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Registries and scorecards

Stratify and manage populations

Establish care programmes for cohorts of your population, proactively identify gaps in care and drive remediation to improve patient outcomes as well as care provider performance with Cerner’s registries and scorecards solution. They enable organisations and integrated care systems to identify, attribute, measure and monitor people and providers at an individual or population level.

The sum of a population’s parts

Treating individual patients may lead to the bigger picture being missed, but not with HealtheRegistries®. As well as providing information about individuals’ health and care records, care professionals can get a bird’s eye view of the population to see where care could be better optimised across the system and if any trends are appearing, whether they’re positive or negative.

A single source of truth

No longer will you have to deal with missing information or data out of context, spend your time mapping data across different sources, or rely on an outdated, rear-view analytics picture. Instead, care professionals can utilise aggregated and normalised evidence that has been collated into a single longitudinal record in near real-time for each person. When filtered through the appropriate algorithms, your health organisation will be able to identify, attribute, measure and monitor both people and care providers.

Evidence for future improvements

Tracking quality measures enables sustainability and transformation partnerships to drive for excellence and remove unwarranted variation in their workflows to meet their specific local population health challenges. Some of these measures along with others like care professional education or patient-reported outcomes can be tracked in scorecards aligned to financial incentives or outcomes-based contracts. Tracking quality and financial control in near real-time with an ability to respond and analyse trends enables you to establish learning systems for agile improvement.


How does Cerner’s approach differ from national registries we have seen in England for some time?

National registers tend to consolidate a minimal dataset including outcomes across a whole nation and guide overall progress in important clinical and epidemiological areas.

For population health management in local health economies, there is a need to set local outcomes to move the needle on local needs and inequalities, and to drive out variation in practice, and to underpin the delivery of new care models. For the move to integrated care, there is the additional need to formally track outcomes against value-based contracts. To achieve this, Cerner and our clients’ strategy is to not just to know populations better with analytics, but to engage individuals and to take action to manage to agreed outcomes.

Consequently, Cerner has built its HealtheRegistries solution with care professionals to be relevant in their workflow and enable them, as an integrated care professional team, to address the gaps in care wherever the citizen is seen and cared for. For this to work well, the data must be near real-time, must be a single source of truth and monitoring must be proactive and available in care professionals working environment.

There is a good opportunity to use the same data that is captured locally in EHR systems and population health management platforms for national registry purposes.

The technology supports and underpins new care models and ways of working in accountable and integrated health and care systems, so they can work off the same source of information to track and drive progress to outcomes. But some of the key aspects to work through for successful population health management and how tools like HealtheRegistries can help improve care are around the broader transformation that is required.

Mature, clinically integrated networks that have taken on integrated care responsibilities have put in place robust governance structures and, in some instances, dedicated governance to define best practice and outcomes to be achieved against their actual population’s needs and challenges, rather than centrally mandated minimum quality standards.

Leadership is key, as well as citizen engagement and the training required for staff and focus on workforce redesign. How are care professionals going to use the information in their working practice? How is practice going to change to drive to these outcomes? What are the broader determinants of health impacting the same outcome and how are they being addressed?

Establishing joint incentive models has been shown to accelerate outcomes and lack of aligned incentives can hold back progress as health and care systems are still held to account for a past way of working.

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