Overview
skyCare for Value-Based Care is an EHR-agnostic, point-of-care AI agent that surfaces Patient 360 data—demographics, vitals, medications, encounters—plus gap assessment and risk stratification inside clinical workflows.
It runs as a lightweight Chrome extension that auto-detects patient context from any EHR screen. The ambient scribe runs as a standalone web app for NextGen practices and as the Chrome extension for eClinicalWorks.
Why It's Needed in the Market
Value-based care teams work across scattered systems: diagnoses, vitals, notes, and claims live in different places, care gap review against HEDIS, USPSTF, and CMS Stars is manual, risk stratification is inconsistent, and nothing prompts clinicians at the point of care.
skyCare for Value-Based Care solves this by bringing insights to the clinician inside the EHR, enabling immediate action and stronger performance under value-based contracts.
What It Does
Detects patient ID, name, and DOB from any EHR view.
Pulls consolidated Patient 360 data through Skypoint APIs.
Shows open gaps aligned to HEDIS, USPSTF, and CMS Stars.
Prioritizes interventions for high-risk patients.
Encounters, diagnoses, vitals, orders, and place of service on one timeline.
Alerts providers during the encounter.
Records the visit with consent, transcribes it live, and drafts a SOAP note for review.
Commits the approved note and coded diagnoses to eClinicalWorks and NextGen, with confirmation and an audit record.
Key Capabilities
Demographics, vitals, medications, encounters, and claims context from Skypoint's unified Patient 360, modelled on FHIR R4 with every record resolving to one patient.
Flags overdue screenings, labs, immunizations, and chronic care tasks.
Charlson, LACE, readmission-risk, and polymedication scores banded high, medium, or low, each with its contributing factors and how it was calculated.
Reads patient details from the page—no EHR integration required.
Data appears as soon as the chart loads.
Azure AD B2C sign-in with PKCE and Microsoft or Google identities. Access is granted per user and instance, and idle sessions time out with a warning, pausing while a visit records or a note is written.
High-risk alerts, coding gaps, and chronic condition indicators.
Health, Insights, Gaps, Timeline, and Prior Auth views.
The problem list grouped by severity, with coding-relevant conditions kept separate.
Switch organization from the header; each switch fully reloads the workspace.
Search Patient 360 by name or MRN as you type, without an open chart.
A provider guide under Settings → Documentation, plus links to the Privacy Portal and Terms of Use.
Ambient Clinical Scribe
skyCare records the visit and turns it into a structured note, so clinicians leave the encounter with documentation already drafted.
Recording starts only after consent is attested, and each attestation stores exactly what was read to the patient. A Dictation mode switch on the consent card covers notes recorded with no patient present.
An encounter can hold several recordings, such as a pre-visit dictation, the visit, and a later plan dictation, all feeding one note. Each recording updates the current draft and keeps hand edits.
The transcript builds on screen as the visit happens, with clinician and patient turns attributed.
Thirteen sections, from history and chief complaints through assessments with ICD-10 candidates, plan, medications, orders, and patient priority goal.
Findings are matched to the tenant's catalogs and to ICD-10, LOINC, and RxNorm, so the note uses terms the EHR recognizes.
Every section is editable and autosaves; a note already in the chart becomes read-only.
Dropped connections reconnect without losing audio. Visits can run up to 3 hours, and the note is ready shortly after stopping.
Pause for up to 30 minutes and resume in the web app and extension; on iPhone, a phone call or app switch pauses the recording. After 30 seconds of silence the app asks whether to continue, and leaving a page mid-recording asks for confirmation.
Play back the recording from the Transcript tab until its retention period passes.
Reopen drafts, retry failed notes, or view written notes read-only. Deleting an encounter removes its audio, transcript, and note; the copy in the chart stays in the EHR.
Set per organization: audio is purged at the recording expiry, and once a note expiry is set, whole encounters are purged at that point.
An editable narrative summary written into the chart's history notes.
A calendar of the provider's encounters by day or week, and patient search by name, MRN, or date of birth. Opening a visit lands on the patient with that visit pinned above upcoming and prior encounters, goals, problems, medications, and vitals. Only the rendering provider can record, draft, or write.
On NextGen, type or speak instructions to skyAgent, with spoken words shown live, then accept, reject, or reword each proposed change. skyAgent asks a clarifying question when an instruction is unclear and never writes to the EHR itself.
On NextGen, a Templates screen holds personal and organization templates. skyAgent inserts a template, fills it only from what was discussed, and merges it with the existing note.
Writing Back to the Chart
- eClinicalWorks receives FHIR R4 records: the note plus coded conditions, medications, and lab orders
- NextGen appends the note under a dated heading so typed text is never overwritten; the patient priority goal is written with the note and replaces the goal on record
- A confirmation step names the patient and encounter; on eClinicalWorks, a warning appears before writing to a different visit
- Failed or partially written sections can be retried alone, and partial writes are never reported as success
- Every attempt is audited back to the recording and consent; once note retention is set, the whole encounter, including that record, is purged at expiry
Tailoring How the Scribe Writes
A SOAP customization screen lets each site add per-section instructions, as site-wide defaults or per-organization additions, or opt a section out entirely. Only sections the tenant's EHR can chart are offered.
Key Metrics It Moves
More preventive, chronic, and coding gaps closed.
High-risk members surface at the point of care.
Zero-click insights; Patient 360 loads in about 2 seconds.
Supports HEDIS and CMS Stars performance.
Better targeting makes interventions more effective.
Notes are drafted during the visit, not afterwards.
Use Cases
Open gaps appear when the chart loads.
Highlights patients needing immediate focus.
Vitals and medication cues for diabetes, HTN, and COPD programs.
Screenings, immunizations, and labs aren't missed.
Full context without leaving the EHR.
Stratification and intervention planning across populations.
Record in the chart and leave with a reviewed SOAP note in the EHR.
Finish a draft from Past Encounters and write it later that day.