In June we are introducing the first version of our Population Health Management (PHM) Engine. This tool is designed to benefit both healthcare providers and patients. It can be used to identify specific patient cohorts for strategic clinical planning and to deliver automated, personalised guidance directly to patients.
This work is possible because, as a single patient record, PKB combines data from multiple sources enabling a holistic view of the patient. Data is aggregated from primary care (GPs), secondary care (hospital specialists), community healthcare organisations, and the patients themselves.
Since May, over 1 million patients have chosen to store a copy of their GP data in their PKB record. The PKB software enriches this data by applying SNOMED CT codes for conditions, medications, and other clinical information. The PHM Engine uses this coded data for automated cohort identification and to translate a patient’s clinical information into simple, actionable prompts.
Example use cases for the PHM Engine
The PHM Engine can be configured to support a range of clinical priorities. Examples use cases include:
1. Medicines Optimisation
Medicines optimisation is about helping people to get the best outcomes from their medicines. Our PHM Engine can be used across all specialities to prompt patients who are not on an optimal treatment regime to speak to their clinical teams. Taking Rheumatology as an example, patients with gout may present to Emergency Departments with recurrent flare-ups because their condition is undertreated.
The PHM Engine can:
- Identify patients with a SNOMED CT diagnosis for gout but without a corresponding SNOMED CT code for allopurinol.
- Prompt the patient to discuss initiating allopurinol with their GP or specialist.
- Notify the clinical team of this patient cohort, enabling proactive communication and management.
2. Patient Support Programmes
Adherence to complex medication regimens can be challenging for patients.
The PHM Engine can:
- Identify a patient prescribed a specific medication via its SNOMED CT.
- Prompt the patient with targeted instructional videos and supporting materials.
3. Chronic Condition Monitoring
Effective management of conditions, like Chronic Kidney Disease (CKD), requires close monitoring of key indicators such as blood pressure.
The PHM Engine can:
- Identify patients with a SNOMED CT code for CKD who lack a recent blood pressure reading in their record.
- Prompt the patient to connect a home blood pressure monitoring device to their PKB account to record regular measurements, which can then be reviewed during their next consultation.
4. Clinical Trial Recruitment
Identifying suitable participants for clinical trials is often a resource-intensive process.
The PHM Engine can:
- Identify patients who match the inclusion criteria for a specific trial.
- Present information about the trial directly to these eligible patients.
- Facilitate a patient-initiated data-sharing process with the research team if they express interest in participating.
How to use our PHM Engine
The PHM Engine is designed to integrate seamlessly into clinical workflows without requiring additional clinical time for training or operation. Clinical teams can define rule criteria for patient cohorts based on their service needs, such as medication optimisation or monitoring. The configuration and application of these rules are managed by the PKB specialist team. Once a rule is configured, the PHM Engine functions automatically and anonymously.To discuss how the PHM Engine can support your service and patients, please contact your PKB Success Team member or fill out our contact form.