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Integrated Care Systems To Improve Primary Care and Population Health


Author: Cerner

It is generally accepted that a common key goal of health systems around the world is to improve the health status of the population served. This article discusses one aspect of this laudable goal – specifically, the need to ensure meaningful access to higher quality primary health care which is seen as a fundamental prerequisite in providing safe and effective care to our growing and ageing population.1

Integrated care as a means to support primary care access and population health improvement

Truly integrated care systems that provide consistent care to patients and clients over time, are believed to be an essential component in the complex journey to improve the health status and outcomes of a given population. This can only be truly optimized in a system where skilled primary and secondary health care teams can have access to meaningful “joined-up data” and shared intelligence. In addition, the necessary resources and infrastructure are needed to make timely interventions that support health improvement. The ability to access this “joined up data” and shared intelligence are seen as essential tools and enablers to successful population health management.2 However, the sheer volume of data and information available as well as knowing what do to with it can create a challenge for large, complex health and care systems with multiple and sometimes competing priorities.

Case Study – Data-driven structured medication reviews in primary care networks, Merseyside, Wirral – UK

Healthy Wirral Partners (HWP) - a place-based health-system covering a population of around 335,000 people in the UK, have been working with Cerner to co-develop and implement digital tools to support Primary Care Networks in providing proactive, personalised structured medication reviews (SMRs) with local residents as part of a wider population health strategy. This articularly included supporting those in care homes, where residents are disproportionately affected by COVID-19 due to their underlying age, frailty risk and the care home environment which requires close, personal care and use of shared living spaces which can lead to greater virus transmission.

In this project, HWP, “joined up” data from across primary, acute, community and mental health care settings, leveraging Cerner’s HealtheIntent® population health platform, which was used to proactively identify and prioritise patients who would most benefit from a structured medication review to improve individual outcomes and prevent the need for higher resource care delivery resulting from poor medicines management.

Drugs recommended for therapeutic monitoring in primary care are particularly important to review in the care home population in order to support reduced risk of polypharmacy and anticholinergic burden.3 During the use of the tool in practice for a group of 30 local residents, the total number of active prescriptions for drugs recommended for therapeutic monitoring in primary care were assessed one day prior to, and 35 days after the delivery of the HealtheIntent®-enabled SMRs – where a reduction in active prescriptions was demonstrated.

A further service evaluation conducted by Imperial College London demonstrated a mean reduction of 3.28 prescribed items per person 8-weeks post intervention, compared to 8-weeks pre-intervention. On the assumption of an average prescription item cost of £9.35 per item and recommended course length of 28 days, this could indicate the SMR intervention supporting a reduction in prescribed items of £398.68 per person per year if reduced prescribing was sustained.4,5

There was also evidence that SMR’s conducted with HealtheIntent® resulted in an improved identification of patients from areas of higher deprivation, with a higher anticholinergic burden score and being prescribed more higher-risk drugs to improve targeting of SMRs to more impactable individuals.

Using ‘joined-up’ data in this way, to support proactive and preventative health interventions, will also support emerging and future approaches to care allowing health and care stakeholders, together with the individuals and communities they serve, to make the best use of their collective resources and assets to improve health outcomes.


First published by:

1. Kindig, D., & Stoddart, G. (2003). What is population health? American Journal of Public Health, 93(3), 380–383.
2. NHS England. 2020. (Accessed online 30th June 2020)3. NHS Specialist Pharmacy Service. Suggestions for Drug Monitoring in Adults in Primary Care.
September 2020. Access online at on 29th June 2021.
4. NHS England. 2020. (Accessed online 28th September 2021)
5. Pharmaceutical Services Negotiating Committee. 2007. Medicines wastage and 28-day prescribing guidance. Pharmaceutical Services Negotiating Committee. London.