Identify · Prioritise · Act · Measure

Population Health Platform

Turn extracted primary care data into clear patient-level worklists and measurable improvement cycles.

DataMedic's Population Health Platform helps GP practices, PCNs and ICBs identify missed diagnoses, overdue monitoring, prevention gaps and patients requiring targeted review — using data extracts from EMIS Web and SystmOne.

5
Core Modules
3
Buyer Types Supported
SNOMED-led
Clinical Definitions
DM Worklist 📊 🩺 Population Health Platform Patient Worklist · Hypertension Register Gap ↓ Export SA 247 Patients Flagged 87 For Review 38 Actioned Last refresh 3 days ago ACTIVE WORKLIST · 87 PATIENTS REQUIRE REVIEW PATIENT REASON FLAGGED MODULE STATUS JB J. Blackwood, 64 DOB 04/03/1960 · NHS 487 321 9012 BP 158/98 × 3, no HYP code Case Find Review MR M. Rahman, 57 DOB 19/11/1966 · NHS 312 089 4451 eGFR 52, raised UACR, no CKD code CKD Urgent TP T. Patel, 49 DOB 22/07/1974 · NHS 621 447 8830 QRISK ≥10%, no statin prescribed CVD Prev Review SH S. Hassan, 72 DOB 08/01/1952 · NHS 554 203 1176 At-risk, no flu vaccination this season Vaccine Pending A. Williams, 61 HbA1c overdue — T2DM register Recall REFRESH COMPARISON — Hypertension Case Finding Previous extract Before Current extract After Improved Patients actioned after refresh · register updates confirmed Data refreshed 3 days ago

Primary care teams do not need more dashboards.
They need clear patient lists they can act on.

Static dashboards show variation, but they often stop short of the real question: which patients need action next?

Missed Diagnoses & Register Gaps

Patients may meet clinical criteria for conditions such as hypertension, CKD or diabetes without being coded on the correct register.

Overdue Monitoring & Recalls

Patients on long-term condition registers may be missing blood tests, BP checks, annual reviews or other key monitoring.

Uncontrolled CVD Risk

Patients with modifiable cardiovascular risk may need assessment, treatment optimisation or follow-up.

Prevention & Vaccination Gaps

At-risk patients may be missing vaccinations, screening support or preventive care opportunities.

Variation Across Practices & PCNs

Aggregated benchmarks show variation, but practices need patient-level cohorts to act consistently.

Difficulty Proving Impact

After improvement work, teams need a clear way to show what changed after the next data refresh.

DataMedic's Population Health Platform acts as the intelligence and measurement layer above existing clinical systems — helping teams identify, prioritise, act and measure improvement over time.

From extracted data to measurable improvement

A structured improvement cycle — from extracted data to measurable change.

The platform does not require live clinical-system integration to deliver value. It is designed around structured data refreshes and measurable improvement cycles.
1

Identify

Analyse structured EMIS Web or SystmOne extracts using SNOMED-led clinical logic.

Input: Structured data extract
2

Prioritise

Group patients into clinically meaningful cohorts: missing diagnosis, overdue monitoring, uncontrolled risk or prevention opportunity.

Output: Clinically defined cohorts
3

Act

Export patient-level lists for review, recall, coding checks or outreach using existing practice workflows.

Tool: Exportable patient worklists
4

Measure

After the next refresh, compare what changed, what improved and what remains outstanding.

Evidence: Pre/post comparison

Built around the areas primary care is already being asked to improve

The platform is being developed around five initial core modules, focused on the highest-impact areas in NHS primary care. Each module is designed to generate exportable patient-level worklists and support measurable improvement after data refreshes.

Case Finding & Register Integrity

Module 1 · Core

Identify patients who may meet criteria for long-term condition registers but are not coded appropriately.

  • Possible hypertension without coded diagnosis
  • Possible CKD without coded diagnosis
  • Possible type 2 diabetes without coded diagnosis
  • Non-diabetic hyperglycaemia identification
Supports coding quality, register accuracy and QOF-aligned improvement.

Monitoring & Recall Gaps

Module 2 · Core

Find patients on registers who are missing key monitoring or annual review components.

  • BP not recorded in last 12 months
  • HbA1c overdue in diabetes
  • Lipids overdue
  • UACR missing in diabetes or CKD
Creates practical recall lists for admin, HCA, pharmacist and clinical teams.

CVD Prevention & Risk Optimisation

Module 3 · Core

Surface patients with modifiable cardiovascular risk where review or treatment optimisation may be appropriate.

  • QRISK assessment missing where appropriate
  • QRISK ≥10% and no lipid-lowering therapy
  • Hypertension not at target
  • LDL or non-HDL above target
Supports prevention-focused CVD improvement across practices and PCNs.

Obesity & Weight Pathway Readiness

Module 4 · Core

Identify patients who may benefit from coding review, monitoring, weight-management support or pathway assessment.

