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Population Health Management Analytics Software

Over 15.5m citizens benefit from targeted care using our population health management tools. In partnership with our ICS partners, we are leading the way in data-rich population health intelligence that provides actionable insights for the reset, recovery, resilience and continuous improvement of health and care economies.

Our population health platform uses integrated health and social care data held in our shared care record to produce richer insights at population, place, cohort and individual level. Insights that are driving actions such as identifying and enrolling individuals onto acute and chronic disease remote monitoring programmes. Enabling clinicians to drill through to the integrated personal health record. Analytical tools are used to evaluate and measure the impact of interventions on patient engagement, compliance to treatment targets, behaviour and disease control. Insight can be presented back into an integrated record, closing the loop and enabling clinicians to use insight to take action through a 360-degree seamless, integrated solution.

Key benefits:

Our population health tools support ICS stakeholders at a strategic, tactical, and operational level, including:

  • Elective recovery analytics enable Acute waiting lists to be analysed alongside wider population health data to allow easy to action, Consultant level lists of patients to aid validation such as deceased patients, duplicate entries or patients who may have been treated elsewhere. By analysing blood tests or BMI scores, consultant lists can also be stratified to identify patients at risk due to their co-morbidities or deterioration. Health equity analysis is also covered through the provision of analysis by demographic influencers, identifying trends in access to vulnerable patient groups and identifying those groups at risk of health inequalities.
  • Command centre dashboards provide an executive lens on local service demand, capacity, and resources to support system-level decision-making. Using a mixture of real-time and regular Sitrep reporting information, Integrated Care System can now understand pressures in their system, such as emergency attendances, the acuity of admitted patients, bed capacity, discharges and the capacity available in social, mental health and community care across their entire footprint. This enables proactive day-to-day management and planning of system capacity and demand.
  • Health Equity analysis is a key component of any population health toolkit, and tools to support the NHS 20+5 approach are embedded within the platform. Identification of the Core 20 population is made easier as each population health patient record is linked to an index of mass deprivation score. Fuel poverty and key national data sets such as Fingertips are available for wider analysis. Pregnancy vaccination uptake and equity dashboards enable analysis of health inequalities in vaccinations for pregnant women through age, ethnicity, and deprivation analysis. Serious mental illness health check dashboards identify vulnerable patients who may have missed a health check, enabling action. Enhanced case-finding tools identify hypertensive patients and candidates for remote blood pressure monitoring. Vaccination uptake of Chronic respiratory disease is monitored through NIMS Covid and Flu uptake dashboards, and Cancer data analysis can better support the NHS’s aim of earlier diagnosis by enabling a better understanding of care and treatment pathways for patient groups at risk of health inequalities.
  • Enhanced case-finding enables an Integrated Care System to case find at scale (from ICB to practice level) by using the rich population health data to rapidly identify individuals and specific groups who could benefit from early intervention for integrated and proactive care. The tool brings together key data points from across health and care, links in health equity markers, and uses the world leading risk stratification algorithms from the Johns Hopkins ACG® System to enable effective population stratification based on several different models, including the risk of emergency admissions and risk of mortality. Rich diagnostic profiling is also enabled, identifying long-term conditions, prescriptions, and patients at risk of polypharmacy or who have frequent admissions to A&E.

In summary:

The data intelligence generated by the population health platform is used to drive actions. This includes planning services such as working out what is needed, predicting when and where a surge in demand will likely come from and putting appropriate measures in place.

The platform enables evaluation and provides learning to support continuous improvement and best practices through the ability to study the impact of interventions. 

It empowers Integrated Care Systems to develop their own analytical eco-systems by providing a configurable platform which enables homegrown analytics, importing local data sets and the opportunity to share and collaborate with colleagues in other areas.  Using shared care and personal health record data intelligently, integrated care systems will operate more agilely, adapting and scaling up new services as demands change. 

Case studies:

Combined Intelligence for Population Health Action (CIPHA) programme.

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The NHS CIPHA programme supported health and care systems across the country to develop their population’s health analytics use by providing a population health platform, analytical insights, and the opportunity to collaborate and share best practice across different geographies. The programme aimed to support Integrated care systems to develop the governance needed to embed the use of population analytics within the culture of an ICS. The expansion programme, run across a population of 15 million citizens, was based on the original CIPHA programme developed by Cheshire and Merseyside in response to the Covid Pandemic in the summer of 2020.

CIPHA analytics uses a combination of local and national data feeds, made available in the Graphnet population health platform, with real-time analytics and dashboards presenting information to allow prompt, coordinated actions at both local and regional levels.

Alongside Covid analytics, virtual monitoring, mental health, equity analysis and elective recovery were key analytics shared across the partner organisations. Academic research was also enabled through the use of trusted research environments.

Using population health and shared records to deliver Covid remote monitoring services to patients in their home

We have been working with Frimley Health and Care ICS to identify patients that would benefit from remote monitoring at home.

Patient groups can now be filtered interactively to identify and highlight cohorts to be monitored more closely i.e. Covid patients, those at risk from Covid, or those with other health conditions who might need flagging and monitoring through programmes such as Pulse Oximetry @Home. 

Findings from 11 Nov 2020 to 27 Feb 2021 (108 day period):

  • 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

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Population health data system working behind the scenes on the Events Research Programme in Liverpool.

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Being development partners with Graphnet and using their population analytics platform has really enabled us to build the supporting analytics that enable our move towards developing a mature population health Intelligence system.

Mark Sellman – CIO Frimley Health and Care ICS & Connected Care

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Population health – providing actionable insights

The need for population health management systems has never been more important as we move ahead into restoring services, reducing backlogs and identifying unmet need – all while tackling inequalities in access, experience and outcomes.

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