Local Health and Care Record Exemplar (LHCRE) - Population Health Management

1. Local Health and Care Record Exemplar (LHCRE) - Population Health Management YHCR Showcase – 3July 2019 Monica Jones Associate Director of Information Services – TRFT Population Health Management Lead – YHCR

2. Yorkshire and Humber Care Record … The Challenge

3. Deliverables Cancer Pathway and Urgent Care Focus Yorkshire & Humber Care Record Year 1 Rapidly Improving Care; extend the established practice and integrated capabilities in Leeds and Rotherham. Yorkshire and Humber Person Held Record; empower citizens to be active participants in their own health and wellbeing through the region-wide adoption. Yorkshire & Humber Care Record Year 2 System of Systems; fulfil the potential of exemplar solutions and practice deployed within Y&H over 10+ years, through building one federated integration infrastructure Yorkshire and Humber Data Ark; extend linked datasets to the entire Y&H population, supporting the triple aim of improving health, care and cost-efficiency, and targeting health inequalities. NHSApp integration with System of Systems Open standards and Open Platforms based upon principles

4. What is Population Health Management? • Recognises that health and wellbeing is more than just being ‘without disease’. • It moves away from managing disease in silos to an approach based on defined populations of people, who may have multiple ‘disease conditions’. • PHM hinges heavily on the use of new technologies and richer information.

5. Existing capability exemplars across YH Region Identifying change drivers Prevention Early intervention Stratifying risk Measuring health outcomes Identifying health inequalities Working with NHS research institutions and partners

6. What will the YH Data Ark will give organisations ? • To enable higher quality reporting and faster, more accurate decision making, Y&H is developing and integrating a new, region-wide information and analytics service to leverage data emerging from people, services and the internet of things. • There will be a secure Data Ark with all the appropriate Information Governance (IG) in place available for YH analysts and population health specialists to use. • We will help organisations to combine that data and determine the value it can provide to enable better data driven decision making on primarily public sector spend (commissioning), optimising pathways/processes, risk stratification, population segmentation and more granular targeted interventions. • We will provide the training (collaborating with existing networks such as the Information Skills Development (ISD) in the region), knowledge transfer and consulting expertise necessary to enable employees and teams to access data. • This will drive a culture of targeting interventions based on maximum value in terms of improved outcomes for people and place. • Using a cloud based platform it is research ready to support Digital Innovation Hubs (DIH) in a scalable, secure and affordable way.

7. Population Health Management Architecture • Multiple instances of a common analytics platform. Including locality-based, and an overarching regional environment • Integration layer for data onboarding • De-id at point of entry to analytics platform Multiple options for data sourcing: Bulk extract from SoS Subscription updates from SoS “Traditional” data load FHIR Store FHIR Bus

9. Questions ? NOW OR later Monica Jones - monica.jones@nhs.net