  • BMI missing or outdated
  • Obesity likely but not coded
  • BMI ≥30 with weight-related comorbidities
  • BMI ≥35 with cardiometabolic risk factors
Supports structured obesity and prevention work using existing practice pathways.

Vaccination & Preventive Care Recovery

Module 5 · Core

Identify eligible patients with missing vaccination or preventive care activity.

Supports targeted prevention campaigns across practices, PCNs and ICBs.
Example Insights Generated
  • Flu vaccination gaps in at-risk groups
  • Pneumococcal vaccination gaps
  • Childhood vaccination recovery cohorts
  • Cervical screening support cohorts

Designed to expand without disrupting existing modules

The platform is designed to expand over time. Initial modules focus on the highest-impact areas in primary care, with additional modules released based on clinical priorities and customer feedback.

Modules shown below beyond the core set are part of the planned roadmap and are not yet available.

Core Modules (Initial Launch)

Initial launch focus

  • Case Finding & Register Integrity
  • Monitoring & Recall Gaps
  • CVD Prevention & Risk Optimisation
  • Obesity & Weight Pathway Readiness
  • Vaccination & Preventive Care Recovery
Coming Soon

Condition-Specific Modules

  • Medicines optimisation
  • Diabetes deep dive
  • CKD deep dive
  • Heart failure optimisation
  • Respiratory diagnostic accuracy & control
Future Roadmap

System-Level & Inequalities Intelligence

  • Health inequalities segmentation
  • PCN-level improvement tracking
  • ICB reporting views
  • Referral readiness & safety-netting

Works with existing practice workflows — not instead of them

The Population Health Platform does not replace EMIS Web, SystmOne, AccuRx or local recall processes. It provides the intelligence layer above them — identifying which patients need action and helping teams measure what changes after refreshes.

The platform does not send SMS messages, book appointments, write back to clinical systems or update patient records automatically. It generates patient-level worklists your team can act on using existing workflows.

Discuss How It Fits Your Workflow

What the platform does

  • Uses structured EMIS Web or SystmOne data extracts
  • Generates clinically defined patient cohorts
  • Produces exportable patient-level worklists
  • Supports local action using existing tools
  • Measures improvement after each data refresh
  • Operates without live write-back integration
EMIS Web
SystmOne
AccuRx
Local Admin

Data extracts from these systems feed the platform. The platform does not write back to any of them.

Built for practices, PCNs and ICBs

The platform is designed to support different tiers of primary care, with value at every level.

For GP Practices

  • Find missed patients quickly
  • Reduce manual search-building
  • Generate recall and review lists
  • Evidence improvement after refreshes

For PCNs

  • Standardise improvement work across practices
  • Support shared pharmacist, HCA and care coordinator workflows
  • Prioritise high-impact cohorts
  • Track progress across member practices

For ICBs

  • Move beyond benchmarking into patient-level improvement
  • Reduce unwarranted variation
  • Segment cohorts by deprivation, ethnicity and practice
  • Measure progress across local programmes

Not another passive dashboard

Many dashboards show variation. DataMedic helps teams do something about it.

Traditional Dashboard

  • Shows metrics and aggregated numbers
  • Requires local interpretation
  • Often lacks patient-level action
  • Hard to prove what changed

Population Health Platform

  • Shows the patients behind the metric
  • Provides clinically defined cohorts
  • Supports exportable worklists
  • Measures improvement after refreshes

The type of insight the platform generates

Each insight results in a patient-level cohort list with a suggested action and a measurable outcome after the next data refresh.

CKD · Case Finding
Possible CKD Not Coded
Cohort: Repeated eGFR <60 or raised UACR with no CKD diagnosis code
Suggested action: Clinical review and coding confirmation
Measured after refresh: CKD coded or remains outstanding
CVD · Risk Optimisation
QRISK ≥10% Not on Statin
Cohort: QRISK ≥10% with no lipid-lowering therapy recorded
Suggested action: Pharmacist or clinician review
Measured after refresh: Treatment started or remains outstanding
Vaccination · Prevention
At-Risk Patient Missing Flu Vaccination
Cohort: At-risk patient with no current season flu vaccination recorded
Suggested action: Invite using existing recall process
Measured after refresh: Vaccination recorded or remains outstanding

Ready to turn population health data into action?

See how DataMedic can help your practice, PCN or ICB turn extracted data into patient-level action and measurable improvement.

NHS primary care expertise, built in

Designed for the realities of NHS primary care — the systems, coding, clinical logic, and governance.

NHS Primary Care Data Expertise

SNOMED-led Clinical Definitions

EMIS Web & SystmOne Extract Experience

GDPR & NHS Data Security Aligned

UK-Focused Primary Care Analytics

Patient-Level Clinical Insight & Improvement Tracking