Greenwich CCG identify extra 4,000 patients with long term conditions

Greenwich Clinical Commissioning Group (CCG) has used data analysis technology to identify 4,000 patients with long term conditions who had previously gone undiagnosed.

The population health management tool is used to help diagnose patients earlier, preventing further issues and improving life expectancy across the borough. 

Vision’s software interfaces with Greenwich CCG’s EMIS system to identify specific cohorts of patients, diagnosed or undiagnosed. 

In 2015, Greenwich CCG entered into a partnership with Vision, a healthcare technology brand, to build a real-time solution to identify patients suffering from diabetes, COPD, hypertension or heart failure.

According to Vision’s chief medical officer Dr Jon Behr, the CCG was aware, that compared to the national average, recorded prevalence rates for the four key long term conditions were low across the area.

“Meaning that there was a sizable group of local residents that were potentially undiagnosed and untreated”, Behr said.

Prior to using Vision’s tool, Behr said that data extraction and analysis was inefficient and time consuming, with CCG members visiting each practice to manually download and collect the entire data set.

Implemented across Greenwich’s 39 practices, using a mixture of EMIS and Vision software, the real-time solution ensures patients receive the most appropriate care as early as possible. This is to avoid hospital admissions and any further complications resulting from their condition.

Behr said that as a practising GP, he fully understands the daily pressures and busy workload experienced in primary care.

“However, this tool runs in the background of daily work so you hardly know it’s there, but so useful when you need refer to it.”

Greenwich CCG directorate of commissioning Jan Matthews said the tool allowed her to easily review  up-to-date information from all 39 practices in the CCG.

“It enabled me to track progress on the identification and review of patients with long term conditions and ensuring accurate service payments were made”, she said.

The population health management tool will also allow healthcare service providers to hit their clinical targets and maximise available funding with negligible disruption to their usual daily routine.