Shared care record programmes are starting to focus on population health management. The first session of the Orion Health UK and Ireland Customer Conference 2022 discussed how the UK’s shared care record programmes can do this: while continuing to extend their data feeds and access to new sites and users.

Bruce Horne, product specialist lead at Orion Health, started with some definitions. Population health management is a contested space, but he suggested both NHS England and Orion Health see population health management having three pillars: infrastructure, intelligence and interventions; or building shared care records, using data to identify cohorts of patients; and then delivering more coordinated care for them. Whatever the complexities: “What we are trying to do is get the right care to the right patient, at the right time.”

Using forms and collaborative worklists

While that is straightforward in principle, the road to getting there “is full of mud and potholes” because, as things stand, a lot of population health management is done by manually searching records, transcribing information from one system to another, or using lists that may not be complete or up to date. But… the Orion Health road “is going to be straight, and clear and we are all going to know where we are going.”

For example, Bruce said, the first step in any population health management intervention is for clinicians to know which patients they should be working with. Using Orion Health Discover, clinicians can search the Orion Health database, and create a collaborative worklist. Shared care record users can use this to enrol patients onto a care pathway, complete a form or carry out other tasks. As an example, Bruce talked about some work that Orion Health did with Connecting Care in Bristol towards the end of the third wave of the Covid-19 pandemic.

Connecting Care had some funding to create a solution for the Community Integrated Care Bureau, which manages the discharge of patients into a community care bed. Patients can be directed onto one of three pathways, which are managed by different hubs. Each of these hubs were “doing the best they could, but were using different methods to manage these patients.” Some were using paper, some were using GP systems. Nobody had visibility over the entire journey.

Orion Health was given seven weeks to come up with a tracking form that would give Sirona Care, the community interest company that oversees the bureau, full oversight of where patients were in the process. Working closely with Connecting Care, adopting an agile approach that saw prototypes delivered in one day for feedback and iteration overnight, and engaging closely with clinicians, Orion Health created a single form for patients who were ready for discharge.

The form could be shared across 24 collaborative worklists, each of which gave up to date information to the right people at the right time. The solution is still in use, and delivering efficiency and quality benefits to the system (Sirona Health put statistics and outcomes in its quality report for 2020-21).

Why use the shared care record?

Of course, integrated care systems and other areas have many ways to address these kinds of population health management. However, Bruce argued there are good reasons for using the shared care record. For a start, NHS England has told all integrated care systems to deploy a shared care record, and has a maturity model for the shared care records in place – so this is in line with national policy.

Also, population health management interventions require shared working, so the shared care record is a great platform. And using the shared care record adds richness to the database that underpins them (Bruce outlined these arguments in more detail in a recent blog). Also, Orion Health has interventions of this kind on its roadmap. It is developing a Covid virtual ward and a care plan. It is working on how to use forms to support remote monitoring.

Using the data

Kevin Ross, research director at Orion Health, took the session back up a level, to talk about the data that Orion Health captures and the analytics that can be applied to it. “It has always been our mission to capture data and to make sure it can be put to the right use at the right time.” He said Orion Heath has 250 data scientists working on research and services to help customers understand their data and how it can be used to improve health and care.

But it also has some data products that customers are starting to use. The first is de-identification; or making sure that population level datasets can be used safely, but without breaching individual patient confidentiality. The second is an evolution of the algorithm hub, which can be used by organisations to write good decision support tools, take them through a review process, store, update and manage them properly, and make them available for use by clinicians.

Kevin explained that the hub was updated during Covid-19, when Orion Health developed a tool to identify Covid positive patients who were at risk of being hospitalised by the disease. One of the interesting issues that this raised was governance: in the early days of the pandemic, New Zealand had very few Covid-19 cases, so “there was a need to agree who could decide whether this would be a good approach to take.” The governance approach taken is now available in the hub, to support other organisations that want to develop similar interventions. “It’s a good example of how work that we do in one healthcare system can have a global impact.”