DSfC NHS Bedfordshire, Luton and Milton Keynes CCG - IV, RS and COMM (ICS Sub-License)

INVOICE VALIDATION

Invoice validation is part of a process by which providers of care or services get paid for the work they do.

Invoices are submitted to the Clinical Commissioning Group (CCG) so the CCG is able to ensure that the activity claimed for each patient is their responsibility. This is done by processing and analysing Secondary User Services (SUS+) data, which is received into a secure Controlled Environment for Finance (CEfF). The SUS+ data is identifiable at the level of NHS number. The NHS number is only used to confirm the accuracy of backing-data sets (data from providers

The CCG are advised by the appointed CEfF whether payment for invoices can be made or not.

Invoice Validation will be conducted by Liaison Financial Services Ltd, NHS Arden and GEM CSU and NHS Bedfordshire, Luton and Milton Keynes CCG.

Liaison Financial Services Ltd conduct an independent ad-hoc review on retrospective payments made. Investing resource, skills and experience into deeper reconciliation, this identifies overcharges already paid and recovers savings for the CCG that would otherwise be lost.

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 Prescribing Services Ltd

COMMISSIONING

To use pseudonymised data to provide intelligence to support the commissioning of health services. The data (containing both clinical and financial information) is analysed so that health care provision can be planned to support the needs of the population within the CCG area.

The CCGs commission services from a range of providers covering a wide array of services. Each of the data flow categories requested supports the commissioned activity of one or more providers.

The following pseudonymised datasets are required to provide intelligence to support commissioning of health services:

- Secondary Uses Service (SUS+)

- Local Provider Flows

o Acute

o Ambulance

o Community

o Demand for Service

o Diagnostic Service

o Emergency Care

o Experience, Quality and Outcomes

o Mental Health

o Other Not Elsewhere Classified

o Population Data

o Primary Care Services

o Public Health Screening

- Mental Health Minimum Data Set (MHMDS)

- Mental Health Learning Disability Data Set (MHLDDS)

- Mental Health Services Data Set (MHSDS)

- Maternity Services Data Set (MSDS)

- Improving Access to Psychological Therapy (IAPT)

- Child and Young People Health Service (CYPHS)

- Community Services Data Set (CSDS)

- Diagnostic Imaging Data Set (DIDS)

- National Cancer Waiting Times Monitoring Data Set (CWT)

- Civil Registries Data (CRD) (Births)

- Civil Registries Data (CRD) (Deaths)

- National Diabetes Audit (NDA)

- Patient Reported Outcome Measures (PROMs)

- e-Referral Service (eRS)

- Personal Demographics Service (PDS)

- Summary Hospital-level Mortality Indicator (SHMI)

- Medicines Dispensed in Primary Care (NHSBSA Data)

- Adult Social Care Data

Processing of the Medicines Dispensed in Primary Care (NHSBSA Data) dataset is only permitted to provide intelligence about the safety and effectiveness of medicines, as specified by the NHS Business Services Authority (NHSBSA) Medicines Data Directions 2019.

The pseudonymised data is required to for the following purposes:

 Population health management:

• Understanding the interdependency of care services

• Targeting care more effectively

 Data Quality and Validation – allowing data quality checks on the submitted data

 Thoroughly investigating the needs of the population, to ensure the right services are available for individuals when and where they need them

 Understanding cohorts of residents who are at risk of becoming users of some of the more expensive services, to better understand and manage those needs

 Monitoring population health and care interactions to understand where people may slip through the net, or where the provision of care may be being duplicated

 Modelling activity across all data sets to understand how services interact with each other, and to understand how changes in one service may affect flows through another

 Service redesign

 Health Needs Assessment – identification of underlying disease prevalence within the local population

 Patient stratification and predictive modelling - to highlight cohorts of patients at risk of requiring hospital admission and other avoidable factors such as risk of falls, computed using algorithms executed against linked de-identified data, and identification of future service delivery models

 Demand Management - to improve the care service for patients by predicting the impact on certain care pathways and support the secondary care system in ensuring enough capacity to manage the demand.

 Support measuring the health, mortality or care needs of the total local population.

 Provide intelligence about the safety and effectiveness of medicines.

 Allow analysis of patient pathways across healthcare and social care.

The pseudonymised data is required to ensure that analysis of health care provision can be completed to support the needs of the health profile of the population within the CCG area based on the full analysis of multiple pseudonymised datasets. The added GP linkage will enhance the population health analytics beyond SUS and LPF's which contain only secondary care activity.

Processing for commissioning will be conducted by NHS Arden and GEM Commissioning Support Unit, NHS North and East London Commissioning Support Unit, NHS South, Central and West Commissioning Support Unit, RSR Consultants Ltd, Optum Health Solutions (UK) Ltd and Circle Health.

Circle Health - this processing allows for the correct charging mechanisms to be applied across the local healthcare system thereby facilitating efficient use of public monies which can support the delivery of frontline healthcare in the local area.

RSR Consultants Ltd - processes the data to help to identify changes that are most likely changes in how activity is coded and counted rather than changes in patient care as well as help understand the likely financial impact. They also provide additional capacity for general commissioning reporting

SUB-LICENSING

In order to assure a smooth transition to the new commissioning landscape, the CCG’s need to be able to share data with members of their Integrated Care System (ICS) in the interim period before April 2022. Currently the CCGs are prevented from giving access to other organisations due to the anonymised small number suppression rule for onward sharing.

