Population Health Use-Cases

Johns Hopkins Patient Needs Groups

The Johns Hopkins algorithm generates a range of outputs.

The ACG “Patient Needs Group” are returned as an Observation. To request this specific output the below query can be used:

GET /Observation?patient.identifier=https://fhir.nhs.uk/Id/nhs-number|[nhsnumber]&patient.birthdate=[birthdate]&category=http://snomed.info/sct|864411000000101&code=https://fhir.graphnethealth.com/CodeSystem-ACGPatientNeedGroups|[code]

This code filter uses a single code for this specific score. It is possible to construct a search using a predefined ValueSet that defines a collection of codes.

The ValueSets that are available for this function will evolve over time. Speak to Graphnet if you intend to use this capability.

A patient may have several scores over time as their score is recalculated, and these will be returned in date order (latest first), so if you just want the latest, it will be the first result. You can request a page size of 1 by adding &_count=1 in the request.

Codes that can be returned are:

Code Display
PNG-01 Non User
PNG-02 Low Need Child
PNG-03 Low Need Adult
PNG-04 Multi-Morbidity Low Complexity
PNG-05 Multi-Morbidity Medium Complexity
PNG-06 Pregnancy Low Complexity
PNG-07 Pregnancy High Complexity
PNG-08 Dominant Psychiatric Condition
PNG-09 Dominant Major Chronic Condition
PNG-10 Multi-Morbidity High Complexity
PNG-11 Frailty

Example response:

{
"resourceType": "Bundle",
"id": "b83a14ed-5d00-41b8-bdca-4f2f97a0a317",
"meta": {
"versionId": "1c56623e-0e14-4c70-89ae-3b1b82f50abc",
"lastUpdated": "2025-02-04T13:12:35.496+00:00"
},
"type": "searchset",
"total": 1,
"link": [
{
"relation": "self",
"url": "https://api-live.grhapp.com/R4/Observation?patient.identifier=https%3A%2F%2Ffhir.nhs.uk%2FId%2Fnhs-number%7C9839281437&patient.birthdate=1980-01-02&category=http%3A%2F%2Fsnomed.info%2Fsct%7C864411000000101&code=https%3A%2F%2Ffhir.graphnethealth.com%2FCodeSystem-ACGPatientNeedGroups%7C&_sort=-_lastUpdated&_requestId=031fc016-1e47-4cdc-9bd1-bb21bf9671e1&_count=5&_skip=0"
}
],
"entry": [
{
"fullUrl": "https://api-live.grhapp.com/R4/Observation/JLF2ZMWM7BR7WRF654RWHXYPSU",
"resourceType": "Observation",
"id": "JLF2ZMWM7BR7WRF654RWHXYPSU",
"meta": {
"versionId": "BLUPXPDT3HMBJPLNCDFLFOEVGM",
"lastUpdated": "2025-02-04T12:18:19+00:00",
"profile": [
"https://fhir.hl7.org.uk/StructureDefinition/UKCore-Observation"
],
"tag": [
{
"system": "https://fhir.graphnethealth.com/CodeSystem-Tenancies",
"code": "998"
}
]
},
{
"system": "https://api.graphnethealth.com/ID/PopHealthInsights",
"value": "0cd86205-aa38-467e-8036-bf7763f05a7d"
}
],
"status": "final",
{
"coding": [
{
"system": "http://snomed.info/sct",
"code": "864411000000101",
"display": "Johns Hopkins adjusted clinical groups system score (observable entity)"
}
]
}
],
"code": {
"coding": [
{
"system": "https://fhir.graphnethealth.com/CodeSystem-ACGPatientNeedGroups",
"code": "PNG-06",
"display": "Low Complexity Pregnancy"
}
]
},
"subject": {
"reference": "https://api-live.grhapp.com/R4/Patient/KWOS5NLJORPXN5PONWAGMLFHUF37ZN5FDHK6GMKACT2QEFY7K5KQ"
},
"effectiveDateTime": "2024-12-20T07:33:15.566Z",
"issued": "2024-12-20T07:33:15.566+00:00"
},
"search": {
"mode": "match"
}
}
]
}

Pre-Operative Triage Category

The pre-operative triage generates a level (Red, Orange, Green or Gold).

