The challenge
HealthBridge Direct, a group of GP practices across Redbridge, needed to improve their prevalence lists for four key conditions: COPD, diabetes, hypertension and osteoporosis. Accurate prevalence data is essential for effective population health management, yet many patients with these conditions remain undiagnosed or uncoded in practice systems.
The scale of the task was considerable – supporting primary care networks across multiple practices and different clinical IT systems.
Our approach
We deployed our bespoke algorithms to tackle this challenge. These algorithms analyse electronic health records, searching for identifiers that suggest patients may have one of these four conditions but haven't been diagnosed or properly coded.
Our technology works systematically through patient records, identifying potential cases that might otherwise remain hidden in the vast amounts of data held by modern GP practices.
Delivering at scale and speed
We completed the analysis across:
- 42 practices within the network
- Four different clinical IT systems
- Four clinical conditions: COPD, diabetes, hypertension and osteoporosis
- All within two months of being commissioned
This rapid deployment meant practices could quickly act on our findings, ensuring patients with these conditions could be identified and receive appropriate care.
The outcome
By improving prevalence lists across HealthBridge Direct's network, we enabled more accurate population health management. Practices could now identify patients who needed reviews, monitoring or treatment for these chronic conditions, supporting better health outcomes across Redbridge's primary care networks.