The ICS Sub-License approach will allow the CCG to share data they receive from NHS Digital via this agreement with members of their ICS. This will be limited to pseudonymised commissioning data with the provider unique local patient id excluded. All data sharing will be restricted to ICS members within the area the CCG is part of and only for the sole purpose of Commissioning.

INVOICE VALIDATION

1. The Controlled Environment for Finance (CEfF) will enable the CCG to challenge invoices and raise discrepancies and disputes.

2. Outputs from the CEfF will enable accurate production of budget reports, which will:

a. Assist in addressing poor quality data issues

b. Assist in business intelligence

3. Validation of invoices for non-contracted events where a service delivered to a patient by a provider that does not have a written contract with the patient’s responsible commissioner, but does have a written contract with another NHS commissioner/s.

4. Budget control of the CCG.

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 by allowing GP's to target 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

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.

COMMISSIONING

1. Commissioner reporting:

a. Summary by provider view - plan & actuals year to date (YTD).

b. Summary by Patient Outcome Data (POD) view - plan & actuals YTD.

c. Summary by provider view - activity & finance variance by POD.

d. Planned care by provider view - activity & finance plan & actuals YTD.

e. Planned care by POD view - activity plan & actuals YTD.

f. Provider reporting.

g. Statutory returns.

h. Statutory returns - monthly activity return.

i. Statutory returns - quarterly activity return.

j. Delayed discharges.

k. Quality & performance referral to treatment reporting.

2. Readmissions analysis.

3. Production of aggregate reports for CCG Business Intelligence.

4. Production of project / programme level dashboards.

5. Monitoring of acute / community / mental health quality matrix.

6. Clinical coding reviews / audits.

7. Budget reporting down to individual GP Practice level.

8. GP Practice level dashboard reports.

9. Comparators of CCG performance with similar CCGs as set out by a specific range of care quality and performance measures detailed activity and cost reports

10. Data Quality and Validation measures allowing data quality checks on the submitted data

11. Contract Management and Modelling

12. Patient Stratification, such as:

o Patients at highest risk of admission

o High cost activity uses (top 15%)

o Frail and elderly

o Patients that are currently in hospital

o Patients with most referrals to secondary care

o Patients with most emergency activity

o Patients with most expensive prescriptions

o Patients recently moving from one care setting to another

i. Discharged from hospital

ii. Discharged from community

13. Validation for payment approval, ability to validate that claims are not being made after an individual has died, like Oxygen services.

14. Validation of programs implemented to improve patient pathway e.g. High users unable to validate if the process to help patients find the best support are working or did the patient die.

15. Clinical - understand reasons why patients are dying, what additional support services can be put in to support.

16. Understanding where patient are dying e.g. are patients dying at hospitals due to hospices closing due to Local authorities withdrawing support, or is there a problem at a particular trust.

17. Removal of patients from Risk Stratification reports.

18. Re births provide a one stop shop of information, Births are recorded in multiple sources covering hospital and home births, a chance to overlook activity.

19. Manage demand, by understanding the quantity of assessments required CCGs are able to improve the care service for patients by predicting the impact on certain care pathways and ensure the secondary care system has enough capacity to manage the demand.

20. Monitor the timing of key actions relating to referral letters. CCG’s are unable to see the contents of the referral letters.

21. Identify low priority procedures which could be directed to community-based alternatives and as such commission these services and deflect referrals for low priority procedures resulting in a reduction in hospital referrals.

22. Allow Commissioners to better protect or improve the public health of the total local patient population

23. Allow Commissioners to plan, evaluate and monitor health and social care policies, services, or interventions for the total local patient population

24. Allow Commissioners to compare their providers (trusts) mortality outcomes to the national baseline.

25. Investigate mortality outcomes for trusts.

26. Identify medication prescribing trends and their effectiveness.

27. Linking prescribing habits to entry points into the health and social care system

28. Identify, quantify and understand cohorts of patient’s high numbers of different medications (polypharmacy)

29. Monitoring, at a population level, particular cohorts of service users and designing analytical models which support more effective interventions in health and adult social care

30. Monitoring service and integrated care outcomes across a pathway or care setting involving adult social care

RSR Consultants Ltd

It is important that the limited resources available to the NHS are utilised in the best way possible for patient care. NHS England have set out, via the NHS Standard Contract, that changes in coding and counting are locally notified so that changes in how patient care are reported are:

1. identified as changes in coding and counting rather than changes in actual care

2. locally discussed to ensure they are valid changes and

3. any financial impact from the change is neutralised for the required amount of time so that the financial impact can be properly planned for.

Circle Health -

Line level data is converted into pivot table which summarises commissioned activity by speciality, HRG subchapter and activity type (outpatient/inpatient).

