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Population Health Management Software

Graphnet is the UK’s leading provider of integrated care and real-time data solutions that are helping transform health and care services nationwide.

Our Population Health Management software supports Integrated Care Systems (ICSs) in delivering joined-up health and social care that reduces hospital admissions, lowers waiting times, provides better patient access, tackles health inequalities, and helps prevent major health issues.


Following the COVID-19 pandemic, the need for data-rich population health management systems has never been more important. Our solutions provide ICSs with a configurable analytics platform that enables clinicians to securely communicate, collaborate and improve patient care in the UK

 

Contact Us About Our Population Health Management Tools

 

System Features

 

We offer a true population health management solution – from enabling cohort identification for existing and new pathways and programmes, through to enrolling, monitoring, and managing these same individuals for proactive and preventative care.

The data intelligence generated by Graphnet’s population health platform produces rich insights at a population, location, cohort and individual level that can be used to drive actions such as predicting when and where a surge in demand will likely come from and putting appropriate solutions in place.

It empowers Integrated Care Systems to develop their own analytical eco-systems by providing a configurable platform that:

  • Seamlessly links an enhanced range of data feeds into a unified shared record.
  • Supports care planning across multi-disciplinary teams.
  • Enables personalised care.
  • Provides personal health records and remote monitoring tools to support patient engagement and virtual care.
  • Enables the evaluation of intervention impacts.
  • Delivers comprehensive reporting and analysis capabilities.

About Graphnet’s population health management program

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. 

 

See how the platform works

 

 

 

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Key Benefits of our Population Health platform

 

In use across ICSs that cover more than 20 million individuals, our population health tools support ICS stakeholders at a strategic, tactical, and operational level, offering benefits such as:

  • Reduced waiting lists

Reducing waiting lists is a top NHS priority. Our Elective Recovery tool helps to recognise data errors and tackle the waiting list backlog. This can include the identification of deceased patients, duplicate entries and those who are not surgically fit. The tool helps support efficiencies, maximise resources and, in the latter case, ensure patients who are not-yet-fit can be targeted for support.

  • Proactive day-to-day-management and planning

The command centre dashboards aid system-level decision-making by providing an executive-level lens on local service demand and available resources – including data on emergency attendances, bed capacity, and acuity of admitted patients.

  • Improved health equity analysis

Our Population Health platform enables better understanding of patient groups at risk of health inequalities. Each population health patient record is linked to an index of mass deprivation score, making it easier to identify the Core 20 population and support NHS 20+5 targets. 

  • Enhanced case-finding at scale

Our integrated Population Health software can case-find at scale – from ICB to practice level. Consultant lists can be stratified to rapidly identify individuals and specific groups who would benefit from early intervention and proactive care across disciplines.

Population health management case studies:

Combined Intelligence for Population Health Action (CIPHA) programme.

 The NHS CIPHA programme

CircusKeyshots JodyHartley

 

Graphnet partnered with the NHS to deliver the Combined Intelligence for Population Health Action (CIPHA) programme across the country. The system supported the national Events Research Programme in building a COVID-19 safety net that allowed public events to reopen by matching Covid test results with ticket purchases.

Based on the original CIPHA programme developed by Cheshire and Merseyside councils, the analytics used data feeds made available in the Graphnet population health platform to allow prompt, coordinated actions at both local and regional levels. Read more about our work on the CIPHA system.

 

Remote monitoring with Frimley Health and Care ICS

Frimley ICS’s Connected Care team has recently used population health management analytics to identify complex and frail patients who had the highest risk of experiencing unexpected illness and deterioration and prevent these patients going into crisis. 

The following service outcomes have been seen in the enrolled patients between Dec ’22 and Feb ’23 against the same period in the previous year:

  • 33% reduction in monthly admissions 
  • 55% reduction in monthly GP face-to-face consultations 
  • 32% reduction in monthly A&E activity

“When we started the evaluation and started seeing the results for the first cohort of patients compared to others, we were astounded by the results! The beauty of having a population health platform is that you can look across the system at the impact you are having.” – Anna Fishta, Programme Lead – Connected Care, Frimley ICS

 

Read more about our work with Frimley ICS

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Population health: data driven change

Population health is much more than an insights programme. It drives action, through the identification of problems, utilising solutions, and evaluating the impact of the interventions taken.

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

Read more 

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.

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

Read more