The pre-operative triage category is returned as an Observation. To request this specific output the below query can be used:

GET /Observation?patient.identifier=https://fhir.nhs.uk/Id/nhs-number|[nhsnumber]&patient.birthdate=[birthdate]&category=https://fhir.graphnethealth.com/CodeSystem-PopHealthInsights|POT&code=https://fhir.graphnethealth.com/CodeSystem-PreOpTriage|[code]

This code filter uses a single code for this specific score. It is possible to construct a search using a predefined ValueSet that defines a collection of codes.

The ValueSets that are available for this function will evolve over time. Speak to Graphnet if you intend to use this capability.

A patient may have several scores over time as their score is recalculated, and these will be returned in date order (latest first), so if you just want the latest, it will be the first result. You can request a page size of 1 by adding &_count=1 in the request.

Codes that can be returned are:

Code Display
gold Gold
green Green
orange Orange
red Red

Example response:

{
"resourceType": "Bundle",
"id": "048ff8ee-0344-4680-b9b3-ff48f0ae8804",
"meta": {
"versionId": "fd3e3790-8729-4d05-a189-8e1522bf5e8c",
"lastUpdated": "2025-02-04T13:18:39.088+00:00"
},
"type": "searchset",
"total": 1,
"link": [
{
"relation": "self",
"url": "https://api-live.grhapp.com/R4/Observation?patient.identifier=https%3A%2F%2Ffhir.nhs.uk%2FId%2Fnhs-number%7C9839281437&patient.birthdate=1980-01-02&category=https%3A%2F%2Ffhir.graphnethealth.com%2FCodeSystem-PopHealthInsights%7CPOT&code=https%3A%2F%2Ffhir.graphnethealth.com%2FCodeSystem-PreOpTriage%7C&_sort=-_lastUpdated&_requestId=0a43e6dc-13ed-4848-90d7-0470fe6ae25a&_count=5&_skip=0"
}
],
"entry": [
{
"fullUrl": "https://api-live.grhapp.com/R4/Observation/462G2HCOEXYYNTTGOG72XW7QFM",
"resourceType": "Observation",
"id": "462G2HCOEXYYNTTGOG72XW7QFM",
"meta": {
"versionId": "ANPEJ6RCZREHSEBADND3XYAOYU",
"lastUpdated": "2025-02-04T12:28:03+00:00",
"profile": [
"https://fhir.hl7.org.uk/StructureDefinition/UKCore-Observation"
],
"tag": [
{
"system": "https://fhir.graphnethealth.com/CodeSystem-Tenancies",
"code": "998"
}
]
},
{
"system": "https://api.graphnethealth.com/ID/PopHealthInsights",
"value": "bb879e0d-1326-4020-8728-0bdb97d6e905"
}
],
"status": "final",
{
"coding": [
{
"system": "https://fhir.graphnethealth.com/CodeSystem-PopHealthInsights",
"code": "POT",
"display": "Pre-Operative Triage"
}
]
}
],
"code": {
"coding": [
{
"system": "https://fhir.graphnethealth.com/CodeSystem-PreOpTriage",
"code": "gold",
"display": "Gold"
}
]
},
"subject": {
"reference": "https://api-live.grhapp.com/R4/Patient/KWOS5NLJORPXN5PONWAGMLFHUF37ZN5FDHK6GMKACT2QEFY7K5KQ"
},
"effectiveDateTime": "2024-12-21T08:35:15.566Z",
"issued": "2024-12-21T08:35:15.566+00:00"
},
"search": {
"mode": "match"
}
}
]
}

Early Patient Identification Category

The Early Patient Identification generates a code (Early Optimisation, Complex Patient, or Very Complex Patient).