The CCG has published their annual report to show their use of the data and the benefits they have seen over the past year - https://www.blmkccg.nhs.uk/documents/blmk-annual-review/

During the first wave of the Covid-19 pandemic BLMK CCG worked with Luton Adult Community Health Services to review people with diabetes at the highest risk of harm. They also created a virtual Multi-Disciplinary Team (MDT) – a GP, Diabetes Specialist Pharmacists, Diabetes Specialist Nurse and District Nurses, to combine expertise and discuss and agree ways to help people with more complex issues. Using the data provided by NHS Digital and linked to GP data, the CCG was able to get a full understating of the current patient pathway of diabetes patients

The CCG also worked with Milton Keynes Council in partnership to open a new health centre so support future demand and GP services. Having access to the data allowed the CCG to discover the best location for this health centre to ensure it met patient demand

INVOICE VALIDATION

Invoice validation is part of a process by which providers of care or services get paid for the work they do.

Invoices are submitted to the Clinical Commissioning Group (CCG) so the CCG is able to ensure that the activity claimed for each patient is their responsibility. This is done by processing and analysing Secondary User Services (SUS+) data, which is received into a secure Controlled Environment for Finance (CEfF). The SUS+ data is identifiable at the level of NHS number. The NHS number is only used to confirm the accuracy of backing-data sets (data from providers

The CCG are advised by the appointed CEfF whether payment for invoices can be made or not.

Invoice Validation will be conducted by Liaison Financial Services Ltd, NHS Arden and GEM CSU and NHS Bedfordshire, Luton and Milton Keynes CCG.

Liaison Financial Services Ltd conduct an independent ad-hoc review on retrospective payments made. Investing resource, skills and experience into deeper reconciliation, this identifies overcharges already paid and recovers savings for the CCG that would otherwise be lost.

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 Prescribing Services Ltd

COMMISSIONING

To use pseudonymised data to provide intelligence to support the commissioning of health services. The data (containing both clinical and financial information) is analysed so that health care provision can be planned to support the needs of the population within the CCG area.

The CCGs commission services from a range of providers covering a wide array of services. Each of the data flow categories requested supports the commissioned activity of one or more providers.

The following pseudonymised datasets are required to provide intelligence to support commissioning of health services:

- Secondary Uses Service (SUS+)

- Local Provider Flows

o Acute

o Ambulance

o Community

o Demand for Service

o Diagnostic Service

o Emergency Care

o Experience, Quality and Outcomes

o Mental Health

o Other Not Elsewhere Classified

o Population Data

o Primary Care Services

o Public Health Screening

- Mental Health Minimum Data Set (MHMDS)

- Mental Health Learning Disability Data Set (MHLDDS)

- Mental Health Services Data Set (MHSDS)

- Maternity Services Data Set (MSDS)

- Improving Access to Psychological Therapy (IAPT)

- Child and Young People Health Service (CYPHS)

- Community Services Data Set (CSDS)

- Diagnostic Imaging Data Set (DIDS)

- National Cancer Waiting Times Monitoring Data Set (CWT)

- Civil Registries Data (CRD) (Births)

- Civil Registries Data (CRD) (Deaths)

- National Diabetes Audit (NDA)

- Patient Reported Outcome Measures (PROMs)

- e-Referral Service (eRS)

- Personal Demographics Service (PDS)

- Summary Hospital-level Mortality Indicator (SHMI)

- Medicines Dispensed in Primary Care (NHSBSA Data)

- Adult Social Care Data

The pseudonymised data is required to for the following purposes:

 Population health management:

• Understanding the interdependency of care services

• Targeting care more effectively

 Data Quality and Validation – allowing data quality checks on the submitted data

 Thoroughly investigating the needs of the population, to ensure the right services are available for individuals when and where they need them

 Understanding cohorts of residents who are at risk of becoming users of some of the more expensive services, to better understand and manage those needs

 Monitoring population health and care interactions to understand where people may slip through the net, or where the provision of care may be being duplicated

 Modelling activity across all data sets to understand how services interact with each other, and to understand how changes in one service may affect flows through another

 Service redesign

 Health Needs Assessment – identification of underlying disease prevalence within the local population

 Patient stratification and predictive modelling - to highlight cohorts of patients at risk of requiring hospital admission and other avoidable factors such as risk of falls, computed using algorithms executed against linked de-identified data, and identification of future service delivery models

 Demand Management - to improve the care service for patients by predicting the impact on certain care pathways and support the secondary care system in ensuring enough capacity to manage the demand.

 Support measuring the health, mortality or care needs of the total local population.

 Provide intelligence about the safety and effectiveness of medicines.

 Allow analysis of patient pathways across healthcare and social care.

The pseudonymised data is required to ensure that analysis of health care provision can be completed to support the needs of the health profile of the population within the CCG area based on the full analysis of multiple pseudonymised datasets. The added GP linkage will enhance the population health analytics beyond SUS and LPF's which contain only secondary care activity.

Processing for commissioning will be conducted by NHS Arden and GEM Commissioning Support Unit, NHS North and East London Commissioning Support Unit, NHS South, Central and West Commissioning Support Unit, RSR Consultants Ltd, Optum Health Solutions (UK) Ltd and Circle Health.

Circle Health - this processing allows for the correct charging mechanisms to be applied across the local healthcare system thereby facilitating efficient use of public monies which can support the delivery of frontline healthcare in the local area.

RSR Consultants Ltd - processes the data to help to identify changes that are most likely changes in how activity is coded and counted rather than changes in patient care as well as help understand the likely financial impact. They also provide additional capacity for general commissioning reporting

INVOICE VALIDATION

1. The Controlled Environment for Finance (CEfF) will enable the CCG to challenge invoices and raise discrepancies and disputes.

