Phil Kirby, Health Intelligence Ltd

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Phil Kirby, Health Intelligence Ltd
Population Based Needs Analysis Population
Based Interventions

• October 2008
• iSOFT User Group

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Agenda

• Health Intelligence
• Export on of Primary Care Data
• Secure Hosting of the Practice Data
• Overall Approach
• Population-based Risk Stratification
• Population-based Interventions
• Summary of Benefits
• Questions

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Health Intelligence Profile

• Established in 1997 Privately owned British
  company, Cheshire, focusing on Healthcare
• Web-Based Cross Sector Managed Services, focused
  on Long Term Conditions, Reporting and supporting
  Managed Programmes of Care
• Flagship service CDRIntell serving eight PCTs
  with populations of over 1.2m. Existing services
  cover approximately 350 GP Practices. Over 1,000
  registered users of the web-based service across
  15 PCTs
• Walsall Teaching PCT
• Swindon PCT and Wiltshire PCT
• Kensington Chelsea PCT and Westminster PCT
• Calderdale PCT and Kirklees PCT
• Blackburn with Darwen PCT
• Four PCTs in Avon

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Challenges

• Overall the NHS faces
• Ageing Population, Rising Costs, Rising
  Expectations
• Reducing Resources, Demand led service
• Our Challenges
• Need for prevention and to priorities
• Some Practice reluctant to provide patient
  identifiable data
• Data Issues, Multiple Data Coding
  Classifications Multiple Sources of Data
• Variable Quality of Data
• Real concerns regarding Security of patient data
  patient consent
• Lack of Time
• Complexity of the business of Healthcare

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Overall Approach

• Partnership with General Practice
• Automated, secure Data Exports
• Patient identifiable data is hosted under formal
  agreement
• Patient data only accessible to Practice, unless
• Explicit agree to share ( consent arrangement)
• Patient provides their informed consent
• Data Transforms to generate Information
• Intuitive, simple to use standard Dashboard
  Reports
• Clinically and Managerially relevant
• Clinical Prompts missing and out of range data
• Risk Assessment Tools

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Export of Primary Care Data
Automated and secure

PCT/ PBC
Data Repository CDRIntell Reporting
Aggregate Only
Data extract using MIQUEST XML SQL process
GP Practice
NHSnet/ N3
GP Practice
Patient Identifiable Data
Data encrypted in transfer
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Population-based Needs Analysis

• Reporting against those who have not had the
  work-up expected
• Population based Risk Stratification e.g.
  Combined Predicative Model
• A range of approaches to identifying need
  stratifying
• LTC Registers
• CVD Primary Risk Assessment
• Combined Predictive Model
• Those on Established Registers Stable/No Stable
  given criteria
• Cost based
• Missing Data based, etc
• Reporting on what is not there as well as what
  has been done

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Types of Registers

• Cross Sector Registers of those with
• Established Disease
• Likely to have the LTC
• At Risk of the LTC
• Clear Clinical Objectives via the NSFs
• Supported by Dashboard Reports and Programme
  Management these Registers provide an excellent
  solution
• Types of Registers value

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Population-based Needs AnalysisLong Term
Conditions Registers

• Primary Care Based typically established as part
  of Clinical System within General Practice
• Secondary Care Based typically established as
  part of outpatient clinical system
• Population Based Inter-organisational by
  definition, looking to ascertain cases from all
  possible sources.

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Types of Registers Coverage

Patients
Hospital patient attendances and episodes
With problems recorded and DIAGNOSES on
GP System
Patients hospital attendances and episodes known
to the GP
Equivocal but no diagnosis is in GP system
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LTC - Chronic Degenerative Disease
Characteristics

• Life Long
• Adversely affects health and well being
• Often secondary complications
• Need for multiple health care professionals to
  support the patient
• Patients can live with their disease for many
  years and can become experts
• Need for patient empowerment
• Often patients can have more than one chronic
  disease

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Population-based Needs Analysis LTCs Registers
Purpose of

• Historic
• Research
• Understand need
• Identify exposed groups
• Target inequalities
• Measure provider contribution
• Understand weaknesses
• Target support
• Measure our contribution

