Connected population intelligence and accountable care workflows.
Turn longitudinal data into coordinated action for defined populations.
- Longitudinal records + claims + ePRO
- Patient matching, terminology and measure calculation
- Cohort/
rule service - Care manager worklists
- Engagement channels
- Outcomes analytics
Care teams struggle to identify priority cohorts, interpret longitudinal risk, coordinate outreach and measure whether interventions are reaching the right people.
We engineer data and workflow foundations for proactive care management: patient registries, cohort identification, care gaps, outreach worklists, intervention tracking and longitudinal outcome monitoring. The solution can support chronic disease, maternal care, behavioral health, transitional care and other care programs based on locally agreed clinical rules and evidence.
How we approach it.
- Define population eligibility and clinical measures with subject-matter experts
- Normalize longitudinal records
- Create worklists and care management interfaces
- Integrate outreach
- Monitor intervention and outcome indicators
What it includes.
- Patient registry and cohort management
- Care-gap identification
- Risk segmentation and stratification workflows
- Care manager worklists
- Longitudinal condition tracking
- Intervention and outreach coordination
- Remote follow-up and ePRO integration
- Population-level performance analytics
Where it fits.
- Diabetes and hypertension monitoring worklists
- Post-discharge outreach to high-priority cohorts
- Behavioral health caseload monitoring
- Preventive screening and vaccination gaps
- Care transitions across providers
- High-utilization cohort segmentation
- Condition-specific longitudinal registries
- Intervention completion and effectiveness dashboards