2. Outputs from the CEfF will enable accurate production of budget reports, which will:

a. Assist in addressing poor quality data issues

b. Assist in business intelligence

3. Validation of invoices for non-contracted events where a service delivered to a patient by a provider that does not have a written contract with the patient’s responsible commissioner, but does have a written contract with another NHS commissioner/s.

4. Budget control of the CCG.

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

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.

COMMISSIONING

1. Commissioner reporting:

a. Summary by provider view - plan & actuals year to date (YTD).

b. Summary by Patient Outcome Data (POD) view - plan & actuals YTD.

c. Summary by provider view - activity & finance variance by POD.

d. Planned care by provider view - activity & finance plan & actuals YTD.

e. Planned care by POD view - activity plan & actuals YTD.

f. Provider reporting.

g. Statutory returns.

h. Statutory returns - monthly activity return.

i. Statutory returns - quarterly activity return.

j. Delayed discharges.

k. Quality & performance referral to treatment reporting.

2. Readmissions analysis.

3. Production of aggregate reports for CCG Business Intelligence.

4. Production of project / programme level dashboards.

5. Monitoring of acute / community / mental health quality matrix.

6. Clinical coding reviews / audits.

7. Budget reporting down to individual GP Practice level.

8. GP Practice level dashboard reports.

9. Comparators of CCG performance with similar CCGs as set out by a specific range of care quality and performance measures detailed activity and cost reports

10. Data Quality and Validation measures allowing data quality checks on the submitted data

11. Contract Management and Modelling

12. Patient Stratification, such as:

o Patients at highest risk of admission

o High cost activity uses (top 15%)

o Frail and elderly

o Patients that are currently in hospital

o Patients with most referrals to secondary care

o Patients with most emergency activity

o Patients with most expensive prescriptions

o Patients recently moving from one care setting to another

i. Discharged from hospital

ii. Discharged from community

13. Validation for payment approval, ability to validate that claims are not being made after an individual has died, like Oxygen services.

14. Validation of programs implemented to improve patient pathway e.g. High users unable to validate if the process to help patients find the best support are working or did the patient die.

15. Clinical - understand reasons why patients are dying, what additional support services can be put in to support.

16. Understanding where patient are dying e.g. are patients dying at hospitals due to hospices closing due to Local authorities withdrawing support, or is there a problem at a particular trust.

17. Removal of patients from Risk Stratification reports.

18. Re births provide a one stop shop of information, Births are recorded in multiple sources covering hospital and home births, a chance to overlook activity.

19. Manage demand, by understanding the quantity of assessments required CCGs are able to improve the care service for patients by predicting the impact on certain care pathways and ensure the secondary care system has enough capacity to manage the demand.

20. Monitor the timing of key actions relating to referral letters. CCG’s are unable to see the contents of the referral letters.

21. Identify low priority procedures which could be directed to community-based alternatives and as such commission these services and deflect referrals for low priority procedures resulting in a reduction in hospital referrals.

22. Allow Commissioners to better protect or improve the public health of the total local patient population

23. Allow Commissioners to plan, evaluate and monitor health and social care policies, services, or interventions for the total local patient population

24. Allow Commissioners to compare their providers (trusts) mortality outcomes to the national baseline.

25. Investigate mortality outcomes for trusts.

26. Identify medication prescribing trends and their effectiveness.

27. Linking prescribing habits to entry points into the health and social care system

28. Identify, quantify and understand cohorts of patient’s high numbers of different medications (polypharmacy)

29. Monitoring, at a population level, particular cohorts of service users and designing analytical models which support more effective interventions in health and adult social care

30. Monitoring service and integrated care outcomes across a pathway or care setting involving adult social care

RSR Consultants Ltd

It is important that the limited resources available to the NHS are utilised in the best way possible for patient care. NHS England have set out, via the NHS Standard Contract, that changes in coding and counting are locally notified so that changes in how patient care are reported are:

1. identified as changes in coding and counting rather than changes in actual care

2. locally discussed to ensure they are valid changes and

3. any financial impact from the change is neutralised for the required amount of time so that the financial impact can be properly planned for.

Circle Health -

Line level data is converted into pivot table which summarises commissioned activity by speciality, HRG subchapter and activity type (outpatient/inpatient).

INVOICE VALIDATION

Invoice validation is part of a process by which providers of care or services get paid for the work they do.

Invoices are submitted to the Clinical Commissioning Group (CCG) so the CCG is able to ensure that the activity claimed for each patient is their responsibility. This is done by processing and analysing Secondary User Services (SUS+) data, which is received into a secure Controlled Environment for Finance (CEfF). The SUS+ data is identifiable at the level of NHS number. The NHS number is only used to confirm the accuracy of backing-data sets (data from providers

The CCG are advised by the appointed CEfF whether payment for invoices can be made or not.

Invoice Validation will be conducted by Liaison Financial Services Ltd, NHS Arden and GEM CSU and NHS Bedfordshire, Luton and Milton Keynes CCG.

Liaison Financial Services Ltd conduct an independent ad-hoc review on retrospective payments made. Investing resource, skills and experience into deeper reconciliation, this identifies overcharges already paid and recovers savings for the CCG that would otherwise be lost.