The Early Patient Identification is returned as an Observation. To request this specific output the below query can be used:

GET /Observation?patient.identifier=https://fhir.nhs.uk/Id/nhs-number|[nhsnumber]&patient.birthdate=[birthdate]&category=https://fhir.graphnethealth.com/CodeSystem-PopHealthInsights|EPI&code=https://fhir.graphnethealth.com/CodeSystem-EarlyPatientIdentification|[code]

This code filter uses a single code for this specific score. It is possible to construct a search using a predefined ValueSet that defines a collection of codes.

The ValueSets that are available for this function will evolve over time. Speak to Graphnet if you intend to use this capability.

A patient may have several scores over time as their score is recalculated, and these will be returned in date order (latest first), so if you just want the latest, it will be the first result. You can request a page size of 1 by adding &_count=1 in the request.

Codes that can be returned are:

Code Display
eo Early Optimisation
cp Complex Patient
vcp Very Complex Patient

Example response:

{
"resourceType": "Bundle",
"id": "ec597c82-3771-4622-9a4c-b705fc1df25c",
"meta": {
"versionId": "52f942ca-b04c-4aae-b1d2-79d3362130b6",
"lastUpdated": "2025-02-04T13:25:04.574+00:00"
},
"type": "searchset",
"total": 1,
"link": [
{
"relation": "self",
"url": "https://api-live.grhapp.com/R4/Observation?patient.identifier=https%3A%2F%2Ffhir.nhs.uk%2FId%2Fnhs-number%7C9839281437&patient.birthdate=1980-01-02&category=https%3A%2F%2Ffhir.graphnethealth.com%2FCodeSystem-PopHealthInsights%7CEPI&code=https%3A%2F%2Ffhir.graphnethealth.com%2FCodeSystem-EarlyPatientIdentification%7C&_sort=-_lastUpdated&_requestId=369caa87-c8bf-4a3c-bd11-d524942334ed&_count=5&_skip=0"
}
],
"entry": [
{
"fullUrl": "https://api-live.grhapp.com/R4/Observation/R5Y3GLXLXR6AE36VVGSM42U6FQ",
"resourceType": "Observation",
"id": "R5Y3GLXLXR6AE36VVGSM42U6FQ",
"meta": {
"versionId": "RG7JXSUEW4JEBZ2KTGEBRSHGAY",
"lastUpdated": "2025-02-04T12:31:20+00:00",
"profile": [
"https://fhir.hl7.org.uk/StructureDefinition/UKCore-Observation"
],
"tag": [
{
"system": "https://fhir.graphnethealth.com/CodeSystem-Tenancies",
"code": "2"
},
{
"system": "https://fhir.graphnethealth.com/CodeSystem-TenancyType",
"code": "gp"
}
]
},
{
"system": "https://api.graphnethealth.com/ID/PopHealthInsights",
"value": "39b65e97-5444-4d99-afe7-bf1f685fc123"
}
],
"status": "final",
{
"coding": [
{
"system": "https://fhir.graphnethealth.com/CodeSystem-PopHealthInsights",
"code": "EPI",
"display": "Early Patient Identification"
}
]
}
],
"code": {
"coding": [
{
"system": "https://fhir.graphnethealth.com/CodeSystem-EarlyPatientIdentification",
"code": "vcp",
"display": "Very Complex Patient"
}
]
},
"subject": {
"reference": "https://api-live.grhapp.com/R4/Patient/KWOS5NLJORPXN5PONWAGMLFHUF37ZN5FDHK6GMKACT2QEFY7K5KQ"
},
"effectiveDateTime": "2024-12-22T09:36:15.566Z",
"issued": "2024-12-22T09:36:15.566+00:00"
},
"search": {
"mode": "match"
}
}
]
}