Problem
Missed interventions
Unnoticed hospital discharges lead to costly readmissions and missed Transitional Care Management windows.
Built for ACOs, clinics, and provider organizations
Point-of-care clinical intelligence for your ACO and provider network
Transform fragmented health data into actionable insights, accurate risk adjustment, and seamless patient care — whether a patient is on your bulk roster or walking into your clinic for the first time.
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Clinician login
Start in the right place
Practice signup
For clinics and practices that want patient-authorized access and web-based clinical intelligence.
Sign up as a providerACO and provider groups
For ACOs and provider groups that need BCDA v3 setup, data processing, and organization-wide rollout.
Contact us to get startedBuilt on official CMS-HCC models
BCDA v3 and Blue Button 2.0 data
Evidence-based clinical rules engine
Web-based on phone and desktop
Care teams are flying blind
For ACOs and modern provider networks, success depends on proactive care. Yet care teams often rely on lagging reports, incomplete ADT feeds, or siloed health records.
Problem
Inaccurate risk scores
Burdensome, finance-driven coding alerts frustrate clinicians instead of helping them document actual clinical complexity.
Problem
Data blind spots
No insight into the care, medications, and diagnostics patients receive outside your immediate network.
A unified, actionable clinical engine
We ingest, normalize, and analyze utilization records, pharmacy histories, and diagnostic profiles to surface exact, time-sensitive interventions when your care teams need them.
Core feature
Intelligent HCC Documentation Assistant
Accurate risk adjustment is critical for MSSP ACOs, but provider abrasion from finance-driven coding alerts is a real challenge. Our HCC Documentation Assistant is a specialized, point-of-care tool designed by and for clinicians. It translates complex coding gaps into actionable clinical insights without the billing jargon.
Recapture candidates
Automatically identifies conditions documented in prior years but not yet evidenced in the current calendar year. Provides the exact date last seen and the specific diagnosis codes used.
Suspect conditions engine
Analyzes pharmacy fills and utilization patterns to surface suspect conditions — like flagging active insulin fills without a diabetes diagnosis, or phosphate binders suggesting undocumented CKD.
CMS-HCC model integration
Built on official CMS-HCC model year artifacts with full hierarchy rule support, ensuring suggestions are always accurate to current CMS guidelines.
Clinical Alerts Dashboard
An inbox-style dashboard giving care coordinators and clinicians a prioritized daily worklist based on the freshest available health data.
- Transitions of care: 30-day alerts for inpatient/SNF discharges and ED visits with facility, diagnosis, and disposition
- TCM timers: Automatic countdowns for 2-day and 7/14-day Transitional Care Management follow-ups
- Medication safety: High opioid dose (MME), opioid+benzodiazepine overlap, and high-risk medication alerts (Beers Criteria)
Complete Patient History
Bulk Medicare data (BCDA) covers your ACO roster, but what about new walk-ins, out-of-network patients, or non-ACO clinics?
We close the data gap with direct provider authorization. Using patient-authorized connections via Medicare Blue Button 2.0 and commercial health plan tools, your clinic users can instantly retrieve years of historical utilization and coverage data for any patient.
Our system processes this fresh data through our clinical engine within milliseconds, ensuring you have a complete, enriched patient profile before the visit begins.
Powered by a comprehensive clinical rules engine
We don't just show raw records — we interpret them using industry-standard, evidence-based algorithms. Our unified enrichment pipeline translates complex health histories into clear patient statuses.
Chronic Disease & Risk Stratification
30 standard chronic conditions via CCW algorithms, CMS-HCC V28 risk scores with demographic factors and disease interactions, and a composite risk score classifying patients into Low, Moderate, or High-risk tiers.
Preventive Care & Screenings
Annual Wellness Visit tracking with rolling 12-month evaluation, colorectal cancer screening aligned with USPSTF guidelines, breast cancer screening per CMS125/QPP 112, and diabetes glycemic and BP control compliance.
Immunization Tracking
Seasonal flu shot compliance tied to the active flu season (August–March), pneumococcal series completion per CDC/ACIP guidelines, and 2-dose Shingrix tracking integrating medical and pharmacy histories.
Medication Adherence & Safety
Proportion of Days Covered (PDC) with per-medication granularity and clinical action zones, days-since-runout tracking, high-risk medication flags via Beers Criteria, and real-time MME calculations using CDC 2022 guidelines.
Care Coordination & Utilization
Avoidable ED use analysis via NYU ED Algorithm, continuity of care index using the Bice-Boxerman formula with both ABFM12 and operational variants, and year-to-date total cost of care with Part A/B breakdowns.
Explore all measures
See the full suite of automated calculations, clinical rules, and quality measures the platform surfaces for your care teams.
Who this platform serves
The same platform supports day-to-day clinical work and ACO-level reporting.
Clinics and practices
Teams that want web-based Medicare clinical intelligence without building a data workflow from scratch.
ACO and provider organizations
Organizations using BCDA v3 to distribute clinical intelligence across care management, quality, and clinic operations.
Care managers and nurses
Teams that need recent hospital, ED, medication, and preventive care information in one prioritized dashboard.
Physicians and quality leaders
Users who need risk, utilization, and care gap context at the point of care and in panel review.
Explore the full clinical engine
See every measure and calculation our platform provides
Risk scores, preventive care tracking, medication adherence, opioid safety, transitions of care, and total cost of care — all powered by evidence-based algorithms.
Frequently asked questions
Common questions from providers, ACOs, and care teams.
What data sources does the platform use?
The platform ingests Medicare data through BCDA v3 for ACO-attributed rosters and through patient-authorized Blue Button 2.0 connections for individual patients. Commercial health plan data from sources like UnitedHealthcare can also be accessed with patient authorization.
How does the HCC Documentation Assistant help clinicians?
It translates coding gaps into clinical language. It identifies conditions documented in prior years that need recapture, surfaces suspect conditions based on pharmacy and utilization patterns, and follows official CMS-HCC hierarchy rules so suggestions are always accurate.
Can non-ACO clinics use this platform?
Yes. Any clinic can use patient-authorized Blue Button 2.0 connections to retrieve Medicare utilization history for individual patients. BCDA v3 bulk data access is available for ACO-attributed rosters.
How quickly is patient data available after authorization?
Patient-authorized data retrieved through Blue Button 2.0 is processed through our clinical engine within milliseconds, providing an enriched patient profile before the visit begins.
What clinical measures does the platform calculate?
The platform calculates chronic condition identification using CCW algorithms, CMS-HCC risk scores, preventive care compliance (AWV, cancer screenings, immunizations), medication adherence (PDC), opioid safety metrics, avoidable ED use, continuity of care, and total cost of care.
See the full measures list for detailed methodology and algorithm references.
Is Informed + Choice a healthcare provider or insurance company?
No. Informed + Choice is a technology platform that provides clinical intelligence tools for healthcare providers and ACOs. We do not provide medical care, sell insurance, or compete with our customers.