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ID

C34

Version

1.0.

1

2

Type 

Type

Capability

Category

Reporting and data analytics

Status

Effective

Effective Date

  Insert excerptFull or Partial CapabilityFull or Partial Capabilitynopaneltrue

Contracting Vehicle(s)

Description

Excerpt
hiddentrue

Enables Organisations to accumulate, analyse and report on Patient healthcare data to identify improvement in care and identify and track Patient outcomes.

Population Health Management is information-enabled, proactive application of strategies and interventions to defined groups of individuals to improve the health of the individuals within the group.  It is a model for helping Service Providers to assess the populations they serve across health and care.

The Population Health Management Capability supports Service Providers

Supports Health or Care Professionals in accumulating and accessing

healthcare

health or care data from various sources, reporting on and

analysing this data, performing risk stratification and segmenting

creating Patients/Service

Users into cohorts. It also supports the setting of target outcomes for groups and the monitoring and measurement of these outcomes.

It enables Service Providers to take a comprehensive approach to uncovering gaps in care, and filling those gaps in order to provide benefits for Patients/Service Users and Service Providers by improving outcomes, aligning Health and Care Professionals, coordinating care, and optimising efficiency and revenue.

Outcomes

Organisation/Service Provider

User cohorts.

Outcomes

For a Patient/Service User:

Receiving targeted interventions, treatment or care as a result of a health or care need being identified through analysis.

For Health or Care Organisations:

Enables models of care to focus on the local population's health

and

or care needs by identifying and analysing Patient/Service User

segments
  • Ability to identify ways to improve population health by identifying Patient/Service User segment's health and social care needs, risks and health and care costs by using process metrics such as the delivery of care services, and desired outcomes
  • Supports development of practice guidelines to achieve desired outcomes for managing Patient/Service User segments
  • Enables stratification of the population to identify at-risk Patients/Service Users and enable preventive care
  • Develop and target interventions to achieve desired outcomes for Patients/Service Users segments
  • Gather outcomes and use these for analysis
    • Patients/Service Users
    • Receive targeted interventions, treatment or care as a result of a healthcare need being identified through analysis
    Integrated and Federated Care Settings

    cohorts.

    For the wider NHS and social care system:

    Plan interventions, treatments and campaigns across the local population

    Panel
    titleColorwhite
    titleBGColor#183152
    titleMUST Epics - Epics and acceptance criteria will be evaluated during the Capability Assessment Stage of Onboarding

    C34E1 - access healthcare data

    As a Service Provider

    I want to access accumulated healthcare data from various sources

    .

    MUST Epics - Describes the minimum functionality required to deliver a Capability. Solutions MUST be successfully evaluated against each Epic and Acceptance Criteria via Capability Assessment in order to be associated with this Capability

    E00618 - report on Population Health Management data

    As a Health or Care Professional

    I want to report on Population Health Management data

    So that I can analyse

    this

    the data and make informed decisions

    Acceptance criterion 1:

    access healthcare data

    define Population Health Management report criteria

    Given the

    Service Provider wants to undertake health management for a population

    When they have accumulated population related data

    Then it can be accessed by the Solution to be used for analytics and reports

    C34E2 - maintain cohorts

    As a Service Provider

    I want to maintain cohorts that segment my Patient/Service User population

    Health or Care Professional is permitted to manage Population Health Management reports

    When the Health or Care Professional selects to define the criteria for the report

    Then the criteria for the report is defined

    Acceptance criterion 2: view Population Health Management reports

    Given the Health or Care Professional is permitted to view Population Health Management reports

    When the Health or Care Professional selects to view the report

    Then the report results are displayed

    Info

    E00618 - Supporting Information

    • Data used for the reports can come from a variety of different sources and and is not limited to Buying Catalogue Solutions

    E00619 - manage Patient/Service User cohorts

    As a Health or Care Professional

    I want to manage Patient/Service User cohorts

    So that I can identify interventions and strategies to support

    defined groups

    the population

    Acceptance criterion 1: create Patient/Service User cohorts

    Given the

    Service Provider has accumulated population related data

    When the population related data is accessed by the Solution

    Then Patient/Service User cohorts can be

    Health or Care Professional is permitted to manage Patient/Service User cohorts

    When the Health or Care Professional selects to create a Patient/Service User cohort

    Then a Patient/Service User cohort is created

    Acceptance criterion 2: view Patient/Service User cohorts

    Given the Health or Care Professional is permitted to manage Patient/Service

    User cohorts exist

    User cohorts

    When the

    Service Provider chooses

    Health or Care Professional selects to view a Patient/Service User cohort

    Then the Patient/Service User cohort is displayed

    Acceptance criterion 3: amend

    a

    Patient/Service

    User cohort

    User cohorts

    Given the Health or Care Professional is permitted to manage Patient/Service

    User cohorts exist

    User cohorts

    When the

    Service Provider chooses

    Health or Care Professional selects to amend a Patient/Service User cohort

    Then the Patient/Service User cohort

    can be

    is amended

    Acceptance criterion 4: delete

    a

    Patient/Service

    User cohort

    User cohorts

    Given the Health or Care Professional is permitted to manage Patient/Service

    User cohorts exist

    User cohorts

    When the

    Service Provider chooses

    Health or Care Professional selects to delete a Patient/Service

    User cohorts

    Then they can be deleted

    C34E3 - stratify population by risk

    As a Service Provider

    I want to be able to stratify Patients/Service Users according to risk profile

    So that I can prioritise the management of their care and define outcome targets

    Acceptance criterion 1: risk stratify Patients/Service Users

    Given that population related data can be accessed by the Solution

    When the Service Provider chooses to stratify Patients/Service Users according to risk levels

