Graphnet newsletter July 2021

Product news

Back to the newsletter

Latest updates on our population health solution supporting pulse oximetry monitoring at home and tackling waiting lists. The development of CareCentric functionality and new features and our PHR latest updates and use cases.

Population health product update

Population health analytics platform release v2.22.2
New capabilities - the team have recently completed the next major release, which adds more platform capability, including:

  • Acute Patient Tracking lists data - for waiting list stratification
  • Cancer data (three different datasets)
  • CareCentric worklists data
  • Johns Hopkins ACG v12 with new laboratory and frailty markers
  • QCovid® algorithm which is used to generate the national shielded list
  • Sustainability environmental and costing data

Release notes are available on the population health Teams group or Confluence. For access, please contact Darryl Davies.

Analytics for direct care, enabling proactive care: BP@Home trailblazers and high intensity users
Berkshire West ICP and their ICS, Buckinghamshire, Oxfordshire, and Berkshire West (BOB) signed up to be one of the Wave 2 Blood Pressure@Home national pilot sites. Their success has led to the ICS becoming a Wave 3 trailblazer.

Berkshire West are using population health intelligence embedded in their shared care record to target the distribution of blood pressure monitors and provide ongoing remote monitoring for individuals with known hypertension. These are individuals residing in their most deprived wards, and who are clinically more vulnerable between the ages of 65 to 74.

In partnership with the project team, we have developed a read code sensitive digital solution to support GP practices signed up to Berkshire West’s BP@Home project.

This includes:

  • A list of potential patients for practices to select from, removing practice analytic burden and providing confidence that they are focussing on the right cohort of patients.
  • Pertinent patient information such as their frailty score, long term conditions, and scheduled and unscheduled care they have received in the past 12 months, to help clinicians select and prioritise individuals.
  • Data extracts for reporting purposes and to prove the impact of targeted interventions.

The solution also offers decision support to care professionals with permission to access this information across the health and care system. Patients coded as ‘enrolled’ can be viewed and monitored on a dynamic caseload list in a virtual hub with the ability to drill down into an individual shared care record. Clinical staff are made aware of any significant changes in observations and readings that may require attention, providing a digital safety net.

Learnings from the Berkshire West ICP BP@Home project are set to optimise the management of many more long-term conditions across the ICS.

BOB ICS is a member of the Thames Valley & Surrey (TVS) Care Record Partnership. The partnership is standing up an analytics platform that will have the potential to offer these types of capabilities across the region. A priority use case is offering proactive care to high intensity users, where service use can cross multiple boundaries. Not only will this allow more accurate identification of high users, it seeks to identify those individuals displaying a trend or pattern that could lead to high use, allowing earlier, targeted interventions.

Early analysis of death rates: impact of Pulse oximetry monitoring
Frimley Health and Care ICS and the Greater Manchester region are using their Connected Care shared care records to proactively support Covid-positive patients on their Pulse oximetry@home and virtual ward programmes. The programmes have been set up using the full Graphnet digital ecosystem: the shared care recordpopulation health management and personal health record app. 

By combining shared care record data with test and trace, public health, and lifestyle data, clinicians can identify and reach out to those individuals in their population most at risk from the complications of Covid. Targeting care to where it offers the greatest benefit. 

When patients are enrolled to the programme they can opt to record and monitor their pulse oximetry readings and symptoms electronically using their Connected Care Personal Health Record (PHR) app. As the app integrates with the shared care record, professionals can access the latest patient recordings, as they are taken.

Frimley has used the pop health analytics function to look at outcomes for a sample of patients on the programme. Findings between 11 Nov 2020 to 27 Feb 2021 on a limited population pilot illustrate the benefits and outcomes of the programme so far:

  • 42% reduction in mortality in shielded, hospitalised patients
  • 50% reduction in mortality in hospitalised patients who are not shielded
  • 28 lives saved
  • Median lengths of hospital stay reduced from 9 days to 7 days

Read more here  

Addressing waiting lists and social inequalities at scale
The latest NHS operational guidance makes clear that in managing waiting lists and reopening services, the NHS needs to go beyond reducing backlogs. It should also focus on identifying unmet need, meet new care demands, and understand and tackle potential inequalities in access, experience and outcomes. 

