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Population Health

The Covid pandemic has accelerated the need for data rich population health intelligence systems that provide actionable insights for the resilience, reset and recovery of health and care economies.

Our population health platform uses the rich data held in our shared care record to produce in-depth insight at the population, cohort or individual level. The insight drives actions such as enrolling identified individuals onto a remote monitoring programme, where clinicians can drill down into the underlying shared care record and patients self-record onto their integrated personal health record.

In addition, analytical tools measure the impact of interventions and the results are fed back into the shared record, closing the loop and creating a 360 degree solution.

Using our population health tools, ICS leaders, public health and care professionals can:

  • Track key aspects of health and care operational delivery and forecast the impact of changing population needs on operational demands

  • Use these insights to take action at population, community and person level

  • Identify groups of vulnerable people who would benefit most from proactive care and target limited resources to where they are needed most

  • Improve existing care pathways and establish new ones with a focus on offering more community-based care and enhancing patient outcomes

  • Study the impact of interventions and use this insight to drive best practice

Using shared care and personal health record data intelligently, integrated care systems will be able to operate in a more agile way, adapting and scaling up new services as demands change.

Key features:

  • Our suite of population health management tools for Covid-19 provides organisations the ability to make decisions using interactive dashboards displaying the Covid-19 status across a health economy

  • CareCentric Business Intelligence: The highly configurable platform enables access to the CareCentric integrated care record data with hourly or daily data refreshes. Up to date data can be used as decision support.

  • Visualisations: Embedded within CareCentric and myCareCentric to be used as part of standard workflows. New visualisations or algorithm output can easily be made available to entire care communities or patients groups via configuration.

  • Collaboration is at the heart: Our approach to engagement with both the customers and academics is to enable collaboration between all three parties. Our ethos is to ensure clear communication, dissemination of knowledge and continuous assistance. This improves better understanding of the analysis and models generated, give academics access to a vast knowledge base and clear routes to implementation. 

  • Putting research into practice: Through our research platform and data mart we can reduce the time between new research and actionable insight. We work closely with leading universities to enable collaborative research. 

  • Integrated security: Ensuring secure, controlled access to the analysis and data that roles need is seamless.

  • Risk stratification: Use advanced machine learning, statistical and mathematical models to actively forecast and monitor patients.

  • Interoperable: The output from analytic models can be exposed via Microsoft Power BI driven visualisations or REST APIs to be consumed by applications.


Benefits include:

  • Detect, alert and optimise: The integration of our business intelligence and data science platforms with CareCentric enables effective communication of key factors, including service utilisation, performance, health outcomes and care deficits.  The detection of these factors supports the shared care record area in highlighting areas for service optimisation, improving services, and reducing health inequalities.

  • Whole system virtualisation: The use of historical data to understand the cause and effect of interventions allows us to enable large scale ‘what-if’ analysis to model potential outcome of new interventions.

  • Stabilising care:  The use of geo-spatial and characteristics analysis enables the early identification of individuals or groups of individuals who are at risk of care instabilities or the rise of care inequalities.

  • Enables impactibility modelling: Application of data mining techniques to understand current health and social care delivery models and monitor the impact of service change through 'what if' scenarios and prediction analysis.

Population Health offers improved monitoring and reporting of Covid-19

We have been working with Frimley ICS and Berkshire West ICP in order to develop enhanced Covid-19 features in our Population Health solution, as part of their implementation of the CareCentric shared care record.

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.

Further, a new Covid dashboard and data tables have been created which display the clinical codes GPs, Out of Hours providers, NHS 111 and acute hospitals are attributing to patients (using new GP codes from EMIS, Vision and TPP, plus acute ICD10 codes). This is an important operational tool, but also helps plan and highlight potential pressure points.

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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