Good chronic-disease care is proactive and register-driven. commvita finds the people (population segmentation, QOF registers, frailty), closes the gaps (QOF indicators, recall, decision support) and manages the condition (seven condition hubs + a frailty virtual ward) — with a prevention & inequalities lens (CORE20PLUS5) over all of it.
Segment the population to find who needs proactive care, surface and close the care gaps, then run the condition on an evidence-based pathway — targeting effort where deprivation makes need greatest.
Population Health builds cohorts from free-text (“diabetics with HbA1c > 75 not reviewed in 12 months”) and portable open phenotypes; QOF registers hold the disease populations; Frailty scores CFS 1–9 and runs a virtual frailty ward.
QOF tracks 25 indicators across 21 domains with exception reporting and a GPES extract; Recall Management and Repeat Monitoring chase what's overdue; the CDSS Engine fires NICE/BNF-backed prompts in the consultation.
Integrated hubs for diabetes, respiratory, heart failure, stroke, cardiac rehab, MSK and neurology — each register-driven, NICE-aligned, with structured reviews and outcome measures. LTC ties multi-condition patients together.
| Patient | Conditions | Next review | QOF |
|---|---|---|---|
| H. Beaumont | Diabetes · CKD · HF | overdue | DM006 due |
| D. Hughes | COPD · HF | due soon | complete |
| R. Adeyemi | Asthma · Hypertension | on track | complete |
Build a cohort in plain English or from an open phenotype, preview the count, save it — then push it to recall, social prescribing or a CDSS review. Segmentation becomes action, not a report.
QOF registers + exception reporting show exactly who is missing what; recall chases them; the inequality lens (CORE20PLUS5, IMD) targets the effort where deprivation makes the gap widest.
Each condition hub is register-driven and NICE-aligned — e.g. diabetes foot-risk stratification and retinal failsafe, COPD GOLD grading and pulmonary rehab, heart-failure GDMT optimisation — with structured reviews and outcomes.
| Capability | Route | Standard | Status |
|---|---|---|---|
| Population Health (cohorts, phenotypes) | /population-health | API /population-health · openEHR/OMOP | ● Live |
| QOF (25 indicators, exceptions, GPES) | /qof | API /qof/ · QOF 2025/26 | ● Live |
| LTC & reviews (multi-condition) | /ltc · /ltc-reviews | API /ltc/ | ● Live |
| Frailty Programme (CFS, virtual ward) | /frailty-programme | API /frailty/ · Rockwood CFS | ● Live |
| CDSS Engine (NICE/BNF prompts) | /cdss | API /cdss/ · NICE · BNF | ● Live |
| Deprivation Mapping (CORE20PLUS5) | /deprivation-mapping | IMD 2019 · CORE20PLUS5 | ☉ Demonstrated |
| Diabetes / Respiratory / Heart Failure | /diabetes-management … | NICE NG28 / NG115 / NG106 · QOF | ☉ Demonstrated |
| Stroke / Cardiac rehab / MSK / Neurology | /stroke-care … | SSNAP · BACPR · NICE | ☉ Demonstrated |