CALDERDALE CARES PARTNERSHIP POPULATION HEALTH ANALYTICS

HEALTH DATA INTEGRATION TOOL

Creating a semantic layer

EXECUTIVE SUMMARY

Introduction

Thank you for the opportunity to propose the implementation of a novel linked health and care data management solution, HDIT (Health Data Integration Tool) to accelerate the development of your Population Health Analytics work programme.

GRiP Analytics has a small, focused team with more than 50 years of experience in the development of Population Health Management analytics and are delighted to offer you this software programme that we have developed.

We have enjoyed conversations with you to date and very much look forward to helping you achieve your ambitions of a mature foundation of data that will yield important insights that underpin key decisions designed to positively impact on patient outcomes.

Paul Molyneux

Company Director | 5^th July 2024

GRiP Analytics Limited | Confidential between GRiP and Calderdale cares partnership

About GRiP Analytics

GRiP Analytics Ltd was founded in 2020 by Paul Molyneux who has a passion for health data, analytics and ‘getting research into practice’.

In order to enable analytical insights to make a difference, additional capabilities of robust data engineering, consultancy and ‘data storytelling’ are critical. This is where GRiP Analytics’ focus is and specifically within the health and care sector.

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Our Commercial Offer

We are recommending an annual subscription to the software license that costs £32,720 (inclusive of Johns Hopkins ACG system, set-up fees and support) but quarterly options are also available. We have included a 10% discount as we recognise you as an early adopter of this novel approach and as a development partner.

Please see pricing schedule in the appendices for breakdown of costs.

We would very much like to offer a demonstration of our tooling and outputs at your earliest convenience and answer any questions you may have.

OUR UNDERSTANDING OF YOUR REQUIREMENTS

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• Building on success
• We have recently supported the PGPA to develop a novel predictive risk model to help find people suitable for enrolment into end-of-life care planning with excellent results
• This clearly demonstrates the utility of the data you are currently processing and GRiP Analytics’ capability

• Accelerating your PHM analytics and deriving new insight and value from your linked primary and secondary care data
• We understand that you have invested a lot of time securing a primary care data feed for TPP practices
• You now have this data in a central repository hosted by your local CSU that also has the SUS feeds available
• The SUS and Primary Care feeds are linkable through a consistent patient pseudonym
• This is a very strong foundation for a PHM dataset that can be used to stimulate and drive a range of PHM use cases
• This will be the first time the Calderdale Cares Partnership team has had access to such a rich and varied set of data and as such will benefit from additional support to accelerate their understanding and use of the data
• We believe we have a strong offer that is comprised of PHM experts together with a novel software solution that can automate much of the ‘heavy lifting’ required to achieve the right target dataset for analysis

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THE CHALLENGE

Primary Care and Acute data are not easily analysable

• In their ‘naked’ form, routinely collected datasets from primary and secondary care are not easy to use. They required complete transformation into a structure that is easy for front end users to query and analyse. This is mainly because they weren’t typically designed for PHM analytics and as such require a tremendous amount of data engineering and the application of a variety of algorithms (see right).
• The resultant ‘semantic layer’ that is produced by HDIT creates an analysable set of data that is heavily anchored to the use cases set out in the national Place Development Programme (PDP) analytics playbook (see below).

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THE SOLUTION

The Health Data Integration Tool helps users quickly create a Population Health semantic layer and allows users to quickly create cohorts of interest

• We believe that Population Health Management digital capabilities should be brought to the data and not the other way round. This ensures that there are minimal information governance implications, and it empowers local health and care informatics teams to take more ownership of the data they process.
• As part of the set-up of HDIT we will help you to create the correct input files of which there are fifteen across four data sources. This will include the provision of SQL scripts, a detailed specification and a coaching service that will ensure you have the procedures standardised for ongoing maintenance.
• Users download the HDIT application in the same environment that their data is stored and through a series of simple and intuitive steps can easily produce a complete Population Health Management target dataset.
• There is in-built functionality to help users interact with the semantic layer to develop, review and save cohorts (bottom left)