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 Prescribing Services Ltd

COMMISSIONING

To use pseudonymised data to provide intelligence to support the commissioning of health services. The data (containing both clinical and financial information) is analysed so that health care provision can be planned to support the needs of the population within the CCG area.

The CCGs commission services from a range of providers covering a wide array of services. Each of the data flow categories requested supports the commissioned activity of one or more providers.

The following pseudonymised datasets are required to provide intelligence to support commissioning of health services:

- Secondary Uses Service (SUS+)

- Local Provider Flows

o Acute

o Ambulance

o Community

o Demand for Service

o Diagnostic Service

o Emergency Care

o Experience, Quality and Outcomes

o Mental Health

o Other Not Elsewhere Classified

o Population Data

o Primary Care Services

o Public Health Screening

- Mental Health Minimum Data Set (MHMDS)

- Mental Health Learning Disability Data Set (MHLDDS)

- Mental Health Services Data Set (MHSDS)

- Maternity Services Data Set (MSDS)

- Improving Access to Psychological Therapy (IAPT)

- Child and Young People Health Service (CYPHS)

- Community Services Data Set (CSDS)

- Diagnostic Imaging Data Set (DIDS)

- National Cancer Waiting Times Monitoring Data Set (CWT)

- Civil Registries Data (CRD) (Births)

- Civil Registries Data (CRD) (Deaths)

- National Diabetes Audit (NDA)

- Patient Reported Outcome Measures (PROMs)

- e-Referral Service (eRS)

- Personal Demographics Service (PDS)

- Summary Hospital-level Mortality Indicator (SHMI)

- Medicines Dispensed in Primary Care (NHSBSA Data)

The pseudonymised data is required to for the following purposes:

 Population health management:

• Understanding the interdependency of care services

• Targeting care more effectively

• Using value as the redesign principle

 Data Quality and Validation – allowing data quality checks on the submitted data

 Thoroughly investigating the needs of the population, to ensure the right services are available for individuals when and where they need them

 Understanding cohorts of residents who are at risk of becoming users of some of the more expensive services, to better understand and manage those needs

 Monitoring population health and care interactions to understand where people may slip through the net, or where the provision of care may be being duplicated

 Modelling activity across all data sets to understand how services interact with each other, and to understand how changes in one service may affect flows through another

 Service redesign

 Health Needs Assessment – identification of underlying disease prevalence within the local population

 Patient stratification and predictive modelling - to highlight cohorts of patients at risk of requiring hospital admission and other avoidable factors such as risk of falls, computed using algorithms executed against linked de-identified data, and identification of future service delivery models

 Demand Management - to improve the care service for patients by predicting the impact on certain care pathways and support the secondary care system in ensuring enough capacity to manage the demand.

 Support measuring the health, mortality or care needs of the total local population.

 Provide intelligence about the safety and effectiveness of medicines.

The pseudonymised data is required to ensure that analysis of health care provision can be completed to support the needs of the health profile of the population within the CCG area based on the full analysis of multiple pseudonymised datasets. The added GP linkage will enhance the population health analytics beyond SUS and LPF's which contain only secondary care activity.

Processing for commissioning will be conducted by NHS Arden and GEM Commissioning Support Unit, NHS North and East London Commissioning Support Unit, NHS South, Central and West Commissioning Support Unit, RSR Consultants Ltd, AH Analysis, Optum Health Solutions (UK) Ltd and Circle Health.

Circle Health - this processing allows for the correct charging mechanisms to be applied across the local healthcare system thereby facilitating efficient use of public monies which can support the delivery of frontline healthcare in the local area.

RSR Consultants Ltd - processes the data to help to identify changes that are most likely changes in how activity is coded and counted rather than changes in patient care as well as help understand the likely financial impact. They also provide additional capacity for general commissioning reporting

AH Analysis Ltd currently analyses local data flows including Service Level Agreement Manager data within NHS Bedfordshire, Luton and Milton Keynes CCG and are therefore listed as a data processor. They supply support to the system, and will need to be a data processor going forward with access to SUS data flows. This will ensure they can support the development of Population Health analytics.

INVOICE VALIDATION

1. The Controlled Environment for Finance (CEfF) will enable the CCG to challenge invoices and raise discrepancies and disputes.

2. Outputs from the CEfF will enable accurate production of budget reports, which will:

a. Assist in addressing poor quality data issues

b. Assist in business intelligence

3. Validation of invoices for non-contracted events where a service delivered to a patient by a provider that does not have a written contract with the patient’s responsible commissioner, but does have a written contract with another NHS commissioner/s.

4. Budget control of the CCG.

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

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.

COMMISSIONING

1. Commissioner reporting:

a. Summary by provider view - plan & actuals year to date (YTD).

b. Summary by Patient Outcome Data (POD) view - plan & actuals YTD.

c. Summary by provider view - activity & finance variance by POD.

d. Planned care by provider view - activity & finance plan & actuals YTD.

e. Planned care by POD view - activity plan & actuals YTD.

f. Provider reporting.

g. Statutory returns.

h. Statutory returns - monthly activity return.

i. Statutory returns - quarterly activity return.

j. Delayed discharges.

k. Quality & performance referral to treatment reporting.

