Overview
skyCare for Value-Based Care is an EHR-agnostic, point-of-care AI agent that delivers real-time, patient-specific clinical insights directly inside healthcare workflows. It surfaces Patient 360 data—including demographics, vitals, medications, encounters—and later versions add advanced gap assessment and risk stratification models to help prioritize interventions and close clinical gaps. skyCare for Value-Based Care runs as a lightweight Chrome extension that auto-detects patient context (ID, name, DOB) from any EHR screen and displays consolidated insights with zero clicks. It transforms fragmented value-based care workflows into a unified, intelligent, point-of-care experience.Why It’s Needed in the Market
Value-based care teams—care coordinators, population health managers, case managers, physicians—struggle with fragmented data and manual workflows:- Clinical diagnoses, vitals, encounter notes, and claims data sit in multiple systems
- Care gap identification requires manual review of guidelines (HEDIS, USPSTF, CMS Stars)
- Risk stratification is inconsistent or absent across care teams
- Providers must switch repeatedly between EHR, BI tools, payer portals, and spreadsheets
- No real-time prompts exist at the point of care, causing delayed interventions
What It Does
Auto-Detect Patient Context
Detects patient context (ID, name, DOB) automatically from any EHR view.
Fetch Patient 360
Fetches consolidated Patient 360 via Skypoint APIs including demographics, vitals, medications, and encounters.
Surface Care Gaps
Surfaces open care gaps aligned to HEDIS/USPSTF/CMS Stars guidelines.
Show Risk Scores
Shows risk scores for prioritizing interventions and targeting high-risk patients.
Present Clinical Timeline
Presents timeline-based clinical activity for rapid orientation during encounters.
Enable Proactive Decisions
Supports proactive decision-making by alerting providers during the clinical encounter.
Key Capabilities
Patient 360 View
Demographics, vitals, medications, encounters, claims-derived context—all retrieved from Skypoint’s unified Patient 360.
AI Gap Assessment
Highlights overdue or incomplete screenings, labs, immunizations, chronic disease management tasks based on guideline models.
Risk Stratification
Displays risk scores derived from claims, diagnoses, and encounter history.
EHR Context Detection
Auto-detects patient details using DOM parsing—no EHR integration required.
Zero-Click Insights
Data appears instantly when chart loads, reducing search and navigation time.
Secure API Access
OAuth2/JWT-secured calls fetch insights from Cosmos DB.
Clinical Flags
High-risk alerts, coding gaps, chronic condition indicators appear inside the extension.
Tab Structure
Organized views: Agenda, Alerts, Analytics for streamlined navigation.
Key Metrics It Moves
Gap Closure Rate
Higher completion of preventive screenings, chronic disease measures, and coding gaps.
Risk Identification Speed
Rapid surfacing of high-risk members at point of care.
Provider Efficiency
Zero-click insights reduce workflow time; Patient 360 loads within ~2 seconds.
Clinical Quality Scores
Supports HEDIS and CMS Stars performance improvement.
Population Health Outcomes
Better targeting of high-risk individuals increases intervention effectiveness.
Use Cases
Care Gap Closure
Displays all open care gaps the moment the chart loads.
Risk-Based Prioritization
Highlights high-risk patients who require immediate focus.
Chronic Condition Oversight
Supports diabetes, HTN, COPD programs with relevant vitals and medication cues.
Preventive Care Compliance
Ensures screenings, immunizations, labs, and quality measures are not missed.
EHR Workflow Optimization
Providers get full context without leaving the EHR.
Population Health Management
Enables stratification and intervention planning across patient populations.