Summary
PRISM is a population health tool developed to help NHS teams identify and prioritise people with diabetes who may be missing from official registers or at risk of deterioration. By integrating with EMIS and SystmOne, PRISM combines national datasets (QOF, NDA) with local records to highlight gaps in care, drive clinical prioritisation, and support proactive interventions. Designed by clinicians, for clinicians, PRISM enables data-led decisions that improve operational efficiency and outcomes. NHS teams have used PRISM to redesign services, better target resources, and ensure high-risk patients receive timely care.
Innovation/Novel approach to an existing problem
Under-resourced teams often struggle to proactively identify high-risk patients, those missing from official registers and even opportunities for routine care. Traditional systems are reactive and siloed. PRISM was developed as an innovative informatics solution to address these challenges. It integrates, via IM1, with EMIS and SystmOne, pulling together local patient records with national datasets to create a validated, real-time view of gaps in care. The system applies clinical logic to highlight patients who are not on diabetes registers but show clinical markers, or who are at risk of deterioration. Promatica’s PRISM empowers clinical teams to redesign pathways, target interventions, and allocate resources. It was used to identify gaps in prescribing of continuous glucose monitors (CGM). Promatica, utilising funding from Dexcom, provided the software at no cost to the NHS. PRISM identified the correct patients to the GP practice, allowing them to join a four-stage clinic process. Stage 1 was a pharmacist case notes review to find people with T2DM having multiple daily injections of insulin and meeting any of the additional criteria for CGM (estimated at 3-5% of the T2D population). The pharmacist used a telephone clinic to validate and verify the information, and invite patients to Stage 2: a face-to-face appointment with a product specialist. The patients were onboarded to the practice-preferred device, and invited to ask questions. Stage 3 was a diabetes specialist nurse consultation. The Promatica nurse checked on the patients after they had been wearing their device for 7-10 days, to ensure compliance and review early data. The clinic ensured that the patient fully understood CGM and any clinical concerns could be raised. Stage 4 was a first-of-type integration with the clinical systems. Patients who chose Dexcom devices were invited by PRISM to consent to share their data with their medical record. Practices then used PRISM to configure the cadence of summarised data fileback into SystmOne or EMIS. This allowed the primary clinical system to act as the single source for CGM data.
Equality, Diversity and Variation
PRISM was designed to reduce unwarranted variation in diabetes care by identifying patients who may have been overlooked due to system fragmentation, socioeconomic barriers, or inconsistent data recording. By combining national datasets, such as postcode deprivation scores, with real-time clinical records, PRISM flags individuals not on diabetes registers but showing clear clinical need. It enables care teams to prioritise patients based on clinical risk rather than their ability to access services, helping to close gaps in access and outcomes. This approach supports equitable care. Promatica clinicians cover most languages spoken in the UK and use translation services. It conducts education clinics in mosques and other community hubs, improving DNA rates and patient trust. Patients can be supplied with transmitters when smartphone compatibility is an issue.
Impact to Patient Care
PRISM ensures earlier intervention, improved outcomes, and reduced harm. Importantly, patients who may have ‘fallen through the cracks’ are identified and supported, leading to more equitable care and better long-term health outcomes across diverse populations. Currently each CGM supplier has an accompanying app for healthcare professionals. By sharing the patient's CGM data with their medical record, Promatica have removed the risk of viewing a patient record ‘out of context’. Promatica hope that other CGM suppliers, not just Dexcom, follow suit with a fileback solution that creates a single source of truth for CGM data in the patient record. Diabetes datasets are plentiful, but omit interstitial glucose data. Promatica are a vanguard in delivering this data to the NHS. Promatica recognised a gap, namely the absence of PROMS/PREMS. They are developing SMS collection of patient feedback via PRISM, to close the QI cycle. Dexcom funded the software and service, but practices were not obliged to choose Dexcom One+.
Results
At Over Wyre Medical Centre, the service resulted in 33 patients being initiated on CGM who had not previously been considered. All remained on the same device at the six-month check, owing to the rigorous onboarding process. Analysis of the patient data in the following six months showed an average reduction of 9.1% in mean HbA1c. This is a significant reduction and demonstrated the impact of CGM in promoting awareness of glucose levels and the immediate impact of food, alcohol and exercise on control. Glucose Management Indicator (GMI) is arguably a more reliable measure of glycaemic control, as it removes variability introduced by red blood cell count, so the intention is to review this in future. In the same population, overall appointment burden was reduced by 28%. Data from the first five sensor-naive patients initiated on CGM showed that, as well as an average reduction in GMI and improving sensor usage, the new CGM alerted them to 97 low or very low glucose levels overnight. This information was filed into the PMR, giving the care team the opportunity for earlier intervention.
User Feedback
Clinicians using PRISM reported that the team and the software were easy to work with. A patient reported, ‘The whole service from start to finish has been superb. From the text message advising me that I was being offered a glucose sensor, the link to click and book a convenient date and time to come to the surgery where the lady who explained everything really well and to finish with a call to check in with me and talk about things that are available to me in the future. I would describe myself as a dinosaur when it comes to tech so hadn’t thought I needed the sensor but now I’ve got it I can only describe it as life changing.’