2. Readmissions analysis.

3. Production of aggregate reports for CCG Business Intelligence.

4. Production of project / programme level dashboards.

5. Monitoring of acute / community / mental health quality matrix.

6. Clinical coding reviews / audits.

7. Budget reporting down to individual GP Practice level.

8. GP Practice level dashboard reports.

9. Comparators of CCG performance with similar CCGs as set out by a specific range of care quality and performance measures detailed activity and cost reports

10. Data Quality and Validation measures allowing data quality checks on the submitted data

11. Contract Management and Modelling

12. Patient Stratification, such as:

o Patients at highest risk of admission

o High cost activity uses (top 15%)

o Frail and elderly

o Patients that are currently in hospital

o Patients with most referrals to secondary care

o Patients with most emergency activity

o Patients with most expensive prescriptions

o Patients recently moving from one care setting to another

i. Discharged from hospital

ii. Discharged from community

13. Validation for payment approval, ability to validate that claims are not being made after an individual has died, like Oxygen services.

14. Validation of programs implemented to improve patient pathway e.g. High users unable to validate if the process to help patients find the best support are working or did the patient die.

15. Clinical - understand reasons why patients are dying, what additional support services can be put in to support.

16. Understanding where patient are dying e.g. are patients dying at hospitals due to hospices closing due to Local authorities withdrawing support, or is there a problem at a particular trust.

17. Removal of patients from Risk Stratification reports.

18. Re births provide a one stop shop of information, Births are recorded in multiple sources covering hospital and home births, a chance to overlook activity.

19. Manage demand, by understanding the quantity of assessments required CCGs are able to improve the care service for patients by predicting the impact on certain care pathways and ensure the secondary care system has enough capacity to manage the demand.

20. Monitor the timing of key actions relating to referral letters. CCG’s are unable to see the contents of the referral letters.

21. Identify low priority procedures which could be directed to community-based alternatives and as such commission these services and deflect referrals for low priority procedures resulting in a reduction in hospital referrals.

22. Allow Commissioners to better protect or improve the public health of the total local patient population

23. Allow Commissioners to plan, evaluate and monitor health and social care policies, services, or interventions for the total local patient population

24. Allow Commissioners to compare their providers (trusts) mortality outcomes to the national baseline.

25. Investigate mortality outcomes for trusts.

26. Identify medication prescribing trends and their effectiveness.

27. Linking prescribing habits to entry points into the health and social care system

28. Identify, quantify and understand cohorts of patient’s high numbers of different medications (polypharmacy)

RSR Consultants Ltd

It is important that the limited resources available to the NHS are utilised in the best way possible for patient care. NHS England have set out, via the NHS Standard Contract, that changes in coding and counting are locally notified so that changes in how patient care are reported are:

1. identified as changes in coding and counting rather than changes in actual care

2. locally discussed to ensure they are valid changes and

3. any financial impact from the change is neutralised for the required amount of time so that the financial impact can be properly planned for.

Circle Health -

Line level data is converted into pivot table which summarises commissioned activity by speciality, HRG subchapter and activity type (outpatient/inpatient).

AH Analysis Ltd

1. Provides the monthly challenge process - running Structured Query Language (SQL) on SUS data to establish counting and coding queries. This ensures the CCG can query the level of detail it wishes to check as opposed to generic CSU packages.

2. Run the analytics for the CCG including Deep Dives for acute activity trends year on year actuals whereby using SUS to append age analysis, outcomes and Length Of Stay (LOS) to the SLAM billing data all of which is at an aggregated level to explain the story and why finances maybe affected adversely. The LOS is a length of stay which we can only usually obtain in SUS as local flows have started to exclude this due to the file sizes In addition LOS helps the CCG to look at for example patients admitted from Accident & Emergency with short LOS, this may be down to hospital flows and meeting their constitutional targets 4 hour wait

3. Provide full Primary Care Network (PCN) GP reporting to look at A&E slot attendance use by practice/locality, planned care volumes over time etc to support system management.

4. Also reconcile SUS to SLAM for assurance purposes which is standard reconciliation practice on acute contracts.

Ultimately the CCGs patients will benefit from improved pathways and service integration further to better decision making as a result of the provision of enhanced analytics. AH Analysis Ltd will require access all the data for the CCG where it can develop population health management analytics. This will support the CCG’s preventative care programme across primary care and the CCG's population health management initiatives. The CCG anticipate the need to use data at its lowest level to facilitate this agenda and for AH Analysis Ltd to actively support key workstreams owing to their expertise. This will support the development of the Integrated Care System (ICS) and enable decision makers to determine the best use of resource for their patient population, make best use of resources and reshape the way contracts are designed. AH Analysis Ltd will act as an enabler to provide the detailed analytics which enable the CCG to improve patient care and outcomes through the analysis and aggregation of such data.

INVOICE VALIDATION

Invoice validation is part of a process by which providers of care or services get paid for the work they do.

Invoices are submitted to the Clinical Commissioning Group (CCG) so the CCG is able to ensure that the activity claimed for each patient is their responsibility. This is done by processing and analysing Secondary User Services (SUS+) data, which is received into a secure Controlled Environment for Finance (CEfF). The SUS+ data is identifiable at the level of NHS number. The NHS number is only used to confirm the accuracy of backing-data sets (data from providers

The CCG are advised by the appointed CEfF whether payment for invoices can be made or not.

