NHS Portsmouth CCG - RS

RISK STRATIFICATION

Risk stratification is a tool for identifying and predicting which patients are at high risk (of health deterioration and using multiple services) or are likely to be at high risk and prioritising the management of their care in order to prevent worse outcomes.

To conduct risk stratification, Secondary User Services (SUS+) data, identifiable at the level of NHS number is linked with Primary Care data (from GPs) and an algorithm is applied to produce risk scores. Risk Stratification provides focus for future demands by enabling commissioners to prepare plans for both individual and groups of vulnerable patients. Commissioners can then prepare plans for patients who may require high levels of care. Risk Stratification also enables General Practitioners (GPs) to better target intervention in Primary Care.

Risk Stratification will be conducted by NHS North of England Commissioning Support Unit & Cerner Limited.

PROCESSING CONDITIONS:

Data must only be used for the purposes stipulated within this Data Sharing Agreement. Any additional disclosure / publication will require further approval from NHS Digital.

Data Processors must only act upon specific instructions from the Data Controller.

Data can only be stored at the addresses listed under storage addresses.

All access to data is managed under Role-Based Access Controls. Users can only access data authorised by their role and the tasks that they are required to undertake.

Patient level data will not be linked other than as specifically detailed within this Data Sharing Agreement. Data released will only be shared with those parties listed and will only be used for the purposes laid out in the application/agreement.

NHS Digital reminds all organisations party to this agreement of the need to comply with the Data Sharing Framework Contract requirements, including those regarding the use (and purposes of that use) by “Personnel” (as defined within the Data Sharing Framework Contract ie: employees, agents and contractors of the Data Recipient who may have access to that data)

The DSCRO (part of NHS Digital) will apply National Opt-outs before any identifiable data leaves the DSCRO only for the purpose of Risk Stratification.

CCGs should work with general practices within their CCG to help them fulfil data controller responsibilities regarding flow of identifiable data into risk stratification tools.

The identifier available in the data set is the NHS numbers. Any further identification of the patients will only be completed by the patient’s clinician on their own systems for the purpose of direct care with a legitimate relationship.

ONWARD SHARING:

There is no requirement for the analytical teams to re-identify patients, but in the development of cohorts of patients considered to be at risk, the data controllers may need the facility to provide identifiable results back to direct healthcare professionals or local authority direct care staff only for the purpose of direct care. Additionally clinicians, made aware of a number of cases that they believe would need intervention may request re-identification for that direct care purpose.

These instances of re-identification will generally be carried out as programmes of work or, rarely, on an individual/small group basis. All re-id requests will be processed and authorised by the DSCRO on a case by case basis. National data opt outs are not applied in these cases as they are for the purposes of direct care which follows the legal basis of implied consent.

The following are typical (generic) examples of instances where a CCG might want to use the re-identification process:

A&E High Attendance usage

The CCG can filter data to show for example the number of A&E attendances in a given period for each patient. The CCG can then flag to the relevant GP of the patient any patients that require intervention. An outcome of this is earlier intervention in the patient(s) care thus potentially reducing future costs and minimising future risk.

Polypharmacy re-IDs

CCG's can request re-ID of a list of patients to be sent to the relevant GP with a high number of medications (ingredient count) and review the medication for these patients. This can help address the risk of polypharmacy which is recognised as an adverse risk factor for patient safety. A by-product of such reviews may be to reduce costs of medication.

The Re-identification process for direct care is as follows:

1. The CCG identifies a patient cohort to be re-identified for the purpose of direct care.

2. The CCG sends a re-id request to the DSCRO. This may be done through the CCG or CSU’s Business Intelligence (BI) Tool, or through a manual form.

3. The DSCRO assesses as to whether the request passes the specified re-identification process checks. Checks include if the requester is authorised to access identifiable data, if the number of patients in the cohort is appropriate, and that the request does not seem inappropriate or outside of expected parameters, including for example around timings and the requestor’s relationship with patients in the data. These checks are carried out either by DSCRO staff using pre-approved information (timing’s, requester’s identity etc) or via an automated system. For automated systems, steps 1 -3 wouldn’t apply in most cases as it would be the direct care professional who identifies the cohort and as long as they are an approved re-id user and have gone through security checks initially, they will be able to re-id without more further checks.

4. If successful/approved, the DSCRO re-identifies the relevant data item(s) for the appropriate patients and returns the identifiable fields to Health or care professional(s) with a legitimate relationship to the patient. The CCG does not see the identifiable record.

5. DSCROs retain an audit trail of all re-id requests

6. National Data opt outs are not applied for the purpose of direct care

Aggregated reports only with small number suppression can be shared externally as set out within NHS Digital guidance applicable to each data set.

SEGREGATION:

Where the Data Processor and/or the Data Controller hold both identifiable and pseudonymised data, the data will be held separately so data cannot be linked.

Where the Data Processor and/or the Data Controller hold identifiable data with opt outs applied and identifiable data with opt outs not applied, the data will be held separately so data cannot be linked.

All access to data is auditable by NHS Digital.