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THE SOLUTION – JOHNS HOPKINS ACG SYSTEM

• The (optional) ACG System provides comprehensive population health analytics algorithms across more than 20m lives in England and more broadly across six continents
• It helps to transforms the raw, unstructured data that exists in primary and secondary care records into a series of patient markers
• ACG System users also have access to a global ‘community of interest’ and access to high quality resources and support materials

• The ACG System supports four key use cases (see right) which helps guide the use of analytical outputs
• Furthermore, the ACG team devised ‘seven quick wins’ (see left) that make recommendations on which programmes of work are most likely to create positive impact

MAKING SENSE OF THE NOISE

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Our approach

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Without processing the data, it can be very difficult to quickly understand someone’s circumstances (below left). Building clinical markers and developing a semantic layer makes it much easier to understand an individual’s clinical position (below right).

74 y/o male – Spring Hall Medical Centre

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• Asthma
• Dementia
• Hypertension
• Hypothyroidism
• Depression
• Parkinsonism
• Smoker
• Severely frail

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• Not on palliative care register

ILLUSTRATIVE PERSON LEVEL PROFILES

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Above: The outputs help users quickly examine their whole population through segmentation and navigate to cohorts and as visualised above, individual profiles that are rich with a range of PHM markers

Whole Population

Individual

OUR APPROACH

Why us?

• Paul Molyneux, company director co-authored the analytics playbook that set the standard for all analytical lines of enquiry in NHS England’s Place Development Programme (PDP).
• GRiP Analytics associates designed, developed and rapidly deployed all analytics using the NCDR (National Commissioning Data Repository) database for the PDP.
• We have more than 50 years' experience between a small, focused team that are committed to better use of data for Population Health Management use cases, gained across a number of integrated care systems in England and internationally.
• We believe that NHS informatics teams should be working the top of their license to answer compelling questions, not performing data management tasks that can be to some extent automated and routinely maintained.

We operate at the intersections between:

• Domain knowledge and soft skills
• Programming and database
• Maths and statistics
• Communication and visualisation

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Key deliverables and benefits

• On premises software solution - there are a range of licensing options whereby you can subscribe to the software package which you will use yourselves to create the PHM data asset
• As part of this subscription model, you will receive support from the team to ensure you’re successful in your implementation (included in the license fee).
• Recommendation: we suggest that our team arrange honorary agreements so that we can remotely access the same data environment to provide direct support if required
• Bespoke services: there will be specific projects that require bespoke analytics to be undertaken e.g. evaluating the GSF lite project - we can provide mini-proposals for additional work when/if required
• Informatics time released from data management tasks
• Shift from transactional to transformational analytics
• Accessing robust and validated analytical outputs in a user-friendly manner
• Experience of GRiP and ACG team in how to apply the outputs in real-world settings

MEET THE TEAM

Paul headed analysis for various International organisations including Cerner and MedeAnalytics before joining PA Consulting to advise and support on Population Health Analytics.

With strong leadership skills, a proven track record of strategic thinking and problem solving, Paul is a skilled communicator and can influence and work across boundaries, identify objectives, define work specifications, functional requirements and deliver high quality outcomes to target deadlines. Paul has strong links with academia, in particular he has a close ongoing working relationship with Johns Hopkins and NYU, he is passionate about getting research into practice.

Paul leads through a shared vision, inspiring others and empowering the team to the best of their abilities. Paul is highly experienced in all areas of information analysis. This includes; national analysis, benchmarking, outlier detection, detecting unwarranted variation, local analyses, machine learning, data science, storytelling, Population health analyses, working with acute and primary care clinical directors, predictive modelling and applied risk models . He is highly committed to the use of evidence to advance the improvement of health and social care outcomes across populations of all magnifications.

GRiP Analytics Limited | Confidential between GRiP and Calderdale cares partnership

Paul Molyneux

Company Director

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Paul is the founder of GRiP and has more than fifteen years health and social care information analysis, consultative and strategic experience gained in prominent public and private sector healthcare organisations both nationally and internationally. During Paul’s healthcare analysis career, he has spent time in a PCT, the Care Quality Commission and Dr Foster Intelligence.

