Tower Hamlets residents have a high prevalence of long-term conditions, and diseases are often undiagnosed. Records can be fragmented as healthcare professionals engage patients across many settings. Tower Hamlets CCG’s integrated care programme relies on GPs being able to identify patients most at risk of hospital admission and refer them into a care coordination package.
We developed a local data warehouse and began extracting and storing GP data, linking it with other data sets and automating care package dashboards.
NELIE helped Tower Hamlets CCG to quickly identify patients with multi-morbidities through its simple point-and-click interface. Rapid population analysis enabled clinicians and commissioners to identify cohorts of patients based on risk score, demographics or long term conditions.
For the first time, GPs and clinicians were able to identify and systematically follow up a cohort of patients at risk and help prevent prolonged hospital stays. This fresh insight has helped Tower Hamlets CCG make decisions around commissioning services across the borough, planning the integration of care services.
As a result of this work, NELIE’s Patient Explorer tool was awarded winner of ‘Best Use of Business Intelligence to deliver analysis to frontline staff’ at the Centre of Excellence for Healthcare Analysis awards.
The technology and the relationships that have been built will continue to be used in Tower Hamlets to support service redesign, and are being developed with neighbouring CCGs.