Our shared record and population health tools can be used to inform its response and direct action in the following ways: 

  • Supporting people while they are on a waiting list. This could include targeting selected groups for general public health messages, more specific information for harder-to-reach patients, or much more focused wrap-around care such as health coaches for patients with multiple long-term conditions.
  • Analysing health inequalities and identifying unmet need, and then putting in place new interventions. One example is providing GPs with lists of hard-to-reach multi-generational households so they can get vaccinated together – addressing vaccine hesitancy – and then leverage the contact to offer health checks and additional advice.
  • Decision support for providers – identifying patients with learning difficulties or those on multiple waiting lists, for example, managing selected patients remotely.

Find out more about Frimley’s take on waiting lists, in this article by Nigel Foster, SRO Connected Care Programme.

CareCentric product update

A major ongoing focus is the development of CareCentric as a transactional space, building on our integrated support and care planning functionality to provide targeted workflows for multi-disciplinary teams and organisations in areas such as frailty, end of life, and complex care. 

This functionality is centred around v2 of our Integrated Care and Support Plan, which includes support for latest PRSB guidance (specifically ‘About You’), new summary views of pertinent data for all forms, and a more detailed ‘contacts’ form. Other condition-specific care plans include:

  1. A new frailty management solution. This provides the ability to proactively assess, monitor and manage frail individuals and enables care teams from across the care community to create, view and contribute to plans, assessments, contacts and other key information in real-time.


  • View any existing frailty status information contributed from primary care
  • Undertake frailty assessments, such as cognition, falls, nutrition, function, skin, wellbeing
  • Record vital signs /quick observations
  • Create an integrated Care & Support Plan (including ‘about you’ details, goal tracking and contingency planning) and/or EPaCCS (End of Life) record, and enter key care contacts (both personal and professional)
  • Add lifestyle & environment details
  • Record MDT meeting actions and outcomes
  • Record, manage and track plans and actions
  • Link to a number of areas within the shared care record, e.g., GP Problems; Medications; and Vitals

  1. Heart failure care planning. This helps care teams assess, monitor and manage patients living with heart failure.

The solution currently offers the ability to record:

  • ‘My heart failure’ details on behalf of the patient
  • Specific heart failure medication details, with quick access views of GP contributed medication information
  • Relevant findings and results details over a full course of assessments
  • Details of patient progress and clinical management plans over the full care journey
  • Create an Integrated Care & Support Plan (including ‘about you’ details, goal tracking and contingency planning) and EPaCCS (End of Life) record, if applicable
  • Enter key care contacts (both personal and professional)
  • Record MDT meeting actions and outcomes
  • Upload images of relevant, supporting care planning documents, such as RESPECT forms

These add to existing multi-disciplinary functionality such as EPaCCS and the Multi-Disciplinary Team (MDT) referral and meeting recording/reporting solution.

Other condition-specific solutions, such as skin integrity, are also planned or underway. 

PHR update

More PHR use cases now live
Use cases are expanding for our PHR app.  

Its primary function to date among customer sites has been as part of Care@Home programmes for managing Covid patients.  

However, GM has expanded its use into a number of other areas, including blood pressure and blood sugar monitoring for pregnant women.  

Women identified as being at risk of pre-eclampsia are provided with free blood pressure monitors and an app to record their readings at home, without needing to attend at hospital or a clinic as frequently. Similarly those women with diabetes can access their treatment plan via the app and record their blood sugar readings in a quick and intuitive way. The women receive immediate tailored advice depending upon their readings. The readings and comments can then be accessed by their midwives who can monitor the readings in real-time and start additional treatment and personalise their blood pressure thresholds if necessary. Clinical teams can send advice to patients who are using the PHR via the GM Care Record clinical portal and this will be immediately available within the app.  

The app and clinical portal content was co-designed and reviewed with the help of the local care teams and highly engaged patients. The project is part of part of Health Innovation Manchester’s work in improving the detection of pre-eclampsia through adoption and spread of Placental Growth Factor (PlGF)- based testing.

Read more here or at Health Innovation Manchester

Other use cases are in development or at the pilot stage at customer sites. These include a full maternity PHR reflecting the national My Maternity Choices priorities. Watch this space. 

Back to the newsletter

Connect with us