Physician-written algorithms ensure that your patients are getting the highest-quality post discharge care.  



  • Physician-written workflows for two dozen of the top discharge diagnoses, such as diabetes, heart failure, asthma, COPD, stroke, heart attack, pneumonia, hip replacement, and knee replacement.
  • Workflows empower your staff to perform a physician-level medical history, that includes relevant symptoms, biometrics, co-morbidities, self-monitoring, lifestyle factors, psychosocial factors, and behavioral data.  Each evaluation includes medication reconciliation and a functional needs assessment.  Workflows are designed to detect patients whose status may be worsening due to chronic disease or a medical complication.
  • A physician-written expert system synthesizes the medical history into a physician-friendly post discharge followup note that includes clinical history, objective measures, and a comprehensive care plan.
  • Assigns a Priority Score to each PDF note to reflect readmission risk.  Priority score (1 to 7) indicates how quickly the note should be reviewed by the provider.  Identifies acute opportunities where timely clinical intervention could avoid an ED visit or a readmission.  Priority Score also identifies situations where intervention could be managed via telemedicine.
  • Calculates Disease Control Score, an objective measure (1-100%) that is calculated using a wide variety of data such as biometrics, symptoms, symptom severity, co-morbidities, and behaviors.  Allows you to quickly identify which patients are doing better and which ones need attention. 
  • Calculates Patient Effort Score, an objective measure (1-100%) that reflects the patient's adherence with the treatment plan. Quickly identify educational opportunities to get the patient back on track. 
  • Extensive medical library supports verbal and web-based education. Links in the care plan provide the medical assistant with instant access to targeted educational content from a 28,000 topic medical library.
  • Creates a personalized, web-based, interactive care plan.  Our Virtual Health Coach allows patients to educate themselves when they want, and perform self-assessments to check for improvement in their Patient Effort Score.
  • Time audit logs encounter start times and duration in the PDF note.
  • Free web-based training every month by a registered nurse.
  • Available as a widget for quick integration into another application (e.g. CRM application).
  • Available as an API, for custom integration into another application.