Invoice Validation will be conducted by Liaison Financial Services Ltd, NHS Arden and GEM CSU and NHS Bedfordshire, Luton and Milton Keynes CCG.

Liaison Financial Services Ltd conduct an independent ad-hoc review on retrospective payments made. Investing resource, skills and experience into deeper reconciliation, this identifies overcharges already paid and recovers savings for the CCG that would otherwise be lost.

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 Prescribing Services Ltd

COMMISSIONING

To use pseudonymised data to provide intelligence to support the commissioning of health services. The data (containing both clinical and financial information) is analysed so that health care provision can be planned to support the needs of the population within the CCG area.

The CCGs commission services from a range of providers covering a wide array of services. Each of the data flow categories requested supports the commissioned activity of one or more providers.

The following pseudonymised datasets are required to provide intelligence to support commissioning of health services:

- Secondary Uses Service (SUS+)

- Local Provider Flows

o Acute

o Ambulance

o Community

o Demand for Service

o Diagnostic Service

o Emergency Care

o Experience, Quality and Outcomes

o Mental Health

o Other Not Elsewhere Classified

o Population Data

o Primary Care Services

o Public Health Screening

- Mental Health Minimum Data Set (MHMDS)

- Mental Health Learning Disability Data Set (MHLDDS)

- Mental Health Services Data Set (MHSDS)

- Maternity Services Data Set (MSDS)

- Improving Access to Psychological Therapy (IAPT)

- Child and Young People Health Service (CYPHS)

- Community Services Data Set (CSDS)

- Diagnostic Imaging Data Set (DIDS)

- National Cancer Waiting Times Monitoring Data Set (CWT)

- Civil Registries Data (CRD) (Births)

- Civil Registries Data (CRD) (Deaths)

- National Diabetes Audit (NDA)

- Patient Reported Outcome Measures (PROMs)

- e-Referral Service (eRS)

- Personal Demographics Service (PDS)

- Summary Hospital-level Mortality Indicator (SHMI)

- Medicines Dispensed in Primary Care (NHSBSA Data)

The pseudonymised data is required to for the following purposes:

 Population health management:

• Understanding the interdependency of care services

• Targeting care more effectively

• Using value as the redesign principle

 Data Quality and Validation – allowing data quality checks on the submitted data

 Thoroughly investigating the needs of the population, to ensure the right services are available for individuals when and where they need them

 Understanding cohorts of residents who are at risk of becoming users of some of the more expensive services, to better understand and manage those needs

 Monitoring population health and care interactions to understand where people may slip through the net, or where the provision of care may be being duplicated

 Modelling activity across all data sets to understand how services interact with each other, and to understand how changes in one service may affect flows through another

 Service redesign

 Health Needs Assessment – identification of underlying disease prevalence within the local population

 Patient stratification and predictive modelling - to highlight cohorts of patients at risk of requiring hospital admission and other avoidable factors such as risk of falls, computed using algorithms executed against linked de-identified data, and identification of future service delivery models

 Demand Management - to improve the care service for patients by predicting the impact on certain care pathways and support the secondary care system in ensuring enough capacity to manage the demand.

 Support measuring the health, mortality or care needs of the total local population.

 Provide intelligence about the safety and effectiveness of medicines.

The pseudonymised data is required to ensure that analysis of health care provision can be completed to support the needs of the health profile of the population within the CCG area based on the full analysis of multiple pseudonymised datasets. The added GP linkage will enhance the population health analytics beyond SUS and LPF's which contain only secondary care activity.

Processing for commissioning will be conducted by NHS Arden and GEM Commissioning Support Unit, NHS North and East London Commissioning Support Unit, NHS South, Central and West Commissioning Support Unit, RSR Consultants Ltd, AH Analysis, Optum Health Solutions (UK) Ltd and Circle Health.

Circle Health - this processing allows for the correct charging mechanisms to be applied across the local healthcare system thereby facilitating efficient use of public monies which can support the delivery of frontline healthcare in the local area.

RSR Consultants Ltd - processes the data to help to identify changes that are most likely changes in how activity is coded and counted rather than changes in patient care as well as help understand the likely financial impact. They also provide additional capacity for general commissioning reporting

AH Analysis Ltd currently analyses local data flows including Service Level Agreement Manager data within NHS Bedfordshire, Luton and Milton Keynes CCG and are therefore listed as a data processor. They supply support to the system, and will need to be a data processor going forward with access to SUS data flows. This will ensure they can support the development of Population Health analytics.

INVOICE VALIDATION

1. The Controlled Environment for Finance (CEfF) will enable the CCG to challenge invoices and raise discrepancies and disputes.

2. Outputs from the CEfF will enable accurate production of budget reports, which will:

a. Assist in addressing poor quality data issues

b. Assist in business intelligence

3. Validation of invoices for non-contracted events where a service delivered to a patient by a provider that does not have a written contract with the patient’s responsible commissioner, but does have a written contract with another NHS commissioner/s.

4. Budget control of the CCG.

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

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.