CDRIntell also provides Cross-sector clinical
governance Improved Detection Rates (those at
risk identified and Lost patient
re-discovery) Capacity planning Quality
monitoring Costing for new interventions Re-admiss
ion reduction Patient empowerment Monitoring cost
reduction Basis for Population-based Intervention
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Dashboard Reporting - Approach

• Dashboard style reporting with date, time period,
  provider
• Drill down drill up, graphical, tabular and
  listing
• Profile population base, those in and out of
  category
• Benchmark data
• Built in Consent Register and Patient Consent
  Recording Functionality
• Patient Health Profiles
• Programme Management applications

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Population Based Interventions

• Specially designed Programme Management software
• Establish cohort of patient for whom
  interventions are targeted. Inclusions Criteria
• Rely on General Practice to validate and refer to
  these interventions
• Maintain status of patients
• Support evaluation of the interventions
• Management of those waiting for the interventions

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Practice view of their Patients by Risk Tier
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PNL process to confirm Your Patients Level
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Selecting Interventions
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Population Based Interventions
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Population Based Interventions
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Population Based Interventions

• Multiple valid solutions to identify those in
  need
• Opportunistic complemented by Systematic
• Keep General Practice in control of who and when
• Specially designed Programme Management software
• Multiple interventions for these people
• Programme Management applications need to keep
  approach patient centric
• Ensure all healthcare professionals understand
  status of their patients and the packages of care
  being delivered supports reinforcement.
• Evaluate and refine.

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Any Questions?
For copies of this presentation or to organise a
demonstration please come along to Stand D4.
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Demonstration
For copies of this presentation or to organise a
demonstration please come along to Stand D4.
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The End Thank you
For copies of this presentation or to organise a
demonstration please come along to Stand D4.
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The Approach Taken in Walsall

• Initial Drivers were LDP, improved efficiency of
  data collection for national returns
• Formed CDRIntell Project Board with GP membership
  
• Broader Consultation
• Pilot arrangements
• Set of Agreements to ensure rigour
• Data Supply Agreement
• Data Sharing Agreement
• Data Access Agreement
• Sophisticated Reporting not only LDP returns to
  PCT, clinically useful for General Practice

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General Practice Access
What is required for General Practice to access
their patient data on CDRIntell?
- A signed Data Supply Agreement needs to be
completed by a senior representative of the
Practice.
Step 1 Agreement to Extract and Host the Data
on CDRIntell
- This process involves automated data extraction
process that delivers daily updates to CDRIntell.
Step 2 Set-up the Automated Data Extraction
Facilities
- A signed Data Access Agreement. This agreement
applies to each and every Organisation, including
the Practice.
Step 3 Obtain Agreements required to Access
CDRIntell
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PCT, PBC Clusters, other Health Care
Professionals Access
What is required for other healthcare
professionals to access patient data on CDRIntell?
- Overall agreement of the CDRIntell Project
Board followed by Practice specific agreement.
This is in the form of a Data Access Sharing
Agreement.
Step 4 Completed Data Sharing Agreement
- A signed Data Access Agreement, which ensures
each and every NHS Organisation, has committed to
using CDRIntell sourced data appropriately.
Step 5 Obtain Agreement for other NHS
Organisations to access CDRIntell
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Business Benefits

• Efficiency in data and information provision
• Improved Security and Management of Consent
• Benchmarking and Performance support
• Transforming Data into Information
• Clinical Governance Reviews
• Time
• Data Consistency
• Pilot GPs encouraging their colleagues
• Identifying hundreds of patients they are keen to
  intervene
• Systematic process Risk Assessment
• Identify those to Target e.g. Diabetes NOS,
  Missing data

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Walsall Developments

• Vital Signs LDP Reporting
• Diabetes NSF Reporting
• CHD NSF Reporting
• Childhood Immunisation and Vaccination
• Data Quality Reporting
• Medicines Management
• Population based Risk Stratification
• Programme Management CVD Prevention Smoking
  Cessation Lifestyle interventions etc

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Consultations per capita in Primary Care
Normalised consultation rates per capita
9.0
8.0
7.0
6.0
5.0
Consultations
4.0
female
3.0
male
2.0
1.0
0.0
lt1
1-2
3-4
5-6
7-14
15-19
20-24
25-34
35-64
65
Age
Note the rapid rise in workload from 34 years of
age