In order to address their future sustainability, care systems – that are currently focused on improving the patient experience of care – need to also focus on the experience of their staff, improving the health of populations, and being good stewards of the per capita cost of care – this is the Quadruple Aim for Health and Care. The UK, with its publicly funded care systems, has a significant opportunity to lead the world in establishing place-based care – that is, partners collaborating together to improve the health and wellbeing of populations, rather than operating in silos.
Population health management is about taking responsibility for the overall wellbeing of a defined population and being accountable for their health and care outcomes. The goal of population health services is to improve the quality of care and outcomes whilst managing costs for a defined group of people. Population health solutions should be viewed as part of a wider health and wellbeing strategy that includes wider determinants of health, such as housing, the environment, faith, fitness, education, and employment.
Against the NHS Long Term Plan, NHS England is encouraging the development of new care models and learning from others on the same journey, similar to the move to value-based care in the USA. Guided by systems, sustainability and transformation partnerships, across the country are forming into integrated care systems to establish new ways of working and take on new place-based population health management responsibilities with population sizes of one-to-two million citizens. Places are formed of multiple neighbourhoods, with primary care networks formed of 30,000 to 50,000 people. This compares to existing models that aren’t centred on the citizen, are reactionary, and allow patients to fall through gaps in care – the reasons for change are necessary and obvious to deliver proactive care.
Population health analytics have a fundamental role to play. Knowing the trends and outcomes of your population allows for a targeted approach to be developed to deliver care. Cerner is leading the world in its vision and execution through our investments in developing HealtheIntent®, our population health platform. Layered over any existing information systems, it standardises and normalises data into a single source of truth record for a patient , and provides the new tools that are required to manage the health and wellbeing of the population. Care gaps, surveillance alerts, and actions to drive data and evidence-based programmes of care are provided directly back into the original source information systems.
Pull together data from GPs, hospitals, mental health services, wearable devices and other sources to create a longitudinal record.
Population health solutions allow clinicians and health professionals to make informed decisions based on all the available information.
Healthcare analytics give caregivers the opportunity to spot any emerging patterns and behaviours among their populations.
By being able to spot emerging trends within the population, it is possible to predict and mitigate the threat to others.
Multiple chronic conditions will be treated in different venues of care, requiring population health solutions to link together all the information.
Authorities will have access to usage and trends, allowing for a data-driven allocation of funds for population health services.
"Being able to become ‘customer-centric’, for me, that will be the game changer, but having richer clinical data too. Suddenly we’re finding out more, and understanding the patient journey better to inform how, when and where our patients’ access and receive care."
— Gary Mayo, system intelligence analyst, Lewisham CCG
GPs from 13 practices in Lewisham, southeast London, have been utilising HealtheIntent to aggregate, transform and reconcile individuals’ data from across the continuum of care to help diagnose people with diabetes earlier, with the aim of cutting complications and costs.
“Cerner are our strategic partner, helping us to gather and use our data to improve decision making, and think about how we intervene earlier in people's journeys.”
— Martin Wilkinson, managing director, Lewisham CCG
“… When we looked at how we might change models of care… the adoption of HealtheIntent as an extension out into the community allowing collaboration between all the different services was a very attractive proposition.”
— Paul Charnley, director of IT and information, Wirral University Teaching Hospital NHS Trust
Whilst HealtheIntent is new to the UK market, Cerner is already well known in the country for supporting health and care integration and has for many years provided Health Information Exchange to enable interoperability of EHRs and ensure the right information is available to the right care professionals.
A key requirement for GDEs to achieve global exemplar status is that they demonstrate how they have improved the operation of the whole care system and not just the hospital in isolation – they are required to be population health ready. Cerner is working with six of the GDE Trusts to establish HealtheIntent to support their own operations, population health management with their health and care partner organisations, and for one Trust, their expansion as a hospital chain.
Our value-driven, community-wide approach to delivering population health services supports clinical, financial and operational needs for NHS providers, health organisations, local authorities and social care, communities, employers, and other venues of health.
The UK is on a journey towards establishing integrated care arrangements to take on accountability for populations, with various organisational forms and partnership approaches, such as STPs and LHCREs. Cerner is working with the GDEs in England tasked with population health readiness, emergent integrated care systems, and health and care provider networks to establish population health management approaches. We are also engaging with smaller clinical hubs to integrate primary care and GP provider federations or integrated practice units.
Cerner’s population health services clients in the USA are performing well against cost and quality in accountable care organisations. Memorial Hermann is the top MSSP in terms of total saved at $89m, while Advocate Physician Partners is number one in terms of size, with savings of $77m. On the clinical side, Advocate has seen a reduction in oncology testing, a 39% decrease in serious safety events and 45% fall in the need for high-risk medication. Read more in Advocate’s value report.
In general, clients are quickly identifying unmet needs through surfacing more complete joined up records, and improving standardisation on population quality metrics through proactively driving out gaps in care. Clients make good sustained progress on their approaches, including how care model redesign, citizen engagement and iterative focus on the things that matter are impacting on reducing inappropriate utilisation of services and optimising appropriate use of services, with overall financial savings.
The foundation for all of Cerner’s population health management solutions is HealtheIntent.
HealtheIntent is a multi-purpose, programmable platform designed to scale at a population level while facilitating health and care at a person and provider level. Population health management applications built on the platform can be securely accessed anywhere, anytime. The platform:
No, organisations do not have to be using Cerner’s EHR to benefit from our suite of population health management solutions and services – our platform normalises and aggregates data from any known source. We realise that organisations need a system-agnostic platform that establishes a longitudinal record across multiple disparate systems, while leveraging your existing infrastructure, and the ability to get new insights at population level back into the workflow of care professionals in the EHRs they use every day.
Yes, HealtheIntent enables the development of applications and extensions that work seamlessly with other solutions and outside vendors. The platform promotes the extension and integration of HealtheIntent solution capabilities into existing, day-to-day applications, regardless of the transactional system being used. Discover more in our Open and interoperable section.
Read how we are forming partnerships with academic institutions and supporting clinical research.
Aggregate and normalise data across the health and care economy to improve performance and outcomes.
We help you to proactively support and manage the health of your citizens.
Find out more about how citizen engagement through our Patient Portal can make you an active member of your care team.
Witness the benefits of securely sharing patient data across organisational boundaries.
Take a high-level view of your populations to help you proactively focus on particular areas.