‘Health and disease management’ is a clinical improvement process aimed at ensuring that the best practices known to medical science are incorporated with minimal variation over the entire continuum of care. The University of Pennsylvania Health System (UPHS) is an academic, integrated healthcare delivery system committed to implementing this approach to care by all providers and at all sites. This report outlines our approach to design, implementation, outcomes tracking and improvement, and highlights how the educational, service and research missions of the academic health system add value to the comprehensive health and disease management approach.The involvement of clinical researchers and academic physicians in the design of programmes contributes directly to improved clinical outcomes. Faculty with specific research interests, and experience with less common conditions, frequently lead this best-practice approach with rarer conditions, so allowing the impact of these programmes on improving the quality of care to be evaluated across many disease states. On the basis of their extensive knowledge of the disease in question, academic faculty play valuable leadership roles in selecting relevant key measures.Education, a key component of health and disease management implementation, is an area of particular strength in academic systems. Provider education, in particular, can be effectively achieved by academic detailing, led by specialists and utilising the involvement of skilled educators.A key requirement for programmes such as these is the need to frequently update the best-practice clinical guidelines. The academic health system is ideally poised to rapidly incorporate clinical advance and emerging knowledge into disease management programmes that can reach a wide audience. Health and disease management offers a unique research opportunity for academic physicians who can adapt the use of process control measurement techniques, which have long been the major approach to performance measurement in industry, to the healthcare environment.Clinical evaluation and outcomes management, has the potential to become widely embraced as a legitimate and important form of research. Substantial effort and resources must be dedicated to gain provider buy-in and achieve compliance. We believe that academic health systems have many of the necessary ingredients to be successful in this initiative. Moreover, if this approach to care is to be widely adopted, and behaviour change achieved, the next generation of healthcare leaders and workers must be introduced to these concepts early in their training.