    Then risk levels are identified for Patients/Service Users

    Acceptance criterion 2: assign risk level to Patients/Service Users

    Given risk levels have been identified for Patients/Service Users

    When the Service Provider chooses to assign risk levels to Patients/Service Users

    Then risk levels can be assigned to Patients/Service Users

    Acceptance criterion 3: stratify based on nationally or industry recognised algorithms

    Given the Service Provider is using a Risk Stratification Tool

    When there is a nationally or industry recognised algorithm for the Risk Stratification Tool

    Then the Risk Stratification Tool uses the nationally or industry recognised algorithm

    Acceptance criterion 4: view Risk Stratification Tool algorithm details

    Given the Service Provider is using a Risk Stratification Tool

    When the Service Provider chooses to view details about the algorithm used by the tool

    Then the algorithm details can be viewed

    And the source is displayed

    C34E4 - data analysis and reporting

    As a Service Provider

    I want to analyse Patient/Service User data

    So that I can view reports, trends and make informed decisions

    Acceptance criterion 1: analyse and view reports

    Given population related data can be accessed by the Solution

    When the Service Provider chooses to view reports on the data based on defined search criteria

    Then the results are displayed

    C34E5 - outcomes

    As a Service Provider

    I want to be able to set, monitor and measure Patient/Service User outcomes 

    User cohort

    Then the Patient/Service User cohort is deleted

    MAY Epics - Describes additional functionality associated with the Capability. Suppliers should consider all MAY Epics as part of their User Research. Suppliers can choose to map their Solutions to these Epics and they will be evaluated via Capability Assessment. Contracting Authorities or purchasing organisations may require these Epics as product qualification or requirements criteria

    E00620 - manage outcome targets

    As a Health or Care Professional

    I want to manage outcome targets for Patient/Service User cohorts

    So that the outcomes can be used to assess

    the value of changes to

    the co-ordination

    , integration So that I have

    and delivery of healthcare

    Acceptance criterion 1: set outcome targets

    Given population related data can be accessed by the Solution

    When the Service Provider wants to assess the value of changes to the co-ordination, integration and delivery of healthcare

    Then they can set outcome targets for Patients/Service Users 

    Acceptance criterion 2: measure and monitor outcomes

    Given population related data can be accessed by the Solution

    When the Service Provider wants to assess the value of changes to the co-ordination, integration and delivery of healthcare

    Then they can view reports to measure and monitor outcomes

    Panel
    titleColorwhite
    titleBGColor#375D81
    titleMAY Epics - All May Epics and Acceptance Criteria will be evaluated during the Capability Assessment Stage of On-boarding. However, these Epics are not mandatory and will not be used as part of the overall assessment of whether the Capability is fully met. Any May Epics that are assessed as met will be available to buyers via the Buying Catalogue.

    C34E6 - dashboard

    As a Service Provider

    I want to be able to view a tailored Population Health Management dashboard

    Given the Health or Care Professional is permitted to manage outcome targets

    When the Health or Care Professional selects to set an outcome target for Patient/Service User cohorts

    Then the outcome target for the Patient/Service User cohort is set

    Acceptance criterion 2: view progress towards outcome targets

    Given the Health or Care Professional is permitted to manage outcome targets

    When the Health or Care Professional selects to view progress towards an outcome target

    Then progress toward the outcome target is displayed

    E00621 - manage Population Health Management dashboards

    As a Health or Care Professional

    I want to manage Population Health Management dashboards

    So that I have the relevant information available to make informed decisions

    Acceptance criterion 1: configure

    dashboard

    Population Health Management dashboards

    Given the

    Service Provider

    Health or Care Professional is permitted to

    configure

    manage Population Health Management dashboards

    When they choose

    When the Health or Care Professional selects to configure a Population Health Management dashboard

    Then they can select the information that they would like to see on

    Then the dashboard is configured

    Acceptance criterion 2: view

    dashboard

    Given the Service Provider has configured a dashboard

    When they choose to view a dashboard

    Then they can see the information that has been configured to display on the dashboard

    Panel
    titleBGColor#ABC8E2
    borderStylesolid
    titleCapability Specific Standards

    Suppliers will have to attain compliance with these Standards during the compliance stage before they can be live on a framework with this Capability:

    None

    Panel
    titleBGColor#C4D7ED
    borderStylesolid
    titleOther Applicable Standards

    Suppliers will have to attain compliance with these Standards during the compliance stage before they can be live on a framework with this Capability:

    PaneltitleBGColor#E1E6FAborderStylesolidtitle

    Population Health Management dashboards

    Given the Health or Care Professional is permitted to manage Population Health Management dashboards

    When the Health or Care Professional selects to view a Population Health Management dashboard

    Then the dashboard is displayed

    Roadmap

    Items on the Roadmap which impact or relate to this Capability

    Suppliers will not be assessed or assured on these Roadmap Items as part of Onboarding

    Page Properties Report
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    headingsStandards and Capabilities, Status, Effective Date, Description, Change Type, Change Route
    pageSize300sortByEffective Date
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