People in the UK are living with chronic illnesses but not getting appropriate treatment. Without intervention, patients face worsening health with irreversible damage. For some, the outcome will be worse than this. No one is to blame for these undiagnosed conditions. The NHS is not at fault. So what is the problem, and what can you do about it?
In a recent survey, sixty-one per cent of Britons said they would consider delaying a GP appointment because they could find out they have a severe illness. If people aren't talking to their doctor, there's no way to provide appropriate care.
Ignorance of the significance of symptoms is also a factor. Football pundit Mark Lawrenson was in an interview on breakfast TV earlier this week. A GP had seen him on the television and sent an email to suggest he should seek medical advice for a dark patch of skin on his face. It turned out to be cancerous. Mark was aware of the blemish but thought it was one of those things that happen to our bodies as we age.
At a time when the NHS is under pressure, and GPs have an unsustainable workload, how can you identify and help people with an undiagnosed illness?
Population health management is a way to improve healthcare outcomes through behavioural change. Collecting and analysing health data allows you to adopt a pro-active approach to healthcare.
You can apply population health management to any healthcare initiative. One example is case finding. You can spot patients that are likely to have a chronic illness, but there is no current diagnosis. Instead of waiting for patients to visit their family doctor, you can identify patients of interest, review their records and invite them to see their doctor when necessary. The GP can diagnose and put appropriate care plans in place.
How does population health management work?
Healthcare data is the core aspect of population health management. To analyse healthcare at a population level, you need information about every person's health. Primary care records from GP practices contain rich detail about our medical histories. In the era of interoperability, GP records can also include data from other care settings.
It's not necessary to replicate the patient records in their entirety. Vision's population health solution, Outcomes Manager, collects statistical data about healthcare information instead of the complete records. You're not taking any patient identifiable data, so the information governance overhead is low. Less data moves around too, so systems are simpler and more agile.
Aggregating the information provides you with a single data set that covers your whole population. That might be for a GP network, CCG or health board area, or an entire country. You can then analyse this data to track trends, identify potential problems and check the progress of healthcare services.
The final stage completes the circle, and it's the most important aspect of population health management. Influencing behavioural change is how you drive transformation with new or redesigned services.
Outcomes Manager gives GP practices matching reports. GPs can identify patients and review their medical records. You can then decide how to intervene.
Interoperability lets you embed standard data entry templates in any GP IT system. These evidence-based care reminders encourage standardised care across clinicians and GP practices. The templates enable the rapid implementation of local policies to every local doctor.
You can apply population health management to any healthcare challenge or initiative. Here are some of the more popular uses:
- Chronic disease case finding. The UK population is ageing, and as people get old, they are more likely to have comorbidities. Case finding is an effective way to identify patients that are very likely to have a condition but don’t have the diagnostic code on their record.
- Disease management. Identify patients meeting specific criteria and change their disease-specific care plans to improve outcomes.
- Prevention. Identify patients that are at high risk of developing a chronic disease. A real-world example is to identify patients at risk of certain cancers.
- Local service reporting. A straightforward application of population health management is to report on service provision. It takes the pain out of collecting and collating information from practices and can even calculate monetary values for payment.
Do you need population health management?
Each GP practice can report on patients’ healthcare using their clinical system. This approach is excellent for a single surgery, but when you need to consider every person living in a town, city or country, direct reporting from GP systems isn’t going to work.You'll need a different approach. Here are some warning signs that it’s time to embrace technology and find a more effective way to report across your population:
- You have manual processes to combine data. Exporting data from individual GP systems is time-consuming. It carries a high risk of error, and your sensitive information is vulnerable in transit.
- Data is old and out of date. If you combine data by hand from GP systems or use a third- party extraction service, data can be four, six or even eight weeks old before it is available for analysis.
- You don't have any flexibility. It's hard to change your reports, especially if this would mean altering data extraction requirements or extra rounds of manual data collection.
- It’s hard to focus. When you have too much information, it can be difficult to know where to start. Focusing on a particular healthcare issue is a challenge when the basis of your data strategy is complete medical histories for all patients.
- It's challenging to track local services. Locally commissioned services are increasingly prevalent. Reporting on services provided can be a painstaking process that delays payments.
Population health management offers an opportunity to take control of your patients' health instead of responding and reacting later. It enables you to:
- put care plans in place sooner
- avoid preventable diseases
- reduce needless deterioration
You can pick out patients at risk of developing a chronic illness or have an undiagnosed disease. These patients will include some of those who avoid visiting their doctor or are unaware of the significance of their symptoms.
Outcomes Manager is an innovative population health management solution. You can:
- collect data daily from all major GP IT systems
- understand your patients' health
- influence behavioural change
Download the case study to see how NHS Greenwich CCG identified more than 4,000 patients with long-term conditions.