COMMISSIONING

1. Commissioner reporting:

a. Summary by provider view - plan & actuals year to date (YTD).

b. Summary by Patient Outcome Data (POD) view - plan & actuals YTD.

c. Summary by provider view - activity & finance variance by POD.

d. Planned care by provider view - activity & finance plan & actuals YTD.

e. Planned care by POD view - activity plan & actuals YTD.

f. Provider reporting.

g. Statutory returns.

h. Statutory returns - monthly activity return.

i. Statutory returns - quarterly activity return.

j. Delayed discharges.

k. Quality & performance referral to treatment reporting.

2. Readmissions analysis.

3. Production of aggregate reports for CCG Business Intelligence.

4. Production of project / programme level dashboards.

5. Monitoring of acute / community / mental health quality matrix.

6. Clinical coding reviews / audits.

7. Budget reporting down to individual GP Practice level.

8. GP Practice level dashboard reports.

9. Comparators of CCG performance with similar CCGs as set out by a specific range of care quality and performance measures detailed activity and cost reports

10. Data Quality and Validation measures allowing data quality checks on the submitted data

11. Contract Management and Modelling

12. Patient Stratification, such as:

o Patients at highest risk of admission

o High cost activity uses (top 15%)

o Frail and elderly

o Patients that are currently in hospital

o Patients with most referrals to secondary care

o Patients with most emergency activity

o Patients with most expensive prescriptions

o Patients recently moving from one care setting to another

i. Discharged from hospital

ii. Discharged from community

13. Validation for payment approval, ability to validate that claims are not being made after an individual has died, like Oxygen services.

14. Validation of programs implemented to improve patient pathway e.g. High users unable to validate if the process to help patients find the best support are working or did the patient die.

15. Clinical - understand reasons why patients are dying, what additional support services can be put in to support.

16. Understanding where patient are dying e.g. are patients dying at hospitals due to hospices closing due to Local authorities withdrawing support, or is there a problem at a particular trust.

17. Removal of patients from Risk Stratification reports.

18. Re births provide a one stop shop of information, Births are recorded in multiple sources covering hospital and home births, a chance to overlook activity.

19. Manage demand, by understanding the quantity of assessments required CCGs are able to improve the care service for patients by predicting the impact on certain care pathways and ensure the secondary care system has enough capacity to manage the demand.

20. Monitor the timing of key actions relating to referral letters. CCG’s are unable to see the contents of the referral letters.

21. Identify low priority procedures which could be directed to community-based alternatives and as such commission these services and deflect referrals for low priority procedures resulting in a reduction in hospital referrals.

22. Allow Commissioners to better protect or improve the public health of the total local patient population

23. Allow Commissioners to plan, evaluate and monitor health and social care policies, services, or interventions for the total local patient population

24. Allow Commissioners to compare their providers (trusts) mortality outcomes to the national baseline.

25. Investigate mortality outcomes for trusts.

26. Identify medication prescribing trends and their effectiveness.

27. Linking prescribing habits to entry points into the health and social care system

28. Identify, quantify and understand cohorts of patient’s high numbers of different medications (polypharmacy)

RSR Consultants Ltd

It is important that the limited resources available to the NHS are utilised in the best way possible for patient care. NHS England have set out, via the NHS Standard Contract, that changes in coding and counting are locally notified so that changes in how patient care are reported are:

1. identified as changes in coding and counting rather than changes in actual care

2. locally discussed to ensure they are valid changes and

3. any financial impact from the change is neutralised for the required amount of time so that the financial impact can be properly planned for.

Circle Health -

Line level data is converted into pivot table which summarises commissioned activity by speciality, HRG subchapter and activity type (outpatient/inpatient).

AH Analysis Ltd

1. Provides the monthly challenge process - running Structured Query Language (SQL) on SUS data to establish counting and coding queries. This ensures the CCG can query the level of detail it wishes to check as opposed to generic CSU packages.

2. Run the analytics for the CCG including Deep Dives for acute activity trends year on year actuals whereby using SUS to append age analysis, outcomes and Length Of Stay (LOS) to the SLAM billing data all of which is at an aggregated level to explain the story and why finances maybe affected adversely. The LOS is a length of stay which we can only usually obtain in SUS as local flows have started to exclude this due to the file sizes In addition LOS helps the CCG to look at for example patients admitted from Accident & Emergency with short LOS, this may be down to hospital flows and meeting their constitutional targets 4 hour wait

3. Provide full Primary Care Network (PCN) GP reporting to look at A&E slot attendance use by practice/locality, planned care volumes over time etc to support system management.

4. Also reconcile SUS to SLAM for assurance purposes which is standard reconciliation practice on acute contracts.

Ultimately the CCGs patients will benefit from improved pathways and service integration further to better decision making as a result of the provision of enhanced analytics. AH Analysis Ltd will require access all the data for the CCG where it can develop population health management analytics. This will support the CCG’s preventative care programme across primary care and the CCG's population health management initiatives. The CCG anticipate the need to use data at its lowest level to facilitate this agenda and for AH Analysis Ltd to actively support key workstreams owing to their expertise. This will support the development of the Integrated Care System (ICS) and enable decision makers to determine the best use of resource for their patient population, make best use of resources and reshape the way contracts are designed. AH Analysis Ltd will act as an enabler to provide the detailed analytics which enable the CCG to improve patient care and outcomes through the analysis and aggregation of such data.

Yielded Benefits is not a requirement for new applications.