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Description
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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.
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Description
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Supports Health or Care Professionals in accumulating and accessing health or care data from various sources, reporting on and |
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creating Patients/Service |
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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
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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 |
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or care needs by identifying and analysing Patient/Service User |
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- Receive targeted interventions, treatment or care as a result of a healthcare need being identified through analysis
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cohorts. | |
For the wider NHS and social care system: | Plan interventions, treatments and campaigns across the local population |
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MUST Epics - |
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EpicPM1 - access healthcare data
As a Service Provider
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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 |
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E00618 - report on Population Health Management dataAs a Health or Care Professional I want to report on Population Health Management data So that I can analyse |
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the data and make informed decisions Acceptance criterion 1: |
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define Population Health Management report criteriaGiven the |
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When they have accumulated population related data
Then it can be accessed by the Solution to be used for analytics and reports
EpicPM2 - maintain cohorts
As a Service Provider
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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 reportsGiven 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
E00619 - manage Patient/Service User cohortsAs a Health or Care Professional I want to manage Patient/Service User cohorts So that I can identify interventions and strategies to support |
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the population Acceptance criterion 1: create Patient/Service User cohortsGiven the |
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When the population related data is accessed by the Solution
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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 cohortsGiven the Health or Care Professional is permitted to manage Patient/Service |
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User cohorts When the |
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Health or Care Professional selects to view a Patient/Service User cohort Then the Patient/Service User cohort is displayed Acceptance criterion 3: amend |
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Patient/Service |
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User cohortsGiven the Health or Care Professional is permitted to manage Patient/Service |
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User cohorts When the |
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Health or Care Professional selects to amend a Patient/Service User cohort Then the Patient/Service User cohort |
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is amended Acceptance criterion 4: delete |
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Patient/Service |
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User cohortsGiven the Health or Care Professional is permitted to manage Patient/Service |
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User cohorts When the |
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Health or Care Professional selects to delete a Patient/Service |
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Then they can be deleted
EpicPM3 - 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
EpicPM4 - 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
EpicPM5 - outcomes
As a Service Provider
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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. Framework Authorities or purchasing organisations may require these Epics as product qualification or requirements criteria |
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E00620 - manage outcome targetsAs 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 |
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the co-ordination |
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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
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| title | MAY 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. |
EpicPM6 - 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 targetsGiven 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 dashboardsAs 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 |
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Population Health Management dashboardsGiven the |
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Health or Care Professional is permitted to |
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manage Population Health Management dashboards |
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When the Health or Care Professional selects to configure a Population Health Management dashboard |
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Then the dashboard is configured Acceptance criterion 2: view |
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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
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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 |
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Suppliers will have to attain compliance with these Standards during the compliance stage before they can be live on a framework with this Capability: |
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Population Health Management dashboardsGiven 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 |
Items on the Roadmap which impact or relate to this Capability |
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Suppliers will not be assessed or assured on these Roadmap Items as part of Onboarding
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