Special Report: Business intelligence: population health management
There is growing interest in population health management, or aggregating data from multiple IT systems to change clinical service and financial outcomes. Lyn Whitfield asks why this is happening now, and hears the big driver is policy.
There is a shift underway in healthcare analytics. Certainly, there is still an important role for what might be called traditional business intelligence – surfacing, analysing, and reporting on the data held by specific systems, departments or organisations.
But interest is growing in what is called population health management – aggregating data from multiple systems hosted by different organisations, and using this to inform changes to clinical, service and financial outcomes.
Or, as Graham James, vice president of CACI, puts it: “We are seeing a move towards a wider range of data being collected and used to deliver health and social care in a different way.”
Barry Duke, group analytics product manager at Emis Health, says this has really picked up in the past few months. “Two or three years ago, we were talking to the NHS about this, but the time wasn't right for a number of reasons. However, this year people have really engaged.”
Getting the data
Why now? Practically, a lot of effort has gone into sorting out the data, technology and information governance required to make a start.
Ashley Woolmore, senior consultant at IMS Consulting Group, says initially a lot of was done trying to tap into and link-up existing data sets, but there are limitations to this approach.
For instance, he points out that while the ONS and NHS Digital have very relevant datasets, combining them is challenging “if you want to look down to patient level, for example down to the level of a patient with, say heart failure.”
Indeed, as people start to live for five or ten years with heart failure or cancer “death (which is only partially available in a dataset such as the Hospital Episode Statistics) might not even be the appropriate outcome measure, particularly where evaluations need to focus on a shorter time horizon.” Sometimes, bespoke data collection is needed.
Yet the traditional way of doing this, through randomised control trials and one-off studies are time consuming and expensive; and might still not provide the kind of trend data needed for service planning.
“What we are interested in doing, and what the NHS is interested in doing is not setting up a seperate study every time [we want to know the impact of a new treatment or intervention],” he says. “We are putting the infrastructure in place to monitor outcomes continuously.”
Cloud changes the BI weather
On the technology front, Duke says the big change has been the arrival of public cloud services, such as Microsoft Azure, that dramatically cut the hardware and software costs of storing and crunching data.
“The cloud is just the most cost effective way of doing this,” he says. “You can pay for what you use, and if something does not work out, you can just switch it off.”
The NHS has been slower to start using the cloud for analytics services than other organisations, partly because of concerns about security and information governance. But the bodies tasked with advising the health service on these issues seem to have decided that this is the way to go.
For example, Duke says, the NHS Digital has said it is acceptable to store patient identifiable data in a public cloud, subject to risk assessment and as long as it does not leave the EEA (or, if it originates from named central bodies, England). Microsoft and Google are both investing in UK data centres.
Meanwhile, Dame Fiona Caldicott’s latest report on information governance gives a significant boost to central data collection and certain uses of information, including risk stratification, despite the new patient opt-outs offered for regulation and research.
Vanguards lead the way
Even so, the big driver is policy. The NHS has a long history of experimenting with integrated working and a shorter one of using data-driven techniques such as risk management to try and divert patients from hospital by providing more support in the community.
But the Five Year Forward View plan to try and close a £30 billion gap between funding, rising costs and demand (and particularly demand) that could otherwise reach £30 billion by 2020-21 takes this kind of thinking to a new level.
It puts a big emphasis on new models of working which reach out across both health and social care; where, as James points out, councils have an even more pressing need to find efficiencies, and are further along the road of changing both their own structures and the channels through which they deal with users.
The Forward View’s ideas are now being tried out by 29 vanguards around the country. The acute-led, or ‘primary and acute care systems’ vanguards have helped to pull new players into the analytics market.
The Salford Together vanguard is using the population health management system from Allscripts, its acute electronic patient record provider, while the Wirral Partners vanguard has brought Cerner’s population health management to the UK on a similar basis.
The established analytics providers are also involved with the vanguards. CACI is working with the Better Care Together vanguard that is focused on the Morecambe Bay Health Community. It is looking to create a system that will “take responsibility for the whole health and social care needs of the population, within a single budget.”
Information wise, “it is really focused on a big data solution that pulls together GP data, hospital data, social care data, and possibly, in the future, information from not for profit providers,” says James. “There is a lot of interest in getting information from wearables, as well.”
Emis is involved with the Fylde Coast Local Health Economy, one of the ‘multi-speciality community provider’ vanguards, that wants to create ‘wrap around’ care for individuals, using community teams. (IMS Health is in advanced discussions with a vanguard, focused on improving outcomes and shifting services for a specific disease, although it can’t yet say which one).
The challenge: the money
The flip side of policy driving interest in population health management is that the financial crisis that has inspired that policy puts challenges in the way of investing in it, and in the kind of service change that it is meant to inform.
“Technically, this is very doable. It has to be pulled together in a secure way. You have to consider the information governance. There are issues with collecting information from wearables. But none of that is undoable, and it cannot be a barrier,” says James.
“What we need is for the money to go with this change. We need to get the money out of fixed assets, like hospitals, and into the community. We may need new CQUINs to support this. Or, maybe, NHS England needs to look at some transition funding.”
NHS England is surely well aware of this issue. Several vanguards, including Morecambe, are effectively collapsing some of the barriers between commissioning and providing that make it hard to shift money between provider organisations.
This year’s operational planning and contracting guidance says some CQUIN money will be available for taking part in sustainability and transformation plan work; while signalling a bigger shift towards ‘control targets’ for STP areas that NHS England chief executive Simon Stevens has said could mean an end to payment by results.
Even so, with the acute sector finishing the last financial year £2.4 billion in deficit, trusts being asked to accept ‘control targets’ to get this down to £250 million this year, and tight controls imposed on access to the relatively small sustainability and transformation fund, transition funding looks unlikely.
Still, Woolmore also feels this is the big challenge. “The only way the health sector generates income is through activity. There is a dynamic to increase activity and unless we tackle that, and allow financial rewards for stuff we do that is not payment by results, we will not get through this crunch,” he says.
“For me, the essence of population health management is reallocation; the question is whether we can do something better by putting resources into different treatments and services.
“Potentially, the only way to do that is to offer some protection to the acute sector for a period of time. We need to buffer change by providing financial continuity; but that is not where we are at the moment.”