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. The same product also runs as a standalone web app for clinicians working outside the EHR browser session, with the same patient view, ambient scribe, and note settings. 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—encounters, diagnoses, vitals, orders, and place of service—for rapid orientation during encounters.
Enable Proactive Decisions
Supports proactive decision-making by alerting providers during the clinical encounter.
Document the Visit
Records the encounter with patient consent, transcribes it live, and drafts a structured SOAP note for the clinician to review.
Write Back to the Chart
Commits the approved note and its coded diagnoses to eClinicalWorks and NextGen, behind a confirmation step and an audit record.
Key Capabilities
Patient 360 View
Demographics, vitals, medications, encounters, claims-derived context—all retrieved from Skypoint’s unified Patient 360. The record is modelled on FHIR R4 and spans conditions, observations, procedures, immunizations, medication requests, diagnostic reports, service requests, care plans, imaging studies, allergies, documents, tasks, coverage, claims, and explanations of benefit, with every row resolving to one patient.
AI Gap Assessment
Highlights overdue or incomplete screenings, labs, immunizations, chronic disease management tasks based on guideline models.
Risk Stratification
Displays Charlson Comorbidity Index, LACE, readmission-risk, and polymedication scores, each banded high, medium, or low. Every score opens into an analysis card showing the factors behind it, and an explainer describing how it was calculated.
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 Sign-In and Access
Sign-in runs on Azure AD B2C using authorization code with PKCE—no client secret in the browser—with Microsoft and Google as identity options. Access is granted per user and per instance, so a clinician who holds no grant is told so plainly instead of being bounced back to the sign-in screen.
Clinical Flags
High-risk alerts, coding gaps, chronic condition indicators appear inside the extension.
Tab Structure
Organized views—Health, Insights, Gaps, Timeline, and Prior Auth—for streamlined navigation.
Health Needs Panel
The patient’s problem list grouped into high, medium, and low severity, with a count for each band and a card per condition. Coding-relevant conditions are separated from the rest so they are not lost in a long list.
Tenant and Instance Switching
Clinicians working across more than one organization switch tenant and instance from the header. Each switch fully reloads the workspace, so nothing from the previous instance can linger on screen.
Patient Search
A patient search screen reads the Patient 360 record directly, for work that starts from a person rather than from an open chart.
Ambient Clinical Scribe
skyCare records the visit and turns it into a structured note, so the clinician finishes the encounter with documentation already drafted rather than a backlog to write up later.Consent Before Recording
The consent wording is served by skyCare rather than held in the browser, so every attestation records exactly what was read to the patient. Recording cannot start until consent is attested, and the approval is stored against the session.
Live Transcription
Encounter audio streams to a medical speech model and the transcript builds on screen as the conversation happens, with clinician and patient turns attributed and filler removed.
Structured SOAP Draft
Thirteen sections are extracted: medical history, chief complaints, history of present illness, review of systems, assessments with ICD-10 candidates, treatment plan, current medications, examination, procedures, diagnostic imaging, lab reports, procedure orders, and patient priority goal.
Grounded to the Chart
Findings are matched against the tenant’s own catalogs and coding vocabularies—ICD-10, LOINC, RxNorm, examination, procedure, and order sets—so what reaches the note is a term the EHR recognizes rather than free text.
Review and Edit
Every section is editable before anything is written. Edits autosave behind a visible saved, saving, or not-saved indicator, and a note that has already reached the chart locks to read-only while still allowing sections to be collapsed and read.
Resilient Sessions
A dropped connection reconnects on its own and the recording continues; audio is buffered rather than discarded, and the session resumes where it left off. Stopping returns control immediately—the note is produced in the background and appears when it is ready.
Past Encounters
Previous sessions are listed by day with patient, time, duration, status, and a preview of the note. A draft can be reopened and finished later, a failed note can be retried, and a written note opens read-only.
Encounter Summary
A narrative summary of the visit is generated alongside the structured sections, editable in place, and written into the chart’s history notes.
Writing Back to the Chart
- Approved notes reach eClinicalWorks as FHIR R4 records—the note document plus coded conditions, medications, and lab orders
- NextGen charts receive the note directly, appended under a dated heading so text a clinician typed is never overwritten
- A confirmation step names the patient and the encounter’s date and time, resolved on the server rather than read from the browser address bar
- Sections that fail can be retried on their own, leaving sections that already landed untouched
- An empty or partial write is reported as a failure, never as a success
- Every attempt records an audit row, so a chart write leads back to the recording and to the consent that authorized it
Tailoring How the Scribe Writes
A SOAP customization screen lets each site steer the scribe field by field, without touching a prompt:- Every section is listed with plain-language copy describing what the scribe already does with it
- Instructions can be added, edited, and removed per section, as site-wide defaults or as per-organization additions, with an administrator control over which layer wins
- An organization can opt a section out entirely
- Only the sections the tenant’s EHR can actually chart are offered, so no one steers a field that has nowhere to land
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.
Documentation Burden
Notes are drafted during the visit rather than written up afterwards, and a stored draft can be finished later instead of restarted.
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.
Ambient Encounter Documentation
Clinicians record the visit in the chart they are already standing in and leave with a reviewed SOAP note committed to the EHR.
Same-Day Note Completion
A note left as a draft is reopened from Past Encounters, finished, and written to the chart later in the day.