CCW Chronic Conditions
Identifies 30 standard chronic conditions using the official CMS Chronic Conditions Warehouse algorithms, with 1- to 2-year claims histories, ICD-10 sets, and claim-type qualification rules.
Back to Medical Providers
Clinical measures and automated calculations
Comprehensive clinical rules engine for provider teams
Our platform transforms raw health data into actionable, point-of-care insights using industry-standard algorithms and evidence-based guidelines across risk stratification, preventive care, medication safety, and care coordination.
What this page covers
A detailed breakdown of every metric and calculation our clinical engine provides — from chronic disease profiling and risk scores to medication safety alerts and cost of care reporting.
These measures power the Clinical Alerts Dashboard and HCC Documentation Assistant described on the main provider page.
CMS-HCC V28 model integration
CCW chronic condition algorithms
USPSTF & CDC/ACIP guidelines
Evidence-based safety algorithms
Chronic disease & risk stratification
Risk scoring and chronic condition analytics
CMS-HCC Risk Adjustment (RAF) Scoring
Calculates risk scores using the CMS-HCC V28 model, including demographics, disease interactions, and hierarchy trumping rules.
Internal Composite Risk Score
Classifies patients into Low, Moderate, or High-risk tiers using cost YTD, SDOH Z-codes, ED and inpatient utilization, AWV completion, and active chronic conditions.
Preventive care & screenings
Preventive care measures and quality tracking
Annual Wellness Visits (AWV)
Tracks AWV completion using a rolling 12-month evaluation for G0438 and G0439, including IPPE blocking periods.
Colorectal Cancer Screening (CRC)
Aligns with USPSTF ages 45 to 75 and tracks colonoscopy, FIT or FOBT, stool DNA, sigmoidoscopy, and CT colonography intervals.
Breast Cancer Screening
Evaluates mammography compliance using CMS125 / QPP 112 with a 27-month lookback window for eligible female patients.
Diabetes Glycemic Status (HbA1c)
Models CMS122 / QPP 001 for HbA1c testing compliance and uses CPT II / QDC result codes to determine controlled versus uncontrolled status.
Controlling High Blood Pressure
Tracks blood pressure control for hypertensive patients based on CMS165 / QPP 236 using QDC result-category codes.
Depression Screening and Follow-up
Aligns with CMS2 / QPP 134 by verifying screenings within 14 days of an encounter and checking for documented follow-up plans.
Immunization tracking
Vaccination insight tied to real clinical timing
Influenza (Flu) Vaccination
Evaluates flu shot compliance dynamically by active flu season, August through March, so the tracking reflects the months that matter.
Pneumococcal Vaccination
Uses CDC and ACIP guidance for adults 65+ and maps lifetime series completion across PCV20 or PCV21 and PCV15 plus PPSV23 sequences.
Shingles (Zoster) Vaccination
Tracks the 2-dose Shingrix series for adults 50+ using Part D NDCs alongside Part B medical claims and monitors the 2- to 6-month spacing window.
Medication adherence & safety
Medication adherence, opioid risk, and prescribing safety
Clinical Medication Adherence (PDC)
Calculates proportion of days covered for maintenance medications with per-medication action zones: Green at 80% or above, Yellow at 50 to 79%, and Red below 50%, plus exact days since runout.
High-Risk Medications in Older Adults
Flags potentially inappropriate medications in adults 65+ using NCQA HEDIS DAE and AGS Beers Criteria, with safer alternative guidance for prescribers.
High Opioid Dose (MME) Alert
Calculates cumulative daily morphine milligram equivalents using CDC 2022 guidance and flags caution at 50 MME and high risk at 90 MME.
Opioid and Benzodiazepine Co-prescribing
Detects concurrent opioid and benzodiazepine use based on FDA black box warnings and calculates exact overlap days for intervention.
Care coordination & utilization
Transitions of care and avoidable utilization insight
Transitions of Care (30-Day Alerts)
Surfaces real-time alerts for inpatient, SNF, and ED treat-and-release visits and includes TCM eligibility timers for 2-day and 7 or 14-day follow-up windows.
Historical Inpatient and ED Utilization
Tracks 12-month utilization using revenue code detection for room and board, ICU, and ED claims to score acuity and identify frequent flyers.
Avoidable ED Use (NYU EDA)
Summarizes 12-month ED patterns using the NYU ED Algorithm to estimate the probability that visits were non-emergent or primary-care treatable.
Bice-Boxerman Continuity of Care Index (COCI)
Calculates care continuity using the Bice-Boxerman formula with both the ABFM12 strict specification and an ACO-operational team-based variant.
Financial
Total cost of care reporting
Total Cost of Care (TCOC) YTD
Aggregates year-to-date Medicare payments and separates Part A from Part B categories to identify high-cost outlier patients.
Built on established standards
Industry-standard algorithms and evidence-based guidelines
CMS Chronic Conditions Warehouse, CMS-HCC V28, USPSTF, QPP/CMS quality measures, CDC/ACIP, NCQA HEDIS DAE, AGS Beers Criteria, CDC opioid guidance, NYU ED Algorithm, and the Bice-Boxerman continuity index.
Frequently asked questions
Questions about the measures and calculations.
What kinds of provider measures does the platform calculate?
The platform calculates chronic condition profiles, CMS-HCC RAF scores, preventive care measures, immunization status, medication adherence, opioid safety signals, transitions of care alerts, utilization history, continuity of care, and total cost of care.
Does the platform use standard clinical specifications?
Yes. The calculations are aligned with standards and specifications such as CMS Chronic Conditions Warehouse algorithms, CMS-HCC V28, USPSTF guidance, QPP and CMS quality measures, CDC and ACIP guidance, NCQA HEDIS DAE, AGS Beers Criteria, CDC opioid guidance, the NYU ED Algorithm, and the Bice-Boxerman continuity index.
Who uses these metrics inside the app?
These metrics are designed for care managers, quality teams, nurses, physicians, clinic managers, and ACO operations leaders who need actionable reporting at the point of care and at the population level.
Where does the data come from?
Data comes from BCDA v3 for ACO-attributed rosters and from patient-authorized Blue Button 2.0 connections for individual patients. Commercial health plan data can also be accessed with patient authorization.
How are these measures different from what an EHR provides?
EHRs typically show what happened inside your clinic. Our clinical engine analyzes data from across a patient's entire care history — including visits, prescriptions, and diagnoses from outside your network — to surface gaps, risks, and opportunities your EHR cannot see.
Ready to put these measures to work for your team?
Schedule a personalized demo to see how our clinical engine surfaces these metrics at the point of care for your providers and care teams.
Resources: Provider overview · Demo · Blog · Privacy · Terms
Informed + Choice is a workflow platform and does not claim Medicare or CMS endorsement.