Barry Holland

Head of Development

• Background and expertise

Barry has previous experience working in the NHS (6 Years) and for PHM Analytics Organisations for 20+ years. He has lead Implementation of products and continual development of our operational and strategic propositions. He has been continually involved in a diverse range of projects including product scoping, requirements analysis and development through to implementation and support. Barry has expert knowledge of health and care datasets and how to access these in an IG compliant manner.

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Denham Steynor

Data Scientist

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• Background and expertise

Denham has expertise in Population Health Management, having worked with health and care datasets including NHS Primary and secondary care datasets. He has particular expertise and experience integrating the Johns Hopkins ACG grouper for risk stratification, segmentation and risk adjustment. Denham has developed population health management solutions including business intelligence and interactive dashboards and methods to support identifying cohorts of patients suitable for proactive care using a combination of case finding tools and machine learning.

WORKING WITH YOU

During the first four weeks of your subscription, we will work with you to create the data extraction plan, develop the routine procedures and deliver the outputs incrementally through regular touchpoints.

Our approach is collaborative, and we will expect to work closely with your core team. We will be working remotely and will aim to create a shared collaboration platform for us all to access throughout the assignment. This means you’ll see the work develop and can contribute/challenge throughout.

AGILE

We will follow an agile delivery approach so that we can fully engage with your core team and any additional stakeholders ensuring we have your input and feedback throughout. This is an effective approach to rapidly test and develop robust information outputs.

GRiP Analytics Limited | Confidential between GRiP and Calderdale cares partnership

GRiP Analytics Limited | Confidential between GRiP and Calderdale cares partnership

We will run on the basis of weekly sprints using the following cadence:

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Kick off meeting – this forms the overall planning session where we’ll create the backlog for the assignment as well prioritise the work for the first sprint.

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Sprint 1 – in the first week we’ll establish the sprint ceremonies:

Day 1 sprint planning:

Confirm the focus and objectives for the sprint

Identify priority areas of work from the backlog

Discuss and resolve issues (or escalate)

Raise risks and establish mitigations (or escalate)

Weekly stand-ups for the whole team to discuss

share progress to date

raise any issues

raise additional risks and discuss mitigations

reprioritise effort based on the outcome of the stand-up

Sprints 2-4 – will follow the same cadence as per Sprint 1

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Handover session – we will present the final outputs to the core group and any additional stakeholders as agreed with the project sponsor. This will give us an opportunity to demonstrate the work completed in the sprint and seek feedback from the group. We will document final suggestions for future activities and provide documentation captured across the project.

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OUR PLAN

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Week 0

Sprint 2

Sprint 3

Sprint 4

Sprint 1

Mobilisation

Data Extraction

Software Installation

Configuration & Mapping

Testing & Training

Handover & Socialisation

Software and Semantic layer

Project kick off;

Governance;

Informatics plan

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Data engineering; business rules; procedures

Review summary statistics, process repeated, descriptive analytics produced

Connections created, mappings executed, processes complete

Download, install, user set-up

Documentation; metric and features inventory; demonstrations

Delivery

OUR OFFER

GRiP Analytics Limited | Confidential between GRiP and Calderdale cares partnership

1. Initial Set-Up - £6k
• We will provide coaching to help you create the right input files and help establish standard procedures for ongoing maintenance
2. Download, implementation and testing of software*
• We will provide two days support each quarter to ensure that any issues are resolved swiftly

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• Recommended: honorary contracts to be arranged in case there are issues with capacity so GRiP staff can operate

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• Analytics projects to be quoted for separately (e.g. quantitative evaluation using causal modelling of End-of-Life project)

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* Priced per head of population assuming a population size for Calderdale of 195,000

** Includes a 5% discount for annual subscription

GRiP Analytics Limited | Confidential between GRiP and Calderdale cares partnership

APPENDIX

TRACK RECORD | 1

NHS England – Place Development Programme

Members of GRiP Analytics led analytics for the National Place Development Programme that NHS England commissioned.

