Population Health Management South East London ICB

This specification outlines the requirements for a Population Health Management (PHM) tool to be used within Lambeth Health and Care Partnership. The tool will extract data from primary care systems, aggregate and present this data on dashboards for various healthcare areas , and provide functionalities to enable GPs to re-identify patients for actionable interventions.

Objectives

The PHM tool aims to:

• Aggregate data from primary care systems.
• Present data on user-friendly dashboards for healthcare areas such as flu vaccination, NHS health checks, blood pressure, and diabetes.
• Allow GPs to re-identify patients for intervention purposes.
• Display near real-time data.
• Explain business rules and criteria clearly on the dashboards.
• Offer ongoing training and support.
• Provide functionality to link additional datasets in the future.
• Support different levels of user access based on permissions.
• Show baseline metrics, trends over time, and outcomes.
• Enable segmentation to identify patient cohorts for targeted interventions.