Improving population health management through data and individualised care

A guest blog by Ben Wilson, Product Solution Director at Orion Health.

The NHS defines population health as ‘an approach aimed at improving the physical and mental health outcomes and wellbeing of people, whilst reducing health inequalities within and across a defined population.’ While we may think that the management of population health takes a ‘one for all’ approach, the system is moving towards putting individuals in control of their own care and making sure that systems support this approach.

Digging deeper to look at what exactly population health management means, the NHS defines this as ‘data-driven planning and delivery of proactive care to achieve maximum impact. It includes segmentation, stratification and impactabilty modelling to identify local ‘at risk’ cohorts – and, in turn, designing and targeting interventions to prevent ill-health and to improve care and support for people with ongoing health conditions and reducing unwarranted variations in outcomes.’

It’s a compelling proposition, but what does the current state of the UK healthcare system look like? Well, it’s fair to say that we’re witnessing the development and launch of digital transformation strategies across the country. These appreciate the need to diminish the backlog of demand for services, the requirement to make healthcare access more equitable, and the extent to which digital will make healthcare more sustainable. Happily, there is also more focus on data and patient engagement and the need to improve conditions for clinical staff.

This is perhaps where change is required most urgently – in improving the healthcare experience for all. For patients, the healthcare system is often difficult to navigate and waiting lists continue to grow. Citizens have very limited digital relationships with providers, with information either siloed or not readily available, and they are too reliant on Dr Google.

At the same time, the experience for clinicians and caregivers can be just as troublesome, with demand for services well outweighing availability. Most are becoming exceedingly overworked and are still facing a battle with siloed or unavailable patient information, meaning too much time is spent chasing this instead of delivering the care that they are so passionate about. Great progress has been made in recent years with shared care records in the health space, but social care, pharmacy, optometry, dentistry and other important settings are typically still on the outside although more recently there has been more recognition of the need for inclusion of these areas. So how can we deliver population health management better?

Patient data is fundamental to successful population health management. By aggregating relevant data from across care settings into a central data platform, this information can then be presented in a shared care record  to ensure that health and care professionals have the access to the information that they need to deliver the best possible care. In addition, this data can provide the necessary foundation for population health management, the platform upon which there is the potential to develop and roll out crucial tools for care coordination, healthcare navigation, patient engagement, analytics and precision medicine.

Surfacing patient data through the shared care record allows you to approach that ultimate NHS goal for population health management. Once the data is centralised you can apply analytics, identify cohorts and introduce more proactive interventions to prevent and treat illness, whether this be at the individual, neighbourhood, place or system level. The aim being to reduce the risk of hospitalisation and address inequalities, while supporting a person’s empowerment.

Here at Orion Health, we are enthusiastic supporters of the PRSB information standards that aim to improve the collection and quality of this crucial patient data. The About Me standard for example, enables people to share information that matters to them with clinicians and care professionals across different IT systems and health and care settings. The #CareAboutMe campaign works to spread awareness about the importance of this standard for better outcomes, and encourages system suppliers to implement it as an essential part of health and care records. The Core Information Standard defines a set of information that can potentially be shared between IT systems across the health and care economy for the benefit of patients. We were the first supplier to achieve accreditation against this, something we’re really proud of.

The focus on population health management is crucial to ensure a sustainable healthcare system for the future. To be successful on this journey we need to work together – with our industry peers, with our NHS partners and with professional bodies like the PRSB to ensure that the foundational layer, an individual’s data, is recorded, aggregated and shared in the appropriate way to facilitate the planning and delivery of the best patient care, today and as we move forward.

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