped with technology, demanding better care, is creating a huge opportunity to deliver value.

Without question, it's "really hard to straddle fee-for-service and value-based care at the same time," said Adrian Zai, MD, clinical director of population informatics at Massachusetts General Hospital. "So many of the pressures are antagonistic."

On the other hand, "in certain places they're not," Zai said. Project such as optimizing cancer screening or improving no-show rates can have the dual benefit of increasing revenue while improving long-term care outcomes.

In a system designed for acute care, "you need to changing fundamentals," said Zai.

Still, it's important to remember that "not a single effort is going to drive population health," he said. It starts with leadership. Good technology is important, too, but it's "just a tool."

Zai said he was recently approached by a vendor representative who asked whether his team was using machine learning technology to identify at-risk patients.

"That's not the problem we have today," he said. "The problem is we're using just one percent of the data on patients: For 99 percent of their lives, they're not in our care."

Getting to where those patients spend most of their lives will be key as pop health management evolves, said Thomas Lundquist, MD, senior vice president and chief medical officer at Optima Health.

"Reducing the number of visits from 12 to 14 is an admirable effort," he said. But there are "myriad opportunities" beneath the iceberg for managing wellness – well beyond merely reducing readmissions or ER visits.

Keeping at-risk and rising-risk patients "from cresting above the water level is a huge opportunity," said Lundquist.

Part of his organization's effort to do that is to make it easier for patients to access their data: "We're on a relentless journey to create a single portal for communication, challenging our vendors to make that work."

After all, said Weidner, what happens outside the walls of the doctor's office or hospital is so much more important than what happens within them.

"Health does not happen at the point of care," said Weidner. "Health happens in the fabric of people's lives."

Twitter: @MikeMiliardHITN

Email the writer: mike.miliard@himssmedia.com

This article is part of our reporting on the Healthcare IT News Pop Health Forum 2016. Other stories in this package include The essence of population health? Design and user experience, Population health management views from the frontline, and Geisinger CEO David Feinberg calls for 'The Year of the Patient'.