We worked with more than 40 ‘places’ that were nominated by their parent Integrated Care Systems to help stimulate, accelerate and advance their Population Health Management ambitions.

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Purpose and Scope

Our role included the design and development of the Analytics Playbook that set the standard for analytics across all places. This was agnostic of each place’s digital and analytical maturity. We also developed a national tool using the National Commissioning Data Repository (NCDR) to produce analytical outputs for places that had no digital capability.

Outcome: We successfully used each place’s ‘best available insights’ to identify key opportunities for improvement and indicate which individuals within the populations were driving the headline figures. With these cohorts formed we provided the right analytical packs to inform the logic models and subsequent planning and delivery activities.

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Above: Dorset ICS custom cohort selection

Below: Rochdale ‘high risk’ population mapped geo-spatially

TRACK RECORD | 2

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NHS Dorset – Development and Deployment of a Falls Risk Model

Members of GRiP Analytics provided a range of insights into the incidence, variability and risk factors associated with injurious falls in the elderly across the Dorset ICS population.

Purpose and Scope

We were commissioned to develop novel metrics to track falls and fractures across primary and secondary care datasets and measure the variability across places and organisations (see PCN distribution in a funnel plot – above right). After a series of stakeholder engagement sessions we began to understand that a contributor to the wide variance was the inability for organisations to systematically identify people at higher risk of having a future fall. We worked with academic partners to implement, calibrate and validate a falls predictive model which had an overall accuracy of 92.96% (see bottom right). This was a model that was implemented across the entire Dorset population with every elderly person scored and stratified. Each Primary Care Network (PCN) had access to their own risk register which they reviewed and made decisions about who was eligible for new models of support and how to design them effectively.

Outcome

Every PCN and GP Practice in Dorset had a much better insight into the scale of falls that their population has experienced historically and have an equitable and accessible view on who they should worry about. This was particularly well received by clinical leads who agreed with the types of people the model was finding and described how it saved them enormous amounts of time that was previously spent conducting complex searches in their clinical systems.

• Primary and secondary care datasets are stored centrally in a server
• Datasets have a consistent person identifier (e.g. common pseudonym) to enable linkage between datasets
• Calderdale Cares Partnership will allow access to the hosted environment for installation of the software
• There is a separate environment for testing that mirrors the production environment.
• Members of the Calderdale Cares Partnership informatics core team will make themselves available for the agreed governance arrangements
• Both parties have identified points of contact for coordination and issue resolution.
• Technical staff will be made available for the coaching sessions and to own the processes following handover
• The client has a change management plan to handle the transition
• The client's hardware, network, and operating systems meet the software requirements (e.g. Windows 10 and above)
• Reliable and sufficient internet connectivity
• The client's existing data is reasonably clean, accurate, and well-organized for migration
• The client adheres to data security and privacy regulations and information governance rules will apply exclusively to Calderdale Cares Partnership
• The project scope is well-defined and agreed upon by all parties.

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ASSUMPTIONS

PRICING SCHEDULE

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Consultancy Services

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Consultancy Services and Advisory

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Bespoke Application Development and Data Science Services

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• Consultancy and advisory services to be ‘called-off’ by Calderdale Cares Partnership on an as needed basis.
• The precise nature of any consultancy and advisory services are a matter of discussion and agreement between Calderdale Cares Partnership and GRiP Analytics.

Above: Table 2

Payment Profile – Proposed

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• Quarter 1 invoice to be issued upon completion of set-up and installation of software. This will include set-up fees and the initial license costs. We imagine this will be approximately four weeks after agreements have been signed. This will be triggered by a successful handover as per our project plan.
• We have included an illustrative scenario (table 1) with a contract signature date of 5^th August 2024
• Remaining quarters will be invoiced on the first working day of the next quarter.

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Above: Table 1

NEXT STEP: DEMONSTRATION

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