DATA MINIMISATION:

Data Minimisation in relation to the data sets listed within the application are listed below. This also includes the purpose on which they would be applied -

For the purpose of Risk Stratification:

• Patients who are normally registered and/or resident within the NHS Portsmouth CCG region (including historical activity where the patient was previously registered or resident in another commissioner

A CCG user will be able to access the provider extracts from the portal for any provider where at least 1 patient for whom they are the registered CCG for that individuals GP practice appears in that setting

Although a CCG user may have access to pseudonymised patient information not related to that CCG, users should only process and analyse data for which they have a legitimate relationship (as described within Data Minimisation).

Amazon Web Services Limited provide Cloud Services for Cerner Limited and are therefore listed as a data processor. They supply support to the system, but do not access data. Therefore, any access to the data held under this agreement would be considered a breach of the agreement. This includes granting of access to the database[s] containing the data.

Microsoft Limited provide Cloud Services for NHS North of England Commissioning Support Unit and are therefore listed as a data processor. They supply support to the system, but do not access data. Therefore, any access to the data held under this agreement would be considered a breach of the agreement. This includes granting of access to the database[s] containing the data.

Pulsant and IT Professional Services Ltd do not access data held under this agreement as they only supply the building. Therefore, any access to the data held under this agreement would be considered a breach of the agreement. This includes granting of access to the database[s] containing the data.

Risk Stratification - Data Processor 1 & 2 - NHS North of England Commissioning Support Unit & Cerner Limited

1. Identifiable SUS+ data is transferred to the Data Services for Commissioners Regional Office (DSCRO).

2. Data quality management and standardisation of data is completed by the DSCRO and the data identifiable at the level of NHS number is transferred securely to NHS North of England Commissioning Support Unit, who securely pass the SUS+ data to Cerner Limited.

3. Identifiable GP Data is securely sent from the GP system to Cerner Limited.

4. SUS+ data is linked to GP data in the risk stratification tool by the data processor.

5. As part of the risk stratification processing activity, GPs have access to the risk stratification tool within the data processor, which highlights patients with whom the GP has a legitimate relationship and have been classed as at risk. The only identifier available to GPs is the NHS numbers of their own patients. Any further identification of the patients will be completed by the GP on their own systems.

6. Once Cerner Limited has completed the processing, the CCG can access the online system via a secure connection to access the data pseudonymised at patient level

RISK STRATIFICATION

1. As part of the risk stratification processing activity detailed above, GPs have access to the risk stratification tool which highlights patients for whom the GP is responsible and have been classed as at risk. The only identifier available to GPs is the NHS numbers of their own patients. Any further identification of the patients will be completed by the GP on their own systems.

2. GP Practices will be able to view the risk scores for individual patients with the ability to display the underlying SUS+ data for the individual patients when it is required for direct care purposes by someone who has a legitimate relationship with the patient.

CCGs will be able to:

3. Target specific vulnerable patient groups and enable clinicians with the duty of care for the patient to offer appropriate interventions.

4. Reduce hospital readmissions and targeting clinical interventions to high risk patients.

5. Identify patients at risk of deterioration and providing effective care.

6. Reduce in the difference in the quality of care between those with the best and worst outcomes.

7. Re-design care to reduce admissions.

8. Set up capitated budgets – budgets based on care provided to the specific population.

9. Identify health determinants of risk of admission to hospital, or other adverse care outcomes.

10. Monitor vulnerable groups of patients including but not limited to frailty, COPD, Diabetes, elderly.

11. Health needs assessments – identifying numbers of patients with specific health conditions or combination of conditions.

12. Classify vulnerable groups based on: disease profiles; conditions currently being treated; current service use; pharmacy use and risk of future overall cost.

13. Production of Theographs – a visual timeline of a patients encounters with hospital providers.

14. Analyse based on specific diseases

15. The addition of Mental Health Services Data Set enriches the data available and will help GPs identify and prevent mental health patients from needing urgent hospital care and / or being admitted to a psychiatric hospital

In addition:

- The risk stratification tool will provide aggregate reporting of number and percentage of population found to be at risk.

- Record level output (pseudonymised) will be available for commissioners (of the CCG), pseudonymised at patient level. Onward sharing of this data is not permitted.

RISK STRATIFICATION

Risk stratification promotes improved case management in primary care and will lead to the following benefits being realised:

1. Improved planning by better understanding patient flows through the healthcare system, thus allowing commissioners to design appropriate pathways to improve patient flow and allowing commissioners to identify priorities and identify plans to address these.

2. Improved quality of services through reduced emergency readmissions, especially avoidable emergency admissions. This is achieved through mapping of frequent users of emergency services thus allowing early intervention.

3. Improved access to services by identifying which services may be in demand but have poor access, and from this identify areas where improvement is required.

4. Supports the commissioner to meets its requirement to reduce premature mortality in line with the CCG Outcome Framework by allowing for more targeted intervention in primary care.

5. Better understanding of local population characteristics through analysis of their health and healthcare outcomes

6. Enables GPs to better target mental health care intervention

All of the above lead to improved patient experience and health outcomes through more effective commissioning of services.

Yielded Benefits is not a requirement for new applications.