Population Health Management South East London ICB

This specification outlines the requirements for a Population Health Management (PHM) tool to be used within Lambeth Health and Care Partnership. The tool will extract data from primary care systems, aggregate and present this data on dashboards for various healthcare areas , and provide functionalities to enable GPs to re-identify patients for actionable interventions. Objectives The PHM tool aims to: • Aggregate data from primary care systems. • Present data on user-friendly dashboards for healthcare areas such as flu vaccination, NHS health checks, blood pressure, and diabetes. • Allow GPs to re-identify patients for intervention purposes. • Display near real-time data. • Explain business rules and criteria clearly on the dashboards. • Offer ongoing training and support. • Provide functionality to link additional datasets in the future. • Support different levels of user access based on permissions. • Show baseline metrics, trends over time, and outcomes. • Enable segmentation to identify patient cohorts for targeted interventions. Functional Requirements Data Extraction and Integration • Primary Care Data: Extract data from primary care systems accurately and efficiently. • Future Dataset Integration: Capability to integrate additional datasets such as acute hospital data, mental health data, and adult social care data. • Data Refresh Rate: Ensure data is updated close to real-time to reflect the latest available information. Data Presentation • Dashboards: Provide aggregated data in user-friendly dashboards covering key healthcare areas (flu vaccination, NHS health checks, blood pressure, diabetes). • Business Rules: Clearly display and explain business rules and criteria used in the dashboards. • Baseline Metrics: Show baseline position on key metrics. • Trends and Outcomes: Display trends over time and outcome measures. Patient Re-identification • Re-identification: Enable GPs to re-identify patients from aggregated data to take actionable steps for patient care. • Privacy Compliance: Ensure patient re-identification processes comply with all relevant privacy and data protection regulations. User Access and Permissions • Access Levels: Provide different levels of access based on user roles and permissions to ensure data security and appropriate use. • User Management: Facilitate easy management of user access rights. Segmentation and Targeting • Cohort Identification: Allow segmentation of the patient population to identify cohorts for targeted interventions (e.g., persistent healthcare service users, patients at risk of health deterioration). • Intervention Planning: Support the planning and execution of targeted healthcare interventions. Non-Functional Requirements Usability • User-Friendly Interface: The tool should have an intuitive, user-friendly interface to ensure ease of use by healthcare professionals. • Training: Ongoing training and support should be provided to ensure users are proficient in using the tool. Performance • Reliability: The tool should be highly reliable, with minimal downtime. • Scalability: The tool should be scalable to handle increasing amounts of data and users. Support and Maintenance • Ongoing Support: Provide ongoing technical support and regular updates to ensure the tool remains functional and up-to-date. • Call Down Days: Offer call down days for changes and additional support as needed. Transition from Current Provider Transition Plan • Transition Strategy: Develop a comprehensive transition plan from the current provider to ensure continuity of service and data integrity. • Timeline: Establish a clear timeline for the transition process, including key milestones and deadlines. Data Migration • Data Extraction: Safely extract data from the current provider's systems. • Data Mapping and Transformation: Map and transform the extracted data to ensure compatibility with the new PHM tool. • Data Validation: Validate the migrated data to ensure accuracy and completeness. User Transition • Training: Provide training sessions for users to familiarise them with the new tool and its functionalities. • Support: Offer additional support during the transition period to address any user queries or issues. System Testing • Integration Testing: Conduct thorough testing to ensure the new tool integrates seamlessly with existing systems. • User Acceptance Testing (UAT): Perform UAT to confirm the tool meets all requirements and is ready for deployment. Go-Live Support • Go-Live Assistance: Provide on-site or remote support during the go-live phase to ensure a smooth transition. • Post-Go-Live Monitoring: Monitor the system closely post-go-live to promptly address any issues. Future Enhancements • Dataset Expansion: Future capability to link additional datasets (e.g., acute hospital data, mental health data, adult social care data). • Functionality Improvements: Continuous improvements and addition of new functionalities based on user feedback and evolving healthcare needs.